Patient perspectives of cost and quality in relation to treatment with antidepressants

1
Patient perspectives of cost and quality in
relation to treatment with antidepressants

• Janet Grime
• Kristian Pollock

2
Introduction

• Spending on antidepressants is increasing

3
NSF Roy Coll Psych

• 30-50 depression undiagnosed in primary care
• GPs better at recognising severe depression
• Antidepressants are an effective treatment
• There may be over prescribing

• Depression is a self limiting illness (8 months)
• Antidepressants are used to treat moderate to
  severe depression
• After 3 months 50-65 of patients will be much
  improved compared with 25-30 on a placebo
• Many psychotherapies are as effective over 12
  months

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Method

• Qualitative interview based study
• 19 GPs and 2 practice counsellors
• 32 patients with mild to moderate depression
  recently diagnosed/treated. Second interview
  after six months
• 30 members of Depression Alliance
• Thematic analysis facilitated by use of NUDIST

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GPs Patients

• Little/no mention of cost
• SSRIs mainly prescribed less toxic in overdose,
  cleaner , better
• Safe, effective

• Little/no mention of cost
• Little reference to quality of different types of
  antidepressant

6
Patients attitudes to antidepressants

• Range of attitudes initially
• 4 hoped for an AD
• No position - take doctors advice
• Resistant to ADs specifically or medicines in
  general
• Contest diagnosis
• Tendency to change attitude in light of
  experience whatever initial position

7
Hard to determine the cause of recovery

• I suppose I didnt feel happy taking them
  really, you know perhaps I thought I didnt know
  how much control they were having over me, you
  know how effective were the other (self help)
  things that I was doing or whether it was the
  tablets that were sort of making me feel better.
  (Patient 309, second interview)

8
Little/no felt effect of ADs

• I didn't ever when I was on the Prozac, feel
  that erm--happy, smiley, jolly or anything like
  that. In fact in many respects I can't actually-
  it obviously did affect me and it obviously did
  stop me feeling so incredibly low but I can't
  actually say that I noticed anything--fantasticall
  y you know. (Patient 310 second interview)

9
Feeling uncertain fear of stopping - becoming
dependent

• She (GP) did say not to rely on them, she
  doesnt want me to become dependent on them, it
  feels like --- I dont think like in an addiction
  sense, but its like the fear of coming off them
  and what I am going to face when I do because I
  mean you cant feel them working in a sense. Ive
  not experienced any euphoria or anything like
  that, so I dont really know if they are working.
  I just know that Im getting better and Im
  wondering whats causing it. The fear of coming
  off them in case it all sinks back again, I just
  dont want to go through that again I really
  dont. (Patient 407)

10
Changed perception of addiction to psychological
dependency

• A Well, he (GP) was insistent that it was
  discussed, it's insisted on the packet, you know,
  they're not addictive-
• Q They're not?
  
• A But how you become addicted to something is an
  interesting one in itself isn't it?
  
• Q Yes?
• A You know, nicotine isnt but it becomes it
  doesn't it, I would not, I hope I will have the
  strength and the emotional support around me and
  wherever I get it eventually to not need these
  things. (Patient 301)

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Cost of psychological dependency

• Changed view of self and how others see you
• I just feel it is not really you, is it, if you
  have to get through each day by taking pills
  really. It is not really me. Whereas if I had a
  physical thing I had got to take it for, I would
  need to take those to live sort of thing just to
  keep the symptoms at bay or whatever.
• I know it is the same, but I cannot think about
  it the same. (Patient 312)

12
Most GPs were not aware of dependency

• I don't feel that I have been able to talk to
  him (GP) enough to say, "Look, I am going to have
  to accept that I do get these lows and I know
  that once I start taking the tablets I start to
  feel better but I don't want to suddenly think
  yes there is going to be a crisis coming up in my
  life and I can't cope so I had better go and get
  these (antidepressants.) (Patient 410)

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Vicious circle

• 1. Dependency affected
• Self esteem
• Social functioning and relationships
• Long term goals and aspirations
• 2. Increased vulnerability to reoccurrence
• 3. Medical response to return of symptoms was to
  re-prescribe antidepressants

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Discussion

• Question widespread use
• Users and anti-psychiatry movement
• Debate about efficacy
• Speed up recovery
• Monetary cost (cf PPIs)
• Personal cost
• ADs creating need (cf psych therapies)

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Conclusion

• 1. GPs need to be more aware of problems as well
  as benefits of ADs for a substantial number of
  patients, to adequately inform so--
• Patients can make a reasonably informed choice,
  in balancing the personal costs as well as the
  benefits of taking ADs versus other available
  treatment/support at least as a first, second or
  even third resort, before prescribing
• Need to take account of patient preferences, but
  our evidence suggests that few patients consult
  in the desire or expectation of being prescribed
  ADs. Many are not even thinking in terms of
  taking drugs or suffering from depression
  albeit many are also willing to go along with
  their GPs advice. Patients dont like taking
  medicines in general, and ADs in particular.