In most countries the use of antidepressants has increased since the year 2000 (although so has the use of anti-hypertension and anti-diabetes medications), yet worldwide less than a fourth of people with depression receive adequate treatment.
As a psychiatrist, I have myself treated thousands of people over the past 25 years for clinical depression, and I’ve seen just how positive and life-changing antidepressants can be.
Over the last few months, I have been able to experience first-hand how controversial this topic can be. First, I was called by the Health Select Committee to present evidence on this issue, in representation of the BAP. Then, I wrote a blog entry on the Huffington Post on this topic, with reference to the recently-published Report of the Health Select Committee. And finally, I wrote a piece on the Daily Mail presenting the pros and cons of antidepressant treatment.
The message that I put across is always the same: when used correctly, antidepressants do work, especially if prescribed with a psychological therapy, and save lives. That’s not just my view, it’s the view of the majority of the medical profession, the NHS, and the leading scientific and medical organisations worldwide.
The Interim Report on Suicide Prevention published by the House of Commons Health Select Committee specifically discusses whether antidepressants are beneficial in preventing deaths by suicide.
Every year, there is approximately 1 death by suicide for every 10,000 individuals in England. Suicide is the biggest killer of men under 49 years of age, of all people aged 15-24, and of mothers in the year after they give birth. Suicide is raising in prisons, and disproportionately affects people in the lowest socio-economic groups and living in the most deprived areas.
The report offers clear recommendations for ameliorate this situation, from supporting public mental health and the ongoing efforts to reduce stigma, to accelerating the establishment of dedicated mental health services in every hospital. And it discusses antidepressants.
Reassuringly for both professionals and patients, the report states: “Whilst we heard concerns in some written submissions about the role of drug treatments and suicide, the evidence we heard from Professor Louis Appleby, Chair of the Government’s suicide prevention advisory group, and Professor Carmine Pariante of the Institute of Psychiatry, was that there is greater risk from not using medication where appropriate, provided that this is following evidence-based guidelines”.
So, what did the BAP say about antidepressants and suicide? What did I tell the Committee? In a nutshell, there is evidence that some antidepressants may increase the risk of non-lethal self-harm, especially in children and adolescents, but there is no evidence that antidepressants increase the risk of suicide, neither in adults nor in children and adolescents.
Of course, for a few patients, antidepressant side-effects can be severe. Some can experience an increased feeling of tension, agitation and restlessness, which can trigger thoughts or acts of self-harm, especially in teenagers. Other patients experience severe side-effects at the time of stopping antidepressants.
But studies have shown that suicidal thoughts and behavior decrease over time during antidepressant treatment, and that, in the population, suicide rates decrease as antidepressant prescriptions increase. Indeed, and most worryingly, the recent decrease in the rates of antidepressant prescriptions in children and adolescents (since warnings about antidepressants and suicide risk have been issued) has led to more suicides in these groups, not less.
Overall, following antidepressant treatment it is 10 times more likely to experience an improvement in the depressive symptoms than to experience an increase in suicidal thoughts or self-harm behaviour.
But how do we address this potentially increased risk of suicidality by antidepressants? We need to maximize the beneficial effects of antidepressants while minimizing their possible negative effects.
We, doctors and mental health professionals, should prescribe antidepressants only to individuals that are most likely to benefit from these medications, so that these benefits outweigh the risks.
Evidence-based clinical guidelines, such as those from the BAP, clearly state that antidepressants should be considered as a first-line treatment only for adults with moderate or severe major depression, that is, when the emotional suffering and the functional impairment reaches significant levels, and should not be used for transient or mild states of emotional distress.
Moderate or severe major depression means feeling sad all the time, for weeks or months; losing hope of getting better; battling with insomnia, loss of appetite, and fatigue; being unable to work and to have a social life; and thinking of, or planning, suicide.
In children and adolescents, the bar for using antidepressants is even higher: only in case of severe depression, thus reaching emotionally and functionally incapacitating levels, or when other treatment strategies do not work.
For those patients who have emotional difficulties but who are not severe enough to require antidepressants, we can support them with our presence and we can help them mobilizing the healing power of their inner resources and of their family and social networks.
We can reassure them that life brings suffering at times of changes and losses, and that this is ok. We can tell them that they do not need antidepressants: they only need time to recover.
At the same time, we must make sure that patients who need antidepressants are recognized by health professionals, are not prevented from accessing help because of stigma, and do embrace our advice when we prescribe the antidepressants that they need.
This way, antidepressants will continue to save lives.