The benefits of antidepressants
Both patients and GPs talked about the benefits of antidepressants as a means of alleviating distressing symptoms. Patients tended to have few concerns about commencing antidepressant treatment. Several had expected a medication to be prescribed and many were willing to accept any help the GP could provide:
‘At that time [commencement of treatment] I didn't really care! If he'd have said take some rat poison I would have probably taken it, you know, I was that down so I didn't bother; and then gradually … it got better.’ (Patient 33)
Many participants responded positively to antidepressants and attributed their effects to helping alleviate their symptoms and contributing to a return to function:
‘It seemed as if some fairy had waved a wand and got me this [drug] which brought me round. I swear by it.’ (Patient 4)
‘My worst point was when I woke in the morning. I just didn't see any point in going on and it certainly helped very much indeed.’ (Patient 18)
GPs considered antidepressants to be beneficial irrespective of their precise action, placebo or otherwise. They allow the doctor and the patient a feeling of doing something in the face of insolvable problems:
‘If the cause is a social factor I can't get rid of that … but I might alleviate their symptoms a little bit.’ (GP 5)
‘If it makes them feel even a bit better it's worth it. Because at the end of the day a lot of them don't cost a huge amount, they are quite cheap.’ (GP 8)
Ambiguities and dissonances in the understanding of depression and its treatment
The term depression is ambiguous with patients applying different identities to their condition, commonly ‘anxiety’, ‘sleeplessness’, and ‘pain’. Use of vague terms which linked a patient's perception of their condition with their physical health was also common. Several participants attributed their condition to failing physical health, identifying with symptoms such as excessive tiredness. By the same token, patients appeared more at ease treating their condition with a medication than with a social or emotional intervention:
‘After that I started to get tired spells where I was abnormally tired, not sleepy, physically tired … it's an effort to walk about and that was when [the GP] said that this was depression, although I'll say I didn't feel depressed. But as far as I know not being very knowledgeable on medical matters you could be what you call clinically depressed without being mentally depressed. That's how I understand it, so although I didn't feel depressed I accepted the fact that it could well be.’ (Patient 4)
The GPs also acknowledged a difficulty in providing a solid diagnosis of depression and understanding and treating its causes:
‘We have to keep figures of who is depressed, but of course loads of people come in and it says“depressed”, but they are not actually clinically depressed. They are depressed because someone has just died … and that's where our figures have been mucked up … I think for all our patients who have coded as depression, maybe 10%, if that, actually have depression.’ (GP 6)
This ambiguity in understanding depression as an emotional or physical condition influences GPs' views of antidepressants:
‘In emotional medicine you are much more predisposed to the individual patient. In cardiology where essentially every patient comes into the sausage factory and gets an aspirin and a beta blocker and an ACE inhibitor and they all come out at the other end, you can't do that with the emotional illness.’ (GP 7)
‘Statins, yes I have my concerns about statins. But I suppose the gain from that is more tangible and more … easy to sell. The problem with general practice is that the perception of psychiatric illness is one where it's still not seen necessarily as a biological condition. I happen to believe it is.’ (GP 10)
GPs acknowledged the difficulties in providing treatments other than pharmaceuticals:
‘We have … a 10 to 11 month waiting list here for CBT [cognitive behavioural therapy], by which time the crisis has gone. People come to us in extremis really, they are usually in a very, very distressed, disturbed state.’ (GP 5)
‘The majority of [patients] have lived through the Second World War and they have an antipathy to counselling.’ (GP 1)
‘I think [antidepressants] do have a place, partly because it's not a lot of other things that help mild to moderately depressed elderly, the CBT has got a very limited place. Counselling; its always very difficult to get them to engage, so we are often stuck with just prescribing, so it's a bit “best of a bad bunch” really.’ (GP 4)
Patients often echoed this antipathy to non-drug treatments such as counselling. Although, where available, they were open to social, rather than psychological, interventions tailored to their needs. Overall, while patients often appeared more comfortable accepting a physical cause and intervention for their condition, GPs tended to acknowledge social and emotional causes that required non-drug interventions they could not always provide, and although antidepressants offered a solution to some patient's problems, there appeared to be sense of unease about prescribing a medical intervention for a social cause:
‘The GP said “Well, do you want to go for bereavement counselling?” Well I didn't and I don't because with my faith and my family, I don't need anyone else. He didn't offer anything else, poor lad, what else could he offer? You feel that they're embarrassed about it sometimes. He's only a youngish man … no, I haven't ever spoken to anybody about it really.’ (Patient 11)
‘I've been offered one or two [alternatives] … and I said“Well I'll see”and let them know. In the meantime I've been missing my little walks. I was offered walks from home but they had to close because no funds. I was offered people to come and have conversation with me … no funds; no volunteers and that's the problem whatever I've been offered.’ (Patient 21)
‘Nowadays there is medicalisation of life, really. There are problems that we all have in our life. Some people need to have it turned into a medical problem to make it more valid or something. Rather than say I'm struggling to cope with my divorce or whatever, they come and say I'm depressed.’ (GP 2)
Both GPs and patients noted some dissonance in defining and treating depression in an analogous way to physical illness. While an illness may be easier to understand in physical terms, the subjective nature of depression can make it difficult to manage:
‘I don't think it's right to prescribe something that they don't necessarily need, so we prescribe for social issues, but should we prescribe … lifestyle drugs? I don't think we should … But it's difficult when you can't measure an outcome. If someone has high blood pressure I can measure that and it's a definite.’ (GP 6)
Barriers to discontinuation of antidepressants
Both patients and GPs described barriers to discontinuing antidepressants. Some were explicit and widely acknowledged by the patient, but others were implicit and difficult for the patient to identify and define.
GPs adopted strategies to facilitate discontinuation. For example, pre-warning the patient of the limited duration of prescription, tapering the dose with support, and timing any discontinuation around springtime. However, discontinuation remains a challenge for doctors who feel their persuasive power less effective in getting people off antidepressants than when initiating them. Four main barriers to discontinuation were identified:
pessimism about the course and curability of chronic depression;
negative expectations and experiences relating to ageing;
discontinuation as a threat to stability; and
therapeutic momentum and maintenance as desirable.
Pessimism
Among the patients there were some for whom antidepressant treatment had been extensive and complex; characterised by repeated and multiple prescriptions for antidepressants, anxiolytics and hypnotics, these patients had a lengthy medical history and multiple medical contacts over many years:
‘It's a part of my life really and I've just got to cope with it.’ (Patient 20)
‘I never get really well … where I can do without these things. I've lived on them all my life.’ (Patient 19)
‘I don't think now at my age … I think I'll be on them for the rest of my life because they can't do nothing for me so I think I will be taking them for the rest of my life.’ (Patient 1)
These thoughts were present even when responders understood their condition to be caused by external factors, such as recurrent bereavement or physical ill-health. Patients felt unable to plan to remove obstacles to achieving a better condition and as a result accepted and internalised their condition as inevitable. Medication was seen as a long-term solution; it was better to take antidepressants as they provided some minor benefit. These participants did not envisage a bright future, instead spoke of ‘plodding on’:
‘He coped with that very well and then was diagnosed with cancer … so that was a big shock to me … we coped with that very well, got over that. And I think I came off the first antidepressant, or whatever they call them … and then 2000 my eldest son was diagnosed with cancer so they put me back on them again … and he died in June 2001 but that was expected, I coped with that quite well, and after a while came off the antidepressants; and then 2003 my youngest son collapsed and died … so my GP put me back on them again …‘ (Patient 5)
‘I'm normally tired and now you see my situation, my wife should have had her hip replacement but her blood pressure is far too high and she can't have it. So it can only get worse so for the last few years I've had to take on more and more to help her like I've had to do all the shopping and … it doesn't bug me and … physically nor emotionally I just do and … we just accept it, it's just another thing that's come over that we have to cope with …‘ (Patient 21)
Patients acknowledged that often this was also a challenge for their doctor:
‘Oh I have done very well with this [recent reduction to antidepressant regimen], in fact I have done better with these people than I have ever done. With the other people, well I think they were just … I don't think they knew what to give me … I mean more than once I've been told “just get on with you” you know. I do get on with it but it can be very debilitating.’ (Patient 19)
GPs also acknowledged the intractability of some patient's situations:
‘I think they have horrible lives, a lot of them … I think it's a combination of all things, their health, their social circumstances … I think a lot of people are on antidepressants because of everything put together. And you can't … change most of the factors that cause it.’ (GP 8)
For others it validates the illness and sends a message to the family. It is the least a patient can do to be seen to be managing their illness:
‘They feel that unless they are on a tablet for it then they are not having any treatment. There are a lot of those kinds of people.’ (GP 2)
Negative perceptions of ageing
Responders spoke of negative associations with ageing that influenced their decisions to remain on long-term antidepressants:
‘They didn't say anything about why I was depressed or anything … they just seemed to think it was a general condition for my age.’ (Patient 20)
As the responders aged many felt significant deteriorations in their physical and mental health. Poor health exacerbated their condition and limited their activities of daily living, contributing to low mood and symptoms of depression:
‘With old age every year you sort of get something which as you get older is expected. I mean if my eyes go they go. You see that doesn't bother me, my legs bother me, yes because I can't use them properly. I was a great walker at one time and I can't do that now.’ (Patient 19)
Paradoxically, as old age and ill-health became more integrally associated with depression and its treatment, the latter was less often mentioned in consultations:
‘[Doctors] are more bothered about blood tests, liver tests, breathing operations. No, the depression has gone into the bottom drawer … I think according to the state of my health and what the doctors think about me … I suppose if I brought it up in conversation they would talk about depression, but if there is no need to talk … why not leave it alone!’(Patient 4)
‘I'm summoned to the surgery once a year because of my age, where I have blood tests and urine tests, and a general talk about my health. But I don't think that either the [antidepressant] or the depression has been mentioned in those talks.’ (Patient 17)
Doctors also acknowledged this phenomenon:
‘I think it's well known that depression is often overlooked in the elderly and people who have got physical disabilities and whose life has been significantly impaired by their illness …‘ (GP 2)
‘There are some bigger battles I think out there, than persuading them to stop their [antidepressant treatment].’(GP 8)
The GPs recognised this state of affairs: many older people do not view depression as an orthodox illness, and they have low expectations, expect to be unwell, and do not actively seek help. Consequently depression, remains under-diagnosed and requires greater vigilance from doctors:
‘Elderly people are generally more self effacing, and they don't make demands on us for treatment. They say “oh I know it's old age”, you know, they expect that they are going to feel low because they are old. They have lower expectations of what can be achieved, I think, and they are wary of antidepressants, but I think antidepressants do work in elderly people.’ (GP 9)
‘It's always difficult to assess because there are so many more layers with elderly people, they tell you what they think you want them to say … I think it takes a lot more detective work.’ (GP 4)
Discontinuation as a threat to stability
Participants were asked about their experiences with changing and reducing antidepressant medication. Some patients are willing to accept some degree of change. Many expressed that ‘less is more’ when it comes to medication, but a reluctance to withdraw entirely was common. For many participants reluctance to discontinue was influenced by previous experiences of withdrawing from antidepressants:
‘I'm not coming off these because every time I come off, something else happens; but these, these are more for a panic attack.’ (Patient 5)
‘I sort of take half of one for so long and then I think “oh blow this I'll get rid of it” and then of course I get the collywobbles then.’ (Patient 19)
It was unclear whether these participants were experiencing discontinuation effects, or returning to their previously depressed state, however these participants now accepted antidepressant treatment as a long-term option and plans to withdraw were seen as potentially threatening to their currently stable situation:
‘I still don't know whether I would sleep if I came off them … I don't want to try!’ (Patient 32)
‘When [the GP] was there she said“well, we could get you off them slowly”, and I was in fear of her doing that because I suppose they're a crutch really.’ (Patient 34)
Concerns about disruption to the status quo were also reinforced by negative perceptions of ageing:
‘I'm not being funny but … would it make any different at my age? I mean why bother changing something now?’ (Patient 6)
‘I think at my age I would just think “well carry on as I am with them”. I think it's too late to change now.’ (Patient 20)
If a patient is stable, GPs were also reluctant to disturb the equilibrium:
‘It's scary to stop a medication that's been going for a long time, because you kind of think am I opening a can of worms here, because I don't know what the reasons were for them starting that medication. To explore all that will take, you know, I can't do all that now, I will have to do that at another time.’ (GP 9)
‘They're frightened of coming off, because they don't want to feel like they did initially. And you can understand that.’ (GP 8)
Doctors felt that most patients could be persuaded to discontinue antidepressants but require extra support. In many circumstances it is easier to follow the path of least resistance and let them be. However, if there are genuine concerns then the GPs did not view discontinuation as a challenge they cannot overcome:
‘I don't agree with this treatment, it's not the best thing to do, but at the end of the day it depends whether harm outweighs benefit and is it worth having that major fall out with the patient and if I'm really stuck and I really want them off it I would send them to psychiatry to get someone else to try and do it for me. I've never had to do that.’ (GP 5)
GPs felt many received inadequate or sub-therapeutic doses, used as a ‘crutch’. They expressed some uncertainty regarding the consequences of long-term antidepressant use, but in the absence of evidence of specific adverse effects there was little concern. Doctors appear to be more willing to let patients decide whether or not they should continue on antidepressants. The goal of both doctor and patient appears to be not to ‘rock the boat’:
‘There are some patients who need that little bit of a crutch, almost a placebo effect, the kind of people who sometimes feel they want to be on a low dose more permanently because they feel it keeps them on an even keel.’ (GP 2)
‘The long-term patients generally are on probably sub-therapeutic doses really, how much actual effect it has on their mental health is probably minimal but it gives them psychological support. If somebody did become more symptomatic then we would up the dose.’ (GP 2)
Therapeutic momentum and therapeutic maintenance
Two broad pictures were identified in relation to continuation of antidepressant prescription: a passive situation, or ‘therapeutic momentum’, where the prescribing and taking of a medication becomes a constant, an action neither subject to impetus nor acted on by an outside force, such as change or medication review. A more active situation, where the repeated prescription is based on appraisal of the risks and benefits of continuation, is described as ‘therapeutic maintenance’. When questioned about their antidepressants, patients in the therapeutic momentum group responded with vague answers about both the effectiveness and future expectations of their medication:
‘But I just do. I take them … I just take them thinking well if they do me good …‘ (Patient 23)
Interviewer (I): ‘Do you think you will continue with the medication?’
Patient (P): ‘Oh I think so. I think now I've got to this age anyway that you know I'll just go on.’ (Patient 26)
A small number of participants were completely unaware of the reason for their prescription and when their medical records were checked a specific diagnosis was not recorded and no review ever present.
Several participants accepted antidepressants as a long-term intervention and prior to interview appeared to have given little attention to the reasons why they continued taking them:
‘I don't really know. The doctors will keep an eye on things and if the time was appropriate then they would take me off it but… having kept me on it I assume they are happy for me to go on taking it so I take it but … with all this medication I would come off it if I could. If I can't come off it then I accept it.’ (Patient 21)
The perpetuation of this steady state of therapeutic momentum can be characterised by long-term prescription, passive acceptance of medication, and lack of meaningful review by either doctor or patient.
Other participants made a more conscious decision to continue on a long-term prescription of antidepressants. Their acceptance of the medication as long-term is not passive in the same way as the patients who describe a state of therapeutic momentum. Instead there is a steady state of therapeutic maintenance, an active situation where the prescribing and taking of a medication becomes a constant, subject to informal review, which seeks to maintain the status quo:
‘As I feel now I feel like I'll be taking them for the rest of my life … after 4 years I can't see it improving, as I say it keeps it in check.’ (Patient 1)
This group of participants had considered their expectations of long-term antidepressant medication, attributed some benefit to them, and expected a course of treatment that would maintain the status quo. They had experienced review by their doctor, but had no desire to stop their treatment or expect repeated and frequent review in the future. Acceptance of therapeutic momentum was also reinforced by patients' thoughts on ageing:
‘Well, I won't be here long so I think I'll keep on it ‘til I go.’ (Patient 27)
‘It would be a marvellous thing if you didn't have to take anything at all, but I think that is asking a bit too much at my age. I think you have to have something to help you along.’ (Patient 29)
One patient described how therapeutic maintenance was a desirable situation and how this state was reinforced by the acceptance of his actions by his doctor:
P: ‘I was called in to see the doctor because I think at that time they were a little concerned about what the long-term effects of taking it would be. And we chatted and the doctor said to me “I think you're taking these as a sophisticated sleeping pill, and if that is the case, I've no objection to that”. And I said “Well, they do help me to sleep, that's the reason why I keep taking them”.’
I: ‘How would you feel if the GP had made a suggestion about that?’
P: ‘I would be disappointed. I feel it's one that suits me and I'd be reluctant either to change or stop it.’
I: ‘Would you have any questions for your GP after this interview about the medication?’
P: ‘No, I don't think so. As I say I'm reasonably happy with taking the … well very happy with taking the drug; it seems to be working and unless I suddenly get an attack of depression, I don't think I would mention it to the GP.’ (Patient 17)
