Eoin Galavan and Sarah Thompson
Abstract: The paper explores the research evidence and critiques of contemporary mental health practice that have emerged in recent years. It examines some of the potential factors that help maintain this model as well as potential alternative approaches to service provision. It concludes by setting the potential implications of such critiques for Clinical Psychology practice.
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’ which include “securing the right to health for all”. Pūras (a Psychiatrist by training) 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.” Concurrently, 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 scientific journalist), presented evidence that the rising rates of disability are correlated with rising prescription rates for psychiatric medication, querying whether the use of such medication may in some way be contributing to the rise of disability rates. This concern echoes a similar, much earlier, concern voiced by the World Health Organisation in their 1992 report on schizophrenia2.
Critiques of a traditional biomedical model
Conceiving of mental health difficulties as deriving from underlying biological diseases is a model that remains dominant in many mental health systems worldwide. Alternative perspectives would include viewing mental health issues as fundamentally social and psychological problems influenced to a relatively minor degree by biological factors3. 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’4 calls for radical reform of mental health care. In this he argues, along with many others, that mental health problems are not best thought of as biologically based illnesses. He argues that there is no biological test or ‘biomarker’ for the ‘biological illnesses’ labelled as, for example, ‘Major Depression’ or ’Schizophrenia’. He states that years of extensive research into genetic links or brain based links have yielded little of value in helping people with mental health problems, or in substantiating the hypothesis that there is a genetic predisposition for Schizophrenia5,6,7,8. Similarly, it has recently been reported that Thomas Insel, former head of the NIMH, acknowledged the failings of this biomedical research paradigm, stating that 20 Billion US Dollars was failing to ‘move the needle’ on helping people with mental illness9. Such critiques also point to the substantive evidence that trauma, for example, is a significant contributing factor to developing psychosis10. Professor Kinderman’s principal suggestion is that we drop the language of illness, in favour of simple, individualised, descriptions of people’s problems. He argues that diagnostic illness categories like ‘major depressive disorder’ have little explanatory power, can ignore the context within which these difficulties arise, and may preclude further exploration of the potential many causal factors in the difficulties’ origin.
In Ireland, a Vision for Change (the 2006 Irish National Mental Health Strategy document), promoted re-investment in mental health services, and largely retained an underpinning philosophy of mental health difficulties as biological illnesses requiring ‘medical treatment’ (predominately medication, thereby requiring specialist medical and nursing staffing expertise). The document makes little to no reference, however, to the contested nature of understandings of mental distress. Alternative perspectives, as cited above, would argue that viewing these difficulties in primarily biological terms can have many potential untoward consequences. These include reducing the individuals’ sense of autonomy and control in their ability to do anything to address their problems, and an unintended increase in stigma11,12,13. Such critiques also point to the potential beneficiaries of a model of mental health service provision that relies heavily on medication (e.g. pharmaceutical companies) and the potential danger that those with vested interests may actively seek to influence prescribing behaviour for their own gain.
Prescribing behaviour and the reviews of efficacy
In terms of the efficacy of antidepressant medication, several studies have questioned the wisdom of the widespread prescription of antidepressants especially in the treatment of milder forms of depression. Irving Kirsh has delivered a review of this issue in his book The Emperors New Drugs14, following on from his analysis of the FDA data in 200815. The research reviewed in this book, including the re-analysis of all data submitted to the FDA for approval published in 2008, (both published and unpublished studies), indicated that, according to Kirsh, antidepressants perform no better than placebo, except for the most severely depressed.
A recent report on illness benefit in the UK16 indicated that being on antidepressant medication correlated with a reduced likelihood of returning to work, a greater likelihood of remaining depressed over the long term, and a greater likelihood of relapse, than not being on antidepressant medication. This correlation could reflect the possibility that those prescribed medication were more severely depressed in the first place, however, it could also echo concerns about the effectiveness and impact of long-term use of such medication. Robert Whitaker has voiced such concerns, (in particular in relation to ‘anti psychotic’ medications) in his book Anatomy of an Epidemic17, and more recently at a UK parliamentary debate earlier this year1.
The evidence around prescribing, however, would indicate that the prescription of antidepressants continues nevertheless to increase: recent data published in the Irish Examiner suggests a range of 4.5-10% of the Irish population is currently taking psychoactive drugs for anxiety and depression18. Whitaker’s review cited above19 notes this trend in many countries including the UK and US.
Evidence on Anti-depressants: placebo, helpfulness and concerns about side effects
In relation to the evidence around psychotropic medication, reviews point to two areas of importance, those of the ‘placebo effect’ and measuring a ‘clinically significant improvement’. The placebo effect has been well documented as the powerful psychological impact of taking a medication prescribed by an ‘expert’ other. Given that this effect commonly results in an improvement in the individual’s presentation, to demonstrate a positive biochemical effect of the medication, the drug needs to demonstrate that it results in a ‘clinically significant improvement’ beyond that achieved by the placebo effect.
The evidence for the effectiveness of anti depressants indicates that, particularly in the most severely depressed group, anti-depressant drugs seem to offer more than placebo, although even in this group the level of difference is clinically relatively small15. The NICE guidelines suggest clinical significance equates to a 3 point difference on the Hamilton Depression Rating Scale (HAM-D), (which is relatively small on a scale with 29 items, 6 of which relate to sleep alone). More recent research failed to find a benefit of anti-depressants above placebo when slightly more stringent criteria for clinical significance were used20. A recent systematic review21 published 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.” In studies which concluded that anti depressants are more beneficial than placebo22 the 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), are questionable 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. Others studies conclude that 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 limited23.
In addition, several studies have pointed to the potential risks of the use of such medication. An increased risk of suicide has been noted with black box warnings now appearing on certain anti-depressants in the US24. Sexual dysfunction is commonplace with as many as 50-80% of people taking SSRIs experiencing sexual dysfunction25,26. Discontinuation syndromes are increasingly recognised with 30-50% reporting significant problems associated with withdrawal, including anxiety and agitation. This has led some to argue that SSRIs need to be added to the list of drugs that should be warned about as having withdrawal effects27. A recent study at Yale University discovered there is also an increased risk of people developing bipolar disorder, when taking anti-depressant medication that appears to be precipitated by the use of the medication. Researchers found that the number of treated cases needed to harm (NNH) is 23. In other words for every 23 people treated with anti depressants approximately one person on average will develop bipolar disorder who would not have otherwise developed this condition28.
The widespread prescription of antidepressant medication needs also to be viewed in the context of the existence of other evidence based approaches which have demonstrated comparable effectiveness; such as exercise29,30 and psychological therapy31. Access to such alternatives may be impaired, however, by a range of factors including: underinvestment in the provision of alternative interventions, the gatekeeping role to such interventions being predominately held by those with medical rather than psychosocial training (e.g. GPs), and a possible perception that prescribing antidepressants is the safest course of action with any presentation of depressive symptoms. The absence of alternative approaches may also render more likely the use of more invasive interventions, such as ECT, when successive medications have failed to be of benefit.
It should be noted that in their review of treatments of depression the National Institute for Clinical Excellence continues to recommend the prescription of particular antidepressants (e.g. SSRIs) for depression. However, the latest update states that for mild-to-moderate levels of depression such medication should only be prescribed if (a) the individual refuses psychosocial interventions (b) has tried psychosocial interventions and they have proved ineffective or (c) the prescription of SSRIs have proved beneficial for this person in the treatment of their depressive symptoms in the past.
Alternative models and approaches and their implications
The prescription of psychotropic medication could be considered in the frame advocated by Professor Joanna Moncrieff in her book The Myth of the Chemical Cure32. 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 Consultant Psychiatrist, asserts has limited 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 requiring a belief in an underlying disease process. Given the documented harmful side effects, for some, of taking certain psychotropic medications, Moncrieff advocates that these risks and side effects are carefully weighed up when prescribing and should not be the sole focus or the frontline of intervention.
Similarly, the model of care proposed by Kinderman3 would involve significant change in current practice moving from a medical care based or illness model to a psychosocial care based or psychological model. Such a shift would necessitate changes in a range of domains including: staffing, use of capital resources, the philosophical underpinning of the work, health policy and even legislation.
Staffing: Such a model would embrace a diversity of disciplines including highly trained social workers, psychologists, social care workers, occupational therapists, counsellors, psychotherapists, family therapists, social pedagogues, experts by experience, peer support workers and other community supports. Nurses and psychiatrists would continue to add their expertise on a consultative basis but not as the dominant disciplines (either in number or authority) in service provision. Decision-making, therefore, necessarily would be through agreement – in collaboration with service users and their supporters- amongst leads of disciplines rather than by a single ‘clinical lead’.
Capital resources: This would entail a move from spending predominately on centralised inpatient units to a multiplicity of sources of community support including: crisis centres, crisis houses, drop in centres, therapeutic communities and other non-medical models of interventions for more severe experiences (e.g. psychosis). Models of such centres and approaches already exist internationally and to a limited degree in Ireland e.g. the crisis houses in the UK, the Finnish Open Dialogue model (West Cork), the Parachute program in New York, the Leeds Survivor Led Crisis Service or Recovery Colleges (UK, Mayo and Roscommon).
Philosophical underpinning: This would involve moving to individualised, formulation-based assessments of people’s needs rather than a diagnostic based assessments33,34. This would entail a shift towards acknowledging the central role that social circumstances, poverty, inequality, educational opportunity, family problems, relationships, stress, loss, our lived experience and trauma all play in our mental health. It also recognises the key element that the individual’s own strengths, and that of their network and community, plays in advancing their recovery goals. In this way professional expertise is de-emphasised in favour of creative, collaborative work with the service user and those around them.
Health policy and legislation: Under such a model, the next “Vision for Change” would embrace the values highlighted above and seek to develop mental health services wherein the challenging and powerful role of relational and emotional work in providing high quality mental health care is prized, and staff are trained and supported to do so. Similarly, ongoing revisions of the Mental Health Act would increasingly seek to empower the service user and their supporters in managing times of crisis. Such revisions would de-emphasise the role of specific disciplines, (e.g. the approved consultant psychiatrist), towards a partnership model where the senior health professional with whom the service user has the closest relationship has greatest say in their inpatient care. Again this may involves a reformulation of roles and further training.
Broader social and economic forces may have influenced the path taken by Clinical Psychology in recent decades. The wish to demonstrate the evidence base for psychological interventions has led the widespread adoption within large research trials of the “diagnosis – intervention” model of assessing effectiveness. This may have brought significant gains in promoting the benefit psychological intervention can bring to individuals in distress. It may, however, have come at the price of obscuring social, political, developmental and interpersonal contextual factors that were crucial both in the aetiology and resolution of many of these difficulties. Increasingly, the potential harm of adopting a “disease model” of understanding mental distress is being highlighted across disciplines, including within psychiatry itself by individuals such as Sami Timimi and Pat Bracken (cf: critical psychiatry network). Increasingly, international psychology bodies are critiquing and often rejecting a diagnosis-led model of service provision. The British Psychological Society have published a range of documents influenced by such thinking (cf: recent BPS publications on Psychosis35, Bi-Polar Disorder36 and a critique of the DSM type diagnostic system37).
Professor Kinderman’s work in this regard constitutes an evidenced based manifesto to radically transform mental health care4. To advance many of the values espoused in such an approach, Clinical Psychologists in Ireland would need to consider a range of actions including:
- Advocating that professional organisations (e.g. PSI) actively petition the government to review mental health policy and legislation in light of the evidence outlined above, and in light of calls for a ‘rights-based’ reshaping of mental health services38.
- Within Clinical Psychology itself, the profession consider promoting the Psychological Model of Mental Disorder3 and recovery oriented approaches, as viable alternatives to the current prevailing illness model.
- That the profession advocates for leadership and decision-making process within mental health services focussed on service user preferences and specific expertise in specific domains (rather than a singular clinical lead model).
- That the profession seeks to fully embrace the service user movement and principles of co-authoring and collaboration in a meaningful way.
Given their in-depth and extended training, Clinical Psychologists can play a useful role in promoting this organisational change and are well equipped, along with others, to inform how such services could be structured and delivered, ultimately to the benefit of all.
Ed. Note: Given the concerns around medication discontinuation noted above, CPT encourages anyone considering a change in their use of medication to consult widely, including with their prescribing medical doctor, prior to altering their use of medication.
- All Party Parliamentary Group for Prescribed Drug Dependence. Rising Prescriptions, Rising Disability – Is There a Link? London, 2016. [cited 2017 June 19]. Available from: https://www.youtube.com/watch?v=vejVt1fNYQk
- Jablensky A, Sartorius N, Ernberg G, Anker M, Korten A, Cooper JE, Day R, Bertelsen A. Schizophrenia: manifestations, incidence and course in different cultures A World Health Organization Ten-Country Study. Psychological Medicine Monograph Supplement. Cambridge University Press; 1992; 20:1–97.
- Kinderman A Psychological Model of Mental Disorder. Harvard Review of Psychiatry. 2005; 13(4):206-217.
- Kinderman A Prescription for Psychiatry: Why We Need a Whole New Approach to Mental Health and Wellbeing. Palgrave McMillon; 2014.
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- Joseph J. The Missing Gene: Psychiatry, Heredity, and the Fruitless Search for Genes. New York: Algora; 2006.
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- Henriques G. Twenty Billion Fails to “Move the Needle” on Mental Illness. Psychology Today. 2017 May 23. Available from: https://www.psychologytoday.com/blog/theory-knowledge/201705/twenty-billion-fails-move-the-needle-mental-illness.
- Read J & Bentall R. Negative childhood experiences and mental health: theoretical, clinical and primary prevention implications. The British Journal of Psychiatry. 2012; 200:89–91.
- Schomerus G, Matschinger H, Angermeyer MC. Causal beliefs of the public and social acceptance of persons with mental illness: a comparative analysis of schizophrenia, depression and alcohol dependence. Psychological Medicine. Cambridge University Press; 2014; 44(2):303–14.
- Speerforck S, Schomerus G, Pruess S, et al. Different biogenetic causal explanations and attitudes towards persons with major depression, schizophrenia and alcohol dependence: Is the concept of a chemical imbalance beneficial?J Affect Disord. 2014; 168:224–8.
- Read, J., Haslam, N., Sayce, L. and Davies, E. Prejudice and schizophrenia: a review of the ‘mental illness is an illness like any other’ approach. Acta Psychiatrica Scandinavica. 2006; 114:303–318.
- Kirsch I, Deacon B J, Huedo-Medina T B, Scoboria A, Moore TJ, & Johnson BT. Initial severity and antidepressant benefits: A meta-analysis of data submitted to the Food and Drug Administration.PLoS Medicine. 2008; Feb;5(2):e45.
- Kirsch I. The Emperors New Drugs: Exploding the Antidepressant Myth. London: Random House; 2009.
- Viola S & Moncrieff J. Claims for sickness and disability benefits owing to mental disorders in the UK: trends from 1995 to 2014. BJPsych Open. 2016; 2:18-24.
- Whitaker R. Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. New York: Crown Publishers; 2010.
- Shanahan C. SPECIAL REPORT: Our €40m drug problem. Irish Examiner. 2015 March 19. Available from http://www.irishexaminer.com/viewpoints/analysis/special-report-our-euro40m-drug-problem-319134.html
- Whitaker R. Mad In America. Causation not just correlation. Undated. Available from http://www.madinamerica.com/wp-content/uploads/2016/05/Causation-not-just-correlation-copy-5.pdf
- Moncrieff J & Kirsch I. Empirically derived criteria cast doubt on the clinical significance of antidepressant-placebo differences. Contemporary Clinical Trials. 2015; 43:60-62.
- Jakobsen JC, Katakam KK, Schou A, et al. Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and Trial Sequential Analysis.BMC Psychiatry. 2017; 17:58.
- Fountoulakis KN, Veroniki AA, Siamouli M, Möller HJ. No role for initial severity on the efficacy of antidepressants: results of a multi-meta-analysis. Gen. Psychiatry. 2013; 12(1):26.
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Eoin Galavan, Senior Clinical Psychologist. Dublin. firstname.lastname@example.org
Sarah Thompson, Senior Clinical Psychologist, Older Adult Mental Health Services.