Environmental impact of antidepressants: Is a new prescription framework possible?

Antidepressants such as venlafaxine and sertraline pose high risks to water ecosystems. As depressive disorders and other mental health conditions become increasingly prevalent worldwide, prescription and environmental presence of these pharmaceuticals continue to rise. This study explores the practical viability of a new framework for prescribing antidepressants-integrating safety, efficacy and environmental impact. This same approach could be applied in the future for reviewing prescription of other drug classes commonly found as pollutants in water.

To assess whether environmental risks could be reduced by prioritizing less polluting active substances, shifts in prescribing practices were simulated: For sertraline, shifts were directed towards citalopram and/or escitalopram, whereas for venlafaxine, the alternative was left unspecified due to the lack of equivalent options; a cost analysis was conducted to research economic feasibility of such an implementation.

Shifting away from sertraline towards citalopram and/or escitalopram would reduce the risk class of sertraline without increasing that of citalopram and escitalopram; the cost of such shifts would increase SSRI expenditure between 0.65% and 8.22% for Italy and reduce it between 3.53% and 12.72% in Germany. Conversely, no change in risk category is observed when the quantity of prescribed venlafaxine is reduced.

In the future, clinical guidelines could be adjusted to favour first-line substances with lower environmental impact but comparable efficacy, as for citalopram and escitalopram compared with sertraline. Together with strengthened implementation of non-pharmacological strategies, these measures could be an active step in fighting environmental pollution and climate change, increasing global health.