Prescribing Review - Drugs Used in Mental Health


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Mental Health

Mental health problems affect around 300 people out of every 1,000 in Britain each year. Mental health problems can often be difficult to diagnose because the range and severity of symptoms can vary between individuals and these symptoms could also relate to more than one disorder. Mixed anxiety and depression is the most common problem, experienced by approximately 9% of adults in Britain, followed by general anxiety in 5% of adults.¹ One person in 250 will have a psychotic illness at any one time such as schizophrenia or bipolar affective disorder.² Prescribing of antidepressants and atypical antipsychotics has gradually increased over the last 5 years (Chart 1). The increased spending on mental health drugs has also been driven by these two groups, however recently the cost of antidepressant prescribing has started to fall due to price decreases for selective serotonin re-uptake inhibitors (SSRIs) (Chart 2).

Depression

An average GP will see between 60 and 100 people with depression each year³ and more than 80% of patients with depression are cared for solely in primary care.⁴ However, around half of all people with depression in the community do not present to their GP.⁴ It is important to distinguish between "normal" mood changes which occur during everyday life and usually just require support and reassurance and those symptoms which are sufficiently prolonged or persistent to require more active management.³ The NICE guideline makes recommendations for the treatment and management of depression based on the classification of symptoms as mild, moderate or severe using the International Classification of Mental and Behavioural Disorders (ICD-10).

'Watchful waiting' is recommended for patients with mild depression who in the opinion of the healthcare professional may recover with no intervention, or for patients who do not want an intervention.⁴ Guided self-help or exercise may help many patients with milder depression. If these methods fail to produce an adequate response in milder depression then antidepressant drugs and psychological therapies can be offered.⁴ Computerised cognitive behavioural therapy (CBT) may be useful in patients with mild or moderate depression, the updated NICE technology appraisal on computerised CBT is due for publication in November 2005.

In moderate to severe depression antidepressants are suitable treatment and they are as effective as psychological intervention.⁴ Choice of antidepressant drug depends on past experience of treatment, patient choice, side effects and in more severe depression, the risk of suicide. SSRIs are recommended as suitable for first line use because they are as effective as tricyclic antidepressants (TCAs)⁴ and less likely to be discontinued due to side effects. Venlafaxine should only be initiated by specialist mental health practitioners including GPs with a Special Interest in Mental Health.⁴ If the first antidepressant tried is poorly tolerated or ineffective it should be stopped (usually if there has been no response at all after one month). After consideration of a range of other treatment options if a further antidepressant drug is decided upon then a suitable second choice would include a different SSRI or mirtazapine. Other second line alternatives for consideration are TCAs (excluding dosulepin), moclobemide or reboxetine.⁴ Patients who are younger than 30 years or considered to present with increased suicide risk should normally be seen after 1 week when started on antidepressant treatment and frequently thereafter as appropriate until the risk is no longer considered significant.⁴

Children (aged 5 to 11 years) and young people (aged 12 to their 18th birthday) who experience mild depression, which continues after up to 4 weeks of watchful waiting, should be offered one of either individual non-directive supportive therapy or group CBT or guided self-help for a limited period.⁵ Antidepressant drug treatment should not be used in these age groups for mild depression. For moderate to severe depression in children, psychological therapy should be offered first-line (for at least 3 months). If there is no response after this time then following multidisciplinary review, either one of the other psychological therapies or additional psychological therapy for the parent or family members could be tried. Fluoxetine can also be considered at this stage for patients aged 12 to 18 years, although it is not currently licensed for use in this age group. Paroxetine, venlafaxine and tricyclic antidepressants should not be used in children and young people.⁵

Anxiety and insomnia

Anxiety disorders are common, chronic and often go unrecognised and untreated.⁶ They include generalised anxiety disorder (GAD) and panic disorder. For people with panic disorder any of the following interventions are suitable: psychological therapy, antidepressant therapy and self-help.⁶ Suitable antidepressants for the long term management of panic disorder are SSRIs (if licensed for panic disorder) and TCAs. Benzodiazepines, sedating antihistamines or antipsychotics should not be prescribed for panic disorder.⁶ For immediate management of GAD the use of any or all of the following are suitable: benzodiazepines, sedating antihistamines, problem solving and self-help. Benzodiazepines should usually only be used for 2 - 4 weeks and if longer-term treatment is required then CBT, antidepressant drugs and self-help should be tried.

Non-pharmacological measures should be considered first for treatment of insomnia. Hypnotic therapy should only be considered where insomnia is severe and interfering with normal daily life.⁷ The newer hypnotics (zaleplon, zopiclone and zolpidem ("Z drugs")) are only indicated for short-term use in insomnia when it is severe, disabling or subjecting the patient to extreme distress. There is no good evidence to show that the newer drugs are more clinically effective, have less adverse effects or a different potential for dependence and abuse than short-acting benzodiazepines, and choice of hypnotic should be dependent on cost-effectiveness.⁷ Chart 3 shows the variation in prescribing across Strategic Health Authorities for hypnotics and anxiolytics. There are still concerns about the excessive use of benzodiazepines, although their prescribing has decreased. Overall the newer hypnotics are increasing in proportion and the quantities used often suggest long-term treatment.⁸ Positive outcomes have also been seen with CBT use for insomnia and this should be considered when addressing National Service Framework recommendations for benzodiazepine use and the needs of patients with long-term sleeping problems.⁹

Schizophrenia

Symptoms of schizophrenia usually develop in early adult life and 1 in 100 people will develop schizophrenia in their lifetime.¹⁰ The atypical antipsychotics are usually better tolerated than typical antipsychotics, however, adverse effects such as weight gain, hyperglycaemia and occasional diabetes can be problematic. Olanzapine and risperidone have also been associated with increased risk of stroke particularly for elderly patients with dementia.¹¹ Randomised controlled trials have found no clear difference between adverse effects or symptom control for the following atypicals: olanzapine, amisulpride, risperidone and clozapine.¹⁰ A recent trial in 1,493 patients compared perphenazine to the newer atypical drugs to establish overall effectiveness for each of the drugs in an 18 month period.¹² Inefficacy or intolerable adverse effects meant that most patients discontinued their treatment before 18 months. The efficacy of perphenazine appeared similar to the atypical drugs but was associated with more discontinuation due to extrapyramidal effects. Olanzapine had the lowest rate of discontinuation, when it was stopped this was because of weight gain or metabolic ef fects.

Prescribing Data

Prescribing of antidepressant drugs has increased by 36% over the last 5 years to 7.3 million items (quarter to June 2005), cost has increased by 20% to £91 million. SSRIs account for half of all prescribing and cost for antidepressant drugs. Prescribing of SSRIs has increased by 45% in the last 5 years whereas cost has decreased by 8%, this is mainly due to decreases in price for fluoxetine and paroxetine. Fluoxetine prescribing has increased by 22% to just over 1 million items at a cost of £3.5 million per quarter. Citalopram prescribing has more than doubled in the last five years to 1.2 million items (17% of all antidepressant items) costing £17.6 million, quarter to June 2005. Prescribing of paroxetine has decreased by 38% over the last 5 years to 0.52 million items at a cost of £8 million per quarter. Prescribing of sertraline has increased to 0.45 million items at a cost of £12.1 million per quarter. Prescribing of tricyclic and related antidepressants has remained fairly static over the last 5 years at 2.5 million items, £12.7 million per quarter and this group accounts for 35% of all antidepressant prescribing and 14% of cost. The majority of other antidepressant prescribing is for venlafaxine with 0.68 million items (9% of all antidepressant items) costing £23.3 million, quarter to June 2005.

Prescribing of anxiolytics has remained constant over the last 5 years at nearly 1.5 million items per quarter, however cost has risen by 47% to £3.5 million. Diazepam is the most commonly prescribed anxiolytic (1.1 million items, £1.7 million, quarter to June 2005). Hypnotic prescribing has also shown little change over the last 5 years at 2.5 million items per quarter, while cost has decreased by 20% to £5.6 million. Zopiclone is now the most frequently prescribed hypnotic with almost 1 million items (39%) at a cost of £2.4 million (43%) followed by temazepam with 0.86 million items (35%) at a cost of £1.0 million (19%).

Prescribing of atypical antipsychotics has increased 3-fold over the last 5 years and now accounts for 61% (0.83 million items) of all antipsychotic prescribing and 95% (£46.2 million) of cost. Olanzapine is the most frequently prescribed atypical (0.33 million items, £24.5 million, quarter to June 2005), closely followed by risperidone (0.25 million items, £9.1 million). Chlorpromazine is the most commonly prescribed typical antipsychotic with 0.15 million items costing £559,000.

REFERENCES

1. Office for National Statistics. Psychiatric morbidity among adults living in private households in Great Britain. 2000
2. National Service Framework for Mental Health: Modern Standards and Service Models. September 1999. www.doh.gov.uk/nsf/mentalhealth
3. National Prescribing Centre. The management of depression in primary care. MeReC Briefing 2005; 31
4. National Institute for Clinical Excellence. Depression: Management of depression in primary and secondary care. Clinical Guideline 23; December 2004
5. National Institute for Health and Clinical Excellence. Depression in children and young people. Clinical Guideline 28; September 2005
6. National Institute for Clinical Excellence. Anxiety: Management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. Clinical Guideline 22; December 2004
7. National Institute for Clinical Excellence. Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia. Technology Appraisal 77; April 2004
8. National Prescribing Centre. Benzodiazepines and newer hypnotics. MeReC Bulletin 2005; 15: 17-20
9. Morgan K, Dixon S, Mathers N, Thompson J, Tomeny M. Psychological treatment for insomnia in the regulation of long-term hypnotic drug use. Health Technology Assessment 2004; Vol 8: No. 8
10. Nadeem Z, McIntosh A, Lawrie S. Schizophrenia. Clin Evid 2004;12:1500-1531
11. Duff G. Atypical antipsychotic drugs and stroke. Message from Professor Gordon Duff, Chairman, Committee on Safety of Medicines. March 2004
12. Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO et al. Effectiveness of antipsychotic drugs in patients with schizophrenia. New Engl J Med 2005; 353: 1209-23

• "Watchful waiting" (a follow up appointment within two weeks) is recommended for patients who may recover from mild depression with no intervention or who do not require one.
• Patients with mild and moderate depression may benefit from computerised cognitive behavioural therapy.
• In moderate to severe depression antidepressant drug choice should be based on risk of side effects, patient preference, past experience of treatment and risk of suicide.
• Insomnia should be treated using non-pharmacological measures first, hypnotic therapy should only be considered where insomnia is severe and interfering with normal daily life.
• Adverse effects such as weight gain and hyperglycaemia are associated with atypical antipsychotic drugs, however the atypicals are usually better tolerated than the typicals because they have fewer extrapyramidal side effects.