Prevalence and variation in antidepressant prescribing across Northern Ireland: a longitudinal administrative data linkage study for targeted support.

Anti-depressant prescription rates in the United Kingdom (UK) are among the highest in Western Europe and prescription rates in Northern Ireland (NI) are significantly higher than the rest of the UK. Moreover, while prescription rates are climbing annually, rates of depression are not changing, and evidence suggests that a range of socio-economic and geographical factors may be responsible. Furthermore, the majority of UK GP's often believe that alternative treatments may be more appropriate and that they would prescribe antidepressants less frequently if other options were available. Evidence seems to indicate generally that (a) there are widely different reasons why people receive anti-depressants and why GP's prescribe them, and (b) the relative importance of these reasons may vary geographically (e.g. the likelihood of receiving antidepressants may vary due to the affluence of an area or the number and proximity of available primary care services; and the associated pressures on these services).
A multi-disciplinary team of experienced academic researchers and the award winning NI charity, Aware Defeat Depression (Aware), aim to maximise the use of Census and Enhanced Prescribing Database data in NI to target, tailor and implement support for individuals in receipt of antidepressant prescriptions and to stimulate 'social prescribing' across the region (a mechanism for linking patients with non-medical sources of support within the community).
Specifically the study aims to (i) provide a detailed geographical breakdown of antidepressant prescribing in NI to identify prescription 'hot spots' at a small geographical level, (ii) use linked census data to identify demographic variables (personal, social, and economic factors) that differentiate 'hot spots', (iii) determine if the association between demographic variables and 'hot spots' differs by geographical location, (iv) determine if long-term changes in people's lives (e.g. change in deprivation, family structure, physical health) are associated with antidepressant use and (v) stimulate 'social prescribing' across the region through targeted intervention.
The project will address two main research questions highlighted in the 2015/16 ESRC strategic priority area 'Influencing Behaviour and Informing Intervention'.
On the basis of the proposed analytic strategy the project team aims to develop a nationwide map detailing the socio-economic landscape of antidepressant prescribing in NI. This map will support the non-academic partners (Aware) in their efforts to develop and implement effective and coordinated intervention programs by (i) highlighting prescription hotspots at a small geographical level (ii) generating 'risk' profiles specific to identified hotspots using personal, social and economic data and (iii) identifying 'vulnerability' at a personal, social and economic level through longitudinal change modelling.
The project has the potential to deliver effective and meaningful change. Partnership with Aware will ensure that findings can be acted upon immediately. Aware has been delivering intensive education and training programmes to thousands of adolescents and adults across NI since 1996 and has been awarded the GSK IMPACT Award in 2014. A primary focus of these programmes is to educate individuals about positive strategies that can be used in the recovery from depression. Aware, on the basis of the project findings, will tailor, target and promote 'social prescribing' in those areas and among those individuals in NI that need it most. Social prescribing may include opportunities for arts and creativity, physical activity, learning new skills, volunteering, mutual aid, befriending and self-help, as well as support with, e.g. employment, housing, debt, or parenting problems. Equipped with a detailed geographical map the project team will develop a targeted intervention strategy for delivering focussed, context sensitive social prescribing across NI.

Who will benefit from this research? The project team are committed to engaging with key stakeholders in the area of community action, and at a public health, primary care, and national policy level. While the NI client base of the projects non-academic partner, Aware Defeat Depression, will be the primary beneficiaries of the research, Aware themselves and other primary care service providers will also directly benefit from the work. The proposed project will also be of interest to a wide range of academic disciplines (public health researchers, epidemiologists etc).

How will they benefit? Aware Defeat Depression (Members & Client Base): Partnership with Aware will ensure that the analytic process and findings will directly inform targeted intervention. Aware, the only charity working exclusively for those with depression in NI, is an established support network ideally positioned to deliver impact. Aware has been delivering intensive education and training programmes to thousands of adolescents and adults across NI since 1996 and has been awarded the GSK IMPACT Award in 2014. A primary focus of these programmes is to educate individuals about positive strategies that can be used in the recovery from depression. Aware, on the basis of the project findings, will be in a position to better tailor, target and promote 'social prescribing' in those areas and among those individuals in NI that need it most.
NI Primary Care Service Providers, GPs and their patients: While Aware can communicate directly with those in receipt of antidepressant medications across NI, primary care service providers and general practitioners constitute another important stakeholder. Through the project, Aware can offer a valuable opportunity to alleviate pressures in primary care (and associated prescription practices) in NI and to link GP patients with a wide range of non-medical sources of support within the community that may address their needs in more effective and diverse ways. In relation to the project report findings specifically, primary care health workers and GPs will be directly informed of (i) variations in prescription rates across NI and (ii) the socio-economic context of prescribing rates in their jurisdiction.

What will be done to ensure that they have the opportunity to benefit?
-A project website and social media account will be created. Specific consideration will be given to non-academic bodies in the design of the website. For maximum impact and utility an interactive map based on GIS principles will be designed. This application will provide users with an efficient means of navigating the project findings geographically.
-A targeted intervention strategy for delivering focussed, context sensitive social prescribing across NI will be formulated by the project team. Using the project findings Aware will target services to 'high-risk' areas across NI.
-A summary report and pathways to policy document will be compiled and sent to the ADRN, the Office of First Minister and Deputy First Minister in NI and the Royal College of General Practitioners Northern Ireland.
-On completion of the analyses the team will organise a briefing conference to ensure that project findings are effectively communicated to all stakeholders. The conference will be promoted and advertised through ARK (based at Ulster University). The primary aim of ARK is to support policy development which it achieves through its Policy Unit which has established connections with the voluntary sector, the Assembly, government departments, practitioners and academics. Importantly, this event will bring Aware and primary care service providers together to ensure that social prescribing is promoted and facilitated as effectively as possible throughout NI.
-Finally, two peer-reviewed publications will be produced, the first targeting GPs (e.g. British Journal of General Practice) and the other, broader social scientists (e.g. Social Science and Medicine).