Are antidepressants overprescribed?

There has been a big increase in the prescription of antidepressants in Primary Care in Catalonia in the last 10 years. The study revealing these results was led by Doctors Eduard Vieta and Diego Hidalgo-Mazzei, from the Depressive and Bipolar Disorders Unit, Psychiatry and Psychology Service at the Hospital Clínic, Barcelona with the collaboration of researchers from other Institutions such as the Data Analytics Program for Research and Innovation in Health (PADRIS) of the Health Quality and Assessment Agency of Catalonia (AQuAS), the Consortium of Eixample Primary Health Care (CAPSBE) and the Center for Affective Disorders (CfAD) of King's College London. The results showed the need to promote optimisation programmes in detecting mental health problems in primary care.

Antidepressants are one of the most prescribed pharmacological treatments in developed countries whose use has increased recently. These are medications with proven efficacy, but which can cause adverse effects, usually mild, but in some cases serious or even life-threatening; so their prescription must be well indicated. The trend in the prescription of antidepressants in Spain and Catalonia had not been studied until recently; many of the studies in other countries have not considered whether this increased prescription is due to a higher prevalence of mental health problems in the population. So, the Depressive and Bipolar Disorders Unit, led by Dr Vieta, reviewed the data of 947,698 people who attended primary care services in Catalonia between 2010 and 2019.

The main outcome was that the prescription of antidepressants increased by 404% during these 10 years, while diagnosis of mental health problems that require treatment with antidepressants (known as indication) did so by just 49%. For a drug to be indicated, it has to have been shown to be effective in clinical trials. In other words, the drug is being used only for health problems it is recommended for. However, the results suggest there is a significant trend towards an increase in the “off-label” prescription of antidepressants in the primary care system of Catalonia; that is, in cases where the use of this medication has not been theoretically recommended.

Women, the elderly and those of a lower socioeconomic status received more antidepressants than the rest of the population. These 3 populations have previously been associated with a higher prevalence of mental health problems, which could justify the increased use of antidepressants. Therefore, it is appropriate to focus the intervention on this population at risk and maintain the gender perspective of this problem. These results are from a large representative sample in Catalonia and show that there is possibly an overuse of antidepressants in the Catalan population. Among the reasons behind this problem are:

An overload in primary care (i.e. a lack of professionals given the high number of patients), insufficient visiting times and limited mental health training.
A tendency to “medicalise” society and life in general.
A lack of mental health resources, such as a lack of specialists (psychologists and psychiatrists) and psychological group therapy; as well as difficulties in referring and prioritising people with serious mental health problems to specialist professionals.

This study highlights the need to promote optimisation programmes in detecting mental health problems in primary care; prioritisation and early treatment for those people with more serious problems (e.g., with suicidal ideation); and a need to facilitate referral to mental health specialists.

Along these lines, various digital, low-cost tools have appeared in recent years to facilitate access to mental health resources which have proven to be highly effective. Taking this into account, the Depressive and Bipolar Disorders Unit of the Clínic's Psychiatry and Psychology Service is developing a digital mental health platform, called PRESTO to support primary care. This platform will help predict the severity of a patient from analyses carried out with machine learning. It will also offer follow-up, personalised psychological treatments and detect risk situations that require immediate intervention through a mobile application.

AUTHORS:

Dr Gerard Anmella, Dr Eduard Vieta and Dr Diego Hidalgo-Mazzei, Depressive and Bipolar Disorders Unit, Psychiatry and Psychology Service, Hospital Clínic, Barcelona.

Study reference:

Overuse of antidepressants in primary care: Prescription trends between 2010-2019 in Catalonia.

Anmella, G., Sanabra, M., Primé-Tous, M., Segú, X., Solanes, A., Ruíz, V., Morilla, I., Fontanet, A.A., Sant, E., Murgui, S., Sans-Corrales, M., Martínez-Aran, A., Fico, G., Prisco, M. De, Oliva, V., Murru, A., Zahn, R., Young, A.H., Vicens, V., Viñas-Bardolet, C., Aparicio-Nogué, V., Martínez-Cerdá, J.F., Mas, A., Carreras, B., Blanch, J., Radua, J., Fullana, M.A., Cavero, M., Vieta, E., Hidalgo-Mazzei, D., 2022. Psiquiatría y Salud Mental Journal. https://doi.org/10.1016/J.RPSM.2022.12.001