Patient Preference and Ethical Prescribing

By Carrie Clark

When does respect for patient preference become an excuse for unethical prescribing?

Writing in the British Journal of General Practice, James Davies and John Read examine the consequences of the “patient preference” clause in the UK’s National Institute for Health and Care Excellence (NICE) depression guidelines.

The NICE guidelines advise that antidepressants should not be offered as a first-line treatment for “less severe” depression but make an exception if the patient expresses a preference for the drugs. But as Davies and Read point out, patient preferences are shaped by sociocultural forces that aren’t always based on evidence, or on achieving optimal outcomes for patients.

Thanks to campaigns by the pharmaceutical industry that were aimed at maximizing profits rather than relieving the suffering caused by depression, many people continue to think that antidepressants correct a “chemical imbalance.” The poor efficacy and risks attached to antidepressant use are not well known by the general public, who have been taught to believe that antidepressants are just as vital to the treatment of depression as insulin is to the treatment of diabetes. Should doctors really defer to patient preferences when those preferences are based on a false premise?

Unfortunately, Davies and Read cite studies showing that doctors often do. It takes time to explore a person’s beliefs about depression and to correct misapprehensions about its causes and treatment. Busy doctors often feel this is time they don’t have and, perhaps for this reason, studies find that patients who ask for antidepressants up front are often prescribed them automatically, even when they aren’t clinically indicated. In this sense, the patient preference clause in the NICE guidelines acts as a get-out-of-jail-free card for poor clinical practice.

Cutting corners might save clinicians time in the short term, but inappropriate antidepressant prescribing has downstream consequences that are bad for both individual patients and society as a whole. Although there is no evidence that depression is caused by a biological deficit, and systematic reviews find that antidepressants have minimal benefits, both the “chemical imbalance” theory and the myth of the “chemical cure” are tacitly affirmed when a doctor prescribes an antidepressant. This in turn shapes the patient’s implicit beliefs, reinforcing the idea that their well-being is dependent on the drug.

This is an objectively measurable effect: a recent survey found that patients who hold biological beliefs about the causes and treatment of depression are more likely to say that they couldn’t cope without antidepressants and less likely to try and stop taking them even when they are no longer clinically indicated. Inappropriate antidepressant prescribing fosters both physical and psychological dependence. This undermines the sense of personal agency that can be so critical to recovery from depression and locks people into the unnecessary long-term antidepressant use that is most likely to cause problematic dependence and severe withdrawal effects.

More broadly, Davies and Read point out that prescribing antidepressants based purely on patient preference deprives people of the opportunity to explore less invasive alternatives to drug treatment. NICE itself lists exercise, cognitive behavioral therapy, mindfulness and meditation, self-help, and behavioral activation therapies as interventions that equal or exceed the efficacy of antidepressants in relieving “less severe” depression. These nonmedical approaches not only have a significantly lower risk profile than antidepressants, they have also been found to reduce healthcare costs. Davies and Read highlight how the patient preference clause further entrenches the biomedical model, with system-wide consequences for the availability of nonmedical treatment approaches:

When medication becomes the de facto first-line response to distress (simply because it is requested), other therapeutic modalities may be deprioritised. Such de-prioritisation, when scaled up, may intensify a self-perpetuating system where investment in therapy, community-based services, peer support, and primary prevention programmes further diminishes, making medication seem the only viable or accessible option. As a result, what appears to be an outcome of free choice in fact results from being subject to a system that has quietly eroded meaningful alternatives.

It’s important to emphasize that Davies and Read are not arguing that patient preferences should be ignored or overridden by paternalistic doctors. On the contrary, both are passionate advocates for patient autonomy and choice. What this article highlights so beautifully is that patient preferences don’t exist in a vacuum. Clinicians have a responsibility to contextualize patient beliefs within a broader evidence-based framework, challenging misinformation with compassion and candor where necessary. The causes of mental and emotional distress are complex and unique to each individual. Every patient is entitled to an evidence-based account of their condition and the relative risks and benefits of the full range of treatments. Patient preference must never be an excuse for depriving people of this information.