IntroductionThere is asubstantial accumulation of evidence to suggest that holistic methods, such asa physical exercise, yoga and cognitive behavioural therapy, are beneficial treatmentsfor patients with moderate and mild depression.

Through the research I haveundertaken, I have collated views of how GP’s and clinical psychologistsresponded to anti-depressants and holistic methods in the treatment ofdepression. My dissertation summarises the benefits of using exercise, yogatherapy, as well as cognitive behavioural therapy to treat mild or moderatedepression, the restrictions to its more comprehensive use, how theserestrictions might be overcome, and how the reduction of anti-depressants andincreasing of holistic methods will have a welcome benefit on the economy,environment and society. However, in order to balance these views, I haveclearly stated the benefits of anti-depressants in order to aid the treatmentof depression. The aim of my dissertation is to advocate the awareness of holistictreatments for moderate depression as a practical and rational available treatmentfor GPs, and a natural option that patients can both understand and choose forthemselves.Background                  AntidepressantsGeneralpractitioners (GPs) prescribe most medication for treating depression, includinganti-depressants, with a total 60-85% of adults receiving them for thetreatment of depression in the USA1 2, and an approximate of5-16% of adults acquiring antidepressants in the USA and Europe yearly3. A combination of severalfactors contributed to the increase in percentage of prescriptions annually: theinvention of tricyclic antidepressants (TCAs) in the late 1950s4, and the introduction of selectiveserotonin re-uptake inhibitors (SSRIs) in the 1980s5; an escalation in thecontinual prescribing in the 1990s and 2000s6; and the current increasein the dosage of anti-depressant. These statistics are reinforced bythe NHS prescribed 64.

7 million variants of anti-depressants in England in 20167,pushing the boundaries to exceed a record number of medication dispensed in2015, the most recent annual data from NHS Digital showed. Worryingly, this hasincited an escalating trend that has seen the number of pills given to patientsmore than double over the last decade. These statistics provoked questions overwhether this dramatic incline in prescribed medication suggests that GPs are freelyproviding anti-depressants rather than considering alternative treatments inorder to relieve patient’s mild and moderate depression.This increase inthe distribution of medication is concurrent with the introduction of SSRI’s, anew variant of antidepressant drugs. While SSRIs are claimed to induce fewerharmful side effects than former antidepressants8,their success and safety are increasingly being disputed.

Claims of withdrawal effectsare troubling9,despite being commonly referred to not an addictive drug, as well as inducing insomnia,nausea, and weight gain/loss that has been treated with escalating concern inthe media and by regulatory bodies, such as the FDA. Through primary research,a concurrent statement from clinical psychologists advises patients against anti-depressants due to analysis that anti-depressants arein fact considered to be as effective as a ”placebo”. According to these health professionals, the”methodology of the FDA is weak”, and around ”70% of my patients do notbelieve in the use of anti-depressants and believe they are ineffective,preferring therapeutic methods instead”.

Though anti-depressants areassociated with, positive effects for some patients, the more crucial side effects that correlate with the druguse, such as increased proportion of self-harm and suicide need to be addressed.These factors combined with high costs and low treatment completion, thebenefits of using these antidepressants as a first-line treatment for mild or moderatedepression is questionable. Despiteprescribing anti-depressants, GP’s understand the side-effects and drawbackassociated with these drugs in question, therefore strict clinical guidelinesstate that this form of medication should not be classed as first-linetreatment for mild or moderate depression.

GP’s are aware of the benefits ofoffering patient’s choice, though are often posed with difficult approaches to thenumber and value of options available, as choice of treatments can often behard to come by. 78% of GPs believe that an alternative approach might havebeen more appropriate, despite prescribing a specific anti-depressant.1066% feel that there is no other option but to prescribe anti-depressantsbecause suitable alternative was not available.

11Therefore, clearly there is a difference in morals amongst GPs betweenprescribing anti-depressants and the effectiveness of them.  How effective areanti-depressants?A study published in July 2017, uses amethodology of interviewing 27 GPs, to determine how they prescribeanti-depressants, whether this involves medicalised or non-medicalisedpatient-centred approaches. The overall results show that GPs were ignorant of theknowledge that higher doses lacked greater efficacy and therefore a change tothe prescription or prescribed dosage within 1-2 weeks, choosing to prolongswitching or increasing medication after 8-12 weeks.12 Acommon cause for this is a pressure on medical professionals to continuallyprescribe anti-depressants due to a fear of symptoms of depression recurring,lack of awareness of all unanticipated problems, because amongst GPs, there isa lack of safety concerns regarding the dispensation of anti-depressants. Due to the variety of anti-depressants available, it isdifficult for GPs to assuredly calculate how well medication will help aparticular individual.

Therefore, GPs will advise treatment that is tolerated demonstratedthe desired effect. Animportant consideration is that the sample of anti-depressants prescribed byGPs were influenced by how serious they classified the depression, thepatient’s symptoms, previous clinical experience of the GP, alongside healthfactors, such as age and gender. Though treatment options were agreed to betweenpatients and doctor, the most commonly prescribed were SSRIs, as they areconsidered to be the most effective, and induce the fewest side effects whencompared to TCAs (Tricyclic antidepressant). However, citalopram and escitalopram are associated with ventriculartachycardia and sudden cardiac death, according to the Medicines of HealthcareRegulatory Agency (MHRA)13,had influenced prescribers who were now using less citalopram and moresertraline.

However,for severe depression the drug mirtazapine’s side effects were consideredbeneficial for some patients for underweight patients as the weight gain causedby the drug was useful, while the insomnia and anxiety symptoms were relievedby the sedative side effects for patients. The fear amongst patients was a recurrenceof the depression, due to withdrawal or reduction of antidepressants, whichcould result in more harmful side effects than positive ones, was deliberated amongstGPs and patients. This was particularly a hazard for patients with severe depression,as reduction caused challenges depending on the stability of individuals, andwhether they could cope without them. Higher SSRI doses associatedwith long-term B&Z treatment were considered to be linked withpatients being more complicated, possibly having greater psychiatricmultimorbidity as well as underlying social and personal issues not beingaddressed but medicated instead.

Patients were generally more willing to engageand seek pharmacological treatment and resisted reductions. However, cliniciansrarely consider adverse effects with higher SSRI doses increasing anxiety orB&Z’s lowering mood.Thus, this study reveals thatpeople with depression may decide for the option of anti-depressants due tothis being the primary option of GPs, rather than having the inability toexplore further options. This restriction often placed on GPs for depressedcases can cause patients to rely more heavily on the use of anti-depressantswhich can have a damaging effect both physically and mentally. From primaryresearch, the clinical psychologist that I contacted believed that holistic methods should be more heavilypromoted within GPs, and that they should be a main focus of treatment for milddepression, and considered for moderate depression. Therefore, this studydemonstrates that those who benefit from anti-depressants, are likely to showsymptoms corresponding with more severe cases of depression, such as majordepression and bipolar depression, and therefore are less effective againstmild depression in comparison to chronic depression. Overall, anti-depressants that wereused regularly, such as tricyclic antidepressants, carried out their functionswell.

Therefore, without anti-depressants, 20 to 40 patients who took theplacebo, but with severe depression noticed an improvement in their symptomswithin six to eight weeks. A considerable greater proportion between 40 to 60patients did feel an improvement in their symptoms by taking theanti-depressant within six to eight weeks. In other words, antidepressantsimproved symptoms in about 20 more people out of 100 though for moderatedepression rather than mild depression.From my research and the pie chart shown, 30% of registeredmental health nurses always prescribed anti-depressants, 40% often prescribed anti-depressants,and 30% sometimes prescribed anti-depressants, though 0% never prescribedanti-depressants. This data clearly describes that all registered mental healthnurses, will prescribe anti-depressants, though this is dependent on the typeof depression, because 50% treated patients with major depression, and 60%treated patients with bipolar depression, and 70% treated patients with psychoticdepression.

  This means that there I aneed for anti-depressants for major depressive types, particular depressionsymptoms that changes aptients characteristics severely, such as bipolar and psychoticdepression. Mental health nurses who treated patients with seasonal affective disorderand atypical depression, sometimes What are the positive and negativeeffects of reducing ant-depressants socially, environmentally and economically?EnvironmentalIf the usage ofantidepressants were reduced, this would have significant positive effectsenvironmentally, socially and economically. Regarding the environment, thesedrugs are passing through the water supply, therefore harming aquatic life. Itis believed that once pharmaceuticals are consumed, the patient will absorb allthe chemicals into their blood stream to induce feelings of content. However,in actuality though the body absorbsthe anti-depressant, and the biochemistry of the brain changes accordingly, thechemicals are secreted from the body as waste. Though the impurities withinthe water are treated, the filtering is not effective enough that the pharmaceuticalsare removed. This means that the drugs are existent in the water, and is integratedinto lakes and streams.Fluoxetine,a selective serotonin reuptake inhibitor (SSRI) antidepressant, is frequently found in the aquatics.

This type of drug alters the chemicals in the brain that areinstable in patients with depression.14 In a study completed by a researcherat the Center for Marine and Environment Research in Portugal, MariaGonzalez-Rey, it was discovered that when mussels were exposed tofluoxetine, the drug caused changes in the DNA structure, which developed intoDNA damage and growth complications. 15  Anti-depressantsare only anticipated to alter chemicals in humans, but as seen with aquaticlife, mussels in particular, the same chemicals can also affect animaldifferently, and harmfully.The drug has such a huge effect on aquatic life asit is stored in fish’s vital organs and tissues, including livers, brains, and muscles,where it not only modifies physical attributes caused by changes to their DNA, butalso has immense impact on their emotion.

  Male fish sought solitude inremote environments, were ascertained to be morehostile, and regularlycomplete identical tasks. This contentiousbehaviour led directly to the death of female fish, and therefore reproduction becamerestricted.  Furthermore, the anxiety levels were increased, inducing the possibility ofcatastrophe, because the animals will have limited awareness of danger and becometargets in the food chain.Therefore, this study suggests that the reductionof anti-depressants will lead to less harm to aquatic life reducing the anxietylevels which induces thepossibility of catastrophe, because the animals will have limitedawareness of danger and become targets in the food chain. This increases reproductionof animals, and the passing of desired alleles to the next generation, whichincreases the number of organisms without fluoxetine and other harmful antidepressantsin their systems. Anti-depressants have a wholly negative effect on the environment,as it increases stress in 1 Prevalence, duration and indications forprescribing of antidepressants in primary care. Petty DR, House A, Knapp P,Raynor T, Zermansky A, Age Ageing. 2006 Sep;35(5):523-6.

2 Patient factors associated with SSRI dose fordepression treatment in general practice: a primary care cross sectional study. JohnsonCF, Dougall NJ, Williams B, MacGillivray SA, Buchanan AI, Hassett RD BMCFam Pract. 2014 Dec 24; 15():2103 Excess risk of hip fractures attributable to the use of antidepressantsin five European countries and the USA. Prieto-Alhambra D, Petri H, Goldenberg JS,Khong TP, Klungel OH, Robinson NJ, de Vries F, Osteoporos Int. 2014 Mar; 25(3):847-55.4 https://www.

healthline.com/health/depression/tricyclic-antidepressants-tcas5 MiddletonN, Gunnell D, Whitley E, Dorling D, Frankel S. Secular trends in antidepressantprescribing in the UK, 1975-1998. J Public HealthMed.

 2001;23(4):262–267. doi:10.1093/pubmed/23.4.262.

6 Petty DR,House A. Knapp P, Raynor T, Zermansky A. Prevalence, duration and indicationsfor prescribing of antidepressants in primary care.

 Age & Ageing. 2006;35(5):523–526.doi: 10.

1093/ageing/afl023 7 https://www.theguardian.com/society/2017/jun/29/nhs-prescribed-record-number-of-antidepressants-last-year 8 https://www.

nhs.uk/conditions/ssri-antidepressants/ 9 https://www.addictioncenter.com/stimulants/antidepressants/10 https://www.mentalhealth.

org.uk/sites/default/files/up_running_report.pdf11 https://www.mentalhealth.org.uk/sites/default/files/up_running_report.

pdf12 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5473964/13 37. Medicinesand Healthcare products Regulatory Agency. Citalopram and escitalopram: QTinterval prolongation—new maximum daily dose restrictions (including in elderlypatients), contraindications, and warnings.

Drug Safety Update.2011;5(5):A1. http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON137769.

  Accessed 13 June 2017.  14 https://www.drugs.com/fluoxetine.html15 https://edblogs.columbia.edu/scppx3335-001-2014-1/2014/04/02/are-fish-and-plants-on-antidepressants/

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