Depression: medication vs social prescriptions

When Sandra turned to her doctor last year after she developed a severely low mood, she was a little taken aback by the treatment he offered her. He listened well  and asked lots of questions – then he handed Sandra a prescription for antidepressants.

‘I don’t know quite what I was expecting but it wasn’t that,’ says Sandra now. ‘Yet when I told my book group, who are all around my age, I was amazed that some of them had been prescribed them, too. Part of me felt an immense relief that there’s something that might get me out of the fog.

‘My husband’s health had not been good for years,’ recalls Sandra, 72. ‘It was one crisis after another – I could navigate to our local hospital blindfold. We’d always travelled and both had good careers – I worked in education until I was 68. But my husband stopped wanting to go out at all. Our world shrank and his worst traits, like impatience, were all I saw. I missed our old life, and cried every day.’ But there was also worry: were drugs the answer?

They are, it seems, ‘the answer’ for an increasing number of older people. Recently, a study from the University of East Anglia caused ripples of alarm when it showed that the proportion of over-65s taking antidepressants has more than doubled in 20 years – while for care-home residents, the rate has soared fourfold. So what is happening?

One of the first to register alarm was Dr John Beer, chair of Action on Elder Abuse. ‘My initial response was: are antidepressants being used to dampen down and pacify people to avoid having to make the changes necessary to improve their lives?’ says Dr Beer. ‘But looking closer, I realised that it’s a complicated picture.’ For one thing, the antidepressants widely available 20 years ago were deemed unsuitable for older people – their side effects often ruled them out. Today’s drugs are deemed safe – and can also be prescribed for a wider range of complaints, including sleep problems and milder depression.

In some respects then, it’s a step forward. ‘There’s evidence that older people with depression traditionally had no treatment options at all, and if they asked for help, they were told that what they were experiencing was a normal part of ageing,’ says Dr Aideen Young from the Centre for Ageing Better. ‘The rise in prescriptions could mean that doctors are paying more attention to older people’s mental wellbeing and that’s a good thing. But if all they are being offered is a pill instead of any other form of help, then that’s not such a good thing at all.’

Depression - alternatives to drug treatment

Unfortunately, this does seem to be the case. Best practice is for GPs to prescribe antidepressants to over-65s only after a full conversation that covers mental, physical and social circumstances, as well as exploring alternative treatments, such as talking therapies or ‘social prescribing’ (sometimes called ‘community referrals’, where people are encouraged – often via a link worker – to join potentially life-enhancing activities such as volunteering or art groups).

However, older people are far more likely to be prescribed medication than younger people: research indicates that GPs are more inclined to talk to them about their physical ailments than their mental concerns. Yet research by the British Association of Counselling and Psychotherapy (BACP) found that 78% of people over 65 would rather speak to someone about their mental health than take medication.

Jeremy Bacon, the Older People Lead for the BACP, says there are many factors at play, including ageism. ‘As a society, we don’t value older people, and that negative view of ageing comes out in all sorts of ways,’ says Bacon. Few counsellors choose to specialise in treating older clients. GPs, health professionals and even elderly people themselves may hold the belief that older people aren’t worth the extra time and investment. ‘When they do have counselling, it’s so common for older clients to start a session by saying, “You must have better things to do than listen to me”,’ says Bacon.

Access is another problem – even getting to a therapy session or a community group can be challenging, especially in a care-home environment. Homes are run on a ‘medical model’ – like hospitals – regulated by the Care Quality Commission, so on one level, the high rate of antidepressant prescribing is not surprising. ‘People in care homes are “looked after” and will have their medical needs met swiftly,’ says Professor Tony Arthur, author of the University of East Anglia research. ‘But are these prescriptions just being automatically repeated?’

Barbara Bloomfield is a Relate- trained counsellor who specialises in therapeutic work with older people with her own Bristol-based group Growing Bolder. She is not surprised by the high levels of antidepressant usage. ‘It’s a very controversial area,’ she says. ‘There are lots of people in mental health work who’ll say antidepressants are used to keep
older people quiet, calm and a little bit more content instead of looking at the real issues – because that would require absolute change in the whole of society. There are lots of challenges to mental health as we age,’ she continues. ‘Retirement, bereavement, we might also have our first brush with serious illness.’

Depression and physical health

Some elderly patients do credit a course of antidepressants with lifting the cloud, removing any feelings of immediate dread (though reactions are very different for everyone). And formal talking therapies have their place. But the gentler, more organic benefits of social prescription can be effective, too. Indeed, they may be especially well-suited to a generation for whom ‘opening up’ does not come naturally (particularly if their feelings of depression are very much circumstantial and unconnected to deep, long-standing trauma).

Certainly, 51-year-old Angela is full of the transformation in her mother after she researched and encouraged her to join her local tea group and community garden scheme. ‘Mum had been really down and lonely since the death of my father last year, but the groups have lifted her spirits. She’s met other widows who share – and understand – what she’s going through; they chat happily together while they’re pruning.

‘And as a member of the “keeping busy” generation – my mother’s catchphrase has always been “got to get on!” – she’s thrilled that the friends she’s made are involved in various charity knitting projects, too – it makes her feel useful.’

Relate counsellor Barbara Bloomfield runs many therapeutic projects that aim to remind older people of their inner strengths and to reflect on a life lived, as well as the skills and wisdom they’ve acquired. These were funded by Bristol Ageing Better, which has distributed £6 million over the past three years in a bid to make Bristol ‘a great place to grow old’.

Other projects it has supported include Intergenerational Storytelling (where elderly participants share stories from their own lives) and Men in Sheds (where older men gather in a container on the common and work on repair and mending).

Another positive approach to the issues of age and mental health is the Transition in Later Life programme, overseen by the Centre for Ageing Better. Seven pilot schemes across the country offered people over 50 help with the many transitions ahead, through planning, goal setting, mindfulness, meditation and cognitive behavioural therapy. Participants reported the schemes to be transformative, leaving them more confident, connected and positive about the future.

For Sandra anyway, medication wasn’t the answer – she chose not to collect her prescription. ‘I know they’ve been a life saver for some people but I’ve reached this age without being on any pills – and when I look at my husband’s daily regime, I want to avoid them as long as possible.’

Instead, she returned to her GP who has helped her access counselling if she wants it, and most importantly, Sandra talked to her husband about how she was feeling. They are now trying to go out more as a couple and Sandra is planning more activities alone, including local volunteering. ‘It’s reassuring to know that the medication’s there if I need it,’ she says. ‘But I’d rather try everything else first.’

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1 in 15 over-65s has depression – a slight fall from 20 years ago (from 7.9% to 6.8%)

32% of care-home residents use antidepressants – a fourfold rise in 20 years (from 8%)

78% of people over 65 would rather talk to someone about their mental health than take pills

10.7% of over-65s are on antidepressants – more than doubled in 20 years (from 4.2% to 10.7%)

Depression case study

Eva Roshan, Textile artist, 69

Eva has had experience of both antidepressants and counselling. Now a great grandmother, she lives in Bristol with her husband Jonny.

‘Four years ago, I asked my GP for antidepressants and therapy as I was in a dark place. There were lots of reasons. I’d suffered a heart attack at 64 and almost died. Recovery had taken nine months of my life.
A long-held dream to retire to St Ives had then fallen through. What followed was confusion, sadness, a sense of time running out and grief for the loss of this perfect sunny future. 

‘The antidepressants were prescribed immediately but the counselling wasn’t so easy to pin down. There were lots of hoops to go through first – including a phone assessment and a group workshop. Then if you were offered one-to-one therapy, the waiting list was 10 months. I’m lucky, I was able to go privately.

‘I did the two things together so I couldn’t say for certain which worked best – but I know what I feel. The antidepressants removed some of the fear and dread but the power of therapy brought me back to life.

‘Having someone not personally involved in your life who’s on your side, listening, offering wisdom, was life changing. My therapist encouraged me to keep a journal, which turned into my book Wearing Red: One Woman’s Journey to Sanity.

‘She changed the way I think and restored my confidence in my own judgment. ‘I don’t want to take antidepressants for ever but I’m still on them. When I decide to stop, I’ll do it gradually. That’s one of the problems – you don’t know if you’ll be OK, and it’s strange to feel reliant on a tablet. When
I read about the number of older people taking them, I felt it was quick fix – an “Off you go, take this and don’t bother coming back”. Without therapy, I believe recovery would have taken me much longer. I’d
never have the insights and contentment I have now.’ 

Eva’s book, Wearing Red, is available at a discount from wordery.com/saga

British Association of Counselling and Psychotherapy, bacp.co.uk, 01455 883300; ageing-better.org.uk, 020 3829 0112

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