Counsellors and therapists could have a key role to play in efforts to halt the steady rise in the numbers of people who are taking prescribed psychiatric medication. So says new guidance produced under the aegis of the All-Party Parliamentary Group for Prescribed Drug Dependence (APPG).1
The guidance comes with the endorsement of the main counselling and psychotherapy associations: BACP, the British Psychological Society (BPS), the UK Council for Psychotherapy (UKCP) and the National Counselling Society (NCS). It urges counsellors and psychotherapists to learn more about the psychiatric medication their clients may be taking – its potential benefits, risks, effects and side-effects – so that they are better informed to make a decision about whether and how they can talk with clients about their drugs. With the information in the guidance, it is hoped practitioners will be able to support clients more confidently, whether they want to start taking or withdraw from their medication while they are receiving psychological therapy.
Its publication follows hard on the heels of a major evidence review by Public Health England (PHE) highlighting growing concerns about dependence and withdrawal from psychiatric drugs such as antidepressants, benzodiazepines and so-called z-drugs (gabapentin and pregabalin), and opioid painkillers.2
More than 11.5 million adults in England are taking prescribed medication for anxiety and depression, and the numbers are rising. The Department of Health and the NHS are deeply worried about not just the absolute numbers taking these drugs but also that so many people are taking them long-term, at no increased benefit and at great cost. In Scotland, Wales and Northern Ireland, the same phenomenon is causing their governments just as much concern. The PHE review, published in September, concludes that, while prescriptions for benzodiazepines and opioids have fallen recently, those for the z-drugs and for antidepressants are increasing – more people are taking them, and for longer. ‘This means more people are at risk of becoming addicted to them or having problems when they stop using them. It also costs the NHS a lot of money, some of which is wasted because the medicines do not work for everyone all the time, especially if they are used for too long,’ PHE says.
The PHE report finds that in 2017 to 2018 in England, 7.3 million (17% of the adult population) were taking antidepressants; 5.6 million (13%) were taking opioid pain medicines; 1.5 million (3%) were taking gabapentinoids; 1.4 million (3%) benzodiazepines; and 1.0 million (2%) z-drugs. Rates of prescribing were higher for women (1.5 times those of men), and generally increased with age. Prescription rates also tended to be higher in more deprived areas. Around half of patients across all medications had been receiving a prescription continuously for at least 12 months. Between 22% and 32% had received a prescription for at least the previous three years.
All these medications are associated with dependence, meaning they provoke unpleasant, debilitating and sometimes dangerous physiological withdrawal reactions when they are stopped, due to the body having adapted to their continued use. All, except antidepressants, are licensed for short-term treatment only (2–4 weeks) – although PHE suggests some people need long-term antidepressants to maintain benefit and avoid risk of relapse. Among its recommendations is a call for more and better support for patients experiencing dependence on or withdrawal from prescribed medicines.
It is against this backdrop that the guidance for therapists has come out. Says Sir Oliver Letwin, independent MP and Chair of the APPG until November this year: ‘Prescribed drug dependence and withdrawal can have severe consequences for the lives of many patients who simply follow their doctor’s instructions. The recent Public Health England report reveals the scale of the problem in this country, with millions of people taking dependency-forming medications including antidepressants for years. The APPG for Prescribed Drug Dependence is pleased to have been able to bring together therapy organisations and academics to provide essential guidance for their members, so that therapists can help their clients cope with the issues that can arise when taking or withdrawing from these drugs.’
Filling a gap
The message that therapists and counsellors could play a more active role in discussing clients’ medications may disturb those who believe that the topic is nothing to do with them, that it is outside their remit and competence to discuss it with clients and unethical to do so.
Says James Davies, psychotherapist, psychologist and a co-editor of the guidance: ‘As a psychotherapist, I was trained to believe these were two very separate dimensions – doctors look after drugs, and therapists keep well away from it all. But in the real world, it’s not so clear-cut. Most clients have some experience of drugs and therapists need to have the information to manage these situations more skilfully. This document is addressing that gap – it’s encouraging therapists to learn about it, take a position, be bold and communicate your concerns to doctors if appropriate.
‘We are not telling therapists to tell their clients to take prescribed drugs or stop taking them; we are telling them they can and should get involved in the conversation – although I think, personally, we as a profession could be more bold in calling out our medical colleagues on this and recognise that we do have a view on these matters and have a place in this discussion, because what they are prescribing our clients is having an impact on what we do.’
Says Peter Kinderman, professor of clinical psychology at the University of Liverpool, past-President of BPS and one of its representatives on the guidance steering group: ‘Psychiatrists and other doctors of course prescribe medication, but we should not simply hand over the responsibility to them, put our fingers in our ears and say “talk to your doctor”, if a patient has questions or problems with medication. We can avail ourselves of this knowledge and talk to our clients about what it means.’
In putting out the guidance, BACP, BPS, UKCP and the NCS are simply putting prescribed psychiatric medication on the agenda as a possible topic for discussion in the counselling room, and pointing out that, as practitioners who often have the most regular face-to-face contact and strongest relationship with the client, counsellors and therapists are well-placed to have these conversations and fill an important gap in service provision.
Currently in the UK there are no dedicated national services working with dependency and withdrawal issues, and the services that do exist cover less than 3% of the national population. In a survey last year, BPS, BACP and UKCP asked members what percentage of their clients were taking prescribed psychiatric drugs: 27% said 25-50%, 23% said 50-75%, and 31% said more than 75%. ‘We know that many psychological therapists are already working with a proportion of those who are likely to be dependent on these drugs and have no access to other services,’ says Anne Guy, psychotherapist, co-editor of the guidance and Chair of the steering group that produced it. ‘There is very little support and information, other than online, for people wanting to withdraw from their medication. Everyone is agreed there is a need for the health service to be alert to the over-prescribing of these medications and take action to avoid unnecessary suffering among patients.
‘We are suggesting there is a role that therapists can play here to help fill that gap and have produced this guidance for therapists to use, if they choose, to inform those conversations with clients that many may be already having. Therapists do not need to be “specialists” in order to be helpful. The content of the guidance will allow them to consider whether and how to begin integrating issues related to prescribed drug dependence in their routine practice.’
Why prescribe?
Given that questions about the rising rates of antidepressant prescribing across the whole of the UK and its effectiveness as a response to increased rates of depression have been in the media headlines for many years, how is it that GPs continue to give them out? Professor Helen Stokes-Lampard, outgoing Chair of the Royal College of General Practitioners (RCGP), says in her response to the PHE report: ‘GPs don’t want to prescribe medication long-term unless it is essential... if we are to reverse the prescribing trends outlined in this report, GPs need better access for our patients to alternative therapies in the community.’ There are simply too few alternatives for GPs and their patients, so they reach for the prescription pad.
Bryan McElroy is a GP with a strong interest in mental health who has, for many years, been trying to persuade his fellow GPs to make less use of antidepressants. He is now based in England but previously practised in Ireland, where he undertook a ‘Quality in Practice’ project to research antidepressant prescribing in his locality and piloted an antidepressant prescribing protocol to guide colleagues. The protocol is, essentially, a checklist that ensures the GP has fully explained to patients the benefits, side effects, withdrawal effects and how antidepressants work before prescribing them, to ensure the patient is giving fully informed consent. Disappointingly, he says, use of the protocol resulted in minimal change in his colleagues’ prescribing practices.
McElroy has also written a leaflet he gives to patients that sets out the benefits, risks and alternatives to medication, and concludes by looking at what might happen if they don’t take an antidepressant. According to research, people with mild-to-moderate depression often recover spontaneously within six to eight months without medication, and there is good evidence too that treating depression inappropriately with drugs can do more harm than good. ‘My approach doesn’t work with everyone,’ he says, ‘but I am continually surprised by the number of people who, when we meet again for review, report a significant shift in their mental and emotion wellbeing, without medication.’
He says that a counsellor in every GP practice would make a huge difference: ‘If people could be recommended to see the counsellor first, even before they see the GP, I believe this could reduce prescribing. In the pressure cooker of the GP consultation, with a stressed-out GP and stressed-out patient, turning to antidepressants is a foregone conclusion.’
He also points out that GPs are, in fact, only following NICE guidelines on the management of depression in adults, which until very recently minimised the withdrawal effects from antidepressants. In October, NICE finally conceded to pressure from the APPG, the Council for Evidence-based Psychiatry and the Royal College of Psychiatrists and has removed its previous statement that antidepressant withdrawal is usually mild, self-limiting and resolves within a week. It now warns that, while many people may experience only mild withdrawal, there is ‘substantial variation’ in people’s experience, ‘with symptoms lasting much longer (sometimes months or more) and being more severe for some patients’.
‘Disease model’
The changed guidance from NICE is a major breakthrough, because, as the guidance says, very often symptoms that emerge when an antidepressant is stopped or reduced are seen as a return of the depression, and the response from GPs has usually been to put their patient back on the drug, or increase the dose again. This can lock a person into continuing to take the medication indefinitely, as withdrawal effects tend to worsen the longer a drug is taken and the more times a patient has tried to come off it.
Psychiatrist Joanna Moncrieff, author of A Straight Talking Introduction to Psychiatric Drugs,3 has long campaigned for better understanding of the effects of psychotropic medication on the human brain and to expose the fallacies in the ‘chemical imbalance’ hypothesis. This is the theory that mental ‘illnesses’ arise from reduced levels of particular chemicals (serotonin or dopamine) in the brain. Drug companies have used this unsubstantiated theory to market their psychiatric products, and many GPs still use it to explain to patients how antidepressants work.
Moncrieff describes this as the ‘disease model’, which assumes that psychiatric drugs work by treating an underlying ‘disease’. There is, she points out, no research to support it. By contrast, the drug-centred model, which the guidance adopts, asserts that psychiatric drugs – like any other psychoactive substance – work by producing physiological and psychological alterations that the patient may experience as beneficial. But they do not act on the actual cause of the problem.
Moncrieff has been working for years to raise awareness of this critical difference and the importance of explaining it to patients. Antidepressants, reviews of clinical trials show, are barely if at all more effective than a placebo, and yet we continue to take them, and give them to children, with no good knowledge of what they may be doing to our brains. Says Moncrieff: ‘These drugs are changing the brain in ways we do not understand and never anticipated. We need to wake up to the fact that we are doling out these powerful chemicals when there is no thorough research on the long-term effects and what happens when we come off them. We saw it with benzodiazepines – how people became dependent and how their use could result in lasting physical effects, and it’s the same with SSRIs – they are resetting the brain structure and chemistry in ways we do not understand.’
The PHE report echoes her concerns. It too points to the scarcity of high-quality studies of prescribed medication dependence and withdrawal and says there should be more information for clinicians on prescribing of medicines that can cause dependence or withdrawal, better guidance for clinicians, patients and carers, and more research on the prevention and treatment of dependence on and withdrawal from prescribed medicines.
Moncrieff sees the reliance on prescribed psychiatric drugs as symptomatic of a prevalent attitude towards dealing with life’s problems in society in general, and there’s an essential role for therapists here. ‘The medical profession has created this whole culture whereby people expect medication at times of distress and GPs expect them to expect it. Therapists can help people explore other ways of managing distress. That is really crucial. Putting across other, non-medicalised ways of understanding distress – how our emotions are a response to our circumstances, how we can exert control over them – is important. We can change how we deal with emotions, though maybe not overnight. Highlighting how there are other ways of conceptualising distress and how we respond to it could help to take some of the pressure off doctors and support them when they say an antidepressant isn’t the right way to go and that there are other approaches.’
Facing life’s problems
Independent psychologist Diane Hammersley worked with one of the earliest projects set up to help people come off benzodiazepines, in Birmingham in the 1980s. She knows first-hand how hard it can be to challenge doctors. ‘What you come up against continually is the assumption that medical practitioners know what they are doing and a deference to the medical establishment. If you are therapist in the NHS, your criticisms are not welcome, and if you are outside the NHS, you are discriminated against because you are not “one of us”. I think counsellors are discounted even more.’
She believes therapists should not be afraid to raise the subject with clients, when the time is right: ‘Sometimes people have a lot invested in being ill and needing medication. Some can’t accept that their problem is due to the situation or relationship they are in. It can be shattering to discover why they have such poor self-regard and struggle to maintain an internal sense of self. They may be frightened to come off in case there’s a 1% chance that it is stopping them feeling suicidal.
‘I raise it in the first session when I take their brief history. I always ask about drugs and what they know about them and what they were told about them. I also ask them: “What was happening to you in the three years before you started taking the drug?” It’s a question that I learned in the withdrawal project that made me realise how important it is to address causality. One fifth said it was following a bereavement. So often other factors like death and loss are implicated. Depression is a common defence against loss.’
She thinks a critical understanding of prescribed drugs should be a compulsory element of non-medical psy-professionals’ training. ‘Too often people designing these courses and curricula say it’s nothing to do with us because we don’t prescribe. Yet millions of people are taking these drugs, including our clients.’ It’s not possible for counsellors and psychotherapists to say it’s not an issue for them, she argues.
‘There is a belief that these pills will take away uncomfortable feelings, as if feelings don’t matter. People don’t understand what feelings are for. They are the means by which we interpret reality. But in today’s world there is a cultural expectation that we should only feel the happy emotions and the rest should be got rid of. It’s our role to help people understand it’s OK to feel.’
Rosemary Rizq, professor of psychoanalytic psychotherapy at the University of Roehampton and co-editor of the new guidance, agrees that one of the more challenging areas in therapy is how to explore with clients their emotional reliance on prescribed medication: ‘Drugs are part of the world we live in. What most concerns me is that people are sometimes drawn to the use of psychiatric medication as an easily available answer to some of life’s more complicated problems. Of course, we shouldn’t forget that, for some people, drugs can be useful. They can have an important role in supporting a diagnosis that people feel gives them a place in the world by recognising their suffering. Psychologically, that can be very, very important. But where it shades off into avoiding looking at problems in living, problems in relationships and other more serious emotional problems, then I worry. Not all emotional problems can be solved with drugs.
‘In this guidance, we’ve tried to help therapists by supporting them to work with clients in a way that takes account of their drugs but doesn’t avoid the psychological distress that brought them to therapy in the first place. It’s important to remember that, if all emotional problems could be resolved with a pill, we would surely all be happy by now. And we’re not.’
Catherine Jackson is editor of Therapy Today.
Copies of the guidance and further information can be found at www.prescribeddrug.info
References
1. Guy A, Davies J, Rizq R (eds). Guidance for psychological therapists: enabling conversations with clients taking or withdrawing from prescribed psychiatric drugs. London: APPG for Prescribed Drug Dependence; 2019.
2. Public Health England. Dependence and withdrawal associated with some prescribed medicines: an evidence review. London: Public Health England; 2019.
3. Moncrieff J. A straight talking introduction to psychiatric drugs. Ross-on-Wye: PCCS Books; 2009.