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.

 

References

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We need a radically different approach to addressing mental health

Time is the most important resource in mental health care

Time is the most valuable thing we can offer people struggling with mental health problems and we have a basic human right to getting this time when needed. It’s very easy to overlook this so let me give you and example of a hypothetical but typical case.

A young woman is sitting with her GP and begins to discuss the people she hears telling her to cut herself, kill herself and kill her family. She looks over her shoulder to find them and is clearly distressed, confused and upset by what’s happening. She describes living alone and her family relationships seem to have come undone for, at the time, unrecognised reasons. Help is offered. The GP refers her to a community mental health team as an urgent referral given the apparent intensity of her difficulties. She is somewhat reluctant but agrees to attend the community mental health team. (1 hour including GP consultation letter writing phone calls etc).

Her initial contact is with a psychiatric registrar who details her history, family circumstances and a description of her current difficulties. (1 hour clinical interview). Her second meeting, two days later, is with a consultant psychiatrist and a clinical psychologist, who jointly review the details of the initial meeting she had with the registrar with her, and come to an initial understanding of her difficulties and develop a treatment plan (1 hour). In the interim she has also met with a psychiatric nurse who has offered to visit her in her home and does so within the first few days of her engagement with the mental health service (3 hours).

At this point much that has been achieved is preliminary, with the purpose of starting some interventions, developing relationships and helping to provide some degree of psychological containment. Medication is prescribed, further appointments with the clinical psychologist are arranged as are home visits with the psychiatric nurse.

During the next few weeks things seem to settle a bit. Perhaps the medication is having some benefits, she is sleeping a little better, or the support from the home visits with the nurse which provides some contact with someone who isn’t judging her, or the weekly sessions with the psychologist where the conversations about how she came to be in this situation and how to manage begin to deepen. Given the apparent improvement in her general state, after another week the home visits with nursing cease and visits with the psychiatric decrease in length and frequency to every two months for a period of approximately 15-20 min. Her distress is lessened, she is sleeping better and is talking about her struggles. At this point the home visits have involved 15 hours (5 visits @3hours each including travel and clinical admin) and psychiatric reviews 2 hours (3 visits at 40 min/visit over three weeks). The psychologist has met with her for 3 further hours at this point for ongoing psychological therapy.

During the sessions with the psychologist it becomes clear that a long history of abuse, separation, neglect and bullying have plagued this persons life. The voices she hears reflect the painful shame she felt having been sexually abused by an uncle who would spend nights in the family home drinking with her parents. Her parents had significant alcohol and substance abuse difficulties and many of her basic needs for security, nurturance and attachment were not met and she was grossly violated in her family home. Reports of these abuses were made as they emerged to the appropriate authority. Mental health social workers began to get involved with the family at this point with a strong connection between the families overall patterns of relating and her distress becoming evident. An initial assessment and several family meetings are arranged.

She spoke in therapy of the incidents of abuse and how her reaction to these experiences involved imaginarily transporting herself to a different place. Feelings of intense fear, hate and loathing at what was happening coupled with the helplessness of being a child meant she had little option but to remove herself from the experience psychologically: what might be termed dissociation. And then the abuse happened again and again and again. So she adapted to this horrific reality by exiting contact with what was happening to her in the world and her perception of and connections with the world, and retreated into herself. An adaptive break from reality, a psychic retreat: what the mind does under extraordinary stress and strain. During these periods of dissociation she would hear the voice of her mother scolding her. And while unpleasant it represented the source of her emotional security, something she could retreat to psychologically that was familiar. She could not fight or engage in flight. She would likely have died or at least felt she was in more danger. Fear protected her and she froze and psychologically retreated. It is during weekly sessions over a period of two years since the initial contact with mental health services (80 hours + 20 admin) that this understanding begins to surface. Years of pretending it didn’t happen are hard to undo. A lot of delicate and patient listening allows this process occur. This process was frequently derailed by turbulent interactions with her family, her reluctance to take medications and subsequent conflict within the community mental health team about the relevence of medication and various other interventions. Finally she simply refused to take her medication. This was approximately 1 year since she had begun taking it, and much of the problems she had presented with continued; she continued to hear voices and experience fear although not to the same extent or frequency. She also hated the side effects of weight gain, emotional numbness and not being able to think clearly that came with them. Fortunately her ceasing taking her medications against medical advice did not create any major difficulties, a risk she was willing to take. The emotional support she was receiving through her psychological therapy and the intermittent involvement with psychiatric nursing (another 20 hours over the two years in the form or home visits during particularly difficult periods of time) proved to be extremely important. Her psychiatrist also maintained a good willed relationship and largely positive rapport. The social worker had made some useful progress working with her family and things seemed to be improving with increased contact with siblings and her parents who had begun to acknowledge the extreme difficulties they had created for her as a child. Not surprisingly it turns out that both parents had been the subject to abuses themselves as children. (Social workers hours at this point 25: 6 family meetings and several phone calls and contacts w various family members).

At this point the psychologist has already hugely exceeded the standard amount of time and the allocated maximum time allowed to spend with any one patient given the long waiting lists in the service. The pressure to allocate this slot to another person is building. Someone else with just as valid a need is not receiving psychological assessment and therapy. This reality also shapes the limits on the psychiatrists, nurses and social workers time. Her own reflections are that the psychological therapy is important to her and not yet complete. In a way she’s only just started. Her psychologist agrees and seeks permission to further extend for another six months although both know this will not likely be enough time. She has made progress and there is concern about how things will go for her if the therapy is not allowed continue. She has identified the difficulties in her childhood that directly relate to her psychotic experiences, has had a supportive series of relationships and interactions with mental health staff that have helped her come to some understanding about how her difficulties have developed and begun to learn ways of managing herself in the world. She has learned to consider her thoughts of suicide and hallucinatory experiences as responses to overwhelming trauma which validates and helps her live with them. These are the normal responses of a person exposed to extraordinarily painful and utterly unbearable experiences. And she has begun the long and difficult journey of coming to terms with the abuse and neglect she suffered as a child, the profound sense of loss of the family and home she wished for and the years of (adaptive and necessary) denial of her lived experience.

The total hours to support her up to this point was substantial (175 hours). Her reliance on services will likely require approximately 120 hours/ year of direct contact with various staff. The capacity for a service to provide in depth psychological and psychotherapeutic care, coupled with supports during times of crisis, psychiatric reviews, and family based interventions, over a prolonged period of time is extraordinarily important and shockingly, extremely rare for the majority of people who attend public mental health services. It is rare even that an understanding of how someone’s difficulties develop. By this I mean going beyond simply identifying adverse childhood experiences as a part of a psychiatric interview and subsequently doing nothing about this. It is rare that someone actually takes the time to explore someones difficulties and their past and seek to help make sense of them and their current struggles and problems. The main reason this is rare is because it takes a great deal of time.

The bottom line is that this work is not only in depth, highly skilled and essential but extremely time consuming. It is also extremely demanding work for the therapists and mental health staff who travel this road. Demanding but incredibly important and well worth doing.

The most important resource a mental health service needs at its disposal is highly trained people who can give time. The people who give this time need to be psychologically and psychotherapeutically trained to an advanced and sophisticated level and be expected to operate in a genuinely ‘bio psycho social’ manner (Not the current bio bio bio framework that operates despite the propaganda to the contrary). People who can work through such a process and understand trauma and its impact on our psychological and emotional lives. A culture of tolerance, willingness, understanding and going the distance must contain this resource of time but without it little can be done to help. And these people regardless of background training, must work in an environment that advocates and supports this effort. Currently services often mitigate against it happening at all by placing demands and limits on in depth relational work that smothers the relationship potential of any one mental health clinician. Arbitrary limits on numbers of sessions or demands to see high numbers of people in short periods of time are two typical such limitations. Does our fictional service user benefit if her psychological therapy is cut short after 6 months? Or worse, 3 months? Does she navigate the crisis if there is no one do provide out of hours care? Does her family ever start to heal if there is no social work capacity to do this work?

After three years of weekly therapy with a psychologist, intermittent support from nursing staff, help from a social worker who dedicated time to working with her and her family, two monthly visits with a psychiatrist things have improved for our fictional, but somewhat typical person. And maybe her care was ok, good enough to help and be of real value to her.

If you have a mental health problem your chances of coming to terms with it, of resolving things within yourself, almost certainly includes spending time, often a lot of time, with people who can truly meet your experience with compassion, understanding and knowledge. Sadly the chances of this happening are very slim, and the culture of ‘managed care’ that is emerging is likely to impose further inhumane and mindless limits on this precious resource.

If you attend mental health care ask for this: I would like to spend time with someone who is trained to help me resolve the traumas and difficulties in my life, even if I’m unsure what this looks like right now. I would like to spend enough time with them until I believe my difficulties are resolved. If I don’t like them or can’t connect with them or they can’t connect with me, if they don’t know how to help me or have an approach that doesn’t suit me, I would like to work with someone else. If someone can’t articulate this at the time, we should hold this hope for them. We all have a right to this. The UN charter states that every individual has a right to the highest possible attainable level of mental health. We all must demand this from our services so that when we or our loved ones need it, it is there.

Time is the most important resource in mental health care

Mental Health Care Reform Needed Now

A paradigm shift, dramatic practice change and revolution of mental health care is required: URGENTLY!

We must radically re think our approach to mental health care. It is not enough to drag along partially paying lip service to the relevance of alternatives while the overwhelming majority of people in mental health care receive nothing more than a brief periodic medication review and a medication only approach to their treatment. This is utterly inadequate, unscientific, misleading and ineffective. We must move forward. We cannot allow this sham prevail any longer. The real tragedy is that we know a great deal about how to move things on. There are several things lacking: a poorly informed or hampered political leadership who continually re boot to a medical led approach. A profound lack of knowledge or motivation amongst the leaders in our health and mental health services about the limits of the current system and what’s required to change it. A profound lack of resources properly allocated and structured to deliver the intensive comprehensive variety of psycho social interventions needed. The following are some key points that must start to shape how we deliver mental health care:

1. There are no diseases or illnesses. Depression is not a disease or illness. Schizophrenia is not a disease or illness. These are categories that are invented to describe sets of experiences, behaviours, psychological and emotional phenomenon. These categories are neither valid nor reliable. There is no underlying biological neurochemical imbalance, or biomarker that has ever been discovered for any of the major categories of disorder or diagnosis that have been described
a. This does not mean these categories don’t point to extreme difficulties, problems, suffering in the minds and hearts, thoughts and emotions, behaviours, lives, relationships and the histories of people seeking mental health care. These difficulties do exist and must be addressed meaningfully
b. This does not mean we cannot acknowledge the immense suffering that occurs or understand this suffering credibly in a non stigmatising way. We do not need a fabricated medical diagnosis to operate effectively in a non stigmatising way

2. Diagnoses don’t help, they harm. Diagnoses increase stigma, they don’t decrease it. Understanding on the other hand is a powerful, therapeutic, transformative and pragmatically helpful exercise and endeavour. Giving a diagnosis (while sometimes seemingly reassuring) does none of these things; a diagnosis in and of itself does not offer understanding or explanation. Telling someone they ‘have depression’ tells them nothing about how they came to experience what they are experiencing that is labelled depression. How do we know you have depression? because you have a loss of motivation , anhedonia, etc. What does it mean that you experience loss of motivation, anhedonia etc? That’s because you have depression. The ‘diagnosis’ doesn’t tell us anything more about the difficulties already described. A diagnosis is supposed to tell us what the underlying problem is, but mental health diagnoses do not do this. Dr Terry Lynch’s book ‘Depression Delusion’ presents a fantastic description of the difficulties as this relates to depression (http://www.recoveryourmentalhealth.com/my-next-book-depression-delusion-volume-one-the-myth-of-the-brain-chemical-imbalance-publication-date-02-sept-2015/) Does this mean that people don’t get depressed? Not at all, of course they do, its simply inaccurate to call it an illness akin to a physical illness.

3. Formulation is a helpful, useful, pragmatic, sophisticated and flexible means of collaboratively understanding a persons difficulties that leads to solutions, interventions, therapeutic direction, support and other mechanisms of helping and addressing difficulties. Lucy Johnston has done a remarkable job making the case for this approach to mental health care. We should base services on a collaborative formulation of mental health difficulties and not on a diagnosis of a fabricated ‘illness’ model of mental health difficulties (https://www.canterbury.ac.uk/social-and-applied-sciences/salomons-centre-for-applied-psychology/docs/resources/DCP-Guidelines-for-Formulation.pdf)

4. All problems are ultimately understandable, and some never will be. With time, care and patience, almost all mental health difficulties can be understood in some way that is useful. Some never will be, but this is a minority, and does not automatically prove the existence of some underlying brain pathology that must be treated medically. Having spent many years with hundreds of people suffering serious and severe mental health problems (including psychosis, mania, depression etc) it strikes me that with some time and effort understanding of how a persons problems have developed and how the create suffering is almost always possible.

5. Medications may help some people some of the time, but they do not cure mental illnesses, have many drawbacks, and offer many people little or nothing in the way of help. Joanna Moncrief in her book ‘The Myth of the Chemical Cure’ presents a brilliant, evidenced based critique of the evidence for and against the use of psychiatric drugs. Her description of a drug model of prescribing, allows for the reality that medications help some people some of the time, without relying on a disease or illness model of mental health (https://www.youtube.com/watch?v=IV1S5zw096U)

6. Psychological, interpersonal and social difficulties including trauma and poverty are a primary cause of much of the mental health problems that people experience, far more so than genetic or biological factors. This should point to a preponderance of psychological, social, and psychotherapeutic interventions in our mental health services, with a minimal reliance on medication and hospitalisation. The opposite is currently true. It is very likely you will be offered a medication only approach if you attend a mental health service. It is very unlikely you will have adequate access to professional psychological care, professional psychotherapy, advanced/professional social care or structured evidenced based psychosocial interventions, groups, programs or therapies

7. It is not dangerous to question the use of medications in addressing mental health problems; it is dangerous to massively over rely on them and use a medication only approach to mental health care, as is currently the case. It is dangerous to suddenly stop taking some medications so only do so under medical supervision

8. A credible alternative movement has been developing for many years, with key critiques of the current ‘disease model’ or ‘illness model’ paradigm coming from both within the ranks of the medical profession and psychiatry and outside from journalists, service users, psychologists and others. We are very lucky to have one such critic in our country, Terry Lynch, GP (author of the fantastic book ‘Depression Delusion’). This movement (often unfortunately called the anti-psychiatry movement) which voices criticism of the current model and offers an alternative road forward has been articulated clearly in many ways. Most recently in an excellent review of the issues by Professor Peter Kinderman of Liverpool University in his book ‘A Prescription for Psychiatry’. But historically by many other highly credible leaders in the field e.g. Joanna Moncreif ‘The Myth of the Chemical Cure’, Robert Whitaker ‘Anatomy of an Epidemic’, Richard Bentall ‘Madness Explained’ and Peter Breggin ‘Toxic Psychiatry’. For anyone seeking a genuine reform of mental health care, this body of thoughtful, evidenced based critiques and understandings should be reviewed and acted upon. A movement called the International Critical Psychiatry Network has been established and is promoting a campaign to abolish psychiatric diagnostic systems such as ICD and DSM (CAPSID). The call for reform is coming from both within and outside of Psychiatry. http://www.criticalpsychiatry.net/wp-content/uploads/2011/05/CAPSID12.pdf

In his book, Professor Kinderman offers a prescription for mental health services. I am summarising, paraphrasing and quoting the central elements below. We should adapt these recommendations without delay.

1. Get the message right. We need to change our whole framework of understanding from a ‘disease model’ to a ‘psychosocial model’

2. Drop the language of disorder, symptom and illness. We must stop regarding peoples very real emotional distress as merely symptoms of a diagnosable illness

3. Be careful with medication. We should sharply reduce or reliance on medication to address emotional distress. We should rely on a ‘drug based’ approach to medication use and not a ‘disease based’ approach, as articulated by Joanna Moncreif

4. Offer holistic psychosocial services. Services should be equipped to address the full range of peoples’ social, personal and psychological problems and also address prevention

5. Offer non-medical residential care

6. Establish democratic multidisciplinary teams that can be lead by members of all disciplines, and are not automatically led by a Psychiatrist thereby automatically frontloading the disease model in considering how mental health problems are conceptualised

7. Plan for mental health and well-being alongside other social, rather than medical, services

The messages in Professor Kindermans manifesto are vital and we should listen and take it seriously. A change must happen sooner rather than later. A massive increase in funding for non medical, psychological and psychosocial interventions and for staff who are expert in the delivery of these interventions is required if we are to move beyond the current paradigm. A significant political and managerial change in ethos is required. It seems likely that until voters start to demand these things from their political representatives the change process will be allowed languish. While some changes have been made, we are a very long way from a genuine and substantive reform of our mental health services.

Mental Health Care Reform Needed Now

The Role of Trauma in Mental Health: The issue cannot be ignored any longer

There is no doubt that trauma is a major contributor, and likely cause of the mental suffering of many people who are given diagnoses for mental illnesses. This has recently been established and articulated by people like John Read. You can see him talk about it here http://youtu.be/Y6do5bkUEys

What is most impressive about this issue is the extent to which childhood adversity and trauma is associated with future mental health difficulties. The relevance of trauma vastly outweighs the relevance of biological or genetic factors. And yet the overwhelming majority of interventions people receive are designed to ‘treat’ biological ‘illnesses’. Medications will not address early traumatic experiences. Psychotherapists and psychologists have known this through the therapeutic process for decades. As a psychologist it has become abundantly clear that early experiences shape profoundly the quality and nature of our health and mental health. This has always been evident even looking back in time through the lense of sometimes hazy memory. Listening to people’s stories over the last two decades (almost) has left me in no doubt. However, it is encouraging to see research establishing this reality in a different and very solid way. No longer is this just the opinion of some psychologists and therapists. John Read points out that trauma, particularly cumulative or multiple trauma (the various forms of child abuse for example) multiplies the risk of developing psychosis many many times over. If trauma was somehow magically erased from our society the incidence of psychosis would reduce by about one third. This is a massively important public health concern. The Advese Childhood Experience Scale research has also established firmly the role of early trauma in all sorts of negative health outcomes both physical and mental. The US centre for disease control now views early trauma as a major public health issue.

Every assessment of every persons in mental health care should now include a comprehensive review of early trauma. All mental health professionals should be highly trained in working therapeutically with trauma. Currently this is not the case, very few disciplines have any comprehensive understanding of early developmental processes and the impact of trauma on our development. I include psychologists in this group, although the problem is less so in this group. Most mental health professionals are poorly equipped to assess, understand and facilitate healing from early trauma, despite the enormous role it plays in so many peoples mental health difficulties. There is a wealth of information to facilitate this healing drawing from PTSD literature and psychological interventions ranging from exposure therapy, to psychodynamic and psychoanalytic theoretical and therapeutic understandings to the work of people like Peter Levine. Looking at things from a problem specific angle, like paranoia or depression, we also find a great deal can be done to help psychologically and psychotherapeuctically. So why is this not the driving force of interventions for those people who present to mental health services? Primarily because clinicians are not looking at people who have been hurt, wounded, abused and traumatised, they are looking at illnesses. Looking at people as if they are illnesses obscures the lived experience and reality of people’s developmental pathway towards the mental health difficulty.

In short, mental health services need to become at least in part, sophisticated and expert trauma healing services. The evidence is overwhelming. We must adapt to this understanding.

 

 

 

The Role of Trauma in Mental Health: The issue cannot be ignored any longer

Mental Health: An urgent need for reform

Mental health has never been more in need of reform and investment. This blog will reflect on the developments occurring around the world that could and should be applied in Ireland and elsewhere.

The first and primary issue requiring reform in mental health is conceptual and philosophical. It would be easier if a particular type of therapy, a number of psychologists or something concrete were ‘the’ central need for reform. These things are indeed also required and will be reflected upon in future posts. However firstly a thought on philosophy. It is the ground from which all else grows. If the philosophy is flawed, all mental health care that follows from it is also flawed. The current system is based on a disease or illness model of mental health. This presupposes the existence of discrete biological diseases or illnesses that can be diagnosed and treated. This is the most fundamental problem with modern mental health care. There are no biologically based illnesses, there are no diseases. This of course doesn’t mean that people don’t suffer or experience low mood, terrifying paranoid ideas, extreme anxiety etc. It simply means these things are not accurately thought of as illnesses.

The first thing we as a society need to do is rethink psychological distress, emotional pain, mental anguish and events that seem extreme and hard to understand. All things can be understood with sufficient time and patience. We must dispose of the disease model and drop the language of medical intervention to stop ourselves repeating the same errors.

Why do we need to make this change? So what if we call depression an illness? The problem with this frame of reference is the likelihood that a medication only approach follows and a cessation of thinking. We don’t need to understand why the person is depressed anymore. It’s sufficient to say they are depressed, because depression is an illness. But this is flawed. Why a person becomes depressed is extremely important. This understanding has enormous consequence for how we might consider helping. An example. Someone has lost their job, lost their marriage, and has a history of childhood abuse. They become deeply depressed and meet criteria for the illness ‘major depressive disorder’. Do we really believe that the problem is a chemical imbalance in their brain that needs to be addressed by medication? Of course not. Help with these specific problems is most likely to benefit this person. The help that might help may be different for different people; psychotherapy, behavioural therapy, social support, occupational therapy, lifestyle changes, exercise, peer support etc. There are many things that might help. Including medication. The fact that a psychoactive substance might help is not the issue. People have always used chemicals to alter how they feel sometimes very effectively. However this does not prove the disease model, and the medications can come with risks, dependency, side effects that all should be understood. Drugs also don’t help many people and even harm some. And they certainly don’t address the underlying difficulties. So back to the point. Why change? Why not use an illness model? Because it stops us thinking about what might be helpful and points inaccurately to a non existing disease that obfuscates the nature of anyone individuals depression.

We should without hesitation switch to a collaborative formulation model which allows for the development of an idiosyncratically based understanding of each persons depression or anxiety or schizophrenia. This shared understanding points to problems and possible solutions. This may at times point to drugs, but almost always won’t, certainly not in the long term and certainly not as a stand alone approach to treat illnesses.

 

 

 

Mental Health: An urgent need for reform