2.12 Defeating Depression
The SSRIs arrived on the scene at the end of the 1980s, just as benzodiazepine prescribing went into sharp decline because of concern about widespread dependence problems and the mass litigation arising from it. The companies marketing SSRIs of course wished to take advantage of this. Firmly labelling their products "antidepressants", they set out to convince doctors of the value of their drugs and their advantages over anxiolytics.
" ... the temptation to market them (the SSRIs) as antidepressants is all but irresistible. These compounds can be produced easily. They are far safer than the earlier tricyclics and MAOIs. They are so safe that it becomes a feasible proposition to take the current findings from social psychiatry and advise general practitioners that there are many more untreated depressives than was formerly thought; often conditions presenting as anxiety stem from an underlying depression, and current evidence suggests that antidepressants (in contrast to anxiolytics) need to be taken chronically, in order to reduce the risk of relapse ..." (Healy, 1991)
The leadership in general practice and psychiatry did not need much persuading. In steering prescribers towards their drugs, the manufacturers enjoyed substantial support from a high-profile, professional initiative, which they in turn part funded. The "Defeat Depression" campaign was organised in the UK (1992-97) by the Royal College of Psychiatrists (RCP) with the Royal College of General Practitioners (RCGP) perhaps rather in tow. The thrust of the campaign was to explain depression and encourage people to recognise it; to persuade sufferers to come forward for treatment; and to emphasise that no stigma should attach to such a commonplace but distressing illness, a major social problem as well. Only two years into the campaign, over three million leaflets about depression had been circulated to the public and many other initiatives had been sponsored as well. (Royal College of Psychiatrists, 1992, 1994, 1996)
The Defeat Depression campaign focused in particular on what the organisers believed were widely-held misconceptions. One concerned the publics failure to recognise the value of drug treatment. Another was the general failure to recognise depression for the complex and hidden disease it may be. The launch of the Defeat Depression campaign was explained as a response to "the tragedy that, despite the availability of effective treatments, 70 per cent of sufferers go untreated". In addition, there was the concern that depression, when recognised, was not treated aggressively enough: over the years, many surveys had established that, as a general rule, GPs prescribe doses of drugs that experts consider ineffective. As GPs treat nine cases in every ten, this implies that most cases of depression are being treated with strong placebos. It would be useful to know what exactly GPs are treating, and whether they appreciate some things that experts dont.
Perhaps by way of dissociating themselves from the BDZ debacle, the RCP/RCGP also addressed what they saw as a widespread, but mistaken belief that antidepressants were drugs of dependence. The Campaigns first press release was headlined, "Antidepressants not addictive ...", because a MORI public opinion poll commissioned by the Campaign had found that "78% of the public believe anti-depressants to be addictive". "It is worrying", said the launch press statement, "that people may fail to take the medicine in the mistaken belief that it can cause dependence". (RCP/RCGP 1992)
In unpublished correspondence, senior figures in both Colleges later explained that they saw no evidence of withdrawal problems (See 3.3) and mainly had in mind lack of evidence of antidepressant addiction and abuse. Essentially the same points had repeatedly been made about the BDZs: (See 3.1)
"We have searched the literature and can find no reference to research evidence that shows that (a) drug seeking behaviour or (dependence), or (b) rebound and withdrawal occur when prescribing antidepressant medication ..." There is no street market in antidepressants. In fact it is our experience that it often difficult to get patients to take some initially, and to continue for the recommended course length." (McBride, 1992)
"The statement that antidepressants are not addictive is correct. Antidepressant drugs do not result in drug-seeking behaviour, i.e. they do not have a market value, neither do they cause dependence in a technical use of the word..." Obviously a person who is still suffering from depressive illness from whom the drug is then withdrawn would suffer a return of depressive symptoms that could have very serious consequences. This, however, is an indication of their efficacy not of dependence." (Sims, 1992)
A former editor of the British Journal of Psychiatry (published by the RCP) went further. Provoked by the suggestion that it seemed folly not to have tested drugs like Prozac for their dependence potential (Medawar, 1994), he argued that it was both mistaken and dangerous to have suggested that the question of dependence arose at all: "It would be regrettable if serious depressive illness, often involving the risk of suicide, remained untreated through people being misinformed about the well-established properties of antidepressants ...".
"During the past 35 years, there has in fact been no evidence that any antidepressants - whatever their structure - cause addiction or dependence. Medawar says there is profound confusion over the meaning of these terms and, if so, he has certainly added to it. Diabetics are dependent on insulin and people with high blood pressure are dependent on hypotensives, in the sense they will become ill again if they stop taking the drugs. Many sufferers from depression are in the same position, but this is totally different from the experience of people who take heroin or cocaine as euphoriants." (Freeman, 1994)
On this basis, the Defeat Depression Campaign emphasised the need for radically different standards of treatment. Fears of dependence were misconceived and resulted from misunderstanding. In future, there should be more prescribing for depression and at higher dosages than before, and serious consideration should be given to continuing treatment indefinitely.
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