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Counselling Often Beats Pills

[October 2011]
Irish doctors over-prescribe anti-depressants, writes Éibhir Mulqueen

One of Ireland’s most recognisable actor exports, Gabriel Byrne, is now famous in the US for a role whose function has just registered in his home country. For the last three years, Byrne has played Dr Paul Weston, a well-to-do psychotherapist in New York featured in intense, often harrowing, half-hour programmes in the HBO hit-TV series In Treatment. His Irish-American character reads the Irish Times and drinks Barry’s Tea, and Dr Weston has his own ‘miserable Irish Catholic childhood’ to reveal, as the series unfolds.
Back home, as a nation, we have made little of psychotherapy, a form of treatment that is, according to Byrne himself, not so different from confession – a search for reassurance. Psychotherapy can be defined as the relief of distress by a therapist trained in a particular method. A more well-known cultural reference for Irish audiences is Dr Melfi from the Sopranos whose treatment of Tony formed the basis for the series’ plot.
With the changes in community structures, the alienation that seems to come with the modern condition, and the disappearance of confession, there is plenty of scope for some kind of ‘reassurance’ to be re-introduced in Irish life. As in the rest of the western world, even where counselling and different forms of psychotherapy are accepted, the gap is being filled by pills.
How big is this gap, this space where people get dragged down by their unhappiness, where they are unhappy but don’t know why? The World Health Organisation says that one in four people in the world will be affected by mental or  neurological disorders at some point. Such a high figure is contested but there are even greater claims being made: in September the European College of Neuropsychopharmacology stated that more than a third of Europe’s population suffers from a mental disorder annually, with conditions including insomnia and dementia.
A 2005 survey in the US found an estimated lifetime rate of 51% for a mental illness and one in New Zealand claimed more than 50% of people had suffered from an anxiety disorder at least once by the age of 32. Such figures have led to accusations of the medicalisation of normality and what Lisa Appignanesi, author of Mad, Bad and Sad, has called “the imperialising tendency of the mental health sector”. The issue can become self-perpetuating. If you are primed to think an unhappiness problem is a mental issue, you will present yourself to a GP with it.
The phenomenon has been a boon to pharmaceutical companies, which stand accused of finding new conditions, like social phobias and post-traumatic stress disorder, for which their products can be prescribed. Glaxosmithkline states its anti-depressant, Seroxat, is also a treatment for “anxiety disorders” in adults. According to Irish-born psychiatrist, David Healy, professor of Psychological Medicine at Cardiff University and author of such books as the Antidepressant Era, there has been a subtle change in the use of terms for what he believes are new, fashionable treatments. The term ‘anxiety disorder’ implies a condition whose treatment is more about drugs, whereas what are also called phobias imply a behaviour that can be treated by therapy, he contends.
Depression was all but unknown half a century ago, Prof Healy has pointed out, and “the idea that there might be a depression that drugs could treat had in one sense to be invented as had the idea of an anti-depressant”.
According to support group Aware, 400,000 people in Ireland experience depression at any one time. But the Lundbeck Mental Health Barometer 2011 puts the figure much lower, saying the condition is “experienced by four percent of the population (180,000) directly at some stage”.
Meeting the undoubted demand are Seroxat and Prozac, drugs which replaced Valium in the nineties as preferred anti-depressants, and which are part of a new generation of medication known as SSRIs (selected serotonin re-uptake inhibitors). Prescribed for depression, they have also been dogged by controversy since they were first stocked in pharmacies.
After raising concerns about the links between Prozac and increased suicide risk, Prof Healy eventually earned himself a New York Times profile as a maverick campaigner against his profession’s overselling of drugs, as he sees it. One drug company described the intrusion as “the Healy problem”.
However, a long, international campaign on the possible dangers of taking SSRIs has resulted in wider recognition of their limitations. In 2006, the Irish Medicines Board updated anti-depressant product information, warning of the possible increase in suicidal thoughts during treatment, especially among children and young adults.
Prof Healy also warns that so-called “direct-to-consumer advertising” by pharmaceutical companies has given the patient the message that the pill is the solution. “In the face of company marketing, and with the advent of the Internet, clinical judgment has been eroded. Patients going on the internet or faced with drug company materials now all too easily find that they meet criteria for a disorder and there is often nothing or no-one to tell them this is not equivalent to having the disorder,” Healy states.
This phenomenon became marked in the UK where it was discovered in a Norwich Union Healthcare survey which questioned 250 GPs and 1,300 parents about teenage mental health. A third of parents surveyed were pressurising GPs to prescribe Prozac for their children  even if they were just unhappy, while 60% said they had to prescribe such drugs because local services were so poor.
In Ireland local services, such as traditionally existed, are being pulled back in the face of economic recession, leaving GPs with few options and built-in patient expectations that a pill should be prescribed. Prescribing psychiatric drugs for want of an alternative was recognised by the Joint Committee on Health and Children in 2006: “the patient presenting with symptoms expects some tangible form of treatment and the practitioner feels under pressure to respond… It is in the absence of a full range of counselling and psychotherapy services that many medicines, intended for moderate to severe psychiatric disorders, are prescribed for minor symptoms leading in some cases to severe adverse reactions”, it stated.
However, psychiatrists and, increasingly, GPs are recognising the merits of counselling, provided by well-trained therapists. The Royal College of Psychiatrists points out there are many different sorts of psychotherapy, “some of which are very effective for people with mild-to-moderate depression”, while the College of Psychiatry of Ireland notes that for many mental-health problems, a GP can refer the patient to a mental-health team, “such as a clinical psychologist, occupational therapist, psychotherapist or specialist counsellor”.
Nevertheless, the College points out that about three percent of Irish adults are currently using anti-depressants, a figure that translates into approximately 100,000 people, more than enough to fill Croke Park. Private prescriptions aside, the HSE spend on anti-depressants has ballooned in recent years. In 2009, on the GMS scheme, it spent €60 million on 2.2 million prescriptions for nine different anti-depressants, most of which are SSRIs. There were 135,000 prescriptions for fluoxetine, commonly sold as Prozac, and 110,000 prescriptions for paroxetine (Seroxat), which, together, cost €5.5 million.
There is no doubt that anti-depressants can be effective. Prof Healy prescribes them in his clinical practice. The College of Psychiatry of Ireland states that they “are effective in the treatment of depression and thus lead to a reduction in suicidal thoughts. The effective treatment of depression is an important means of reducing suicide rates”.
And it is at this extreme end of the scale that it is most obvious that Ireland has a mental-health problem. A total of 9,630 people presented to hospital emergency departments after deliberately harming themselves last year, a 27% increase for men and a 7% increase for women since 2007.
Over-medicalising swells drug company profits, plays into the expectations of the patient and gives GPs and psychiatrists a quieter life. But it is wasteful and it may often be ineffective. Last year, the Journal of the American Medical Association published a study that found anti-depressant drugs, while useful in cases of severe depression, are generally no better than a placebo for most patients presenting as mild to moderate cases.
To have 100,000 adults and €60 million of HSE funds being spent on more than two million prescriptions for depression annually suggests that many such cases fall into the mild to moderate category. Overhauling mental health treatment with an effective, holistic approach has been proposed.
The government’s Vision for Change mental-health policy (2006) recommends a multi-disciplinary model and an urgent review of GPs’ mental-health training, noting the contemporary “predominance of drug treatments” for patients and “the limited opportunities for discussion and resolution of their problems through counselling and psychotherapy”.