The more psychiatry, the worse mental health?

hA couple of articles have come out recently that raise many interesting questions that share the question: Why have increased mental health services not reduced the prevalence of mental disorders? I do not have the answers to all of these questions, but I can make some reflections on the problems they raise based on research, clinical experience, and the daily reality of my work as a psychiatrist.

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The first is a small one in the Australian & New Zealand Journal of Psychiatry where Roger Mulder, Julia Rucklidge and Sam Wilkinson argue that developed countries face a dilemma: they have increased their resources aimed at treating mental problems but measures of psychological stress are worsening. In New Zealand, for example, investment in mental health rose from 1.1 trillion New Zealand dollars (NZD) in 2008/2009 to around 4 trillion NZD in 2015/2016. The number of psychiatrists and psychologists has practically doubled from 2005 to 2015 and more people than ever are receiving treatment for their mental problems. Prescriptions for antidepressants and antipsychotics have increased more than 50% and there are more people on medication than ever.

But despite that effort, certain objective measures of mental health have not improved but worsened. According to surveys, the number of children suffering from psychiatric disorders has more than doubled between 2008 and 2013. The percentage of the population suffering from psychological stress has increased from 4.5% in 2011 to 6.8% in 2016. Work disabilities due to mental illness have multiplied by four between 1991 and 2011 and the suicide rate remains high.

These data lead to an obvious question: if treatments are effective, shouldn’t increasing them decrease these measures (psychological stress, suicides, etc.)? Since this seems not to be the case, is it reasonable to continue doing more of the same? Is it a good idea to train more staff in mental health, prescribe more treatments and increase services? There are treatments that work in controlled studies but do not seem to work at the community level. Are non-diseases being overdiagnosed and more serious illnesses where it appears treatment could be more effective left untreated? Is the treatment of poor quality? Are treatments applied too late? Would things be much worse without this growing investment in mental health?

According to the authors, and I agree with them, these data require us to stop and reflect on the service model we have and ask ourselves if it is not causing harm in certain areas. It is possible that to achieve more what we need is to do less, not more. Maybe the biomedical model is forgetting other factors such as economic inequality, unemployment, prejudices, and competitive and materialistic values ​​that increase mental illness. According to them, we would need a vision that goes beyond giving more treatment. It is still necessary to provide the basic needs of daily life and they propose modifying factors such as parental behaviors, at school and at work, diet and lifestyle.

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I quite agree with what the authors propose and I am going to draw a parallel with another chronic medical disease, diabetes, to help us understand that these data, which seem paradoxical, may not be so. Let’s ask ourselves the same question: has the provision of antidiabetic treatments decreased the prevalence of diabetes? This is the evolution of antidiabetic sales in the USA:

According to the International Diabetes Federation of people in 2030. As we see, diabetes treatment does not seem to be reducing the prevalence of diabetes either.

And what is the explanation? I would point out two aspects:

  1. Our lifestyle is diabetogenic, we do not exercise, we do not follow a proper diet, etc.
  2. The treatments are not curative but symptomatic, that is, they treat or improve the disease but do not cure it.

Does the same happen in mental disorders? I think so:

  1. Our lifestyle is depressogenic.
  2. Psychiatric treatments (antidepressants, antipsychotics, anxiolytics…) are effective while they are being taken, but their effect disappears when they are stopped. They treat but they don’t cure.

Why is our lifestyle depressogenic? Well, because, as the cited authors say, there is economic inequality, a lot of stress and pressure in the world of work and at all levels. Our values ​​are competitive and materialistic and, on the other hand, the social support that people enjoyed has been reduced: the extended family, the town priest and religion, the number of people living alone is increasing by leaps and bounds in countries developed, etc.

This diabetogenic and depressogenic lifestyle is causing more and more people to call endocrinologists and psychiatrists and psychologists. Neither psychiatric nor psychological treatments can stop this avalanche, they can relieve and treat symptoms but they cannot change the world out there. The problem is not in people’s heads, the problem is in the world in which people are living (I’m talking about the milder adaptive symptoms, I don’t think the same about serious psychiatric illnesses).

II

The second article is a longer one by Robert Whitaker, the author of titled . The article asks things like whether there is a suicide epidemic in the United States, whether suicide prevention campaigns work, or whether antidepressants reduce the risk of suicide. The answer to the first question is that there is no suicide epidemic in the US. If we look at a long historical series, suicide in the USA in 1950 was 13.2/100,000 and in 2015 it was 13.3/100,000, so . There seems to be a decreasing trend until the year 2000 and then it rises again to the same level. Regarding the effectiveness of suicide prevention programs, they began in approximately the year 2000 and since then there has been an increase in the suicide rate, so there does not seem to be an influence. As for whether antidepressants reduce suicide, it is not confirmed by saying no, which I think the data does support, but it is proposed that they increase it, which I think the data does not support.

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Whitaker examines whether increasing mental health services and resources decreases suicide. And for this he focuses on three types of indicators:

  1. The effectiveness of health policies, programs and legislation: concludes based on studies such as . that countries with better psychiatric services and a greater number of psychiatrists and psychiatric beds have a higher suicide rate.
  2. The risk of suicide in patients receiving psychiatric treatment: and concludes that the higher the level of intensity of psychiatric treatment, the greater the risk of suicide.
  3. The impact of antidepressants. Here he reviews placebo-controlled studies, epidemiological studies and ecological studies and concludes that there is a correlation between the increase in suicides in the period 2000-2016 and the increase in the prescription of antidepressants.

Finally, he concludes that a new conceptualization of suicide is needed, other than the medicalization of suicide, and the way to respond to it. According to Whitaker, it should be seen as something that arises within a social context and there must be a response with greater respect for the autonomy of the person who has suicidal feelings.

Overall, the article is very interesting and the questions are very valid although the answers are more debatable. But the article has its problems, in particular two very important ones. First of all, everything Whitaker analyzes are correlations and from there it is impossible to extract causality, he himself says so in passing. Furthermore, Whitaker selects certain periods such as 1987-2000 and 2000-2016. Selective serotonin reuptake inhibitor (SSRI) antidepressants appeared in 1987 and a decline in the suicide rate began until the year 2000. Some psychiatrists proudly attributed this to SSRIs, which Whitaker dismisses (probably rightly so) and attributed to the decrease in the number of weapons and decrease in unemployment. Since guns and unemployment have not fluctuated since 2000, Whitaker attributes the increase in suicides to antidepressants. This is too simplistic and risky. In such a complex phenomenon and over such long periods, literally thousands of factors influence, many of them unknown. Wanting to explain these changes with 3-4 factors is a risky task (for example, in other countries the increase in suicides has not occurred in the years 2000-2016 as in the USA despite similar increases in the prescription of antidepressants).

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The second problem that the article has is that it continually falls into confusion due to the indication or confusion due to the disease, as for example in point 2) and in part of point 3) when it says that the greater the intensity of treatment, the greater the risk of suicide. . This is something obvious. Where do more people die, in a hospital or in any company? Obviously in a hospital because patients with serious illnesses come there and have a higher risk of mortality. Psychiatric patients who have been admitted have a higher risk of suicide, Whitaker says, and he attributes this to the trauma of admission. But patients are not admitted at random but rather based on more serious symptoms and clinical signs, which are related to a higher risk of suicide.

In any case, and accepting that antidepressants can induce suicide in some cases, I do not believe that the evidence that Whitaker presents demonstrates that antidepressants are the cause of the increase in the suicide rate in the USA, but I do believe that the data supports that antidepressants Antidepressants do not reduce the risk of suicide overall, at the community level. With the great increase in the prescription and sales of antidepressants, if they are being prescribed to the right people, to those who suffer from conditions related to the risk of suicide, I believe the suicide rate should have decreased. I also agree with Whitaker on the need to reconceptualize suicide and common mental disorders differently and that medicalization may not be the appropriate response.

But it seemed to me that Whitaker’s study was a bit lame, focusing only on psychiatry and antidepressants. When reading it he asked me: And what about psychotherapies? Many people, whether or not they take medications, also do some type of psychotherapy. Can we make correlations between the number of people doing psychotherapy and suicide rates or measures of mental health in general?

I started searching for scientific publications on the Internet and I have found absolutely nothing about the number of people who perform psychotherapies and the historical evolution of this number, that is, what has…