Welsh Government Response to Withdrawal Petition

For Context to this post – See Welsh Senedd Withdrawal Seminar and Welsh and Scottish Petitions on Antidepressant Dependence.

From Stevie Lewis

Dear All,

At the back end of last week I received the Welsh Government’s response to the Petitions Committee’s recommendations – see HERE.

As you’ll see from the attached, they have accepted 9 of the 10 recommendations. Accepting the majority is extremely positive. Also the Government accepts, finally, there is a difference between substance misuse and therapeutic drug use, and also that antidepressants cause withdrawal. Believe me, based on all previous correspondence I’ve had with Vaughan Gething’s team on the subject, this is a huge step forward and they can’t wriggle out of these statements we now have in the public domain.

They rejected only the one recommendation, requesting a national prescribing indicator for antidepressants. Still work to be done there.

My comments on the Government’s response will go to the Committee Chair, Janet Finch-Saunders, who will open and close the debate on Wednesday afternoon.

Despite accepting all these recommendations, when you look into the detail it is hard to see how things are going to change. The Government only has the existing guidelines to work with and quote back to us! Much of it seems to hang on the two forthcoming updated NICE guidelines on depression, and on antidepressant prescribing and withdrawal. We are in limbo until we have the detail of those to work with

Small but important fact I discovered from the petitions clerk – they have received hundreds of petitions since this Assembly started in 2016, but this is only the 6th for which they have produced a formal report and which will trigger a debate.

If you are interested you will be able to see the debate on Weds afternoon live here, probably some time after 3pm:

http://www.senedd.tv/

or in the archive section afterwards.

RESPONSE TO THE GOVERNMENT’S WRITTEN RESPONSE OF 14^TH MAY

I know that I speak for many in the community of those who have struggled with dependence on and withdrawal from prescribed medicines, in welcoming the work undertaken by the Petitions Committee and the Welsh Government’s acceptance of nine of the ten recommendations from report P-05-784 Prescription drug dependence and withdrawal – recognition and support.  There are certain statements made in the Government’s written response which are an enormous step forward in helping existing patients who are dependent on prescription drugs, and those who will inevitably become so in the future.  I would like to thank the Committee for their achievement in encouraging the Government to make firm statements on their position.

The Welsh Government has given:

1. Their commitment to distinguishing between substance misuse and therapeutic use.
2. Their acknowledgement that SSRI and SNRI antidepressants are associated with withdrawal symptoms consistent with inadvertent dependence, despite appropriate therapeutic use.

My petition is about change, change which is necessary because the current evidence and guidelines on SSRI and SNRI antidepressants are out of date and under review (as acknowledged in the response).  The Government has, nonetheless, made statements in the response which are based on the current thinking that has directly led to patients being harmed by antidepressants.

Two of these are:

1. “…evidence supports the positive impact of antidepressant therapy in longer term use. This includes continuing the use of antidepressants for up to six months following remission.”

Published research from October 2018 states:  “While shorter antidepressant usage is associated with more successful antidepressant discontinuation, (Eveleigh et al., 2017) rising long-term antidepressant use is of serious concern. In addition to the obvious economic costs incurred, the human costs of long-term use are well documented, being linked with serious adverse effects such as increased severe side-effects, (Ferguson, 2001) the impairment of patients’ autonomy and resilience (increasing their dependence on medical help) (Kendrick, 2015), increased weight gain, (Gafoor, Booth, & Gulliford, 2018) worsening outcomes for some patients, (Hengartner, Angst, & Rössler, 2018; Shea, 1992) poorer long-term outcomes for major depressive disorder, (Vittengl, 2017) greater relapse rates, (Viguera, 1998) increased mortality (Maslej et al., 2017) and an increased risk of developing neurodegenerative disease, such as dementia (Richardson et al., 2018)”.¹

2. Withdrawal symptoms “….can occur despite appropriate therapeutic use. Where they occur, withdrawal symptoms typically last for a few weeks”

The latest evidence provided to the Public Health England (PHE) Review of Prescribed Medication states: “It is incorrect to view antidepressant withdrawal as largely mild, self-limiting and of short duration.  The available research shows that antidepressant (AD) withdrawal reactions are widespread, with incidence rates (i.e. the percentage of antidepressant users experiencing withdrawal) ranging from 27% to 86%, and with nearly half of those experiencing withdrawal describing these reactions as severe. Available research also indicates that withdrawal reactions are not ‘self-limiting’ (i.e. typically resolving between 1-2 weeks). Rather, approximately 25% of users experience AD withdrawal reactions (such as raised anxiety) for at least 3 months after cessation, with many experiencing AD withdrawal for longer than 6 months.”²

The Government has commented on the definition of dependence. Quoting ICD-10 as their source, they state:  “We believe caution should be exercised so as not to conflate problems of dependence with withdrawal symptoms, as doing so may be counterproductive.”

I would like to clarify –  SSRI and SNRI antidepressants successfully meet:³

3 out of 7 DSM-IV criteria necessary to be classed as dependency forming.

2 out of 11 DSM-5 criteria necessary to be classed as dependency forming.

3 out of 6 ICD-10 criteria necessary to be classed as dependency forming.

In each case, one criterion is about withdrawal. However, the inability to stop taking their medication because of the severity of withdrawal symptoms is the key indicator to patients that they are “dependent”.  Some describe themselves as “addicted”.  This is the case for most dependency forming drugs including anxiolytics and hypnotics.

MORE ACTION IS NEEDED FROM THE GOVERNMENT THAN IS COMMITTED TO IN THE RESPONSE

Following publication of the Government’s response, it is apparent there is more work to do to ensure that safety in prescribing antidepressants is given sufficient attention. Despite accepting nine of the ten recommendations, there is nothing that I have read that tells me that anything different is going to happen in a GP’s surgery.  In three key areas, I would like to ask the Welsh Government to do more. This is to minimise harm to patients and to better support prescribers. By doing this, the Welsh Government will underpin and achieve its commitment to provide recognition and support to those who experience inadvertent prescribed drug dependence

1. Adopt a National Prescribing Indicator for Antidepressants

The Welsh Government chose to not accept this recommendation for fear that it would interfere with prescribing. I ask how the Welsh Government can assure themselves that the other recommendations have been acted upon unless they have access to data that shows that antidepressant prescribing is proportionate and appropriate?

Between 2002 and 2017 there was a 168% increase in antidepressant prescribing in Wales.⁴  It seems to be expected that prescribing will continue to increase. I am therefore disappointed that this recommendation was rejected because I feel this information would actually assist the Welsh Government in keeping track of the prescribing of medications which it now accepts have the potential for dependence. This information is less about reducing prescribing, but more concerned with the information necessary to ensure safe prescribing across Wales. No doctor can predict who will be helped by antidepressants and who will suffer debilitating side effects or withdrawal effects.

2. Underpin the adoption of new NICE guidelines

The new antidepressant and depression guidelines from NICE are expected to be based on new evidence and be more definite in their recommendations than those currently available. The Welsh Government commits to sharing the new guidelines, but I would like to see a more active role than merely “circulating widely”.

The new guidelines may call for a very different approach to informed consent than is currently the case in GP’s surgeries across Wales. To help this change land, I feel that the guidelines should be accompanied by appropriate training materials which will need time to prepare. I am aware that already available are educational packs to support the Appropriate Prescribing of Hypnotics and Anxiolytics; I would like this to be joined by a guide to Appropriate Prescribing of Antidepressants which itself is informed by the acceptance of recommendations from the Petitions Committee report. I realise this will need to be developed over time and can’t be in advance of new NICE guidelines, but the groundwork could be prepared in advance to ensure that the Welsh Government remains ahead of the issue.

In addition to GPs surgeries, new NICE guidelines would need to inform services such as DAN 24/7, the CALL mental health helpline, and official Wales NHS information sources. There will be a good deal of coordination needed to ensure that new guidelines are adopted and can guide safe prescribing including the provision of informed consent.   More action taken with this could address a large part of the issue of the potential for dependence well before it becomes a downstream problem with consequent impacts on Welsh communities.

3. Address inconsistencies across Health Boards

Another issue of concern remains that people in different Health Boards will get different support. In some Health Boards, we are content for those experiencing prescribed drug dependence to rely solely on their GP surgery for help. In others, we provide a specific support service that GPs can refer patients to. To help address this inconsistency and to provide the best possible support both to patients and struggling GP surgeries, I respectfully request that the Welsh Government consider formally sharing best practice from the North Wales Prescribed Medication Support Service across all Health Boards. Sharing best practice could help alleviate some pressure on GPs and provide a more consistent experience across Wales. The current situation begs the question – is it fair to GPs in the south and west that they have to carry the burden of providing patient monitoring, safe tapering support and withdrawal management advice, whereas in the north there is a specialist service? Surely some of the £50m currently spent predominantly on substance misuse could be made available for a more robust Wales-wide support service, leaving GPs to do their part by focusing on informed consent in the early consultations.

I very much hope that acceptance of the Petitions Committee recommendations provides a foundation upon which we can build to ensure that the minimum possible number of people become dependent in the future and those that are unfortunate enough to struggle can be properly supported.

References

1. https://www.sciencedirect.com/science/article/pii/S0306460318308347#bb0180

A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based? Davies and Read (2018)

2. Antidepressant Dependency and Withdrawal: a report from the All-Party Parliamentary

Group for Prescribed Drug Dependence. May 2018.  This report was written for the PHE review and is not yet in the public domain.  The APPG has kindly provided a .pdf copy attached to this email.  Quote taken from page 2 – Executive Summary.

3. Antidepressant Dependency and Withdrawal: a report from the All-Party Parliamentary

Group for Prescribed Drug Dependence. May 2018.  Reference taken from pages 9-11 – Are Antidepressants Dependence Forming?

4. https://gweddill.gov.wales/docs/statistics/2018/180523-prescriptions-dispensed-community-2017-en.pdf page 9.