As a study questions the science behind antidepressants, a pioneering Health Centre is prescribing financial advice, art classes and gardening- with impressive results.
VICKI COUCHMAN FOR THE SUNDAY TIMES
Additional reporting: Ben Spencer
Gerry Gajadharsingh writes:
“With more than eight million people in England prescribed antidepressants last year — one in six adults, an 18 per cent rise from 2016, the research below which looked at 10 years of previous research regarding antidepressant medication, is now challenging the concept of depression is simply a chemical imbalance in the brain. However, the focus is on serotonin and that doesn’t mean antidepressants can’t work by other mechanisms. What it does mean is that the modern thought of “a pill for every ill” gives yet another pause for thought. A GP quoted in the article says. “Do we prescribe too many of them? Yes, and historically the reason is that when somebody comes to see you, as a doctor, in your ten-minute consultation and says they are very depressed, what options are there? The choices are essentially psychological therapies or antidepressants.” Even before the pandemic, waiting lists for talking therapies were months long, so for many doctors — and patients — there isn’t much choice.
With the severe financial pressures facing the UK and many countries around the world it’s quite clear that a dramatic rethink is necessary in regard to the responsibility the state has in providing healthcare, versus the responsibility that we need to take as individuals to support our own health, physical and mental well-being.
Depression can be characterised into different subtypes, of which reactive depression tends to be situational and from many patients short not long-term, as long as the situation rectifies itself or the patient find better coping strategies. This is expanded on in the article below with a good case history.
Professor Joanna Moncrieff, the consultant psychiatrist who led the study says that depression is a human response to things going wrong, or things being wrong in your life. Therefore, she thinks a medical response is inappropriate.
“We need to help people to sort out what’s going wrong in their lives and we need to — as a society — work out why so many people are struggling and so many people feel under so much stress and feel so dissatisfied.”
Solving complex problems can take a long time and may cost more than writing a prescription, I suspect this is at the root of the problem.”
Tracy Orsolyak is a busy woman. On Mondays she has a walking group, on Tuesday she meets her friends for lunch in the park. For a time, she did art on Wednesdays but that didn’t work too well. “The lady I was drawing wasn’t round, but she was by the time I’d finished,” Orsolyak says. Today, Thursday, she has a gardening club, sowing beetroot seeds on the roof. Six months ago, this would have been unthinkable.
Orsolyak, 56, has been severely depressed for many years. A victim of domestic violence, she lost her job and moved into a hostel. She has been taking antidepressants for eight years. Then she got a flat near the Bromley-by-Bow centre in east London. She heard people laughing inside and eventually decided to go along. Her life began to improve in small ways.
First, someone from the welfare team told her which benefits she could apply for. She bought furniture and food. She gained confidence and started joining in with various groups. She made friends. As she got healthier, she found she didn’t need her wheelchair and could manage with a walker. Earlier this month she stopped taking the pills. “Things have changed but not because of the medicine, because of the centre,” she says.
A study published last week by University College London appeared to debunk the theory that depression is caused by a chemical imbalance in the brain. By analysing ten years of research, scientists found “no convincing evidence” of a link with serotonin, a neurotransmitter in the brain. Though this is generally accepted among doctors, the idea that depression is caused by a chemical imbalance has lingered among swathes of the wider public.
Professor Joanna Moncrieff, the consultant psychiatrist who led the study, believes the “chemical imbalance” theory of depression has driven the use of antidepressants. “It is high time to inform the public that this belief is not grounded in science,” she says.
Antidepressants have been in use since the 1960s, with a particular boom in the late 1980s when blockbuster drugs such as Prozac arrived.
Her view — disputed by many psychiatrists — is that depression is not caused by biology. “What’s wrong is that we are viewing it as a medical condition in the first place,” she says. “In my view, depression is not primarily a biological event. It is a human response to things going wrong, or things being wrong in your life. Therefore, I think a medical response is inappropriate.
“We need to help people to sort out what’s going wrong in their lives and we need to — as a society — work out why so many people are struggling and so many people feel under so much stress and feel so dissatisfied.”
Professor Allan Young, director of the Centre for Affective Disorders at King’s College London, stresses that however they work, antidepressants are effective. “The whole serotonin hypothesis is a straw man,” he says. “The evidence — which is really quite extensive — is that antidepressants work. These drugs are clearly efficacious.”
But the study still raises an important question: if chemicals aren’t the cause — or at least not the only cause — of depression, are pills the best cure? With more than eight million people in England prescribed antidepressants last year — one in six adults, an 18 per cent rise from 2016, it’s a question that needs an urgent answer. “Antidepressants are great drugs,” says Dr Saul Marmot, a GP. “Do we prescribe too many of them? Yes, and historically the reason is that when somebody comes to see you, as a doctor, in your ten-minute consultation and says they are very depressed, what options are there? The choices are essentially psychological therapies or antidepressants.” Even before the pandemic, waiting lists for talking therapies were months long, so for many doctors — and patients — there isn’t much choice.
GPs at the Bromley-by-Bow centre, founded in the mid-1990s by the social campaigner Lord Mawson, have another choice. Marmot, who runs one of the three practices based here, can prescribe drugs or refer patients to the social prescribing team — or both. These link workers, part social worker, part therapist, have more time than his ten-minute slots allow to try to unravel the underlying problem in people’s lives.
“Imagine someone has got diabetes,” Marmot says. “They are in a job with ridiculous hours that makes them feel very stressed and their mental health begins to suffer. They can’t make changes to their life, they can’t exercise or eat properly, so their diabetes gets worse.”
It is the link workers’ job to try to make that spiral stop. Amy Trigg, 33, is one of them, based at the health centre. She has six one-hour sessions to seek a solution to problems that may be practical — to do with employment, benefits or housing — or social, perhaps as a result of bereavement, isolation or a stressful period.
Often it isn’t what the doctors think it is. “One woman came for help with weight loss, but it turned out she was struggling as a single parent and her children had difficult behaviours, causing her to stress-eat.” It is Trigg’s job to be up to date with the services in the area and to direct patients to the right one — maybe a parenting group, cookery course or the on-site employment hub. She then stays in touch to try to establish whether or not it is helping.
An evaluation by the University of Westminster of a smaller scheme in Shropshire found improved health outcomes and a 40 per cent decrease in demand for repeat appointments with a doctor from patients who had seen a link worker.
Mental health, like our physical health, is an ever-changing thing. “I might be at the height of physical fitness, or I might have a really sore knee. That is all part of my physical health and I can move up and down that spectrum, that applies to mental health too,” Marmot says. Social prescribing, as it’s known, is not always an alternative to medication — people with certain conditions will always need drugs — but it is another tool in the doctor’s belt and the two can work together in an effective way.
“In a lot of circumstances antidepressants are the crutch that people need to lean on in order to give them the headspace to make a change,” Marmot says.
In 2017, I had started to feel depressed during my pregnancy, struggled with it for a while and eventually went to see my GP. He gave me the two options of antidepressants or talking therapies. I chose the latter. And I waited and waited and waited. My son was born and still I was nowhere near the front of the queue. Partly this was because my needs weren’t life-threatening, or I hadn’t admitted to anyone that they were, and I’m sure the NHS would have snapped into action if I had been. But I wasn’t getting better and the situation was unsustainable so eventually I went back and took the pills.
I’m glad that I did. They gave me a breather from that hellish period, but they didn’t make me well again, that happened later and it was down to a stroke of luck. Being depressed with a newborn was a battle of wills — I wanted to lie in bed all day; he did not. So, I trudged around south London instead, avoiding everyone and longing generally for this nightmare to stop. Then I stumbled across Walworth Community Garden, near my home in southeast London, a community charity which offered a horticultural therapy course. I overcame my natural scepticism and went along.
I won’t pretend that the change was miraculous or immediate — there were plenty of times when I asked myself what I, a professional woman in her late thirties, was doing here contemplating a mint leaf — but gradually I did begin to improve.
I’m still not sure what it was, whether it was the garden itself, the satisfaction of learning something or the company — we didn’t talk about our problems, but we did drink tea and laugh a lot. It gave me something to look forward to and gradually I did begin to feel like myself again. I’m not sure the garden would have stopped me needing pills, but it did allow me to stay on a low dosage — and, eventually, to come off them. That is not a pleasant process: one of the reasons that a lot of people stay on them for a long time.
The problem was that I had to seek out this alternative for myself: I had to print off a referral form from the garden’s website and take it to be signed by a GP.
In 2018, just as I was coming back to work, it looked like the Department of Health had recognised both the potential and the flaw. Matt Hancock, who was health secretary at the time, announced that this would be part of a new revolution in personalised primary care, including the national rollout of social prescribers.
NHS England would cover the cost of one link worker’s salary for every primary care network, usually made up of six GP practices. The plan was to have 2,000 link workers in place by this year and for at least 900,000 people to be referred to by 2023. In theory, all GPs would have a third option like those at Bromley-by-Bow, and so would people like me.
Unfortunately, the policy stumbled almost immediately. The funding covered one link worker’s salary, but for the already cash-strapped voluntary sector who provided the support there was nothing at all.
According to reports, when Hancock announced the policy, a question from the audience flashed up on the screen behind him: “What about the funding?” A cheer went up in the room. Then the pandemic came along.
Post-pandemic, the demand for mental health services has escalated while dire economic conditions continue to ravage the voluntary sector.
The introduction of link workers is progressing in a half-hearted way. There are only just over a thousand of them, few of them full-time. Many GPs don’t know how to use them effectively and the wider public is largely unaware of them.
Bromley-by-Bow’s health centre survives because it is well established and receives NHS funding. The sister charity has a development team looking for new funding to keep services running. The GP surgeries based locally contribute to funding the social prescribing side. “We are skint like most of the NHS,” Marmot says. “So, we’ve got to make choices. Do we hire an extra nurse? Do we hire an extra doctor? Or do we keep funding the population team?”
It does not help that the benefits of social prescribing are hard to quantify. Solving complex problems can take a long time and may cost more than writing a prescription. But for Marmot the benefit is clear. How many of his patients would benefit from seeing a link worker? “Most of them,” he says.
For the rest of the country, it is a postcode lottery. But if you in the queue for therapy or if the pills aren’t doing what you hoped, one positive thing to try is to ask if there is a link worker you can see. I, for one, am hopeful that Bromley-by-Bow will not become a chimera; a reminder of how it could have worked and what might have been.