Pill-free prescriptions for depression

Tessa Hilton / 25 September 2018

With the Government recently pledging funding for a new kind of therapy to help anxiety, low mood and loneliness, Tessa Hilton finds out how it all works.



A slightly crumpled, not terribly accurate, sketch of a sheep’s skull doesn’t sound like the kind of early work an aspiring artist would cherish. But for Debbie Taylor, it’s very special.

‘I had never drawn anything before and to say my life changed at the point I went to an art group is an understatement,’ says Debbie, from Mirfield, Yorkshire. She had been plagued by long-term depression, was on a regime of ever-increasing medication and was unable to work.

She went to the art group after her life appeared to reach rock bottom. A psychiatrist told her she would never come off antidepressants or work again and, after the death of her mother, she became so low she took an overdose. But as part of the hospital’s discharge process she was referred to the art classes run by Creative Minds, a charity within the South West Yorkshire NHS Trust.

Nearly eight years on, Debbie, 50, has been able to stop all medication, is now a Creative Minds project development worker and exhibits her paintings. She has also become an advocate for the process she benefited from – ‘social prescribing’ – and has talked at a conference on the subject held by healthcare charity The King’s Fund, at which Prince Charles was present.

A host of other people have found their depression, anxiety or loneliness helped by getting a prescription not for antidepressants but to join a group, to exercise, garden, dance, volunteer and more. Social prescribing is becoming increasingly interesting at a time when prescriptions for antidepressants have doubled in a decade. In July, Health Secretary Matt Hancock pledged £4.5 million to support the concept, to reduce ‘the over-prescription of unsophisticated drugs’.

How does social prescribing work?

Did you know?

Depression and anxiety are common – according to Mind, one in six people experience such problems every week.

Loneliness is also widespread and is as damaging to our health as smoking 15 cigarettes a day, says the Campaign to End Loneliness.

So why can social prescribing really help someone in the grip of depression? After all, many of the symptoms – low mood, lack of interest or pleasure in almost all activities, fatigue and feelings of worthlessness and lack of confidence – are the very reasons why it may seem impossible to try new things or join a group of strangers.

GP Dr Michael Dixon’s practice in Cullompton, Devon, was one of the first to offer social prescribing. He is NHS England’s national clinical lead on the issue and chair of the College of Medicine. ‘We don’t directly prescribe an activity,’ he explains, ‘but refer patients to a link worker who has time to talk about what might help and, crucially, can go with a patient to a group or class.’

It was by looking at conditions often not helped much by conventional medicine, such as depression, stress and fibromyalgia, that Dr Dixon became interested in social prescribing. ‘Antidepressants can be the answer for some people who lack serotonin. You give them SSRIs [selective serotonin reuptake inhibitors] and they literally change personalities, but antidepressants are not the answer to social problems or loneliness – or they may be part of the answer but need to be supplemented.’

The next step can be to refer a patient for a talking therapy – usually cognitive behavioural therapy (CBT) or group therapy – but provision on the NHS varies from area to area and can mean a long wait.

‘It can be damaging to have to wait an inordinately long time, commonly more than a year, for a course of CBT. It gives the message to the patient that they don’t matter,’ says Dr Dixon. ‘Social prescribing can happen quickly and working on an allotment, for example, is more interesting.’

The best way forward for social prescribing

There’s no single model for social prescribing and NHS England is working to develop a standard. But with many GPs already using social prescribing, it is growing rapidly as a grass-roots movement. Dr Marie Polley of the Social Prescribing Network, which brings together social prescribing practitioners, doctors, academics and others, describes it as ‘one of the positive things to come out of austerity.’

What is becoming clear is that a link worker is vital – someone who can spend time getting to know patients and what they’d like to try. Ruth Tucker is the health facilitator at Dr Dixon’s practice in Devon. The surgery has a café, which acts as a social hub, and Ruth has volunteers who run walking, gardening, art and knit-and-natter groups.

‘Listening and motivational skills are key, but local knowledge and the ability to network is too,’ she says. ‘After all, I’m only as good as what I can offer.’

The cost of the link worker should be met by the clinical commissioning group (CCG) or local authority or both but, at the moment, less than half of CCGs do so. ‘In my area there’s no funding so I have to get sponsors – Dial A Flight last year and a drug company this year,’ says Dr Dixon. ‘So it’s fairly hit and miss whether it’s paid for.’

Helen Stokes-Lampard, who is chair of the Royal College of GPs, welcomes the idea of a link worker to give time that a GP doesn’t have to spare. She doesn’t have one yet at her surgery in Lichfield, Staffordshire, but says that, ‘Disentangling the physical from the social and psychological and the interplay of those things is the art of being a good GP.’  

Meanwhile, if social prescribing is to be converted into standardised NHS practice, it may pose questions for some groups. For example, the hugely successful nationwide Men’s Sheds movement (menssheds.org.uk) where men get together to mend, make and create, may be wary of accepting funding.

Geoff Allison, who is secretary of the award-winning Dalbeattie Men’s Shed, in Scotland, puts the dilemma neatly: ‘We do care, but we’re not carers. Money from the NHS would come with strings attached and we’re all men who’ve had a lifetime of employment and don’t relish being told what to do.’

What’s undoubted is that social prescribing, in all its many forms, is here to stay. For an increasing number of us, and for many reasons, it may prove in the future to be just what the doctor orders.

Case study: Learning to swim makes me feel on cloud nine

Teresa Hamlin, 58 and an interior designer, lives in Cullompton, Devon and is a patient at Dr Michael Dixon’s surgery. Health facilitator Ruth Tucker used social prescribing to help Teresa overcome depression after breast cancer.

‘Setting future goals had been part of a recovery programme after cancer and one of mine was to learn to swim. But I was self-conscious about my scars and had always been terrified of the water.

‘Ruth and I talked about what was holding me back. I didn’t feel able to cope with our public pool so, with her encouragement, I found an aqua-aerobics class in a private pool. It was far less intimidating and I joined this lovely group of ladies who were so supportive and welcoming.

‘At first I screamed blue murder if I went under water, but they all egged me on and I gained enough confidence to go to one-to-one swimming lessons.

‘Now, 18 months on, I can swim in the deep end at the public pool and I’ve swum in the sea – something I never would have dreamt possible. I still have bouts of feeling low, but the exercise makes me feel good – I’m losing weight, too.

‘Swimming has also given me a new group of friends because I’ve only lived here for a few years and I work from home, which can be lonely. When I come out of that pool I feel on cloud nine and have a great big grin on my face.’


When more help is needed

No one thinks joining a gardening group alone is going to resolve severe depression, although social prescribing might still be part of a treatment plan. Certainly antidepressants do work as a major study earlier this years (subs 2018) led by psychiatrist Andrea Cipriani of Oxford University proved after looking at the results of more than 500 trials.

Although it’s often trial and error to discover which works best for each individual because we all react differently, and they don’t work for everyone, the study did rate 21 antidepressants.

The most effective was agomelatine (brand name Valdoxan), a relatively new drug which mainly works by mimicking the action of melatonin, the hormone that controls our sleep and waking cycles.

Second most effective was amitriptyline, often used to treat nerve pain, and belonging to a group called tricyclic antidepressants which have been around since the fifties. They are sometimes used to treat pain and other conditions such as fibromyalgia.

Surprisingly Prozac, now out of patent and known by its generic name fluoxetine, was amongst the least effect. This group of antidepressants called SSRIs or selective serotonin reuptake inhibitors are thought to work by increasing serotonin levels.

Mind, the mental health charity has more on antidepressants. Visit mind.org.uk

The new antidepressants?

There’s increasing evidence of a link between inflammation in the body and depression.

Inflammation is a normal response by the immune system to fight infections when we get ill or cut ourselves. However, when the immune system is constantly activated by stress it can cause increased inflammation in the body which, in simple terms, causes changes in how the brain works and can lead to depression.

Drugs targeting these mechanisms could be the antidepressants of the future explains Carmine Pariante, professor of biological psychiatry at King’s College London, and one one of the authors of a study published last year.


Winter mood food from the Med

There’s no miracle food that will instantly lift your mood and the impact of nutrients is the subject of much ongoing research but experts agree the Mediterranean diet is best to nurture a diverse microbiome, the gut ecosystem that plays a part in lifting mood and reducing anxiety. Elena Paravantes, a registered dietician and specialist in the Greek Mediterranean diet (olivetomato.com), has delicious dishes to tempt as the temperatures drop …

Broccoli gets a roasting Drizzle with olive oil and roast in the oven with pine nuts. Broccoli is a good source of folate or vitamin B12 which supports the brains ability to produce neurotransmitters such as serotonin.

Cauliflower in a pot A popular Greek dish - bake in a pot with tomato passata and a little olive oil. Cauliflower is a rich source of anti-inflammatory compounds.

Leafy veg pie You’ll know spanakopita, the famous spinach and feta cheese pie, but a greens pie is tastier and one of the secrets of the Greek diet. Use any dark leafy greens mixed with herbs and a bit of feta (or not) tucked in layers of filo pastry. Make your own filo with olive oil, like the Greeks, or buy one with fewest ingredients. Leafy veg are a source of antioxidants which counter inflammation and also omega three fatty acids, low levels of which have been linked to depression. Although oily fish like mackerel are the richest source you can add salmon or anchovies to the pie.

Green beans go Greek Use frozen green beans and half a cup of olive oil per pound of vegetables (don’t stint) to make Lathera, a Greek dish of beans stewed with olive oil and tomato passata. Green beans are a form of fibre which allow beneficial gut microbes to thrive and tomatoes are a source of lycopene, a powerful antioxidant thought to reduce inflammation.


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