A significant change has been introduced recently to National Institute of Health and Care Excellence (NICE) guidance on mental health, whereby medication is no longer in the initial recommendations for the treatment of mild to moderate depression.
My personal experience of medication for mental health
This is an important move and on a personal level, I am in agreement, since experiencing the iatrogenic harms of medications I did not need. I was prescribed quetiapine by a community psychiatrist after experiencing acute anxiety problems and I do wonder if I ever really needed something with such incredibly strong effects. I suffered from many side effects, including weight gain, problems with walking without tripping over, and eccentric behaviours to name a few. When my GP agreed I should taper off this gradually, my symptoms greatly improved.
My therapist was great but a more structured rehabilitation was required in my recovery from coming off this drug, as it in itself - and in its withdrawal - had come with many problems.
Subsequently, I ended up in the mild to moderate depression category, and the main thing to give, seeing that I was exercising and already having therapy, was more medication, this time in the form of a selective serotonin reuptake inhibitor (SSRI) - venlafaxine, with its notorious implications in a difficult withdrawal. Sometimes I wish I had just had a better program of more social interventions, given I was very lonely and needed more guidance in my interactions with others, rather than going on a medication that took away the depression but also took away nearly everything else at the same time.
Therefore, I am passionate on the subject of iatrogenic harm caused by the over-prescription of medication for mental health, and my perception is that it is a good thing for the new guidance to no longer recommend medication as a first-line approach in the treatment of mild to moderate depression.
Tailored to patient need
That being said, medication plays an extremely important role in the recovery of many patients from a multitude of problems, and I would not want to discourage its use for those complex patients who may benefit, or indeed from those who are borderline in the moderate depression category, where medication could be given first or could be considered after trying other interventions. Individual symptoms and responses to treatments, whether medical or social, should be monitored carefully and tailored to the individual needs of the patient and their preferences. It is a difficult choice to make, which is why it is always useful to discuss the patient with the team first, although some of the time it is important to also remember that the decision cannot always wait. The crisis team should be considered and involved in some cases, for example.
Increasing numbers experiencing depression
Public Health England carried out a review of the evidence in 2019. This was entitled ‘Dependence and withdrawal associated with some prescribed medicines’. The review found that 17% of the adult population in England (7.3 million people) had been prescribed antidepressants in the year 2017-18. Office for National Statistics (ONS) figures show that 17% of adults aged 16 years and over in Great Britain experienced some form of depression in summer 2021 (ONS, 2021). The rate remains higher than observed prior to the coronavirus pandemic (July 2019 to March 2020), where 10% of adults experienced some form of depression.
The impact of the pandemic on mental health
For further insight, the ONS (2021) found that from 21 July to 15 August 2021 younger adults were more at risk of depression, especially women, with 32% of women aged 16-29 years experiencing moderate to severe depressive symptoms, in comparison with 20% of men at the same age. They also found 36% of disabled people and 28% of clinically extremely vulnerable (CEV) people experienced some form of depression in comparison with 8% of the non-disabled population and 16% of the non-CEV adults. Unemployed adults were twice as likely (31%) than employed adults (15%) to experience some form of depression. Socioeconomic factors played a role, as well as employment, with adults in the most deprived areas of England being twice as likely to experience some form of depression compared with adults in the least deprived areas of England (24% vs 12%). Significantly, the ONS (2021) stated that of adults experiencing some form of depression, nearly three-quarters (74%) reported that the coronavirus pandemic was affecting their well-being, compared with around one in three (32%) adults with no or mild depressive symptoms. Although COVID-19 restrictions were necessary, I do worry that an entire generation of younger people are being neglected, as the figures clearly reflect the catastrophic effects of the pandemic on their wellbeing, alongside people in the poorest areas, those who have lost their jobs to the pandemic, and those considered disabled or CEV.
Draft guidance from NICE
The guidance from NICE for the treatment of depression is still in its draft publication stage was open for comments until mid-January.
The draft guidance was published late last year and a flurry of media outlets published the news that medication was no longer the first-line strategy, without too much thought for other things. It is clear from the statistics that social matters impact on someone's risk of depression and current mood. Therefore, the draft makes many more social prescribing and therapeutic interventions as recommendations, with medication being the last option to try for mild to moderate depression.
A wheel of options
NICE (2021) has created a wheel of options that should be considered when allocating a treatment to someone with mild to moderate depression. If the person has no preference, the practitioner can move clockwise from the start (>) around the cycle of options, and reach a shared decision on which treatment to try first (NICE, 2021). If the person has a clear preference - or experience from previous treatment can be used as a guide - clinicians should support the person's choice, unless there are concerns about suitability for this episode of depression, NICE (2021) states. Antidepressants should not be given as a first-line treatment, unless that is the person's preference, NICE (2021) also states.
The first option on the wheel in its draft stage is group cognitive behavioural therapy, and the options listed clockwise from this are as follows (NICE, 2021):
- Group behavioural activation
- Individual cognitive behavioural therapy
- Individual behavioural activation, self-help with support
- Group exercise
- Group mindfulness or meditation
- Interpersonal therapy
- SSRI antidepressants
- Counselling
- Short term psychodynamic psychotherapy.
Conclusion
It is encouraging to see that a range of interventions and new guidance are being considered, so that practitioners can work with patients to achieve the best results for their mental health, without patients automatically being given SSRIs in an overstretched GP service and sent on their way. It is also great for practitioners who already do such a thoughtful job, to have up-to-date, carefully written and research-based guidance to go by. Making the diagnosis between what is mild, moderate and severe depression can also be aided by other parts of the guidance. Hopefully this new wave of mental health issues can be softly brought ashore, with as little damage as possible brought to those who are suffering from the difficulties of depression.