The largest review of the class of antidepressants known as selective serotonin reuptake inhibitors, or SSRIs, has found that the drugs are often overprescribed and should not be given as the first treatment for patients suffering from mild depression.

The possibility of side-effects, including suicidal thoughts and self-harm, prompted the review of the drugs, which are used by 3.5 million people in England.

The Medicines and Healthcare products Regulatory Agency and the National Institute for Clinical Excellence issued yesterday a list of recommendations for doctors to make sure that the drugs are used only where most appropriate. The institute said that for patients with mild to moderate depression, psychological treatments, such as counselling, could be as effective as drugs.

Doctors voiced concerns that these therapies were scarce. As a result, GPs were erring on the side of caution and prescribing antidepressants where they thought that it was in the best interests of their patients to avoid the possibility of suicide.

In England in 2003, there were 19 million prescriptions handed out for SSRIs, which include drugs such as Prozac and Seroxat. It is estimated that as many as one in five adults will have depression at some point in their lives and 30 per cent of patients entering primary care have either depression or anxiety problems.

The review of SSRIs by the Committee on Safety of Medicines began in May 2003 to investigate concerns about the drugs, particularly regarding suicidal behaviour, withdrawal symptoms and dependence.

Last year the committee gave warning that the majority of SSRIs should not be prescribed to under-18s because of the possibility of an increased risk of suicide. As a result of the review, which involved data from 600 published and unpublished trials, new guidance has been sent to doctors covering adults and under-18s.

Kent Woods, the chief executive of the MHRA, said that patients needed to be informed about all aspects of their treatment and the possible risk of side-effects and withdrawal symptoms, such as headaches and vomiting.

“SSRIs are an important group of medicines, which help patients who suffer depressive illness,” Professor Woods said. “They have been widely prescribed and I think it is very likely that they have been overprescribed — but it is difficult to quantify because it is not a precise science in determining the difference between moderate forms of depression and milder forms.

“The downside of any patient receiving medication they do not need is they are exposed to unpleasant side-effects.”

The review said that warnings about the risk of experiencing withdrawal reaction when finishing a treatment should be strengthened. It said that in the majority of cases the lowest recommended dose of SSRIs should be prescribed. Data did not show any extra benefit from increasing the dose above the recommended daily level.

The review concluded that a slight increase in the risk of suicidal thoughts and self-harm for SSRIs compared with dummy pills “cannot be ruled out”. However, it said that evidence suggested that there was no clear increase in the risk of suicide from SSRIs compared with other antidepressants.

The experts recommended “careful and frequent” monitoring of patients using SSRIs in the early stages of treatment, particularly young adults because of their increased risk of experiencing adverse effects.

The committee recommended that the SSRI venlafaxine (Efexor) should be prescribed only by specialists and patients monitored closely. Patients with heart disease should not be given the drug, it said.

ADVICE TO GPs

• Generally prescribe lowest recommended dose
• Stronger warnings needed about risk of withdrawal reactions
• Increased risk of suicidal thoughts and self-harm “cannot be ruled out”
• Careful monitoring needed in early treatment
• SSRIs carry no increased risk of suicide compared with other antidepressants

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