Prescription dread: measuring psychiatric drugs against the alternatives

In November, the Organisation for Economic Co-operation and Development estimated that mental health diagnosis and prescription drugs cost the UK economy £94bn annually. With this in mind, mental health-focused technology company Smart TMS recently published a report on the UK’s attitudes towards depression and prescription drugs for this indication. 

The report found a ‘prescription dread’ trend in the UK where people are wary of antidepressants and are keen to try new innovative approaches.

Although Smart TMS medical director and consultant psychiatrist Dr Leigh Neal emphasises that depression drugs do work, and patients go into remission in 70% of cases, he does acknowledge a reluctance to take antidepressants, which was identified in the report. The paper found that 14% of respondents had avoided getting treatment for long-term mental health conditions because they did not want to take the prescription drugs available. 

Neal sees this reluctance as having increased in recent years; when psychiatric drugs were first introduced 60 years ago they were “revolutionary” as at that time the primary treatment approach was “long-term psychotherapy, which is very expensive…and didn't work”. Now there has been “a loss of memory and people’s expectations about medication have gone up”.

A primary issue with antidepressants is that they can have serious side effects. Smart TMS’s report found that 14% of respondents had been dissuaded from taking prescription drugs again because of side effects, 15% who had taken antidepressants had found them to be ineffective, 12% had to stop taking antidepressants either because they were ineffective or due to side effects. 

Although there is a range of side effects associated with antidepressants, including insomnia, tremors, constipation and nausea, Neal particularly associates what he terms ‘zombification’ with the negative attitudes towards antidepressants. He describes this side effect as a “lack of variability of mood” where “patients don't feel happy or depressed. And they're just sort of stuck in the middle.”

Although progress has been made in reducing side effects in newly developing drugs – Neal emphasised the huge leap forward made with the approval of selective serotonin reuptake inhibitors (SSRIs) in the 1990s – the report showed that UK patients desire radical alternatives; 24% of survey respondents thought GPs should offer effective alternatives to anti-depression drugs. 

One alternative option for patients with depression is brain stimulation therapies. These involve activating or inhibiting parts of the brain directly with electricity. This can be administered using a variety of different direct and non-invasive methods. 

Smart TMS, as the name implies, focuses on the transcranial magnetic stimulation (TMS) method, which was approved by UK’s pricing authority the National Institute of Health and Care Excellence (NICE) in 2015. 

“TMS is a pulsing electromagnetic field, [which] is able to stimulate electrical currents on the surface of the cortex of the brain,” Neal explains. “Over a period of time, it propagates the effects from the surface of the cortex, down into the deeper parts of brain. It has an effect on the neurotransmitters, and on neuroplasticity within the brain.” 

It differs from the original electroconvulsive therapy (ECT) because “you don't require a general anaesthetic and you don't have a convulsion or memory issues”. 

TMS is usually performed once a day for between 15 and 30 sessions, and the form approved by the UK’s healthcare pricing regulator in 2015 involves a 20-minute stimulation on the left, frontal side of the brain.

Neal argues TMS is more effective than antidepressants. Based on a rolling audit kept by Smart TMS, it can get roughly 60% of its patients into remission and 75% have a more than 30% reduction in symptoms. 

TMS also has lower relapse rates in resistant patients – Neal claims relapse for resistant patients on antidepressants is 60%, whereas it is around 5% for resistant patients undergoing continuous TMS care, which is defined as two sessions every month. 

In addition, this brain stimulation technique causes fewer side effects than antidepressants. “The quality of improvement from my perspective as a psychiatrist is a lot better with TMS because you don't have this zombification feeling; you actually get a proper recovery where people’s mood returns to normal,” Neal says.

The only serious side effect associated with TMS is convulsions, which occur in about one in 50,000 patients, research suggests. However, Neal notes that in the five years the company has been working in this area, not a single patient has had a convulsion – in fact he had never heard of a patient in the UK having a convulsion as a result of TMS. 

He says the company manages the less serious side effects, like discomfort on the scalp, by reducing the power of the magnetic field until the patient becomes accustomed to it. 

To make it even more effective in certain patients, TMS has been combined with antidepressants. However, Neal notes that “this has not been subject to thorough research yet, so we don't know the answers” about why some patients require both antidepressants and TMS to achieve remission. 

Importantly, TMS is not only effective for depression; Smart TMS uses it to treat patients with “depersonalisation disorder, nicotine dependence, cocaine dependence, obsessive compulsive disorder, post-traumatic stress disorder and generalised anxiety disorder”. Particularly noteworthy, according to Neal, are its PTSD and cocaine dependency programmes; patients have been able to eliminate the craving effects of the latter with seven days of treatment, he says. 

There is an issue with the convenience of TMS therapy, compared to simply taking a pill once a day, which Neal acknowledges. This is because it has to be administered 30 times by a healthcare professional at a clinic, and if a patient is engaged in continuous care, they can require two sessions a month for an extended period of time. This means patients have to set time aside for the treatment, as well as travel to the clinic. 

Another current flaw with TMS and other brain stimulation approaches for depression is the cost. Despite being approved by NICE for use on the UK’s National Health Service (NHS), there are very few NHS clinics that offer TMS to patients for free, and those that do are faced with very long waiting lists. 

Although 8% of the respondents (approximately 4.2 million people) in the Smart TMS survey stated they would be happy to pay more than £2,000 for an innovative therapy, TMS does fit below this threshold.

Smart TMS charges £2,750 for 15 sessions, increasing to a total of £5,750 for 30 sessions; other TMS centres charge a similar rate. For example, the rTMS Centre’s treatment costs £3,000 for 20 sessions.  

This means that although research has suggested that it is more cost-effective than antidepressants over the long term, according to Smart TMS’s research, this pricing is too high for it to be perceived in this way by UK patients who primarily have to pay out of pocket.

As researchers and pharma firms continue to deepen their knowledge about mental health issues and their most effective treatments, there will be no single approach that works universally across the board. Instead, patients increasingly expect a range of options – whether pharmaceutical, technological or face-to-face – to maximise their chances of finding a treatment approach that works for them. 

From the global pharmaceutical industry’s perspective, Smart TMS’s report should make it clearer than ever that new drugs developed for depression and anxiety – an incredibly complex indication – must focus on reducing the burden of side effects and winning back patients’ confidence. As, unlike 60 years ago, psychiatric drugs are no longer the only horse in the race.