Antidepressants: The real story behind their increase in use and the side-effects
It's 26 years since the antidepressant Prozac was launched on the Irish market. It was hailed as the "sunshine drug" and it heralded a medical - and cultural - revolution.
According to Aware, a voluntary organisation that supports people through depression, 450,000 people in Ireland (one in 10) will suffer from the "black dog" at any one time.
Depression wasn't common parlance in Ireland prior to the launch of Prozac. Irish people were more inclined to say that they "suffered with their nerves" or concede that "Mammy had taken a turn".
If they presented to a GP, they may have been prescribed a "first generation" antidepressant such as a TCA (Tricyclic Antidepressant) or an MAOI (Monoamine Oxidase Inhibitors).
In more serious cases, Lithium may have been prescribed for manic depression (now known as bipolar disorder).
These drugs were largely effective, but caused many unwelcome side-effects such as constipation, difficulty sleeping and shaking/trembling.
Prozac soon ushered in the "second generation" of antidepressants - along with a new generation of mass marketing.
This family are known as SSRIs (Selective Serotonin Reuptake Inhibitors). Today they are the most-widely used - and widely criticised - class of antidepressant, closely followed by the "third generation" SNRIs (Serotonin Norepinephrine Reuptake Inhibitors).
SNRIs were developed to be more effective than SSRIs, but empirical and anecdotal evidence doesn't always bear this out. GPs also prescribe these classes of antidepressants for social anxiety disorder and post-traumatic stress.
Many more SSRI antidepressants have entered the ever-expanding market since the late Eighties.
According to the HSE PCRS report 2012, the top five most commonly prescribed in Ireland are Escitalopram (Lexapro), Citalopram (Celexa), Sertraline (Zoloft), Fluoxetine (Prozac) and Paroxetine (Paxil). And supply most definitely meets demand.
Prescription rates for SSRIs in Ireland have escalated to an alarming degree. The State spent almost €40m on 2.3 million prescriptions for the most popular SSRIs and anti-anxiety medications in 2012, covering 330,000 patients.
"In Ireland it is estimated that as many as one in 10 people are on antidepressants at any time (some estimates put this at one in five)," says Dr Charlotte Blease, an Irish Research Council Postdoctoral Fellow at the School of Philosophy, University College Dublin.
"In Northern Ireland things are even worse: they are one of the world's leaders in prescription medication (twice as many people are prescribed these drugs compared to the rest of the UK).
"This is a serious issue," she continues. "By 2020 the World Health Organisation estimates that depression will be the leading cause of disability in the world."
This figure dovetails with Dr Blease's more conservative estimate, though other reports show that prescription rates differ across geographical regions. In Limerick, for example, 10pc of the total population was prescribed anti-anxiety pills or anti-depressants, the highest percentage in the country, in 2012. The percentage was lowest in Dublin South at 4.3pc.
Are these drugs being over-prescribed?
Dr Terry Lynch
"Antidepressants have a place, but they are over-used," says psychotherapist and author Dr Terry Lynch.
"These issues are primarily emotional and psychological, so the first response should be emotional and psychological, with the proviso that medication is available if needed.
"While there are of course physical aspects to depression, what is diagnosed as depression is primarily a collection of emotional and psychological issues. A major concern of mine, at a more global level is how we as a society deal with emotional and psychological distress and how people's experiences and behaviours are interpreted.
"I also have concerns about the level of understanding GPs have about these issues. I'm in the mental health field for 15 years and I was a GP for a further 12 years, and I'm not convinced that doctors understand what they are dealing with."
Side-effects, contraindications and withdrawal processes also need to be better outlined.
"SSRIs need to be reduced slowly, in small increments," continues Dr Lynch. "This process may need to take several months. Patients are likely to experience an increase in emotions and tearfulness. When a person stops, they may feel fine for a few weeks and then they feel the emotions beginning to come up.
"We generally advise people not to withdraw from antidepressants during stressful or emotional periods, or at uncertain times such as during a house move or a new job."
The HPRA (formerly the Irish Medicines Board) "continually urges patients and caregivers to read the patient leaflet which accompanies their medicine as it contains important information on the safe use of that medicine, including what it treats, dosing information, storage information as well as pre-cautions and known side-effects".
Dr Terry Lynch's latest book, Depression Delusion Volume One: The Myth of the Brain Chemical Imbalance, will be available by September