We need a radically different approach to addressing mental health

We need a radically different approach to addressing mental health

Authors: Eoin Galavan, Sarah Thompson

In an open statement published ahead of World Health Day on 7 April 2017, the UN Special Rapporteur on the right to health, Dainius Pūras, said societies must reconsider dominant biomedical approaches to depression in line with the Agenda 2030 Sustainable Development Goals to secure the right to health for all. Pūras (a psychiatrist) stresses: “Treating depression and other forms of psychosocial distress with drugs, and medicalizing these conditions, has become the dominant approach. However, the use of psychotropic medications as the first line of treatment, especially for mild and moderate cases of depression, is quite simply unsupported by the evidence. The overreliance on biomedical interventions causes more harm than good, undermines the right to health, and must be abandoned.”  A recent parliamentary debate in the UK held by the All Party Parliamentary Group for Prescribed Drug Dependence highlighted the serious and growing problem of rising mental health disability1. Robert Whitaker, a world renowned scientific journalist, presented evidence that the rising rates of disability are correlated with rising prescription rates for psychiatric drugs. In other words the prescription of psychiatric drugs is linked to and possibly contributing to the rising rates of disability resulting from mental health problems. The evidence suggests that if psychiatric drugs were not prescribed for long periods of time then many, if not most people would be better off. This reality, long suggested by the WHO report on schizophrenia2has been largely ignored by successive governments, health service leaders and mental health professionals across the western world.

 

The topic of mental health has received a great deal of comment and attention in recent years. A Vision for Change (the 2006 National Mental Health Strategy document) while promoting an increase in resources and some shifting in philosophy, which is to be welcomed, is, in our view, fundamentally flawed, as is our mental health legislation. Both of these fall prey to the same central error i.e. that mental health issues are viewed as biological or brain based illnesses. The use of the term ‘mental illness’ is only useful as an analogy, and yet it is treated in practice as if it is a scientific fact pointing to presumed underlying biological diseases. This conceptual error may seem insignificant and distinguishing it may seem trite, however many contend it causes serious problems for people who seek help and maintains an unnecessarily medicalised approach to providing mental health care. In addition, conceptualising human distress as ‘mental illness’ indicating an underlying biological aetiology can actually lead to an increase in stigma, the very problem that proponents of the illness model purport to be addressing by comparing it to physical illness3,4,5. In addition, it also has the unfortunate side effect of reducing the individuals’ sense of autonomy and control in their ability to do anything to address their problems. This medicalisation subsequently supports corporate interests in the form of pharmaceutical company profit and may be leading to a huge rise in mental health disability world-wide6. The rate of prescription drugs in the treatment of mental illness in the US for example is reaching staggering heights with approximately 10-20% of the population currently taking psychiatric drugs7and yet this country has arguably the worst mental health outcomes1.

 

Mental health issues are best viewed as fundamentally social and psychological problems influenced to a relatively minor degree by biological factors8. Professor Peter Kinderman (past President of the British Psychological Society & Professor of Clinical Psychology at the University of Liverpool) in his book ‘A Prescription for Psychiatry’9calls for radical reform of mental health care. In this he, along with many others, argues that mental health problems are not best thought of as biologically based illnesses. There is no biological test or ‘biomarker’ for the so called biological illnesses labelled as, for example, ‘Major Depression’ or ’Schizophrenia’. Years of expensive research into genetic links or brain based links have yielded little or nothing of value in helping people with mental health problems, or in substantiating the hypothesis that there is a genetic predisposition for, Schizophrenia10,11,12,13. Indeed there is substantive evidence that trauma, for example, is a far more significant contributing factor to developing psychosis14. Professor Kinderman’s first and most important suggestion is that we drop the language of illness, in favour of simple descriptions of people’s problems. It does not help us understand someone any further by saying ‘they have a depressive illness’ for example. How do we know they have a depressive illness? It’s because they talk about feeling very low, tired, sad and being unable to work or relate to people, unable to enjoy life, for a period of time. Therefore they have a depressive illness. And what does saying you have a depressive illness mean? It means you are feeling low, have little energy, are feeling sad, unable to enjoy life etc. The term depression, as a diagnostic illness concept, tells us nothing more about the individual and their problems. A diagnosis is supposed to tell us about an underlying cause or provide an explanation for symptoms, and in medical terms this typically means an underlying physically based, biologically identified, pathology. Not only does a diagnosis in mental health not do this, and not reveal anything more about the person than we already knew, but it can inhibit us from asking what has happened in this person’s life that has led them to experience the problems of low energy, low mood, sadness, struggling to relate and enjoy life etc. Diagnostic illness categories like ‘major depressive disorder’ masquerade as explanations, are not based on scientific discovery and are invented by conjecture and debate.

 

In the example of depression, the myth of the serotonin hypothesis has been promoted in the absence of any credible scientific evidence (see Lynch15for review). The use of the illness model of depression facilitates the ongoing prescription of drugs that have little or no benefit, except to a small degree to a very small proportion of the most severely depressed people16. Irving Kirsh has delivered a review of this issue in his book The Emperors New Drugs17, following on from his landmark analysis of the FDA data in 200816. The research reviewed in this book, including the thorough re-analysis of all data submitted to the FDA for approval published in 2008, both published and unpublished studies, should have profoundly changed the way mental health care responds to depression. Anti depressants perform no better than placebo, except for the most severely depressed and to a very limited degree. However in terms of prescribing rates, it seems things have worsened: recent data published in the Irish Examiner suggests a range of 4.5-10% of the population is currently taking psychoactive drugs for anxiety and depression18. Whitakers review cited above19notes this trend in many countries including the UK and US. A recent report in the UK threw further light on the massive price paid by society and those relying on anti depressant medication20. It would appear that being on anti depressant medications means you are less likely to get back to work, more likely to remain depressed over the long term and more likely to relapse than if you were not treated at all. The long term reliance on psychiatric medications of all sorts seems to carry great risk, and for many people, may make things worse in the longer term. Robert Whitaker has outlined this evidence in particular in relation to so called anti psychotic medications in his bestselling book Anatomy of an Epidemic21, and more recently at a UK parliamentary debate earlier this year1.

So what about those people who say, ‘the drugs help me’? Of course they can help some people, or at least they seem to help. There are two elements to consider, firstly drug effects and secondly the placebo effect. Psycho active drugs have effects, and have always been used to alter how we feel, and sometimes to our benefit. This does not mean we should rely on them over the long term, nor does it mean we are ‘curing’ or ‘treating’ some underlying biological basis of depression or psychosis. It also does not mean that it necessarily makes sense for someone to use a drug to alter how they feel as a way of coping with difficult experiences like depression or psychosis. It is not necessarily a healthy thing to rely on drugs to alter feelings of depression when there are reasons for being depressed, for example. It is my experience that with time and patience the reasons for being depressed, and for most other mental states including psychosis, are not that difficult to discover, even if they elude someone at the outset of such a process. Have we lost our common sense about this? Taking a drug to artificially alter your mental state or feeling state is not necessarily a healthy thing to rely on, particularly for a prolonged period of time. In the short term there can be obvious advantages. For example if someone is highly activated, finding it impossible to sleep or slow down their thoughts and behaviour, having a drug that can have a sedating effect, can obviously be useful. Drug effects can be useful, sometimes, for some people.

 

One of the problems with the seeming effectiveness of drugs is that when someone takes a drug and says they feel better (less depressed for example) it seems to prove the drug is effective in ‘treating’ the depression. It does not prove this. This is why we have placebo controlled trials, to see if drugs deliver more than the placebo effect. The evidence for the effectiveness of anti depressants indicates that only in the most severely depressed people do anti depressant drugs seem to offer more than placebo, and even in this group the level of difference is clinically relatively small16, and it is possible that the effect is more to do with the decreased impact of the placebo effect, than the increased relevance of the drug. The NICE guidelines suggest clinical significance equates to a 3 point difference on the Hamilton Depression Rating Scale (HAM-D), (which is still minimal on a scale with 29 items, 6 of which relate to sleep alone). More recent research would suggest no benefit of anti depressants above placebo when slightly more stringent criteria for clinical significance are used, which still represents a relatively minimal level of clinically significant change, even for those who are classed as severely depressed22. A recent systematic review23published in the BMC Psychiatry suggests “SSRIs might have statistically significant effects on depressive symptoms, but all trials were at high risk of bias and the clinical significance seems questionable. SSRIs significantly increase the risk of both serious and non-serious adverse events. The potential small beneficial effects seem to be outweighed by harmful effects.” For those authors who conclude that anti depressants are more beneficial than placebo24the effect sizes reported are small (0.34) and the clinical effects as opposed to statistical effects (2.82 on the HAM-D, with the Confidence Interval ranging from 2.21 to 3.44) when either the NICE guidelines levels for clinical significance (3 points on the HAM-D) or the slightly more stringent clinical significance levels noted above (7 points) are taken into account, are questionable. Others go further and claim there is evidence of effectiveness of anti depressants above placebo in the severely depressed group, however still conclude that other less risky interventions should be utilised first given the small effect sizes, and acknowledge the effects of anti depressants are limited25.

 

So what’s the problem with taking them? People still improve while taking them, albeit at a rate similar to placebo, so where’s the harm? There are several problems with relying on medication to address mental health problems. Research shows that individuals on medication are more likely to end up on long term illness benefit and less likely to return to full health, more likely to relapse and develop a long term dependency on a drug to help you ‘feel normal’ 17,19,20. Surely being drug free and less likely to relapse should be goals of mental health care. As with all drugs, there are risks. An increased risk of suicide, has been recently acknowledged with black box warnings now appearing on anti depressants in the US26. Sexual dysfunction is common place with as many as 50-80% of people taking SSRIs experiencing sexual dysfunction27,28. Discontinuation syndromes are now being more widely recognised with 30-50% reporting significant problems associated with withdrawal, including anxiety and agitation and some have argued SSRIs need to be added to the list of drugs that should be warned about as having withdrawal effects29. Due to discontinuation effects, people therefore frequently become dependent on these drugs for prolonged periods of time. Major researchers in the field have now recognised that anti-depressant drugs may cause worse mental health problems for those taking them long term, in addition to the general negative outcomes discussed above. For example, writing about the phenomenon of Tardive Dysphoria researchers have warned that continued drug treatment may induce processes that are the opposite of what the medication originally produced. This may “cause a worsening of the illness, continue for a period of time after discontinuation of the medication, and may not be reversible.”30A major study at Yale University discovered there is also an increased risk of people developing Bi-Polar disorder (a more serious condition) when taking anti depressant medication that is causedby the medication. Researchers found that the number of treated cases needed to harm is 23. In other words for every 23 people treated with anti depressants 1 Bi polar patient is created who would not have otherwise developed this condition31. That means there are literally thousands of new cases of Bi Polar disorder being created every year. Surely we should be asking the question:

Why take a drug that is largely ineffective and creates these risks when there are other evidence based approaches which have comparable if not superior results to medication; such as exercise32,33and psychological therapy34?

The answer to this question is of course ‘don’t take the drug, choose other options first’. However there is a systemic reason for the rising rates of prescription of anti depressants. If for example, you see a psychologist or psychotherapist when you first experience depression, you will probably not be offered drugs as a treatment option, and will instead likely, and in the best case, be offered an effective, time limited psychological or psychotherapeutic approach to helping you with the experience of depression. However, this does not happen as currently we require people to see medical doctors first with few if any alternatives available. Well-meaning, medically trained doctors, with little access to alternative resources have a high level of likelihood of prescribing a drug rather than working psychologically through the issues linked to the depression, or offering alternatives. This may also be further fuelled by a fear of being found guilty of negligence or at fault in the case of death by suicide if they haven’t prescribed an anti depressant: a perfectly vicious circle for them despite ineffectiveness and risk concerns previously outlined. Drug use in the treatment of depression in mental health care should be the last port of call, for the most severely depressed people, and only when other more effective, less risky, less expensive, evidenced based interventions have demonstrated to be ineffective (this would amount to a miniscule fraction of those currently being treated with anti depressants and represent a major change in the culture of mental health care). In reality, those who do not respond to anti depressants are often labelled ‘treatment resistant’ and after trials on multiple types of anti depressants may be referred for the more invasive, risk laden and controversial treatment of ECT, rather than a consideration of psychological therapy or other psychosocial inputs, earlier in the journey.

 

Drug use could be considered in the frame advocated by Professor Joanna Moncrieff in her book The Myth of the Chemical Cure35. Professor Moncrieff outlines a drug model approach to using medications as opposed to a disease model approach. In the drug model, drugs are used on the basis of the effects they actually have, which may or may not be helpful to a person at a particular time, rather than as addressing an underlying disease state or ‘chemical imbalance’, a theory which Moncrieff, a working Consultant Psychiatrist, asserts has no supporting scientific evidence.  This is a similar idea to the way in which paracetemol works-we take paracetemol to help with the symptoms of a headache-we do not assert that an imbalance in acetaminophen (the active ingredient in paracetemol) caused our headache, nor do we assume that because the headache resolves after taking the medication that the reason for the headache has been discovered. A drug model approach allows for the short term, ethically informed, prescription of drugs without fabricating brain pathologies to justify their use. For example, Lithium causes people to feel numb, to slow down their thinking, to reduce their experience of emotion, to dull their sense and mental activity, and some people report this to be helpful during particular states. However there are many risks including long term liver damage, decreased tolerance of the drug over time, and the drug does not facilitate exploration of the reasons for the difficulties occurring in the first place or allow the development of coping strategies to deal with the problems36. Therefore Moncrieff advocates that these risks and side effects are carefully weighed up when prescribing psychotropic medications and should not be the sole focus or the frontline of intervention.

 

Sadly we are not frontloading our services with talking therapies, evidenced based effective and time limited psychological or psychotherapeutic models of care or with other psycho-social, social or lifestyle based models of helping people: we are instead drugging people at an alarming rate, and this is costing us dearly20. The most important shift we need to take in mental health care is to move it from a medical care base or illness model to a psychosocial care base or psychological model as described by Kinderman8. This would shift the balance towards social and psychological interventions, recognising the absolutely central and fundamental role that social circumstances, poverty, inequality, educational opportunity, family problems, relationships, stress, loss, our lived experience and trauma all play in our mental health. This does not remove rather reconceptualises the role of biology and genetics8. We need to remove the requirement for a medical doctor or Psychiatrist to be at the centre of the ‘treatment’ milieu, because mental health problems are not primarily medical problems. We should move to a psychosocial care base with highly trained social workers, psychologists, social care workers, occupational therapists, counsellors, psychotherapists, family therapists, social pedagogues, experts by experience, peer support workers and others. We should provide individualised and collaboratively developed programs of care that are based on psychotherapeutic, psychological8, social and systemic understandings of mental health difficulties, that are evidenced based, recovery oriented and include connections to health services. We should shift to a formulation based assessment of peoples need rather than a diagnostic based assessment37,38. This proposed reshaping of services can include crisis centres, crisis houses, drop in centres, therapeutic communities and other non medical models of interventions for the extreme and severe experiences of, for example, psychosis; the well established and highly successful Finnish, Open Dialogue model, the Parachute program in New York or Leeds Survivor Led Crisis Service provide useful examples. More importantly such services will appropriately address the needs of the vast majority of service users. Medical psychiatric assessment, drug and hospital based interventions may be important for a small number of people, some of the time, within such systems, and can be included on a consultation basis (much like how a GP service would relate to for example an Intellectual Disability residential service). This shift in philosophy and structure is no small endeavour, with many challenges inherent. We need to rewrite the mental health act and rewrite our mental health policy (A Vision for Change is really a Vision for ‘More of the Same’ as long as the illness model and medicine, are made central to the entire system). We also need to invest in the building of appropriate (non medical) centers and the training and hiring of sufficient staff suitable for the task. This latter point is of immense consequence. If we are genuinely looking to improve mental health care, and remove the current massive over reliance on a drug based approach, we must take the staffing issue far more seriously than ever before. One reason the current system has perpetuated, is the fact that a psychiatrist can review many people in a short period of time, which seems on the surface to be efficient. However, in the long term it costs much more, is highly ineffective and the least preferred option for patients34. We must also prize and value highly the challenging and powerful role of relational and emotional work involved in providing high quality mental health care, where the most important resource is the capacity of staff to relate in a therapeutic manner, not hospitals or medications.

 

As Clinical Psychologists have we too long colluded with, ignored, ‘worked around’, tolerated, and even promoted the predominant unreliable and ineffective illness model of mental health? We have of course challenged and offered alternatives as well. It is understandable how this has happened. If for example, you wanted to establish the efficacy of a psychological approach for a mental health problem, like depression, you needed to seek funding in the US for example, through the National Institute for Mental Health. This national government based organisation restricted funding to interventions specifically targeting diagnostically labelled illnesses for many years (something that has recently changed in light of the recognition of the lack of scientific merit of the DSM diagnostic system). This meant if you wanted to establish the efficacy of CBT in treating depression for example, you needed to play along with the diagnostic label game: We have developed a psychological treatment for the mental illness called depression. If you don’t ‘treat the illness’, then you are not providing care to people who experience depression and are outside the prevailing culture of mental health care: a double bind. It is also true to say that the evidence of the flawed basis for the illness model has only come to light sufficiently in the last 10 years, making this collusion one that could have occurred with genuine belief in the validity of the illness model, something society in general has accepted (the illness model is still one way of looking at problems however it lacks any scientific merit)8. We also work closely with Psychiatrists and at one point in our history were hired by Psychiatrists. Clinical Psychology training programs have often directly or indirectly promoted the DSM diagnostic model. However, things have changed and we must be compelled by the evidence now available to us and the withering feedback from many service users about their experiences in modern mental health care. Is it ok to provide ‘pockets of something different’ within a profoundly flawed system? We no longer need to play along with the diagnosis game to establish efficacy or be aligned with the more powerful profession in mental health care to establish credibility. Being opposed to the illness model does not equate to being ‘anti psychiatry’, a term we strongly reject. Indeed many psychiatrists have publically critiqued the diagnostic or illness approach to delivering mental health care including Sami Tamimi founder of the International Critical Psychiatry Network (http://www.criticalpsychiatry.net). As Psychologists we do not require diagnostic labels to do our jobs well or establish the efficacy of our approaches to helping people with serious mental health problems using a psychological model of mental disorder8. As Irish Psychologists is it time we publically asserted the point of view many may have long held in private?; mental health problems are primarily psychological and social in nature, services should reflect this and the current system as it is, is profoundly broken. Our colleagues in the UK have begun to do so in force, with the BPS publishing several key documents on Psychosis39, Bi-Polar Disorder36and a critique of the DSM type diagnostic system40that could shape our thinking here in Ireland.

 

Professor Kinderman has delivered an important, scholarly and evidenced based manifesto to radically transform mental health care9. There are some actions we could consider in furthering the development of mental health care in Ireland: Firstly, call on the PSI, to petition the government to review mental health policy in light of (1) Professor Kindermans book9(amongst the contributions of many other key authors e.g. Kirsch, Moncrieff, Whitaker, Bentall, Gotzsche, Breggin, Bracken, Read, Lynch, Cooke) and (2) the extremely worrying findings regarding the long term use of medications1,19,20and (3) the need for a radical rights based reshaping of mental health services41; secondly consider promoting the Psychological Model of Mental Disorder8and recovery oriented approaches, as viable alternatives to the current prevailing illness model and outdated bio-psycho-social model8; thirdly, advocate for democratic teams of mental health professionals led by those best equipped to lead, which is not necessarily a medical doctor or psychiatrist. Psychologists can play a vital role in this process of change and are well equipped, along with others, to inform how services could be structured and delivered. If we continue to do more of the same, we will get more of the same outcomes, and follow Britain and the US more deeply into a serious public health problem.

 

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We need a radically different approach to addressing mental health