A very interesting piece of information recently published in the Australian and New Zealand Journal of Psychiatry may show just what an impact psychologists have on the mental health of Australians. The study, conducted by Atlantis, Sullivan, Sartorius and Almeida (2012), reviewed Australian National Health Survey data on over 48,000 adults and found that although “the prevalence of psychological distress was relatively stable (3.9 vs. 3.7%) between 2001 and 2008, ... in contrast, the use of antidepressants or anti-anxiety medications decreased from 7.3 to 4.8%” (p. 445). The authors contend that “practitioners may have been relying less heavily on the use of these agents to manage psychological distress in the community because of the mental health care reforms initiated in 2001 and 2006 which provided better access to psychological treatments” (p. 453). The authors do note other possible influences on prescribing practices over this period, including efforts to reduce the stigma associated with the symptoms of depression and a heightened focus on safety and efficacy concerns. The results, however, are striking.
Although the study showed a recent reduction in antidepressant prescribing, according to the Australian Institute of Health and Welfare's biennial report card, Australia's Health 2010, there were still 12.3 million prescriptions written for antidepressants in 2008-2009. Spending on mental health medications in 2008-2009 accounted for 10 per cent of the total cost paid out by the Pharmaceutical Benefits Scheme (PBS) and by the Repatriation PBS, a figure of $743 million – or $34 for every Australian.Of the PBS supply of antidepressants, more than four in five prescriptions are written by general practitioners, with the most prominent type of depression treated being ‘chronic mild depression’ (McManus et al., 2003). These trends are worse in the United States, where antidepressants are the second most commonly prescribed drugs of all, only exceeded by drugs used to lower cholesterol. According to industry data (Smith, 2012) the use of psychotropic drugs by adult Americans increased 22 per cent from 2001 to 2010, with one in five adults now taking at least one psychotropic medication. In 2010, Americans spent more than $11 billion on antidepressants.
‘Doing the same thing over and over again and expecting different results’ is the very definition of insanity according to Albert Einstein, thus it is perhaps time to re-think whether more prescribing is the real answer to our burgeoning mental health problems. Clearly the unqualified success of the Better Access initiative, enabling greater community access to psychological services, is showing the way ahead.
A number of recent studies have indicated that the exclusive use of antidepressants, as the silver bullet in the treatment of depression may be overstated. Professor Mark Olfson, Professor of Clinical Psychiatry at Columbia University (Olfson & Marcus, 2009) takes the view that antidepressants, paradoxically, are both under-prescribed and over-prescribed in the US. He contends that many adults with major depressive disorder go for a long time without receiving treatment, yet many people who suffer from mild depression are being prescribed antidepressants and may be unlikely to benefit from the drugs.
A number of meta-analytic studies of the antidepressant efficacy literature have revealed that the treatment efficacy of the selective serotonin reuptake inhibitors (SSRIs) may be somewhat less than has traditionally been asserted. In these studies, placebo effects constituted a major portion of the measured improvement noted, and studies which reported large effect sizes for medication also had large effect sizes for placebos.
The meta-analysis undertaken by clinical psychologist and researcher Irving Kirsch is a particular case in point (Kirsch et al., 2008), which studied the complete data sets from all trials of SSRI medications (published or not) submitted to the US Federal Food and Drug Administration. Data on fluoxetine, venlafaxine, nefazodone (now withdrawn), paroxetine, sertraline and citalopram (SSRIs) was obtained and 47 trials (randomised, double-blind, placebo-controlled) were identified. The patients had all been diagnosed as suffering from unipolar major depressive disorder using DSM criteria and the inclusion criteria required ≥70 per cent completion rate over the 6-week trials (treatment efficacy with the SSRIs is generally achieved within 2-4 weeks following commencement). The weighted mean improvement on the Hamilton Rating Scale for Depression was 9.6 points in the drug groups and 7.8 with placebo. The authors observed that this level of treatment effect does not meet the three point drug-placebo criterion for clinical significance advocated by the UK National Institute for Clinical Excellence (NICE).
Interestingly, the amount of improvement was a function of baseline severity, with those at the lowest and highest levels of depression experiencing smaller gains whereas those in between demonstrated larger gains. Kirsch and colleagues noted: “the overall effect of new-generation antidepressant medications is below recommended criteria for clinical significance. We also find that efficacy reaches clinical significance only in trials involving the most extremely depressed patients, and that this pattern is due to a decrease in the response to placebo rather than an increase in the response to medication”(p. 265). Findings from the more recent meta-analytic study conducted by Taylor et al. (2011) indicated a slightly more powerful effect (pooled standardised mean difference was 0.34).
As every psychologist knows, medication is not the only or necessarily the best way to treat depression and anxiety. The cognitive behavioural therapies have long been demonstrated to have equivalent or better efficacy than psychopharmacology alone, without the serious risks of side effect and with a lower incidence of relapse.
A recent review in the prestigious journal Nature Reviews Neuroscience (DeRubeis, Siegle, & Hollon, 2008) began by reconfirming the well replicated evidence that cognitive therapy and antidepressant medications have comparable short term effects (i.e., at 8 and 16 weeks). Phase two of the study followed up those patients who had responded to antidepressant medication (ADM) or cognitive therapy (CT). The patients who responded to ADM were randomly assigned to either continue medication for one year or were changed to placebo for one year. Patients who responded to CT were allowed three further sessions of CT during the one year continuation period. In a follow-up period none of the patients received any treatment. The data clearly demonstrated that prior treatment with CT protected against relapse of depression at least as well as did the continued provision of ADM and better than ADM treatment that was subsequently discontinued. Thus CT fundamentally changes the trajectory of the disease, diminishing the likelihood of relapse.
The application of combined therapies (i.e., pharmacological and psychotherapeutic) as the best possible treatment regimes for our clients leads to consideration of prescribing rights for psychologist practitioners following the appropriate additional training.
The unmet need for mental health services is tremendous (and failing to treat mental health disorders is tremendously costly). There is a severe shortage of psychiatrists in Australia, and this is not going to change any time soon. Primary care physicians, who prescribe the majority of psychotropic drugs, are overburdened and unfairly expected to treat all their patient's mental health problems (although admittedly aided significantly and successfully by the Better Access initiative). As the inevitable consequence of this situation, medications are being over-utilised and other treatments are less effectively utilised, leading to burgeoning pharmacy costs. Patient care is often fragmented, and therefore inadequate, and as a result proves to be much more costly.
Psychologists already frequently collaborate with physicians regarding psychotropic medication dose, type or toxicity, and often monitor medication effectiveness and side effects. The possibility of a psychologist having prescribing privileges could mean increased access to the public of well trained professionals who are able to effectively prescribe psychoactive medications. This may be particularly important for psychiatrically under-serviced areas such as rural areas and in prisons. Many other non-medically trained healthcare providers have the legal authority to prescribe. This includes dentists, podiatrists, optometrists and advanced nurse practitioners. Prescribing authority of varying kinds currently exists for specifically trained psychologists in Guam and three states of the US (Louisiana, Oregon and New Mexico). The limits of prescribing authority, and the education, training and supervision required to gain accreditation as a prescribing psychologist varies across states and countries.
While general practitioners use medication as their customary and primary mode of treatment, psychologists would be able to evaluate client needs more effectively and would only prescribe when necessary. Psychologists’ prescribing privileges could lead to superior treatment integrating psychotherapy and pharmacotherapy (which has been the experience in Louisiana). In fact, in those areas where psychologists have this privilege, it has been the experience that prescribing rates diminish significantly. The ability of psychologists to remove clients from medications when suitable may be beneficial for the client, and the provision of psychotherapy and pharmacotherapy from one provider can create greater continuity of care and convenience for the client.
Clearly, the contributions of psychologists through the Better Access initiative has fundamentally changed the Australian landscape with regard to mental health outcomes, and I believe that a next step should be to at least consider the possibility of the right to prescribe as well as the right not to prescribe.