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SPECIAL REPORT: The anti-depressant generation
Thursday, March 19, 2015
By Catherine Shanahan
Irish Examiner Reporter
We have alwayssought ways of copingwith depression andanxiety, but ourreliance on drugs andthe regional variationsmake for alarmingreading, writesCatherine Shanahan.
“A triumph of chemistry over insanity” was how a friend once summed up his need for anti-depressants.
For him, taking drugs was a Hobson’s Choice — he loathed toying with his circuitry, but failure to do so meant the darkness could overwhelm.
There are many thousands dealing with a similar dilemma, because like cancer, depression is an illness few families escape. Voluntary organisation Aware, which supports people with depression, estimates 450,000 are affected in Ireland, the equivalent of one in 10, at any one time.
Thousands more are grappling with disabling anxiety disorders, the most common mental health problem along with depression. It is estimated that one in nine will suffer a primary anxiety disorder over their lifetime, but only a fraction receive appropriate treatment.
Sometimes depression and an anxiety disorder go hand in hand. Neither have any regard for age, gender or background and can strike at any time.
Given the extent of depression and anxiety within our population, we decided to examine prescribing rates for the top five anti-depressants and anti-anxiety medication in each of the country’s 32 local health offices (LHOs)* in an attempt to get some kind of handle on how dependent we are as a nation on mood-altering drugs.
An analysis of the figures based on publicly-prescribed drugs under the General Medical Services (GMS) Scheme (which covers medical card holders) shows a whopping two million plus prescriptions were written for the top five in 2012, enough to cover half the population, but in fact for the benefit of 331,368 patients.
That figure doesn’t include prescriptions for the same pills under the Drug Payment Scheme (340,917), or the Longterm Illness Scheme (12,493), or private patients who don’t spend enough on drugs each month to qualify for the Drug Payment Scheme (DPS threshold 144).
The figures also exclude anti-depressants and anti-anxiety drugs that fall outside the top five and they do not capture those who resort to the black market. Taking all these exclusions into account, the actual number taking these drugs is probably closer to half a million.
Our examination of the statistics shows wide variation in the size of the population in the different LHOs prescribed anti-depressant and anti-anxiety drugs under the GMS. In Limerick, prescriptions were written for 10% of the total population, the highest in the country. The percentage was lowest in Dublin South, at 4.3%.
So why so high in one county and so low in another? Could it be a higher percentage of Limerick’s population is anxious or depressed? Does the presence of a prison in Limerick push up the numbers?
Do patients have a higher expectation of leaving the surgery with a prescription to improve their mood? Are patients being appropriately diagnosed and distinctions drawn between clinical depression and just feeling down?
Are prescribing habits influenced by kickbacks from the pharmaceutical industry?
These questions are hard to answer in the absence of research, but in relation to Limerick, we looked at some statistics collated by the Institute of Public Health*.
The percentage of the working population aged 15-64 in receipt of benefits for anxiety and depression in 2013 was not noticeably higher in Limerick than anywhere else.
The number of admissions to psychiatric hospitals for anxiety and depressions were at the higher end, but not the highest point, of the scale. So we looked at medical card coverage and that shed some light.
The percentage of the population in Limerick with medical cards (47%) is more than twice that of Dublin South (20%) which includes some of the more affluent suburbs of Dún Laoghaire, Blackrock and Dalkey.
It seems likely therefore that the Limerick figure is higher because a greater proportion of its population has medical cards.
Where this argument falls down is when you look at the figures for Donegal where 56% of the population has a medical card (highest percentage in the country) but where the percentage of the total population prescribed these drugs is lower than Limerick, at 7.3%.
Digging deeper, the number of GMS patients prescribed these drugs in Donegal is the lowest in the country. In fact just over one in 10 (13%) is prescribed the drugs in Donegal, compared to one in five in the majority of the LHOs.
For instance, 23.5% of the GMS population in Cork South Lee is prescribed the drugs, the highest percentage in the country. Why? As Martin Kenneally, director at the Centre for Policy Studies at University College Cork points out, it’s hard to understand the variations in prescription rates across the different regions “in the absence of any in-depth research linking them with the prevalence of illness”.
Mr Kenneally is currently conducting research in this vein. Mr Kenneally and colleague Brenda Lynch published a working paper last year entitled ‘Why do drug prescribing rates differ across Irish regions’.
They found the GMS prescribing rate in the North West was a significant “around 25% below the national GMS norm”, echoed in our finding in relation to Donegal.
Our research also suggests that depression and anxiety affect a lot more people than the official guesstimate of one in 10.
In the majority of the LHOs, one in five GMS patients are prescribed anti-depressants and/or anti-anxiety meds.
Figures for Dublin South, Dublin South East, Dublin South City, Dublin North Central, North Dublin, Limerick, Cork South Lee, Cork North Lee and South Tipperary show more than one in five GMS patients in each of these LHOs are prescribed the drugs in question. Laois/Offaly, Longford/Westmeath and Waterford are also tipping one in five, as are Louth, Carlow/Kilkenny, Kerry and Wexford and Dublin South West.
Donegal also has the lowest number of prescriptions per patient in the country, at 6.3, compared to 8.3 in Galway, which suggests Donegal patients are receiving two prescriptions less per year than GMS patients in Galway.
A total of 103,844 prescriptions were written for 12,447 patients in Galway for the drugs discussed here; a total of 75,281 were written for 11,940 patients in Donegal. Despite a difference of just 500 patients between the two LHOs, 25,000 plus additional scripts were written in Galway.
In addition to differences in prescribing frequency between the different LHOs, the cost of the different drugs appears to vary widely. For example the cost per patient for the antidepressant Escitalopram, the most prescribed drug of those examined here, is higher in Dublin South than anywhere else in the country.
Escitalopram, brand name Lexapro, costs 245.94 per patient in Dublin South compared to 213.97 in Dublin West, where it’s cheapest of all. You could argue that because more patients are prescribed the drug in Dublin West (2,052 v 1,211 in Dublin South) that it drives down the cost, but this does not follow through in other LHOs. For example, in Dublin South East, where 1,024 patients are prescribed Escitalopram, almost 200 less than Dublin South, the cost of the drug is cheaper per patient, at 232.89.
The variation between the LHOs in cost per patient of Diazepam, brand names Valium/Anxicalm, the most popular benzodiazepine under the GMS scheme, is also substantial. Donegal comes in at the cheapest rate of 24.49 per patient.
The most expensive rate is in Dublin North Central, where it costs 59.27. The difference between the numbers of patients prescribed the drugs in both LHOs is not huge.
The figure for Donegal is 3,914 while the figure for Dublin North Central is 3,147. The most prescriptions for Diazepam are written in Cork North Lee, where the cost per patient is 40.99, more than 15 dearer than Donegal.
With the exception of Alprazolam, the cost of drugs per person in Donegal is consistently cheaper, ranking cheapest for Diazepam and Sertraline, second cheapest for Escitalopram and third cheapest for Venlafaxine.
These variations in the cost of public medicines are also highlighted in the Kenneally paper, which reported that in 2010, “GMS medicines cost €625.85 per person covered in the North-West and Donegal but were over a third more, €841.55 per person covered, in the Midlands”. Mr Kenneally made the point that
“To date, these regional differences have attracted little research attention”.
A total of 2,283,489 prescriptions were issued for all the drugs looked at here at a cost of almost 40 million, enough to cover half the population. The figures do not clarify how many patients were in receipt of more than one drug.
What is clear is that thousands and thousands around the country are taking these drugs on a daily basis to alleviate acute anxiety and depression.
“Society has always looked for ways to relieve anxiety,” said pharmacist Dr Dolores Keating “whether through alcohol, or bromides in the 19th century or barbiturates which increased in popularity after World War II or meprobamate, [brand name Miltown, a class of tranquilliser released in 1956] which Hollywood embraced”.
More recently, we’ve turned to benzodiazepines.
Our relationship with anti-anxiety medication was the subject of a recent talk delivered by Dr Keating as part of the Royal College of Surgeons in Ireland (RCSI) minimed lecture series.
She said while benzodiazepines were “once embraced as a triumph of pharmaceutical science, their misuse has led to significant health issues in Ireland today”.
“They are useful medications in certain circumstances but, as with all medications, their benefits must be balanced against the risks associated with their use for every individual patient.”
Dr Keating said while anti-anxiety medicines are generally considered safe and effective for short term use (two to four weeks, at a low dose) in the treatment of anxiety and insomnia, the risk of overuse, abuse and dependence remains a key concern. In fact a report by the Health Research Board “Trends in Treated Problem Drug Use in Ireland 2005-2010”, found that the highest proportional increase (233%) over the six-year period was among new cases reporting a benzodiazepine as their main problem drug.
A paper published last week in the Irish Medical Journal ‘An Audit of Prescribing Practices for Benzodiazepines and Z-Drugs” [non-benzo sleeping pills] found that despite publication of the Benzodiazepine Committee’s report and good practice guidelines in 2002 (Department of Health and Children), “there is evidence that inappropriate benzodiazepine prescribing (ie prescribing for durations in excess of 2-4 weeks) persists in Ireland in both general practice and residential care settings”.
The authors, from the School of Pharmacy and Pharmaceutical Sciences, Trinity College, and the School of Pharmacy, Queen’s University, Belfast, found there were “also ongoing concerns over the extent to which benzodiazepines are implicated nationally in cases of problem drug use and deliberate self-harm”.
The bottom line is nobody wants to find themselves in a position where anti-depressants or anti-anxiety pills are the only way of getting through the day. There are other aids to coping such as “talking therapies” like counselling.
We asked the HSE if public patients were automatically offered therapy/counselling as a first treatment step. The HSE said patient management is based on the findings of a GP assessment and that those with mild to moderate anxiety and/or depression would usually be offered therapy at primary care level.
The HSE said this might be “a short focused intervention as offered by Counselling in Primary Care (CIPC)”, which usually consists of eight sessions.
However when we asked how many patients are on the waiting list to access to CIPC, the HSE said there were a total of 478 waiting longer than three months; 39 waiting longer than six months and six waiting more than nine months, hardly ideal for anyone desperately in need of a listening ear.
The HSE blamed most of the delays on “specific requirements” of patients, “for example they can only attend on a Monday morning, or after 4pm, or are waiting to be seen in a particular area. These will have been offered access to counselling but have chosen/had no choice but to wait for an appointment that best meets their needs”.
For people found by their GP to have more serious symptoms, the HSE said they are “usually” referred to the local secondary care mental health service where they are seen by a psychiatrist and undergo a mental health assessment.
"Following that a decision is made on the most appropriate intervention... Such interventions might include individual or group work for anxiety symptoms very often delivered by occupational therapists,” the HSE said, while other possibilities “include psychotherapeutic inputs such as Cognitive Behavioural Therapy”. The HSE said medication may also be recommended “specifically for those with more severe depressive episodes”.
The reality, according to Professor Paul Gallagher, head of the RCSI School of Pharmacy, is that therapies are not easily accessible and are expensive when the patient has to pay. He said unlike the UK, where the Labour government introduced an Improved Access to Psychological Therapies programme in 2008, continued under the Coalition, the government here hasn’t invested in psychological forms of treatment.
This is despite the fact that an Economics of Mental Health Care In Ireland report, commissioned by the Mental Health Commission and published in 2008, estimated that the overall cost of poor mental health in Ireland was just over 3 billion in 2006, or two per cent of GNP. That’s just the economic cost. But what about the human cost?
*Local Health Offices: HSE administrative areas that broadly coincide with individual counties, with some exception such as Dublin and Cork.
*Source: Health Research Board National Psychiatric In-patient Reporting System (NPIRS). (2015) Rate adm psych hosp RoI 2013 [Online].