Can the Rate of Antidepressant Prescribing Be Reversed?

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According to Our World in Data and prescribing data across Europe, 108 people of every 1,000 take an antidepressant in the UK. That makes the country’s prescribing rates for SSRIs and SNRIs the sixth highest worldwide—double that of France (54/1,000) and substantially higher than Germany (at 62/1,000).

In the same data, the United States places just ahead of the UK at fifth from the top, with 110 people in every 1,000 taking an antidepressant. Both countries are behind only Australia (122/1,000), Canada (130/1,000), Portugal (139/1,000), and Iceland (161/1,000), the world’s highest users of antidepressants.

Earlier this month, a group of 27 medical professionals, researchers, patient representatives, and politicians decided to act on the data, calling for the UK government to approve guidance that would reduce and, ultimately, reverse the rate of antidepressant prescribing.

Over the past decade, the group explains in an open letter in the British Medical Journal, antidepressant prescriptions have “almost doubled in England, rising from 47.3 million in 2011 to 85.6 million in 2022-23. Over 8.6 million adults in England are now prescribed them annually (nearly 20% of adults), with prescriptions set to rise over the next decade.” Comparable rates and trends are prevalent in Scotland, Wales, and Northern Ireland.

In addition to the drugs’ common adverse effects—weight gain, sexual dysfunction, bleeding, and falls—the authors argue that “rising antidepressant prescribing is not associated with an improvement in mental health outcomes at the population level, which, according to some measures, have worsened as antidepressant prescribing has risen.”

Drawing on well-examined studies and meta-analyses, the group points to further reasons for the overprescribing, including that the average length of time on the drugs “doubled between the mid-2000s and 2017, with around half of patients now classed as long-term users.” In the United States over similar years, the data on length of treatment are worse. According to the CDC, two-thirds of U.S. patients between 2011 and 2014 had taken antidepressants for more than two years, and one-quarter for longer than 10 years.

When widely occurring withdrawal effects from antidepressants are factored in, the group of 27 argues, the evidence-base skews negative:

• Multiple meta-analyses have shown antidepressants to have “no clinically meaningful benefit beyond placebo for all patients but those with the most severe depression.”
• 58% of people taking antidepressants for more than two years “failed to meet criteria for any psychiatric diagnosis.”
• There are now “evidence-based objections to prescribing antidepressants for people with chronic pain, where efficacy is very low,” alongside evidence of “disproportionate prescribing to women, older people, and those living in deprived areas.”
• This last point leads to consideration of whether we are “wrongly medicalising and medicating the effects of disadvantage and deprivation.”

The authors outline several less-expensive alternatives to antidepressant prescribing, including social prescribing and psychosocial interventions.

If the UK’s rates of prescribing were brought into closer alignment with the National Health Services’ latest (2023-24) guidelines, SSRIs and SNRIs would no longer be the first-line treatment “for mild conditions for new patients.”

Closer adherence to the UK’s 2022 guidance on safe prescribing and withdrawal management and the World Health Organization’s updated 2023 guidance on treating anxiety and depression would also shift resources from pharmaceuticals to psychotherapy, group therapy, cognitive behavioral therapy, and other treatments aligned with “social prescribing, lifestyle medicine, and psychosocial interventions.”

Finally, the authors urge countries with similarly high levels of antidepressant prescribing to commit to reducing their prescribing rates as well. One already has. Australian doctors and researchers, The Australian reported on December 6, “have added their support to a major push in the UK to reverse high rates of antidepressant prescribing, saying the problem of overprescription and unwarranted prescription is just as extensive in Australia.”

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Rapid Responses

The BMJ has to date published seven “rapid responses” to the open letter. All but one welcome the move. Two raise concerns about the data and how it can be interpreted.

In one of the first responses, the executive to the British Society of Lifestyle Medicine writes explicitly to “support the call” to reduce antidepressant prescribing: “Evidence suggests that over-prescribing and the harm of polypharmacy is an issue for all areas of medicine, not just for mental health.”

The BSLM adds that systematic reviews and meta-analyses of randomised controlled trials indicate that “interventions to improve physical activity and nutrition may be as effective as antidepressants for some people.”

In a second rapid response, Radoslaw Stupak, a psychologist and lecturer at the University of the National Education Commission, Krakow, Poland, comments on the majority of countries where antidepressant prescribing is highest: “What has been called ‘marketing-based medicine’ in many cases still seems to triumph over evidence-based-medicine, not only when it comes to antidepressant prescribing.”

In the case of SSRI and SNRI antidepressants in particular, he continues, “Key opinion leaders repeat the old message of ‘safe, effective and non-addictive’ drugs that save lives,” even though the research on anti-suicidal properties of antidepressants is inconclusive and the opposite effect cannot be excluded.”

Eugene Breen, a psychiatrist and associate clinical professor in Dublin, writes in another supportive response: “Population dependence on mood pills looks like a fantastic marketing strategy, but it must be over-the-top and we must be missing something…. The social determinants of health and mood are where we need to focus.”

Further, Anand Ramanujapuram, a psychiatrist based in Scotland stresses in his supportive response that the “pressure to prescribe” is tied to reimbursement and other incentives, as well as “a greater increase in people seeking ‘medical’ consultation for ‘psychiatric’ disorders than ever before.”

Ramanujapuram spotlights an associated “paradox of reductionism,” tied to this emphasis, in which the “brain basis for explanatory models of psychiatric conditions perpetuated in public media and elsewhere puts professionals in paradoxical positions during clinical practice.”

“If that’s the case,” he says of a standard follow-up question, “Why are you not prescribing?”

Representing biological psychiatry at King’s College London, Sameer Jauhar, David J. Nutt, Carmine Pariante, and Allan H. Young call the initiative to reduce overprescribing a “prescription error.” They assert: “The evidence cited, inferences drawn and alternatives proposed make it difficult to see how large-scale health benefits could result,” referencing their own published critiques of meta-analyses that have already been addressed and debunked.

The same “difficulty in seeing” recurs when the respondents argue that it is “difficult to see how either the withholding of antidepressants can practically take place, and evidence given to curtail use is underwhelming.”

Nowhere in the letter is there any call for antidepressants to be “withheld”—the suggestion otherwise is inaccurate. Far from being “underwhelming,” too, the evidence cited in the meta-analysis made international news when it was first reported.

In other parts of their response, the respondents from KCL unwittingly bolster the case for reducing prescribing. They confirm usefully that “SSRI antidepressants now supersede benzodiazepines as first-line pharmacological treatments for anxiety disorders.” Their “Competing Interests” section is nonetheless longer than their written response, listing promotional and consultancy work for more than 20 different pharmaceutical companies, all with a clear stake in the high rates of prescribing continuing.

Representing colleagues at Oxford, Kyoto, and London universities, Pia Hardelid, a professor of epidemiology, writes in a recently added response: “We agree that unwarranted drug treatment should be [stopped], and that patients should be given clear, evidence-based and up-to-date information about antidepressant side effects and withdrawal symptoms so that they can make informed decisions about starting treatment.”

Hardelid and colleagues also point to meta-analyses that, they argue, “demonstrat[e] the efficacy of antidepressants for moderate to severe depression.” However, the original letter cited meta-analyses showing that the drugs’ benefit over placebo is clinically negligible when adverse events and other harms such as withdrawal are factored in.

In his rapid response, “Antidepressants do not work for very severe depression either,” which itself indirectly addresses Hardelid and colleagues’ claim about efficacy, former University of Copenhagen professor Peter C. Gøtzsche restates that multiple meta-analyses have “shown antidepressants to have no clinically meaningful benefit beyond placebo for all patients but those with the most severe depression.” He adds: “the fact is that the pills do not have clinically meaningful benefit for very severe depression either…. The apparently larger effect in severe depression is likely just a mathematical artefact.”

The open letter and the majority of responses generated point to a serious problem of overprescribing and extended use in several countries. SSRI and SNRI antidepressants are being prescribed in increasing numbers for mild conditions and for much longer periods of time.

The call to reduce overprescribing is sensible and well-supported by evidence. The United States should be next in agreeing to tackle its high rates of prescribing.