After having children, Jenna Clarke re-entered the workforce. With her husband regularly working away, Clarke was juggling raising a three-year-old and a five-year-old, managing a household and working three days a week with no help. It quickly took its toll.
“Initially, I thought my panic attacks and mood swings were anxiety, but when I stopped wanting to exercise, struggled to get out of bed and became reluctant and fearful of socialising, I knew I needed help,” she says.
Following a 15-minute consultation with her GP, Clarke, who is in her mid-30s, was diagnosed with depression and left the surgery with a script for antidepressants and Valium.
“I’d never felt this way before and the significant change of returning to work correlated exactly with when my symptoms started,” says Clarke.
“The doctor didn’t ask anything about my family history of mental illness, or any questions to differentiate whether my depression was situational or clinical. He just handed over the script and told me to return to exercise.”
When she asked her GP about Medicare’s mental health plan, which subsidises 10 sessions with a psychologist, Clarke was told it wasn’t initially necessary. “I left with a script for drugs I knew little about and no education about the risks or long-term impacts of taking them.”
With the rise in antidepressant use in Australia, it’s fair to assume that Clarke’s story is common.
In 2018-19, 4.3 million Australians were prescribed mental health-related medications (subsidised and under co-payment), totalling 39 million prescriptions. Seventy per cent of these were for antidepressants, predominantly prescribed by GPs.
Such statistics have experts concerned that we’re now in a cycle of overdiagnosis and overmedication.
Dr Grant Blashki, the lead clinical adviser at Beyond Blue, says antidepressants are not for everyone and factors such as age, medical history and a patient’s perception of antidepressants need to be considered.
“Ideally, GPs have partnerships with their patients where together they can explore various psychological treatments, medication and complementary therapies as well,” he says. “While there’s high-level evidence for the benefits of antidepressants for some depression and anxiety conditions, medications need to be prescribed carefully and patients educated on the benefits, risks and side effects too.”
A 2016 paper published in the medical journal Patient Preference and Adherence explored what long-term antidepressant users said about the side effects they had experienced. Sexual problems, weight gain, reduced positive feelings and suicidal ideation were among the key effects.
About 73 per cent of people reported withdrawal symptoms when trying to cease medication and some said they lacked information and support about ceasing antidepressants.
When prescribing antidepressants, there are a number of factors that may present challenges for GPs.
“Full diagnosis doesn’t always happen, and GPs have limited time to distinguish what the patient is suffering,” says Dr Caroline Johnson, spokesperson for the Royal Australian College of General Practitioners (RACGP).
“Large numbers of people present with anxiety and are prescribed medications, but depending on the type of anxiety it is, treatment options are different.”
Juggling patient preferences also plays a role. Johnson notes that some prefer counselling, some like medications, some want both. Sometimes it’s about cost or convenience and social factors that affect people’s care. “I don’t think we have any hard evidence to support overprescription of medications, but it’s certainly a valid hypothesis,” she says.
So, do health professionals need more guidance when it comes to antidepressants and the bigger picture?
Professor Jane Gunn, of the faculty of medicine, dentistry and health sciences at the University of Melbourne, thinks so. In 2019 she received funding to develop an intervention that will guide GPs and other health professionals on their management of antidepressants, as well as monitoring usage and overprescribing.
The WiserAD project aims to help GPs and patients make decisions about how and when it’s safe to reduce or cease medications.
“As Australians, we are large consumers of antidepressants – one of the largest groups of users worldwide,” she told newsGP. “Whilst we have good resources to assist with commencing antidepressants, we do not have resources to support GPs and patients to decide whether and when to cease using antidepressants.
“… It is vital that we build a strong evidence base to guide our practice, as starting and stopping medications are decisions that impact greatly on our lives and should not be made lightly.”
While antidepressant usage and management need to be addressed, other areas of mental health care do too.
A recent RACGP “Health of the Nation” report found that psychological consultations are GPs’ most common consultations. However, a number of limitations mean that overall mental health plans are not being offered.
Earlier this year, the Department of Health issued a letter to 341 GPs querying their billing over mental health items, such as treatment plans, alongside normal consultation items.
Under Medicare Benefit Schedule (MBS) rules, GPs should not claim normal consultation items if a patient has initially attended for a mental health item, unless it is “clinically indicated that a separate problem must be treated immediately”.
“The government is doing this because they don’t want GPs to bill inappropriately or double dip,” says Johnson. “But the perception from the profession is that physical and mental health care shouldn’t be integrated. That’s a challenge that undermines the ideal of quality care and the idea that people shouldn’t just get a script and head out the door.”
Johnson says the financial incentives for GPs to offer mental health treatment plans are significantly less than those for managing chronic physical illnesses.
“Obviously GPs don’t make clinical decisions based on how they get paid, but financial incentives do drive practice and it’s a concern to me that we don’t get enough reward and recognition under the MBS for the time it takes to do quality mental health care.”
RACGP president Dr Harry Nespolon criticised Medicare’s compliance push and more than 700 GPs have signed a petition calling for this compliance campaign to end. An outcome is pending. However, the RACGP indicated many compliance activities had been suspended by the Department of Health due to the pandemic.
Aside from the billing issue, Johnson notes that GP training is in place to provide better care for mental health patients. “GP training has been introduced, with specific standards for mental health care, and 90 per cent of GPs have done this training,” she says.
“Whether it changes practice when there are all these other issues going on which relate to complexity of diagnosis in a certain context and the system and how it funds healthcare, education is only one part of the puzzle.”
Following her consultation, Jenna Clarke researched the side effects and withdrawal symptoms of antidepressants and subsequently decided not to take them. “I was too afraid to commit to medication for any extended period of time when I felt like I was just having a hard time and needed short-term help,” she says.
Lifestyle changes helped her get through and she has not looked back. Her thoughts on GPs and overprescription, however, remain unchanged.
“I believe that GPs are absolutely too quick to prescribe meds for mental health issues,” she says. “More collaboration is needed between GPs, mental health professionals, government and mental health industry bodies to better qualify and diagnose patients in the limited consultation times.
“It would, in the very least, qualify whether further consultation is required and might assist in determining whether a patient’s symptoms are clinical versus situational.”
This article was first published in the print edition of The Saturday Paper on Jun 27, 2020 as "High anxiety".
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