Matthew Paris, whose family has been affected by depression and suicide, argues it’s wrong to spend so much on talking therapies and medication when there is little evidence they work
Gerry Gajadharsingh writes:
“The recent news suggesting that GP’s are trying an average of 12 types of antidepressants on some patients before referring them for specialist help helps put this article by the journalist Matthew Paris in perspective. He begins by saying “There are subjects so sensitive that it becomes necessary to begin with a warning. I do not want to attract murmurs of support from the “Mental illness? Stuff-and-nonsense!” brigade. Concern about mental health is not a fuss about nothing and there is no denying either the problem of mental illness or its scale.
Mental imbalance, depression, demotivation, trauma, anger, suicide, paranoia and schizophrenia in all its forms eat away lives, wreck families, damage society, burden the police, cram the courts and disrupt the workplace.”
There are more than 1 million Britons with treatment resistant depression who fall through the gap between GP and specialist services. My experience, and I see a lot of patients with anxiety and depression spectrum, is that as with many health problems the causes are complex and multifactorial and therefore the treatment interventions probably need to be multi-disciplinary, except for straightforward cases!
People are individuals and their biochemistry is therefore also individual, so it’s not surprising that whilst one type of anti-depressant works for one person it may not work for another. Medication can be an important part of treatment especially in moderate to severe depression.
I think Paris has a point regarding the numerous types of “therapy” that are on offer. But as with other types of “therapy” for “physical” problems, it’s not necessarily the name of the therapy that is important but the clinical experience of the clinician/therapist offering the treatment and the frame work that they use. There is no doubt that many patients tell me that seeing therapists regularly for years with insufficient change (at least from the patient’s perspective) is frustrating and expensive. It could be that helping patients with “mental problems” can be more challenging than “physical problems”, but I suspect its more to do with the paradigm of diagnosis and therefore treatment.
Rarely do I see a complex set of physical symptoms without underlying psychosocial/emotional factors and vice versa, psychological presentations have a host of underlying physical and biochemical dysfunctions. Some patients aren’t interested which is their choice, but increasing numbers are understanding that taking a more holistic approach to their problems, can lead to better clinical outcomes.”
There are subjects so sensitive that it becomes necessary to begin with a warning. I do not want to attract murmurs of support from the “Mental illness? Stuff-and-nonsense!” brigade. Concern about mental health is not a fuss about nothing and there is no denying either the problem of mental illness or its scale.
Mental imbalance, depression, demotivation, trauma, anger, suicide, paranoia and schizophrenia in all its forms eat away lives, wreck families, damage society, burden the police, cram the courts and disrupt the workplace.
Nor am I arguing that the mentally ill should just “snap out of it”. I have reason enough in my own life and family history (and so, reader, do you) to know that barking at people that “it’s all in your mind” is both a profoundly true and a profoundly useless thing to say to those in mental distress.
Nor am I saying there can be no helping the mentally ill. We know this to be untrue; know how we have helped or been helped ourselves through friendship or family. The empathy and openness our era is bringing to these matters — and the recognition of the problem — is to be welcomed.
My focus is elsewhere, and upon one word: “treatment”. Does it actually work? How well? When politicians wrap themselves in the flag of “increased spending on mental health”, what treatments are they actually talking about? Do we know how much they achieve? What do they cost?
What treatment for mental disorder costs the taxpayer is a cloudier question than you might think. Politicians talk as if they knew. “There are many pressing demands on additional NHS funding,” Philip Hammond said last month, announcing that 10 per cent of the NHS budget is to be spent on mental health, “but few more pressing than the needs of those who suffer from mental illness.” Said Theresa May: “We have to change this.” Jeremy Corbyn joined in at Labour’s conference the month before, saying: “I’m going to challenge the Tories to make parity of esteem for mental health a reality not a slogan. With increased funding.” But they all steer clear of specifics.
So what counts as “spending on mental health”? NHS England publishes a jargon-heavy Mental Health Five Year Forward View Dashboard (a spending plan, to you and me). I’ve searched in vain for a clear government breakdown of funding, but slippery definitions make capturing the meaning of “mental health funding” fiendishly difficult. The Department of Health tells me it’s “too hard to disaggregate”. It seems, though, that the extra billions touted by ministers are mostly additional to what’s spent on mental health through GPs, prescriptions, the police, the military, schools and local government social care.
Final decisions are local. Each can be subject to a last-minute switch, a diversion of funds elsewhere. “We were always told not to define what we thought mental health was,” a former NHS manager who worked in health budgeting told me, “because you run the risk of people not responding to local needs.”
I have met a degree of vagueness so striking I begin to wonder if it is not intentional. When Mr Hammond announced his big boost to mental health funding in the budget, while the government boasts about the highest levels of investment ever, they trade on this vagueness.
I want to look at the forms this “treatment” for mental illness takes, but first the most fundamental question of all. Is psychiatry even a science, in the way medicine is?
Sciences are based on theory: an explanation of how things work and the “laws” according to which they behave. Newtonian physics forms the theoretical base for our understanding of the interactions between matter. It has reliable predictive power. If a billiard ball smashes into one end of a line of static billiard balls, the ball at the end will come loose and shoot forward with the same momentum as the first ball imparted. We can predict this. If we cannot predict on the basis of our theory, or if our predictions prove wrong, we question, abandon or refine the theory. We feel safe in an aeroplane because theories of aerodynamics have been tested for their predictive power.
Like British Airways, the NHS is based on science. Physical health — the drugs, therapies and surgery with which what we loosely call “medicine” treats bodily ailments — is a group of advanced sciences. William Harvey described and explained the circulatory system. Thomas Lister pioneered theories about infection and hygiene. J S Haldane established the ruling theory of respiration.
Within (of course) limits, doctors can predict what will happen if you swallow this pill, drink that medicine, receive this injection or have that bit cut out of you. We know what works, we know what it costs, we can estimate the chances of an effective cure, we can (approximately) measure improvements in a patient’s health, and we can do the cost-benefit analysis. Cost-benefit analysis should be the foundation of all efficient governance.
On such a definition of science, psychiatry’s claims to be a science are weak. For a start, there is no universally agreed ruling theory of the mind. Who are the Harveys, Haldanes or Listers of psychiatry? Freud, Adler, Jung, with their theories variously positing realms like the ego, super-ego and id, the “will to power”, the “collective unconscious”? People pay good money for sessions with psychoanalysts who base their disciplines on such claimed structures of the mind, but as a theoretical basis for the science of psychiatry, they find no general acceptance and appear incapable of being tested. Then you have electro-convulsive therapy (ECT) for which large claims are made by its disciples in the treatment of depression and “psychosis” but for which systematic evidence of success is thin.
I cite these (usually privately paid for) therapies only to indicate the confused state of theories of the mind. Government-sponsored mental health provision is generally more workaday. Cognitive behavioural therapy (CBT) is often favoured: a treatment which aims to change the way people with mental disorders respond, in thought and action, to the world. You could call it a glorified version of age-old adult guidance to errant children to look for the good in others, see the glass as half full, turn the other cheek, breathe deeply and count to ten, etc . . .
CBT on the NHS takes place in counselling sessions for which taxpayers pay. I’ve yet to see systematic evidence of its effectiveness. There’s a lamentable tendency among mental health professionals to measure success by asking patients but asking someone whether a mental health treatment is helping them proves little if unsupported by any other data. They’ll have made an effort with a treatment, feel warmly towards the counsellor who is trying to help, and gratified that a trained person is spending time with them, talking sympathetically, listening to their problems. Their answers to the question “Do you think this is helping?” are bound to be unreliable.
Systematic and large-scale testing would be necessary to prove the efficacy of CBT. For comparison with results for those receiving expert professional help, one would need two sets of “controls”: first, a set of patients receiving no treatment at all and left to fend for themselves; and, second, a set of patients receiving what they believed to be professional counselling, but which was in fact carried out by amateurs with people-skills but no theoretical psychiatric training. The kind of thing that a good vicar does.
The same is true more widely of the whole counselling business. I’ve been unable to establish what the British state spends on counselling. In various forms the police, the NHS, the armed forces, education authorities and social services (to name just a few) provide counselling; training to be a counsellor is becoming a popular career path for community-minded younger people.
After I’d reported seeing a dead body by the Thames, my flatmate and I were both offered counselling. After my suitcase was ransacked on a train I was offered counselling. I accept that my response (to shrug off the very idea) will not be typical of everyone, and perhaps this service does protect some people from serious psychological damage; but again I ask, what systematic inquiry has been made into outcomes, as between those who receive professional counselling, those who think they have, and those who receive none? The cost to the taxpayer of state-funded counselling services must be considerable. What therapeutic bang are we getting for our taxpayer buck?
This brings me to a very hazy area indeed. Prescription drugs, uppers, downers and the range of chemicals we now call opioids, “happy pills”, and Ritalin (the so-called “chemical cosh” for “hyperactive” children) ought, I suppose, to be included under the heading “spending on mental health”. Sleeping tablets? Codeine? Where do you stop?It’s not for me to pronounce on how effective these various and very different chemical compounds are at producing the changes to the brain and to behaviour that Big Pharma claims. We’ve all read of trials that suggest that in some cases placebos achieve strikingly similar results to the real thing; but that cannot be universally true. Chemicals, licit or illicit, can clearly be mind-altering substances.
What is not in doubt is that patient demand for these drugs has grown and is growing, and our era’s fashion for “medicalising” mental problems is growing with it. Overworked GPs may fall back on easy pills for mental ills and addiction may follow.
All this medication for what are mental rather than physical disorders may boost the total national expenditure on mental health which politicians like to boast about, but is it always a positive step? Years ago I visited a primary school in Tyneside where the head teacher told me that a quarter of her children were on Ritalin. Many will progress to other mind-altering prescription drugs later. According to the figures from the NHS Business Services Authority, one in six 18 to 64-year-olds were prescribed antidepressants at some point last year, rising to one in five among those aged 65 and over. The costs will be huge.
However, there’s nothing black and white about our grey matter. I question whether the direction we’re going in — of ever greater categorisation of mental disorder — is affordable or of proven worth. Of course, there are levels of autism that seriously interfere with a person’s ability to co-exist satisfactorily with others. Obsessive-compulsive disorder does sometimes amount to mental illness. Anxiety, untreated, can paralyse. Hyperactivity in a child may amount to a mental disorder. Grief and shock may be so severe that post-traumatic stress disorder becomes a real diagnosis. Low self-esteem, if low enough, can cripple. I know from the suicide of my own brother how an unbalanced mind can tip a person into horrors every bit as cruel as physical pain.
All this is true — but does the use of medicalese to describe what may simply be unusually striking instances of common human qualities and responses encourage us to reach too easily for a mental “disorder” to blame? The Timesreported yesterday the results of a survey of more than 9,000 young people which suggests that one in four young women “has mental illness”. So the state is called in. And soon politicians are congratulating themselves for “recognising the scourge” of mental illness, and demanding an NHS “parity of esteem” between those sick in mind and those sick in body. And the cost mounts. And it’s unclear whether the benefits follow. Is anyone in government really thinking this through?
Airing mental illness has to be right. On and off throughout his life my late father suffered from what it’s now clear were spells of severe depression. You could actually see his skin change colour. Yet these dreadful troughs were never defined or talked about among us Parrises. We were just sad that Dad sometimes seemed so depressed and withdrawn; and it hurt my mother, a bright and loving soul, particularly.
I wish he had been able to talk about it, to explain. These days we would have invited him to, but if I am honest I cannot say this would have made Dad happier. His drug was nicotine, and anyone who thought my father would have benefited from “counselling” would not have known my father.
And if I am even more honest I would admit to just a trace of admiration for Dad’s silence. We talk now about the “stigma” of mental disorder as though this arises only from ignorance but it’s as old as man — Jesus cast out “demons” — and there’s a Darwinian reason for it. The presumption of sanity in another is vital for human association. If people are sometimes not “themselves” then this must always be slightly frightening in a way that physical impairment is not. No government programme, no “parity of esteem” will ever eradicate that response.
We should never be unkind. We should always be ready to listen and to comfort. We must not airily dismiss. And if drugs of proven efficacy can sometimes help, we should not rule these out. Beyond this, though, and until a proper science worthy of the name can point the way, we should be cautious about throwing too much money at too speculative a profession. In our understanding of the mind and treatment of the mind, we are still in the Dark Ages. Results, please, first.
- 1 in 4 people in Britain will experience a mental health problem this year, according to the charity Mind
- 18% of those who tried to contact services when experiencing a crisis said they did not get the help they needed
- 7.3m people in England were prescribed antidepressants in 2017-18, 4.4 million of whom were also prescribed such drugs in both of the two previous years
- 1 in 4 patients surveyed said they had not seen NHS mental health staff enough to meet their needs in the past year