Friday 8 April 2011

Hell in a Handcart

News that prescription of anti-depressant drugs has increased by 40% in the last four years (see the story here) should be treated as a national catastrophe, not because it indicates a 40% increase in depressive illnesses (which it surely does not) but because it signifies the "normalisation" of drug-use to address personal problems.

The figure coincides with a big increase during that period in talking therapies in England so the only conclusion must be that people are much more likely to resort to (primary) mental health services when they encounter personal problems.

Is that a good thing? Many in the mental health establishment (and including the "progressive" third sector) think so but these statistics should make them think again.

Of course it is a good thing if people with significant mental health problems seek assistance early but if the consequences of seeking that assistance is that they are routinely prescribed anti-depressants (and increasingly people expect them to be prescribed) then they are being very badly served. And if troubled people without mental health problems are being prescribed these drugs (which they surely are) then we are on the way to hell in a handcart.

And talking therapies also aren't the answer for most people encountering even serious personal problems (though at least such therapies will not blunt the resolve of people to address their problems as the drugs inevitably do). Their best point of help is friends, family, and practical advice from the likes of the CAB and other action-orientated support.

Talking therapies should be available for people who have significant mental health problems, meaning at a minimum that (i) their anxieties, sadness and troubled thoughts are out of proportion to their actual situation and (ii) the natural processes of resolution which work for most of us most of the time are stuck so the person cannot move on.

Short of this kind of situation we are much better off keeping well clear of mental health services which have a baleful record of misunderstanding the human condition and consequently mistreating (I mean literally in the sense of providing the wrong treatment) and disempowering people.

Some public health enthusiasts do not seem to understand the risk of inviting the public to see life as some kind of exercise in "maintaining mental health", a concept which is either completely meaningless (because saying no more than that we should try to stay happy) or sinisterly undermining of our good instincts to look after ourselves in our own way without resort to the unnatural, mechanistic, and disempowering language of mental health services. Incidentally this unhealthy message is being reinforced by New Age "therapists" who offer an alternative but equally illusory path to "mental wellbeing", usually for good money exacted from vulnerable customers.

Until recently there was a healthy distrust of involving mental health services in assisting children which might have served as a useful model for getting such services out of the faces of most adults too. Sadly, no I should say scandalously, this principle is also being lost as mental health services resort routinely to drugging children who are troubled (or, I suspect, just troublesome). We should certainly think twice before allowing mental health service insiders to induct children into their way of thinking about wellbeing.

That takes us back to the issue of the anti-depressants. I firmly believe that such drugs should be treated as a very last resort, to avert risk and extreme distress, because they operate on the principle not of helping people resolve problems but rather of taking their minds off those problems.

Anti-depressants are the wrong treatment for the great majority of real mental health problems. They are always the wrong treatment for people who do not have mental health problems but are sad, anxious, concerned about their job, etc, in a proportionate way - because those people may well need help but they don't need mental health services or treatment.

But in practice the use of these drugs is exponentially out of control and mental health services (with the connivance of thoughtless and facile media obsessing about drugs and therapy alike) are rapidly losing sight of what it is to be a human being and interfering with apparent alacrity in our natural hopes and fears, inviting us to replace our freedom and good instincts with their drugs and therapies.

And what of serious mental illness? The same principles apply. Drugs, in particular anti-psychotics, are commonly used to treat serious illness and we should not condemn that but certainly we should challenge the assumption that drugs are always required or that they are the single, central plank of treatment. I suspect that anti-depressants are also over-used with high-needs patients, though their use in reducing risk and helping people manage extreme distress should be acknowledged.

The greatest scandal in mental health services is the lack of talking therapies for people with a serious mental illness. This is partly a matter of resources but the fundamental problem is the failure of services to acknowledge the humanity of patients who still commonly report not just a lack of formal talking therapies but negligible or non-existent warm personal contact of any sort even (or especially) in extremely expensive services such as acute inpatient units.

There have been some improvements but only recently patients have told me that the only friendly words in hospital came from fellow-patients and the cleaners, the latter presumably because they didn't see themselves as providing mental health services. Work it out.

There is no psychology; there is only biography and autobiography - Thomas Szasz