Medicine has progressed at an astonishing rate over the past 40 years. If, in the late 1970s, a child had contracted leukaemia, their chances of survival would have been around 20 per cent — today it would be 80 per cent.
Similar impressive rates of improvement can be found in almost every other area of medicine. With one exception: mental health.
In this area, not only have clinical outcomes broadly flatlined but, according to some measures, they have actually got worse.
And this is despite tens of billions of pounds having been spent on psychiatric research in the past two decades; despite £18 billion being spent on mental health services annually in the NHS; and despite nearly a quarter of the entire UK adult population now being prescribed a psychiatric drug each year.
Public conversations around mental health have proliferated. This, of course, is a good thing. But it is clearly insufficient in making things better.
Research published in the British Journal of General Practice back in 1998 found that patients prescribed antidepressants stopped getting better after three months, while a group who didn’t receive the drugs continued to improve
According to the NHS’s Independent Mental Health Taskforce (set up to create a national strategy for improving mental health services), mental health outcomes have worsened in recent years, as have rates of suicide. And there has been no reduction at all in the prevalence of mental disorders since the 1980s.
Why? Is this all just down to sparse resources, or is there something more ominous about our approach to mental health?
The answer lies in something I, as a fledgling psychotherapist, had not expected to encounter when I started working in the NHS in the early 2000s. I soon realised that the vast majority of people who’d been diagnosed and prescribed psychiatric medication were not mentally ill or dysfunctional in any substantiated or medical sense.
Rather, they were people experiencing the inevitably painful human consequences of being engulfed by life’s difficulties or severe misfortunes. Far from being pathological, they were having sane yet painful reactions to factors such as poverty, trauma, family breakdown, social discrimination, abuse and so forth.
My first placement, in 2004, was at a small family-centre charity on a council estate. Most of the people I saw were living with very difficult situations, yet the human and social causes of their suffering went largely ignored.
Emotion labelled as ‘mental illness’
Instead, after a seven-minute consultation with a GP, they ended up being prescribed psychiatric medication (antidepressants, tranquillisers), which they took for extended periods, while nearly every one of them had been given a psychiatric label, usually that of a depressive or anxiety disorder.
After 12 months, I moved to an NHS clinic in a more affluent area, serving a mostly white, middle-class and well-educated clientele. Here, once again, most people had been prescribed medication and given labels — anxiety, depression and, sometimes, more severe diagnoses: bipolar, personality or psychotic disorder.
But here, too, I never met anyone I felt comfortable calling mentally ill. Instead, there were relationship problems, sexual problems, unhappiness at work, low self-esteem, bereavement and loneliness.
But these understandable yet painful experiences had been recast as symptoms of a specific psychiatric disorder, to which a specific psychiatric drug was then matched.
In the UK, our attachment to psychiatric drugs appears to be stronger than ever. We are now witnessing long-term prescribing for milder and moderate problems — for the kinds of mental health issue managed by GPs
Harms of chemical ‘imbalance theory’
This is the typical response to anyone who opens up about their mental distress today: completely overlooking harmful social, political and work environments and, instead, relying on drug interventions which may do more harm than good in the long run. I often wondered: How did we get here?
Mental suffering is blamed on faulty minds and brains — the so-called chemical imbalances — despite there being no known tests or other kind of physical examination that can prove this or verify any diagnosis.
What’s more, recent research has shown that believing mental illness is rooted in biological abnormalities can have an adverse impact on someone’s recovery.
For example, people diagnosed with depression who believe their problems are due to chemical imbalances experience greater pessimism about their recovery, as well as more depressive symptoms after their treatment has ended (according to a Harvard study published in 2020).
I say this not to shame anyone who takes medication for their real distress. There may be some rational use for psychiatric drugs, particularly in the short term, for the most severe forms of distress.
Nor do I mean to diminish the often overwhelming effects of suffering, nor to deny that those affected deserve care and support — quite the opposite.
But since I moved from clinical practice into research (in 2014, I co-founded the Council for Evidence-based Psychiatry, which advises the All Parliamentary Group for Prescribed Drug Dependence), my work with others has shown, among other things, the great difficulty many people have in coming off medications such as antidepressants.
And the problems run deeper, with over-diagnosis and overtreatment of mental distress that is driven by a medical model — which in turn is driven by drug manufacturers.
The truth is that since the 1990s, the pharmaceutical industry has significantly shaped psychiatric research, training and practice through financial sponsorship. It has funded many influential mental health charities, patient groups and heads of psychiatry departments.
Furthermore, the industry has paid for, commissioned, designed and conducted nearly all the clinical trials into psychiatric drugs.
Even the two questionnaires that have been widely used in the NHS to help doctors determine if a person has depression or anxiety — the PHQ-9 questionnaire and the GAD-7 questionnaire respectively — were originally developed by Pfizer, which, incidentally, makes two of the most prescribed anti-anxiety and antidepressant drugs in the UK: Effexor and Zoloft.
Faster recovery without the pills
It is little wonder that the over-medicalisation — and subsequent medicating — of emotional distress has proliferated.
Yet in nations where antidepressant prescriptions have doubled in the past 20 years (including the UK, U.S., Australia, Iceland and Canada), we have also witnessed the doubling of people claiming disability payments due to mental health problems, as the work of Robert Whitaker, a U.S. researcher (and the author of Mad In America, a book on psychiatric treatment) has shown.
This is the opposite of what you would expect if the drugs were working — and it can’t simply be put down to an increase in awareness of mental health conditions. If psychiatric medications were effective long-term treatments, then an increase in diagnosis and treatment shouldn’t lead to a rise in disability.
There is a large body of evidence that could explain the link — that psychiatric drugs appear to worsen long-term outcomes.
For example, a large 2017 study into long-term antidepressant use assessed the progress of 3,300 patients over nine years. It showed that medicated patients had significantly more severe symptoms after nine years than those who had stopped treatment.
In fact, even people who received no treatment at all did better than those who received medication over the long term.
It is far from the first finding of this nature. Research published in the British Journal of General Practice back in 1998 found that patients prescribed antidepressants stopped getting better after three months, while a group who didn’t receive the drugs continued to improve.
In 2007, the most comprehensive study of long-term psychiatric drug use at that time was published in the Journal of Nervous and Mental Disease.
It followed a large cohort of patients diagnosed with schizophrenia, asking how they were doing five, ten and 15 years after their first diagnosis and course of antipsychotic treatment.
Medications can shrink the brain
After four-and-a-half years, 39 per cent of those who had stopped their medication had fully recovered, compared with only six per cent of those who had continued taking their medication.
After ten years, that gap had widened further. In fact, the longer people stayed on the drugs, the worse their outcomes on every measure, including anxiety, cognitive function and capacity to work.
More recently, in 2019, researchers at Zurich University of Applied Sciences found that in the long term, antidepressants might increase the risk of re-hospitalisation in patients diagnosed with both depression and bipolar.
As they stated: ‘Our findings, therefore, challenge the alleged long-term benefit of antidepressants and raise the possibility that, in the long run, antidepressants may do more harm than good.’
Most unnervingly, there is evidence that long-term use of psychiatric drugs can change the brain, which may explain the increased risk of relapse or worsening symptoms described in other studies.
For example, in 2011, one of the foremost neuroscientists in the U.S., Professor Nancy Andreasen, led a team exploring long-term drug use. MRI scans revealed that long-term use of certain anti-psychotics was ‘associated with smaller brain tissue volumes’.
Crucially, this degeneration was not a symptom of the disease, as previously thought, but an outcome of long-term psychiatric drug use.
And although the study looked at people being treated for schizophrenia specifically, the researchers noted that anti- psychotics are increasingly used for other conditions (such as bipolar and depression).
This is just a small sample of the evidence. It suggests that our drug-heavy approach may at least partly explain why mental health outcomes are falling far behind other areas of healthcare, especially since the long-term use of psychiatric drugs is associated with an increase in a whole host of other problems such as weight gain, risk of neurodegenerative diseases such as dementia, and sexual dysfunction.
Yet in the UK, our attachment to psychiatric drugs appears to be stronger than ever. We are now witnessing long-term prescribing for milder and moderate problems — for the kinds of mental health issue managed by GPs.
Today, about 4.4 million people in England have been taking antidepressants for longer than two years.
One reason why people seem unable to come off medications such as antidepressants is widespread misunderstanding about the withdrawal effects, which have been assumed — incorrectly — to be mild and short-lived, resolving in a week or two.
In fact, we now know that many people experience severe symptoms — such as increased anxiety, trouble sleeping and even suicidal thoughts — for months and beyond when they try to stop their medication.
Truth about the CBT success story
The main type of mental health therapy offered on the NHS — Improving Access to Psychological Therapies (IAPT) — has been heralded as a big success, with nearly ten million people treated since its inception in 2006.
It is claimed that almost half of people recover as part of their IAPT treatment, which generally involves up to six sessions of CBT (cognitive behavioural therapy, which is largely about changing people’s perspectives; helping them adapt better to the circumstances in which they found themselves).
It was built on the promise that it was a quick, cost-effective way to get people back to work. Yet underneath the impressive headline figures, there is evidence that IAPT is, in fact, failing hundreds of thousands of patients annually.
In 2010, Dr Michael Scott, a clinical psychologist at the University of Manchester, noticed something odd when he was assessing IAPT patients.
Alongside his work as an academic and clinician, Dr Scott acted as an expert witness for the courts — where he heard time and again that people’s IAPT treatment had not helped.
He decided to conduct his own — admittedly small — review. Looking at 65 cases of those who had passed through IAPT services, he found that whatever the condition being treated, only about 16 per cent of people could be said to be recovering — an outcome seriously at odds with the results reported by IAPT.
Why? It turns out that IAPT only includes patients who complete the course of treatment in its results. This means that a full half of all IAPT patients — those who don’t turn up or drop out — are simply not factored into the success rates.
And when you include those who drop out of treatment — as the University of Chester’s Centre for Psychological Therapies did in a 2013 study — the number recovering plummets to about 23 per cent.
In other words, only around two in ten people recover as a result of IAPT — woefully below the nearly five in ten reported.
In fact, this is also no more effective than no treatment at all, when you consider that a large review of data by Australian researchers in 2012 showed that 23 per cent of people spontaneously overcame their symptoms of depression within three months, without receiving treatment.
The origins of this myth can be traced to a decision by a committee at a 1996 symposium, funded by the drug company Eli Lilly.
This myth made its way into clinical guidelines internationally, despite no real corroborating research. As it took root, doctors who encountered more severe or protracted withdrawal would assume that their patients were relapsing and the drugs would often be reinstated.
This may partly explain why, since the guidelines on withdrawal were issued in 2004, the length of time the average person in the UK spends on an antidepressant has doubled.
In 2018, a review I conducted along with Professor John Read, a clinical psychologist at the University of East London, finally helped to debunk the withdrawal myth.
Our study showed that withdrawal affected more than half of antidepressant users, with up to half of those reporting it as severe — and that a significant proportion experienced withdrawal for many weeks, months or more. This research and other studies led to the UK’s guidelines being revised — as well as to a U-turn by the Royal College of Psychiatrists.
Of course, many people take psychiatric drugs simply because there are so few alternatives. In England last year, 7.4 million adults were prescribed an antidepressant in the NHS, while just over a million were referred for a psychological therapy.
Could Covid change our approach?
This isn’t because people prefer the drugs. Research shows that the majority of people consulting a GP for help would prefer a talking therapy or some form of social support. Even when people do receive some form of counselling, the results are often unsatisfactory (see box above).
This matters now more than ever. In a post-Covid world, there is every chance that the psychological aftershocks of the pandemic will be reframed as rising ‘mental illness’, with psychiatric prescriptions further rising in response.
In April 2020, with lockdown already taking its toll, the Royal College of Psychiatrists warned of a coming ‘tsunami of mental illness’.
By July, the Office for National Statistics reported that ‘rates of depression’ had doubled in four months, while the London School of Economics concluded that, by the end of the year, the nation as a whole had pretty much reached the threshold for psychiatric illness.
But what was being medicalised as a ‘mental illness epidemic’ did not look like illness at all.
Data emerging during the 2021 lockdown showed that the worst-affected people were women with small children, the ill, the bereaved, those losing their jobs, and young people aged between 18 and 24.
At the root of this distress were not misfiring brain chemicals or a genetic predisposition to mental illness, but the obvious social stressors to which these groups were exposed.
In this sense, Covid may yet prove an opportunity to re-evaluate and tackle the bigger problems that underpin our nation’s apparently declining mental health.
When YouGov undertook the largest survey into the national outlook, only nine per cent of people reported wanting life to return to ‘normal’ after the pandemic.
Many of them were relieved to be temporarily away from jobs they disliked or found dissatisfying. Others found unsought-for opportunities to spend more time with family, to deepen connections, to read, to reflect, to walk and to exercise.
Covid, then, has changed our sense of what matters most and least in life. And it has transfigured our understanding of what makes us tick, what brings us down — and what is really necessary to raise us up.
James Davies is a reader in medical anthropology and mental health at the University of Roehampton. He is a qualified psychotherapist and co-founder of the Council for Evidence-based Psychiatry.
Adapted from Sedated: How Modern Capitalism Created The Mental Health Crisis, by James Davies (Atlantic Books, £18.99). © James Davies 2021. To order a copy for £16.90 (offer valid to 30/6/21; UK P&P free), visit www.mailshop.co.uk/books