“Keep the antidepressant gun in the holster”

Keep the antidepressant gun in the holster – Prof Bruce Arroll

November 2019

Bruce Arroll is Professor of General Practice and Primary Health Care at the University of Auckland and a practising GP. He has a particular interest working with patients to find ways of addressing depression and anxiety without prescribing medication too quickly – ‘Talk first and prescribe later’. This mirrors a Choosing Wisely approach – with a focus on discussing lifestyle and other options with patients rather than rushing to give them antidepressants.

Prof Arroll says doctors need to remember that they may be seeing people on the worst day of their life.

“We shouldn’t be giving diagnoses at that point; we should be giving people more time and more visits. I rarely give labels like anxiety or depression now – labels are unhelpful and can be harmful. I refer to the patient as being distressed. I generally let patients go three or four weeks and if they’re not getting better – if their mood scores are staying elevated – then I’ll have the discussion about medication.”

His message to primary care clinicians is to ‘keep the antidepressant gun in the holster initially’.

“Just wait and see. Most of the time in primary care we are not dealing with seriously sick or depressed people. At least 40 percent of people will be better within a couple of weeks just by the use of behavioural activation.

“Behavioural activation is about getting people doing things. It is easy to shrink down into your world when you get distressed – that is a natural human reaction under stress; but the solution then becomes the problem.”

One of the risks of medication is overdose, he says.

“Doctors worry the patient may harm themselves if they don’t get pills – well there’s a flip side to that. The patient may swallow their pills and overdose – I’ve had that happen. I literally had to take my pills out of my patient’s stomach in Canada when I was working there – we ran the local emergency room.”

Another harm is the difficulty of withdrawing from medication, particularly from SSRIs (selective serotonin reuptake inhibitors).

“There are well described withdrawal syndromes. It feels like the bad feelings are coming back, so the temptation is to go back on the medication. But it’s not the bad feelings coming back, it’s just the withdrawal stage.”

He says he’s not against medication for depression or anxiety, but it shouldn’t be the first thing to go to in primary care (he stresses this is quite different to what may be required in psychiatric outpatients where the patients have been sicker for longer). It’s also important to remember that only a small percentage of people actually benefit from antidepressants.

“The absolute benefits of medication range from 25 percent for severe depression through to about 6 percent for mild depression. Most people we see in primary care are in the 6-11 percent range.

“Unless you are particularly concerned about the patient – they are very, very flat and have been like that for a very long time, or they’ve tried things and haven’t felt better – there are other things you can do before prescribing medication. Most people are better catching up with friends, exercising, sleeping, eating better and doing activities – most will feel better within a week or two.”