Chapters

X

Chapters

The Script Report

Introduction

Happy pills, tranqs, benzos, cotton, mother's little helper, fizzies. For every pill in the growing variety of modern psychotropic medication, a pet name. Some, a product of abuse; others, fondness.

But with international studies questioning the growing use of prescription drugs such as antidepressants, US journalist Jon McClure, who specialises in analysing large volumes of data, examined 36 million prescription records from across the UK including 3.5 million scripts written by GPs in Northern Ireland.

The results of The Detail's Script Report suggest:

  • Northern Ireland has prescribed proportionately more antidepressants than the 23 countries that were examined in a major international study that identified significant increases in use across much of the western world.
  • The link between deprivation and antidepressant prescription rates is stronger in Northern Ireland than in England or Wales –but not as strong as might have been expected. NI consumed more than two-and-a-half times the antidepressants per head than in similarly wealthy economic areas in England.
  • Antidepressant use is higher among women than men in NI, with antidepressant, opiate and sedative use higher among 35-64 years old. And while this is often attributed to the fallout from decades of violence in Northern Ireland, doctors now report growing usage in age groups too young to have directly experienced the Troubles.
  • In addition to the findings on antidepressant prescription rates, the Script Report studied rates for over 50 drugs categorised as antidepressants, sedatives, painkillers, or anti-anxiety medicines. In more than 40 of the drugs, Northern Ireland prescription rates exceed those of England.

The advent of these drugs reviewed in the Script Report - antidepressants, anti-anxiety drugs, opioid painkillers and benzodiazepine sedatives – are said to represent a major medical advancement and greatly increased doctors' ability to help patients suffering from a range of conditions, but fears of over-prescription persist and recent international studies point to striking upward trends.

A senior medic interviewed for the Script Report cited greater pressure than ever on Northern Ireland GPs to prescribe such drugs to patients who believe they require medication, while in extreme cases doctors face intimidation from those aggressively demanding drugs.

Existing data also points to the misuse of prescription drugs by criminals, while drug deaths have also been repeatedly linked to mis-used medication.

An examination of the prescription history of every GP practice in Northern Ireland – data which has never been released before – cross-references GP prescriptions with the levels of deprivation in the area where they are based, plus the prevalence of depression in that area.

Doctors have told us that many factors can influence levels of prescribing of the types of drugs examined in the Script Report: the scale of need in the community they serve, better diagnosis, longer periods of treatment to ensure better patient outcomes, as well as patient pressure and new health policies that inadvertently fuel `self-diagnosis’ by patients.

But nevertheless, the Script Report raises fresh questions over the scale of prescription drug use in Northern Ireland as a whole. Our interactive charts and graphics illustrate links between prescription rates and deprivation. They also compare prescription rates for drugs in England and Wales with Northern Ireland.

In the six months of prescribing data that The Detail analysed, from April 2013 to September 2013, GPs in Northern Ireland prescribed enough antidepressant drugs to give every man, woman, and child here a 27-day supply at the Defined Daily Dosage limits. English GPs prescribed enough for 10 daily doses per registered patient. The figure in Wales was 19.

Statistics also indicate that England ranks highest in the rate of depression diagnosis and yet prescribes fewer antidepressants per patient than Northern Ireland and Wales.

The Script Report is an analysis of prescribing rates in Northern Ireland using recently released GP prescribing data.

The data comprises all prescriptions written by Northern Ireland GPs and filled between April and September 2013. The records are publicly available online via the Health and Social Care Business Services Organisation, but the data is so large, The Detail needed special database administration software to view it. The sheer size of the data generally puts it beyond reach for the average health care consumer.

The Detail focused on prescription rates for drugs which fell in to one of four categories according to their major indication in adults: antidepressants, anti-anxiety drugs, opioid painkillers and benzodiazepine sedatives.

Our analysis compares average prescription rates in Northern Ireland with those of GPs in England and Wales. (Only Scotland does not release comparable data in the UK.) The Detail also considered the level of economic hardship in a GP’s immediate community in making comparisons.

The goal of the project is to make the data transparent and useful to health care consumers, as well as to survey an important issue receiving significant public attention in recent years: the high or increasing prescription of psychotropic medicines.

Responding to the Script Report findings a spokesperson for the Department of Health for Northern Ireland said: “The Health and Social Care Board (HSCB) are currently establishing Primary Care Talking Therapies Hubs in each Trust area.

"When these Hubs are fully developed over the next 3 years the Hubs will improve access to low intensity psychological care, promote a culture of early intervention and reduce reliance on pharmacological interventions.”

The board said factors including public information campaigns had added to greater awareness of mental health issues.

It said it had made an initial investment of £1.7million to support the establishment of the Hubs and to extend the range and scope of psychological therapies across mental health services.

A spokesperson for the Board said: "The HSCB recognises that much more needs to be done in order to provide alternatives to drug therapy for people who present with common mental health needs."

Read the HSCB's complete response here, but first:

Two important concepts to understand

Defined Daily Dose

Per the World Health Organization:

The Defined Daily Dose is the assumed average maintenance dose per day for a drug used for its main indication in adults.”

The Detail used the Defined Daily Dose (or just "daily dose") to make different drugs prescribed at different strengths comparable. For example, diazepam has a Defined Daily Dose of 10mg. So 10 diazepam pills at the 10mg dosage are evaluated the same as 5 pills at 20mg: 10 daily doses.

The daily dose is a statistical average and not a prescribing guide. Doctors prescribe different daily regimens based on individual patients and their particular conditions.

Deprivation

National statistics agencies in the UK estimate the level of economic hardship in a community using statistical measures known as indices of deprivation. The poorer the economic opportunities in an area, the more deprived it's said to be.

The Detail grouped GPs into four categories based on the level of deprivation in their local community to make the most informed comparisons possible of their prescription rates.

The groups range:

  • LEAST deprived GPs are in wealthier areas
  • LESS deprived
  • MORE deprived
  • MOST deprived GPs are in some of the poorest areas

On the Rise

The World Health Organisation estimates that by 2020 depression will be the second leading cause of disability, worldwide. Only heart disease will afflict more people.

Tom McEneaney, Head of Statutory Business Development Aware Defeat Depression

In Northern Ireland, the causes behind high levels of depression, anxiety and other neural disorders are multiple.

Perhaps the most recognised contributor is the legacy of the Troubles.

The Detail previously reported almost as many people have died by suicide in the years since the Good Friday Agreement as were killed during the Troubles.

“As a society emerging from conflict, people are beginning to talk about and recognise the impact of the Troubles has had on their mental health including post traumatic anxiety , depression and stress,” said Tom McEneaney of Aware Defeat Depression, a charity in Northern Ireland.

“Nobody’s shouting from the rooftops, but depression is sitting under the sofa, gathering momentum.”


Top Prescriber

In a widely publicised report last November, the Organisation for Economic Co-operation and Development (OECD) showed a significant increase in the use of, specifically, antidepressants during the last decade among 23 member countries, mostly European. According to the report, the wider use of antidepressants to treat milder symptoms “raised concerns about appropriateness.”

The report also compared prescribing rates among member countries using the number of defined daily doses per 1,000 people per day, which is a measure designed to approximate the number of patients regularly using a medication per thousand.

The United Kingdom ranked 7th highest among OECD member nations at 71 daily doses per thousand people per day. Topping the list was Iceland at 106 daily doses per thousand per day.

The Detail’s analysis indicates, if Northern Ireland was considered separately from the rest of the UK, it would take the top spot internationally in the OECD report at 129 daily doses per thousand per day.

Within the UK, Northern Ireland outpaced England and Wales in its per person rate of drug consumption across all categories The Detail analysed. (Scotland does not release comparable data at the GP level).

Antidepressants

Average daily doses prescribed per 1,000 patients per month


This graph shows the average monthly rate antidepressants are prescribed by GPs in Northern Ireland. The units are defined daily doses per 1,000 registered patients per month. Click GROUP to show GPs by local deprivation levels. SORT aligns the bars for comparison within deprivation groups or between countries. The TOP DRUG bar shows how the current drug compares to the maximum antidepressant prescription rate.

Northern Ireland patients consume more antidepressants than all other categories of prescription medicine in The Detail’s study combined – almost 7.5 million daily doses per month. In the six months of prescribing data that The Detail analysed, GPs prescribed enough antidepressant drugs to give every man, woman, and child a 27-day supply at the Defined Daily Dosage limits. By comparison, English GPs prescribed enough in six months for 10 daily doses per registered patient. The figure in Wales was 19.

Depression prevalence statistics reported by GPs as part of the Quality and Outcomes Framework are an indication of depression rates in the general population. Northern Ireland ranks middle of the pack in the UK, with an average of about 5.1 percent of a GP’s registered patients who have been diagnosed with depression at some point in their lifetime. England ranks highest at about 7.5 percent of patients having been depressed. Wales reports just over 4 percent.

All GPs don’t necessarily recognise symptoms of depression in the same way, still the statistics indicate England ranks highest in the rate of depression diagnosis and yet prescribes significantly fewer antidepressants per patient than Northern Ireland and Wales.

Click a link to see more information on some of the most widely prescribed antidepressants, such as:

Self-diagnosis

Dr Tom Black, chair of the BMA Northern Ireland General Practitioners Committee, said part of the increase in prescription rates — often the subject of public scrutiny, now — is a direct effect of another public campaign to increase attention on the prevalence of depression in the population.

“Politicians, the media and the public felt we were under-diagnosing, and they wanted to put the control in the patient’s hands,” said Dr Black.

If we appear to be over-diagnosing and over-treating, that’s to some extent what happens when you empower the public with knowledge and information.”

Dr Tom Black, chair of the BMA Northern Ireland General Practitioners Committee

Take, for example, the PHQ-9 questionnaire. The PHQ-9 was designed to encourage GPs to accurately diagnose patients’ depressive symptoms, but Dr Black said many GPs now say it takes the power to diagnose completely out of their hands.

The questionnaire consists of ten multiple-choice questions meant to gauge whether a patient is suffering clinical depression. A patient is asked, for example, how often during the last two weeks he or she has felt tired, has had a poor appetite or showed little interest in doing things.

The problem: if a patient is convinced before the test he or she is depressed, it’s very easy to answer the questions according to that assumption.

Dr Black said: “Now try a situation where I tell you you’re not depressed. Impossible. Patients were essentially diagnosing themselves.”


The “Sandwich Generation”

According to estimates released by the Health and Social Care Board based on 2011 census figures, antidepressant use among females is significantly higher than among men.

The prevalence of antidepressant, opiate and sedative use is also significantly higher among patients 35 to 64 years old than those 15 to 34 years old.

But GPs see steady gains in the consumption of these drugs among those groups much younger than the generation who experienced the Troubles, firsthand.

“The big trend I see is the ‘sandwich generation’ are getting hammered,” said Dr Black. “Someone stuck in the middle, looking after children, working hard at a difficult job and looking after parents and grandparents. They’re sandwiched between all those responsibilities. Females, late 20s, 30s and into their 40s, they’re having a tough time out there.”


Economic Deprivation

As part of the GP prescribing data analysis, The Detail tested whether economic hardship was related to antidepressant prescription rates, which might help explain why Northern Ireland rates outpace those of the rest of the UK.

Anti-Anxiety Drugs

Average daily doses prescribed per 1,000 patients per month


The average monthly rate anti-anxiety drugs are prescribed by GPs in Northern Ireland. Click GROUP to show GPs by local deprivation levels. SORT aligns bars for comparison within deprivation groups or between countries. The TOP DRUG bar shows how the current drug compares to the maximum anti-anxiety prescription rate.

Local economic circumstances are measured by statistics known as indices of deprivation, which score local areas according to income and employment levels. The Detail used these indices to statistically test the relationship between the economic deprivation in a GP’s local community and its antidepressant prescription rate.

According to the analysis, deprivation scores are only weakly correlated with the number of antidepressant daily doses a GP prescribes per registered patient.

The relationship between deprivation and antidepressant prescription rates is significantly stronger in Northern Ireland than in both England and Wales. But even in Northern Ireland the relationship was too weak to reliably indicate a relationship.

Based on the analysis, it would be problematic to say economic deprivation drives the high prescription rate of antidepressants in Northern Ireland.

In fact, the difference between antidepressant prescription rates was greatest among GPs in least deprived areas. Northern Ireland consumed more than two and a half times the antidepressants per head than GPs in similarly wealthy economic areas in England.

Click a link to see more information on some of the most widely prescribed anti-anxiety drugs, such as:

Welfare Reform

But the link between economic deprivation and antidepressant consumption may become stronger as proposed welfare reforms begin to hit those at the bottom of the economic ladder.

Groups like Aware Defeat Depression said they are already seeing an effect.

“We’re getting increased numbers of people worried about what’s going to happen to their benefits,” said Mr McEneaney.

“It’s increased anxiety, increased depression, increased stress among them. Clients who have existing conditions are reporting that their condition has deteriorated as a result of worrying about welfare reform and the impact it is going to have on their health and well-being. We believe welfare reform has the potential to have a major impact on people’s lives and we expect to see an increase in people using our services as this rolls out.”

While broad welfare reform may increase the severity and prevalence of depression, the charity believes the lack of available counselling treatments may also drive more patients with mild to moderate symptoms to prescription drugs where a non-medicated alternative might suffice.


The Waiting List

Both Dr Black and Mr McEneaney said the lack of timely-available counselling heavily influences a GP’s decision to put a patient on a drug regimen.

“I rarely refer patients for counselling in the first instance because I know they will become frustrated waiting for service,” Dr Black said.

Mr McEneaney said waiting times for counselling services range anywhere from 4 to 16 weeks.

“GPs would say that’s a long wait for someone with mental health issues, and right enough, people can deteriorate while on waiting lists.”

This leaves doctors facing the prospect of having only one ready alternative for patients — medication.


A Magic Pill

Dr Black said where possible, GPs prefer to prescribe milder selective serotonin re-uptake inhibitors, or SSRIs, to treat symptoms of depression and anxiety.

“I know we’re over-prescribing, but an SSRI is magic,” said Dr Black. “They work so well: they have virtually no side effects, they work within 3 to 4 weeks and they normalise people back into the workplace, back into their family environment. SSRIs have just transformed what we can do for patients.”

Opioid Painkillers

Average daily doses prescribed per 1,000 patients per month


This graph shows the average monthly rate opioids are prescribed by GPs in Northern Ireland. The units are defined daily doses per 1,000 registered patients per month. Click GROUP to show GPs by local deprivation levels. SORT aligns bars for comparison within deprivation groups or between countries. The TOP DRUG bar shows how the current drug compares to the maximum antidepressant prescription rate.

Benzodiazepines, commonly called “benzos,” are a class of drug that feature prominently among anti-anxiety medicines and sedatives. They are used to treat a series of disorders, but can be addictive.

“It’s a really slow project. They’re so addictive,” said Dr Black. “You’ll do (a patient) great harm if you stop someone’s benzo who you shouldn’t.”

The Health and Social Care Board (HSCB) said over-prescribing among benzos and antidepressants was a problem the HSCB was well aware of.

The HSCB’s Medicines Management Advisors annually identify and advise GPs in the top 30 percent of prescribers of antidepressants, anti-anxiety drugs and opioid painkillers. In its 2013/14 cycle, the group said 169 GPs took action to reduce prescriptions of painkillers, while 35 agreed to change their anti-anxiety prescribing and 28 reviewed their antidepressant prescribing.

Click a link to see more information on some of the most widely prescribed opioids and sedatives, such as:

Constant Pressure and Abuse

But GPs face constant pressure from patients seeking to abuse or illegally sell drugs. For the same reasons self-diagnosis is problematic, GPs can find themselves at a significant disadvantage in identifying fraud in self-reported symptoms of mental health.

“There is a cohort of young, aggressive males who are trying to access antidepressants, anxiolytics and strong opioid painkillers,” said Dr Black. “In terms of painkillers, we come under daily assault.”

My young female doctors find it quite intimidating when you have a 6-foot, drug-abusing, alcoholic young man refusing to leave the room unless you give them Tramadol. They’ll exaggerate and manipulate and intimidate until they get it. And if you give it to them once, you’ll give it forever more, amen.”

The PSNI also refer to a significant overlap between abuse of prescription drugs and other, illicit drugs.

A spokesperson said: “Many drug users in Northern Ireland are polydrug users and as such may use prescription and illicit drugs, with one drug used to counteract or replicate the effects of another.”

The illegal trade in prescription drugs is conducted by multiple actors. Organised crime groups import prescription pills with other illicit drugs, while online marketers outside the UK attempt to ship the drugs in through the post. Patients also sell medicines personally prescribed to them. But most illegal pills, according the PSNI, come from sources outside the UK.

That also means consumption of those drugs isn’t included in official statistics like those The Detail surveyed.


An Open Debate

Despite the steady increase of antidepressant consumption in the UK, experts are still split on whether they are over-prescribed. A recent debate in BMJ (formerly the British Medical Journal) set out both sides of the argument.

Making the case that antidepressants are over-prescribed, some GPs say symptoms have to meet a relatively low bar to be considered clinically depressive.

Des Spence, a Glaswegian GP writing in BMJ, said official guidelines state that two weeks of low mood should be classified as clinical depression, even after a family bereavement.

Spence also said he sees the influence of the pharmaceutical industry on prescribing practice:

Mental illness is the drug industry’s golden goose: incurable, common, long term, and involving multiple medications. This relation with industry has engrained a therapeutic drug mindset to treat mental illness. … Isn’t this medicalising normality?”

Other experts say antidepressant prescription has risen due to appropriate increases in the duration of treatment rather than an increase in the number of patients diagnosed with depression.

Ian Reid, a professor of psychiatry at University of Aberdeen writing in BMJ, blamed the media for promoting the idea “that GPs are handing out antidepressants 'like sweeties.'” He emphasised antidepressants within a range of tools available to GPs to mitigate the complex symptoms of depression:

Antidepressants are but one element available in the treatment of depression, not a panacea. Like “talking treatments” (with which antidepressants are entirely compatible), they can have harmful side effects, and they certainly don’t help everyone with the disorder. But they are not overprescribed.”

Spence questioned, though, whether prescribing antidepressants is altogether necessary in many cases. Research indicates only one in seven people actually benefit from an antidepressant regimen, he said.

"Thus millions of people are enduring at least six months of ineffective treatment. People who do not respond fare worse, with switches of medications and often multiple drug combinations. How often do we tell patients these undisputed facts?"

Reid said research in the US, which appeared to show antidepressants were no more effective than a placebo, was methodologically flawed. Other studies, he said, showed not only significant benefits for those suffering severe depression but also improvement in patients with milder symptoms.

Neither side specifically addressed prescription rates in Northern Ireland which are significantly higher than those in other parts of the UK surveyed by The Detail.


Alternatives

Support groups and educational programmes can successfully mitigate mild to moderate symptoms of depression, often in place of a drug regimen.

In 2009, Aware Defeat Depression began offering the Living Life to the Full programme, founded on Cognitive Behavioral Therapy principles and with funding from the Department of Health, Social Services and Public Safety. The programme provides educational counselling including coaching on how to cope with depressive symptoms and general wellness tips.

An evaluation of 394 participants found the programme highly successful. Using a standardised classification method administered before and after a 6 to 8-week administration period, the number of participants classified as “depressed” dropped 59 percent, while the number classified as “happy” increased 57 percent. Trends were similar between male and female participants.

Aware Defeat Depression are hopeful positive results like these will bolster support for future investment in therapies and psycho-educational programmes so more free services can be offered to patients whose GPs may have no other alternative but to place their patients on medication.

“We try to intervene with as little as what is needed, but something that has an evidence base to it and something that will give people support and hope towards their recovery,” said Mr McEneaney.

It’s about giving people the tools, the strategy and building up their own personal resilience to look after their own health and well-being and of each other.”



PLEASE ... don't make health care decisions based on this report alone. We're not doctors. The data presented here are for the purpose of broad consideration. Information on particular drugs should not be considered exhaustive or necessarily applicable to your individual health.