As if the Covid-19 pandemic wasn’t enough, unprecedented numbers of people are suffering emotional fallout from isolation, money worries and fear of coronavirus infection, leaving Britain facing a tidal wave of anxiety and depression.
That’s the stark warning from the Royal College of Psychiatrists, with the organisation’s president, Professor Wendy Burn, declaring: ‘Our fear is that lockdown is storing up problems which could lead to a tsunami of referrals.’
The Royal College of Psychiatrists predicts that many of those affected will be people who have never before been diagnosed with depression or anxiety.
While some patients certainly do say they benefit from being prescribed antidepressants, the overprescribing of the drugs to people who don’t need them is now a major concern in the UK [File photo]
Its early survey evidence indicates men aged 18 to 25 are particularly badly affected by first-time mental health issues.
Meanwhile, a study by the Office for National Statistics found that nearly half of Britons interviewed as the UK went into lockdown said they were experiencing ‘high anxiety’.
Levels were highest among 8.6 million people whose income was falling, with those renting accommodation and the self-employed particularly affected.
But is this really evidence of incipient mental illness? Might such anxiety instead be a natural response that can pass with time — and, indeed, ultimately strengthen people’s emotional resilience? That is the view of some leading experts.
Yet there is a real risk that instead of this temporary worry being recognised as such, many people will instead be diagnosed with depression or anxiety, and end up on prescription pills they don’t need (possibly causing crippling side-effects and withdrawal problems).
Just how many patients have been diagnosed as depressed or anxious using the free PHQ-9 and GAD-7 tools is difficult to determine because no official tally has been kept — but NHS policy is to recommend their use by GPs and other primary services [File photo]
For, as Good Health has discovered, the tools medics commonly use to diagnose depression are given out free to British doctors, psychiatrists and psychologists by a drug company that manufactures antidepressants. What’s more, these tools significantly overdiagnose the condition.
New research shows that at least one such diagnostic tool, called Patient Health Questionnaire-9 (or PHQ-9), seriously increases the likelihood of people being diagnosed as depressed.
Good Health can reveal that this diagnostic tool is already being used on at least four million NHS patients every year and is widely available via the NHS website.
Free test from drug company
The PHQ-9 is an easy-to-use nine‑point questionnaire that asks patients basic questions, such as the extent to which they have had low energy, sleep and concentration levels over the past fortnight (see below).
Each answer is awarded a points score. The points are totted up against a depression severity scale that ranges from ‘not depressed’ to ‘severely depressed’.
The dangers of using this diagnostic tool have been exposed by an international consortium of psychiatrists that included experts from King’s College London and the London School of Hygiene & Tropical Medicine.
Their examination of evidence on more than 9,000 patients concluded that the diagnostic questionnaire ‘substantially overestimates the prevalence of depression’.
In fact, the PHQ-9 identified patients as depressed at a rate 2.5 times higher than normal, according to research published in the Journal of Clinical Epidemiology in February.
The questionnaire that ‘overdiagnoses’ depression
Are you depressed? This is a version of the patient healthcare questionnaire (known as PHQ-9) that your doctor may use to help them decide.
The questionnaire is widely available across all kinds of healthcare settings, including on the NHS website. These all have the same nine questions, although the wording might differ slightly.
It was originally developed in 1999 by researchers funded by drug giant Pfizer, which makes antidepressants. New analysis suggests it significantly overdiagnoses depression (see main story).
Some experts believe that, as a result, some people will end up being prescribed medication that they do not need.
Patients rate their responses to the following questions, then add up the total (the electronic version on nhs.uk, which these questions are taken from, does the maths for you).
Over the last two weeks, how often have you been bothered by any of the following problems?
- Score 0 — Not at all
- Score 1 — On some days
- Score 2 — On more than half the days
- Score 3 — Nearly every day
1. Have you found little pleasure or interest in doing things?
2. Have you found yourself feeling down, depressed or hopeless?
3. Have you had trouble falling or staying asleep, or sleeping too much?
4. Have you been feeling tired or had little energy?
5. Have you had a poor appetite or been overeating?
6. Have you felt that you are a failure or let yourself or your family down?
7. Have you had some trouble concentrating on things such as reading the paper or watching TV?
8. Have you been moving or speaking slowly, or been very fidgety, so that other people could notice?
9. Have you thought that you’d be better off dead or hurting yourself in some way?
Add up total for depression severity: 0-4, none; 5-9, mild; 10-14, moderate; 15-19, moderately severe; 20-27, severe.
Most psychiatric questionnaire tools have to be bought by practitioners from specialist publishers at a cost of hundreds of pounds. These are complex assessment tests that are peer-reviewed and regularly updated.
By contrast, the PHQ-9 has a tick-box questionnaire format and is distributed to clinicians on a free-to-use basis.
The PHQ-9 questionnaire was developed in 1999 by academics who were funded by Pfizer.
This company manufactures some of the most commonly prescribed drugs for depression and anxiety in the UK, such as venlafaxine and sertraline.
There is another free-to-use questionnaire used in primary healthcare as an alternative to PHQ-9. This is called the Generalised Anxiety Disorder Assessment 7 (GAD-7). Its development in 2006 was again funded by a grant from Pfizer.
GPs may use other non-Pfizer tests (which must be paid for), or simply use their own clinical judgment to diagnose depression.
Just how many patients have been diagnosed as depressed or anxious using the free PHQ-9 and GAD-7 tools is difficult to determine because no official tally has been kept — but NHS policy is to recommend their use by GPs and other primary services.
However, figures released to Good Health from databases held by NHS Digital show that last year the PHQ-9 and GAD-7 questionnaires were used four million times in one area of the health service alone, not counting their everyday use by GPs, which is where most cases of depression are diagnosed.
This usage solely involved assessing individual patients to see whether they had benefited from a course of talking therapy, or if they needed antidepressants instead.
In other words, there will be countless other patients who will have been initially diagnosed with the ‘test’.
Pills given needlessly
While some patients certainly do say they benefit from being prescribed antidepressants, the overprescribing of the drugs to people who don’t need them is now a major concern in the UK.
Furthermore, these questionnaires over-diagnose as ‘clinically depressed or anxious’ patients whose symptoms are actually healthy responses to stressful events, warns Dr James Davies, a reader in social anthropology and mental health at the University of Roehampton, and secretariat member to the All-Party Parliamentary Group for Prescribed Drug Dependence.
‘PHQ-9 sets the bar very low for diagnosing depression and, thus, encourages antidepressant prescribing,’ he says. ‘GAD-7 also sets the bar low for diagnosing anxiety, and a large population of people diagnosed with anxiety are given antidepressants.’
The Royal College of Psychiatrists predicts that many of those affected will be people who have never before been diagnosed with depression or anxiety. Its early survey evidence indicates men aged 18 to 25 are particularly badly affected by first-time mental health issues [File photo]
This means that Pfizer is both setting the diagnostic bar for depression — then profiting from prescribing a drug for it, he warns. ‘We should be very concerned about this conflict of interest. The danger is exacerbated now because we fear a rise in people being diagnosed with depression when they are having natural responses to the circumstances in which we find ourselves [i.e. the threat of Covid-19]. This is not a mental health issue. We should instead offer social support.’
Dr Davies fears that the outcome, instead, will be myriad new — and needless — prescriptions for dependency-forming drugs.
‘This will only cause further problems along the line with withdrawal,’ he says. ‘We also know that the efficacy of these drugs is far from certain. Often, they are no better than placebo pills.’
John Read, a professor of clinical psychology at the University of East London, adds: ‘Being scared at the moment is normal. It is a social problem, not a mental health one. We fear we are about to see a big rise in prescribed medication. Already in the U.S., there has been a 30 per cent increase in drug prescriptions for depression and anxiety since the start of the coronavirus outbreak.’
The danger of doctors’ diagnostic tools exaggerating illness has prompted serious concern in the U.S., in particular clinicians’ increasing reliance on an emerging generation of computer apps called electronic diagnosis-aiding tools.
In the U.S. in January, a company that makes electronic diagnosis-aiding tools called Practice Fusion agreed to pay $145 million (£116.7 million) in fines to resolve criminal and civil allegations that it had accepted illegal payments from a manufacturer of powerful dependency-creating opioid painkillers.
In exchange for the illegal payments, Practice Fusion created a tool that deliberately over-estimated patients’ need for the drug-maker’s opioid painkillers.
The drug-maker’s marketing staff helped write the clinical criteria to trigger it for patients with lower pain levels than usually required before addiction-forming opioids are prescribed — when, instead, much less risky pain relief can be used.
Doctors who used the tool prescribed the unnamed drug company’s opioids at a higher rate than those who did not, the journal JAMA Internal Medicine reported last month.
In a further disturbing development, UK researchers have now suggested that rather than only giving antidepressants to patients with depression, doctors should prescribe them to people who are merely ‘at risk’ of developing depression in future.
Psychiatrists from the universities of Keele and Stafford, and Toronto University in Canada, reviewed 28 trials that used a variety of treatments to prevent depression in people considered ‘at risk’. These were primarily antidepressant pills, but also included the supplement selenium, HRT, omega-3 fatty acids and the sleep hormone melatonin.
The analysis concluded that antidepressants may help keep mentally healthy people from becoming depressed if they have conditions such as heart attacks, strokes and hepatitis C. This is because such people have a higher-than-normal risk of depression, said the researchers in the Journal of Affective Disorders.
Saeed Farooq, a professor of psychiatry and public mental health at Keele University, who led the study, told Good Health: ‘Prevention is not high on the research agenda in mental health. Our article shows for the first time that using drugs may be a viable strategy for prevention.
Under the microscope
Former England cricket captain David Gower, 63, answers our health quiz
Can you run up the stairs?
Yes, though not with the same gazelle-like alacrity that I used to. Before Covid-19 I had a personal trainer called James. I’d train with him for an hour a couple of times a week, alongside a group of friends.
How has the pandemic affected you?
I’ve been out on my bike more than I have for years, but it’s one of my failings that I tend not to get as far as the home gym, unless there is a trainer booked in.
Get your five a day?
My household is rather vegetable-conscious. And there’s a fruit bowl — though sometimes it just sits there, being ignored.
Not really. I got to 60 having put on about a stone and a half, but I didn’t look or feel particularly porky. I’m 6ft and nearer 15st than 14st.
Former England cricket captain David Gower, 63, answers our health quiz
It has long been acknowledged that I like a glass of wine.
Any family ailments?
My mother was terribly asthmatic and died at about 60 as a result. My father died of motor neurone disease in his mid-50s. I remember coming back from boarding school as he went into hospital for the final time and having that numb feeling when my mother said: ‘I’ve got bad news.’ I was about 16.
Sepsis in the early 1980s. We played a game at Lord’s and I got a tiny little graze on the knuckle of my finger, which swelled up. I spent a week in hospital on antibiotics.
Had anything removed?
A tonsil or two.
Ever have plastic surgery?
Yes. If possible I’d love to just magic away this extra stone and a half.
Cope well with pain?
I can harrumph with the best. I’ve got tennis elbow and I’ve tried acupuncture, which did nothing, and cortisone [steroid injections]. But you can’t keep pumping cortisone into yourself or your elbow will dissolve.
Ever been depressed?
Back in the early 1990s, when playing for Hampshire, I had a summer where it all went wrong. It was the worst loss of form I’d encountered, and it was quite frightening. I ended up very depressed. I had some psychological help. In the end it is confidence in one’s own ability that is the key.
Just time and water.
‘Further research will be needed before the strategy can be used more broadly for conditions such as Covid-19 or related isolation.’
Healthy people may be targeted
Professor Farooq had declared ‘no competing financial interests’ in his paper. However, Good Health has discovered he had, in fact, received payments from drug companies that manufacture antidepressants.
While he told us the payments were related primarily to work on psychosis, he said he would ask the publishers to issue a correction to the conflict-of-interests statement. This has now been done.
Dr Read said he found the paper’s intent ‘disturbing’.
‘We are already concerned about a further increase in unnecessary antidepressant prescribing during the pandemic,’ he says.
‘The bizarre notion of using drugs to prevent depressive reactions happening could push prescribing rates through the roof. This is very worrying when we already have one in six adults taking antidepressants.
‘The paper also makes no mention of problems withdrawing from antidepressants.’
Last October, Dr Read co-authored a review of evidence, in the journal Addictive Behaviors, which found that 56 per cent of those who attempt to come off antidepressants suffer withdrawal effects.
The study echoes an official Parliamentary report last year that surveyed more than 300 former antidepressant users and reported that around half had experienced withdrawal symptoms such as severe anxiety, brain fog and feelings of unreality for more than one year.
This was followed by a landmark report on prescription-drug dependency from Public Health England last September, prompted by a campaign led by the medical royal colleges and the Daily Mail. The report urged the Department of Health (DoH) to set up a dedicated 24-hour helpline for people suffering problems withdrawing from antidepressants. The DoH is still considering its response.
A spokeswoman for Pfizer said: ‘Health professionals’ use of PHQ-9 and GAD-7 should be accompanied by clinical assessment. The professional’s clinical judgment should be used to make any formal diagnosis.
‘These tools are designed to support the evaluation and diagnosis of patients who could potentially have a mental health condition. Since the questionnaires rely on the patients to self-report, all responses should be verified by a healthcare professional and a definitive diagnosis made on clinical assessment.’
Tidal wave of mental woes?
Meanwhile, are we really about to suffer a ‘tsunami’ of depressive, anxious mental illnesses, as the Royal College of Psychiatrists sensationally predicts?
Other professional organisations are more measured.
Professor Martin Marshall, chair of the Royal College of GPs, told Good Health: ‘It is likely lockdown measures will be having an impact on some patients’ mental health. GPs are seeing a rise in the number of patients presenting mental health concerns and we expect to see this rise continue in the aftermath of the pandemic.’
This hardly amounts to a tsunami, however. And, as the professor is keen to underline, we can all take a level-headed ounce of prevention in order to save ourselves a pound of cure.
‘Early intervention is key, so it is important patients continue to report any concerns to their GPs,’ says Professor Marshall.
‘We can all help to maintain good mental health throughout the crisis by practising good self-care: staying digitally connected to friends and family, and participating in regular outdoor exercise.’