Why are prescriptions of antidepressants at an all-time high?

Prescriptions of antidepressants are at an all-time high, with almost eight million being issued a year in London alone. Are we over-medicating? And why is demand so great? Hannah Betts, who has been on them for seven years, investigates...

Hannah Betts

31 August 2017

Allow me to introduce myself. I am a journalist with a fulfilling career, a happy relationship, and a large and supportive social group. I’ve also been on the antidepressant citalopram for the past seven years. I have to email my doctor to ascertain how long it has been because this situation is my old, new normal. I’m open about it, have written about it — even put a packet on my Instagram feed to counteract all those #blessings-type posts, because my happiness comes in pill form.

I’m not alone. In June, the NHS announced that the number of prescriptions for antidepressants (ADs) is growing faster than that of any other type of medication. Last year, 64.7 million antidepressant items were prescribed in England, up 6 per cent in a year. The figures represent an all-time high — and four times as much pill popping as 20 years ago. Meanwhile, according to NHS Digital, the number of antidepressant items prescribed in London and the Thames Valley area increased by more than 18 per cent in the three years to March 2017, with some 7.8 million items prescribed in 2016/ 17.

Hysteria ensued. One paper produced the headline, ‘A dribbling, suicidal mess — until I kicked the kill pills’, to coincide with a BBC Panorama episode entitled ‘A Prescription for Murder?’ The programme asked: ‘Is it possible that a pill prescribed by your doctor can turn you into a killer?’ (Answer: probably not, given that the reaction it was describing afflicts a ‘tiny minority’, if any.)

The genre of AD the documentary was referring to — and that most people mean when talking about medicalising misery — is selective serotonin re-uptake inhibitors, or SSRIs: drugs that increase the amount of serotonin (the chemical that helps regulate mood) available in the brain. Examples include fluoxetine, known by its brand name Prozac, sertraline (Lustral), paroxetine (Seroxat) and citalopram (Cipramil). I take 30mg of the latter every day and have no ambitions to stop. I went on my AD because — after a lifetime of never being that happy — I started seizing up with wretchedness for no apparent reason. And they worked. The only side effect — other than stability — has been an irritating yet manageable thirst.

Most people take ADs for a short time to address a specific challenge. Lucy, 43, a teacher from Blackheath, is typical. ‘I used to take fluoxetine in my late-30s, following a bereavement,’ she explains. ‘I was depressed, tearful, under a black cloud — literally shuffling. When my doctor prescribed pills, I sobbed with relief. I got severe headaches, but ploughed on, wanting, beyond anything, to feel better. It worked — like a miracle.’ Gradual withdrawal is recommended after nine months of medicated wellbeing, when side effects can include nightmares, headaches, and pins and needles. Lucy, who continued on ADs for two years, managed to avoid this.

Some patients, like myself, take up ADs without an ostensible external trigger, and remain on them because of long-term depressive tendencies. Other people feel the same. Ben is a 28-year-old medic from Kensington. ‘Smoking, drinking and my beloved hashish did a good job of masking the misery,’ he says. ‘However, I began to realise that what I felt was not entirely to do with my personality, or circumstances, but a chemical imbalance that some have and other “normal” people don’t. Eight months on sertraline, and — for the first time ever — I feel positive.’

Experts argue that the ‘chemical imbalance’ theory is simplistic. Professor Carmine Pariante of King’s College, London, tells me: ‘The action of antidepressants is more complex than that and involves stimulating the birth of new brain cells and regulating stress hormones.’ However, it’s a shorthand that makes sense to many.

Whatever their motivation, for most people who take them, ADs are a normal, quotidian thing: a practical choice with no disturbing consequences. As Professor Wendy Burn, president of the Royal College of Psychiatrists, says: ‘In mild cases, doctors tend to wait and see before prescribing: recommending talking therapies and lifestyle changes. But, yes, the pills do work… The effect can be instant, although we say two weeks to see an improvement, six weeks for full benefits.’

Some are less convinced and have questioned whether effective non-pharmaceutical options, such as therapy, are being sidelined in favour of immediately medicating. Science writer Robert Whitaker, author of Anatomy of an Epidemic, argues that ‘antidepressants are being prescribed for general unhappiness, or for people going through some difficulty. And then, once a person starts an AD, a significant percentage continue to take the drug long-term, partly because it can be so difficult to withdraw. The rising number of people on ADs should really be conceptualised as a “drug use” problem, rather than a barometer of “unhappiness”. This is a big problem for our society. Many could be said to be addicted, and long-term risks include a significant possibility that people will become chronically depressed, a condition called “tardive dysphoria”.’

Certainly, locating the right drug can prove a disturbing process. Martha, a 32-year-old marketing manager from Clapham, is a veteran of this process. ‘As a teenager, Seroxat gave me auditory hallucinations, night sweats and made me suicidal,’ she says. ‘Coming off it was like coming off heroin. Later, I tried nearly every other AD — all gave me severe nausea, hair loss or acute anxiety — until, finally, we hit on sertraline.’

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Matters are complicated by the fact that ADs are generally first prescribed by GPs, some of whom may never have had psychiatry training. At times, a diagnosis will be plain wrong. Sarah, a full-time mother in her mid-30s from Bethnal Green, recalls: ‘I was very ill at 22: tired, weak with muscle pain. My GP kept prescribing happy pills. Finally, a psychiatrist actually listened and put me in an MRI machine. He found giant cysts on my ovaries caused by insulin resistance.’

One understands why overworked GPs might fall back on SSRIs — depression can be a fatal condition; the numbers presenting with it grow ever more legion; while access to psychological therapies can take up to a year. Part of this could be put down to more people seeking help. But clearly, other factors are at play. Julia Bueno, a psychotherapist and counsellor with a busy north London practice, and co-founder of the London Psychotherapy Network, observes: ‘Many of us live in a climate of uncertainty and fear right now; not an atmosphere of warmth and wellbeing. We are addicted to smartphones, isolating ourselves from each other, while consuming a stream of news that reminds us of the threats we are under: terrorism, climate change, the future of Europe and other peoples’ “better lives”. None of this stacks up to good mental health.’

When I sat in my doctor’s waiting room weeping over the mental-health questionnaire that qualified me for my prescription, I was surrounded by other women hunched over the same form. As a psychiatrist who works in a hectic London hospital explains: ‘One of the reasons psychiatrists and GPs are in favour of medication is that we see the devastating effects of this kind of illness and the broadly beneficial effect of SSRIs.

One area of concern, however, is that of young people. Everyone’s risk of suicide goes up in the first two weeks of SSRI usage, ironically partly on account of the increased motivation that comes with improvement. With teenagers, this tendency is more pronounced. Others worry about the effect of chemical control on developing brains. SSRI critic Dr David Healy maintains: ‘Children’s mental health services have become a horror story with youngsters even more likely than adults to end up with a plethora of gateway diagnoses leading to shocking cocktails of treatment.’

Bloomsbury researcher Cassie, 28, remembers: ‘I was medicated at 17 after a suicide attempt, and have been on and off so many ADs since. At one point, they upped the dose so much that I have no real memories of the ages 18-20. Drugs saved my life countless times, but I think, where possible, small doses are key.’

Yet, as Professor Burn remarks: ‘We’re right to be careful, but I’ve seen antidepressants save teenage lives — and despite the hysterical headlines I’ve never seen anyone become either a zombie or a killer.’ It is a lack of sensationalism backed up by Professor Pariante: ‘One in 11 of us is taking anti-depressants. If prescriptions are going up, this simply means that more people are asking for help. More significant is that only a third of people suffering from depression actually seek help.’

He’s not wrong. Those of us who do manage to ask for support typically only do so after losing ourselves in a mire of pain and shame. As the daughter — and granddaughter — of a psychiatrist, you might imagine I would be more robust about such matters. I wasn’t. Even now I can only write so openly about my depression because I want others to suffer less.

Still, the voices of concern worry many. Robert Whitaker again: ‘The drug industry has lead us to expect to be somewhat happy continually. This also prevents us from addressing social issues — the state of our schools, income questions, housing — that can affect our wellbeing. When people are struggling with situations with such an obvious social context, our use of antidepressants means we locate the problem inside the head of the individual, rather than the broader frame, which is what we should be addressing. The day will come when we look back and think: “What in God’s name were we thinking?”’