4 November 2019
A study published on 7 October 2019 in the British Journal of Psychiatry has called long-overdue attention to a growing problem: burgeoning overprescription of antidepressant drugs to older people despite a lack of evidence of benefit.
The study, titled ‘Changing prevalence and treatment of depression among older people over two decades‘, found that more than twice as many people over 65 had been prescribed antidepressants in 2011 compared to 1991 (10.7% vs 4.2%), yet in the same 20 year time period, depression rates in this age group remained fairly stable, dropping from 7.9% to 6.8% which was not statistically significant.
Even more worryingly, the researchers found that most of those taking antidepressants did not actually have depression, based on their responses to a validated psychiatric diagnostic instrument, AGECAT, which was specifically developed to detect mental health disorders in the elderly.
Furthermore, the proportion of non-depressed study participants who were taking antidepressants rose sharply from 2.7% in 1991, to 8.8% in 2011.
The research on antidepressant prescription was conducted as part of the Cognitive Function and Ageing Studies (CFAS), which are population-based cohort studies led by the University of Cambridge. The aim of CFAS is to examine generational changes in the health needs of older people.
CFAS I recruited participants in 6 geographical areas of England and Wales, and interviews were conducted detailed interviews including an assessment of mental health and medication use with 1457 of them between 1990 and 1993. CFAS II continued the study in 3 of these areas – Cambridgeshire, Newcastle and Nottingham – and interviews were conducted with 7723 participants between 2008 and 2011.
Interestingly, over the 20 years between CFAS I and II, the prevalence of dementia has dropped despite there being no effective medical treatment, but depression rates have not budged. In the words of principal investigator Carol Brayne,
“Our research has previously shown a major age-for-age drop in dementia occurrence across generations. This new work reveals that depression has not shown the same reduction even in the presence of dramatically increased prescribing
Key findings of the study included:
- Women were more likely than men to be depressed (according to validated diagnostic criteria) and more than twice as likely to be prescribed antidepressants. 6.3% of male participants in CFAS I were depressed and 2.9% were on antidepressant medication. In CFAS II, 4.5% were depressed but 6.6% were on depression drugs. Among female participants, 9.1% and 8.3% were depressed in CFAS I and II respectively, while 4.6% and 13.9% were taking antidepressant medications. In both sexes, antidepressant prescriptions more than doubled despite depression rates falling.
- Higher rates of depression were found in people living in more economically deprived areas.
- Living in a care home (e.g. nursing home or hostel) was associated with a higher risk of becoming depressed than living in the community, and this did not change over time. 1 in 10 people living in residential aged care were depressed in both CFAS I and II, while among those living in the community, depression rates dropped from 8% to 6.5% in the 20 years between the two recruitment periods. While 7.4% of care home residents were taking antidepressants in 1991, by 2011 the percentage had skyrocketed to 29.2%.
The authors propose several possible explanations for their findings:
- Improved recognition of depression, resulting in more people being accurately diagnosed and receiving medication that reduces their symptoms of depression;
- Overprescribing; and
- Use of antidepressants for other conditions.
In analysing the evidence for each of these explanations, they cite a US study titled ‘Trends in psychological distress, depressive episodes and mental health treatment-seeking in the United States: 2001-2012‘ which reached the dismal conclusion that
“Despite increasing use of mental health treatments in the US in the first decade of this century, there is no evidence of decrease in prevalence of psychological distress or depression.”
In other words, we can probably rule out explanation #1, since people who seek out mental health care don’t seem to become any mentally healthier, and in fact often end up worse off.
How about explanation #2? Far more likely – see my previous articles Who says you’re depressed or anxious? Pfizer does and ‘Depressed’ or just going through a rough patch – have you been misdiagnosed?
And explanation #3 is also a likely contributing factor; roughly one third of antidepressants are prescribed for so-called ‘off-label indications’ – that is, diagnoses for which government regulators have not approved the drug’s use – and only 16% of these off-label prescriptions are strongly supported by scientific evidence.
So what’s the problem with prescribing antidepressants to older people, especially those who aren’t actually depressed and have very little likelihood of gaining any benefit from taking them?
Like all drugs, antidepressants have side effects, which in the case of SSRIs, the most commonly-prescribed class, include sexual dysfunction, drowsiness, insomnia, weight gain, and fatigue (all of which could potentially contribute to feelings of depression). And worryingly,
“The risk of adverse drug events has been found to be 54% higher when drugs are used off-label without strong scientific evidence than when drugs are used on-label.”
In addition, serious safety concerns about SSRIs have been raised, including an increased risk of bone fractures and upper gastrointestinal bleeds – both conditions that older people are at heightened risk of in the first place, due to normal processes of ageing, and other drugs that they’re likely to be prescribed.
The conclusion drawn by the authors of the study on antidepressant use is worth pondering:
“Over two decades, substantial increases in access to anti-depressant medication do not appear to be associated with change in prevalence of late-life depression. The natural history of treated and untreated depression, particularly for older people, remains poorly understood.”
Or in plain English, antidepressants don’t appear to be helping older people less depressed, and we don’t really know whether we’d be better off leaving them untreated (at least with drugs).
From my point of view, prescribing antidepressants to older people who show signs of psychological distress rather than attempting to understand and address the causes of that distress is irrational, inhumane and a flagrant waste of health care resources.
Poor diet, lack of exercise and disrupted sleep are major contributing factors to depressed mood, and should be addressed as part of a comprehensive lifestyle intervention.
Loneliness, poverty and loss of a sense of meaning and purpose in life are also key factors in depression. It is beyond ridiculous – not to mention profoundly dehumanising and insulting to suffering individuals – to maintain the fiction that the consequences of social and spiritual isolation and economic deprivation can simply be medicated away.
Yet as Johann Hari has documented in his wonderful book Lost Connections, effective interventions to address these psychosocial causes of depression can and have been implemented in communities throughout the world. Connecting individuals who are suffering from depressed mood with a community of people who share their interests and experiences should be a key plank of any treatment program.
The answer to the mental health crisis is not ‘better diagnosis’ or ‘better drugs’, but a better understanding of why humans experience psychological distress and how it can be resolved at its roots.
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