Since the beginning of the pandemic, there has been a soaring demand for mental health services, with an estimated 1.6 million people in England waiting for specialised support, and another 8 million who would benefit but whose deterioration in mental health is not considered serious enough to even get on the waiting list. Anxiety rates have been recorded as rising significantly between 2008 (the year of the financial crash) and 2018, with increases in all age groups under 55, but trebling in young adults.
The number of prescriptions issued for anti-anxiety medication has also been rising. Earlier this year, research was published showing that between 2003 and 2008 the use of drugs to treat anxiety was steady, but by 2018 it had risen considerably. During that earlier period, new anti-anxiety prescriptions rose from 25 or 26 per 1,000 person years at risk – a measure of the prevalence of anxiety – to 43.6 in 2018. Nearly twice the number of women are being prescribed medication as men.
This rise could be due to a number of things. “I think GPs are getting much better at detecting anxiety,” says Charlotte Archer, senior research associate in primary care mental health at the University of Bristol, who led the study. Before, she says, there were concerns “it would go undiagnosed. I think that’s starting to change. And that is going to have an impact on prescribing rates.” She also thinks patients are more aware, not just of anxiety but how it can be treated. “They know that they want a prescription. I don’t think that’s always been the case.”
When people see their GP, says Dr Trudi Seneviratne, consultant psychiatrist and Registrar of the Royal College of Psychiatrists, treatment is “very much led by what individuals want. ‘How severe is it and how would you best like to manage it?’ is often the conversation. If it is more mild to moderate, would you like to go down the route of talking therapies? Would you like a combination of psychological therapies plus a medication? What are the other lifestyle changes that you can make to manage this anxiety?”
Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) such as sertraline and citalopram, are most commonly used. “Anxiety and depression can go together,” says Seneviratne. “You don’t necessarily get somebody just with anxiety, although you can.” Antidepressants, such as the SNRI group, can be used if an SSRI hasn’t worked. “The other group we use are benzodiazepines, which are sedative drugs – things like lorazepam or diazepam – but they should only really be used in the short term because they can be addictive.” Others include beta blockers, medication used for epilepsy and anti-psychotic drugs. Depending on the drug, side-effects can range from headaches and nausea to a reduced sex drive and even increased anxiety. The latest thinking on medication suggests that it is not to be generally considered “lifelong” as Seneviratne puts it, and it should be monitored and reviewed about every three months.
Medication tends to be prescribed, says Seneviratne, “when anxiety is becoming debilitating … when it’s having a severe impact on quality of life – not being able to sleep, to function, to work, struggling to even do simple things like go out of the house, or maintain self-care.” By that point, someone experiencing anxiety may not be able to effectively engage in therapy.
With milder forms of anxiety, she says, people should initially be offered psychological therapy such as counselling or cognitive behavioural therapy (CBT). The latest National Institute for Health and Care Excellence (Nice) guidelines for depression recommend other treatments such as therapy, mindfulness and exercise are offered to patients before medication.
For some people, it can simply involve making their own lifestyle changes, improving diet, sleep and exercise. If that doesn’t work, “then from mild to moderate, and for more severe anxiety, talking therapy should always be offered”. However, Seneviratne adds, “access to talking therapies is really patchy and there’s huge waiting times depending on where you are”. What isn’t clear is whether medication is being prescribed where there are long waiting lists for talking therapies. For people who need more urgent help and don’t want to take medication, private therapy can cost upwards of £40 per hour.
“There’s a dizzying array of therapies, which can be confusing for the sufferer,” says Dr Stephen Blumenthal, a clinical psychologist and psychoanalyst. “Broadly speaking, they’re grouped into two types – one, which is more exploratory, which treats the anxiety as a symptom of something underlying, which needs to be understood. And on the other side of the spectrum, are [therapies] more aimed at relieving symptoms.” The latter tend to be behavioural therapies such as CBT and DBT (dialectical behavioural therapy, which is based on cognitive therapy but incorporates an element of acceptance at the same time) which are, he says, “basically strategies to deal with the fear. It’s not mutually exclusive with a more psychodynamic approach, which would be to try and explore what it means.”
He adds: “Of course there are times when it is necessary to take medication.” But he is wary of it being seen as a quick fix. “Suffering from anxiety can be so utterly crippling that you want to resolve it as quickly as possible,” he says. And our mental health service, “under severe strain as it is, it’s extremely action-orientated. When somebody presents to a GP, you’re going to have seven minutes, and the poor GP is under a deluge of people, about 40% of whom involve mental health problems of one kind or another.” He believes that, for many people, anti-anxiety medications “don’t resolve anything, they just cover up the symptoms for the time that the person is in a state of anxiety, and they can actually undermine our natural coping mechanisms”. Coping strategies, he says, “need to be supported with psychological therapies”.
In July last year, Hannah Duran’s depression and anxiety – which had been recurring for years – began to worsen. “I felt that I needed a little more help,” she says. She referred herself to the Improving Access to Psychological Therapies service (IAPT), which runs in England, but heard nothing. By February, unable to cope, she was signed off work. “Coincidentally, the day after I went off sick I got a call from a local talking therapies to offer me an appointment,” she says. Then that appointment was cancelled, and so was the rearranged date. Nine months on from her initial contact, she says she still hasn’t been offered treatment. The NHS recently reported that almost 90% of IAPT referrals for talking therapies in England were on average seen within six weeks but it varies by area and people have reported long waits.
Paying for private therapy isn’t possible for Duran, but she did access counselling that she started in March, through the mental health charity Mind. “They’ve been fantastic,” she says, but she is frustrated that the IAPT service wasn’t available. “I think there’s every possibility that I wouldn’t have gone off sick if I’d had access to therapy sooner. Things just got worse and worse until I reached breaking point.”
Talking therapy can work for some people but not others, and it’s the same with medication. For Duran, a combination of both has been effective. For others, medication has not been effective. Freya Jenkins has suffered anxiety for most of her life, and was recently hospitalised for a week after her mental health rapidly declined last January. She has been on beta blockers, a short course of diazepam and, for the last two months, venlafaxine, an SNRI. “I haven’t noticed any difference,” she says. She would prefer to have therapy but needs longer-term and specialised treatment, under the care of a psychologist, and now faces a wait, even though she’s clearly struggling. “I’ve had someone tell me [it could be] up to a year,” she says. “It’s not the NHS’s fault. There’s not enough funding and it needs an overhaul.”