The prescribing of anti-depressants by GPs in England accelerated during the period 2008 to 2012, rising from 29 million items to 40 million items. With the start of the financial crisis in 2008, it would be easy to conclude that prescribing has gone up to deal with depression triggered by changes in economic circumstances, specifically unemployment and deprivation. However, our report suggests a more complex and nuanced picture than this initially suggests.
We looked at the period from 1998 to 2012 to see whether prescribing rates changed at different rates. As the chart below shows, prescribing rates increased throughout the whole period, with an average increase of 7.2% per annum over the whole period.
However the rate of increase went up from 6.7% in the years up to 2008 to 8.5% in the period 2008 to 2012 meaning, a further 2.7 million antidepressants were prescribed in 2012 over and above what would have happened if the trends up to 2008 had continued. Interestingly, since 2009 increases in prescribing are much higher than the changes in the number of cases of depression recorded by GPs in the Quality and Outcomes Framework (QoF).
Figure 1. trend in prescribing of antidepressants in England, expressed as a total count, and as a proportion of all items prescribed (1998 - 2012).
However, when we looked at rates of unemployment and deprivation from 2010, we found less clear associations with prescribing by GPs.
While there was some initial association between antidepressant prescribing and rates of unemployment and poorer housing conditions in 2010/11 and 2011/12, the effect of unemployment was weaker in 2012/13. However, one thing we know is that unemployment was less affected in this recession than in the recessions of 1984 and 1990. At its peak, the unemployment rate in 2008 was lower than either of those recessions. Focusing on the unemployment rate alone may explain why our analysis did not show a more persistent effect on prescribing by the recession.
So could the recession still explain the increase in prescribing levels?
First, our research focused on unemployment, but there is evidence to show that the phenomenon which had a more marked impact is that of underemployment. Research has shown that increases in zero hour contracts and casual employment have been much more far-reaching in this latest financial crisis than straightforward unemployment. The precarious nature of these types of employment has been shown to have negative impacts on mental health, potentially leading to individuals seeking help for anxiety and depression.
Second, the election of the coalition in 2010 ushered in austerity Britain. Our analysis showed higher prescribing rates by GP practices with higher proportions of women and of people over 65. One observation about the cuts is that they have had a disproportionate impact on women and it would be interesting to know if the two are related.
It also raises questions about whether cuts in the provision of social care services have affected those women over 65 who either need care, or who have stepped in as unpaid carers to fill the gap which would have been filled by formal care services. Unpaid carers have been found to suffer higher levels of anxiety and depression.
So the recession could well be the cause behind increases in prescribing practices, but the data we would need to demonstrate some of these effects are simply not available.
What other factors could explain variation?
So the jury is still out on the impact of the recession on antidepressant prescribing and the general mental health of the population since 2008. To use that well worn phrase “more research” and better data are needed to fully understand all of the complexities of the issue.
Further research also needs to look at factors on the ‘supply’ side. Our report uncovered strong links between levels of antidepressant prescribing and different GP practices and the attributes of the GPs themselves. As we often find there was wide variation in the prescribing habits of individual GP practices and regional areas.
These elements of our findings will be the subject of a series of guest blogs from the Nuffield Trust and the Health Foundation in the forthcoming weeks.