Bitter pills to swallow
Do the drugs work? The number of antidepressants and drugs being prescribed for mental health problems is increasing – but a growing movement is questioning the true value of the medication
COULD IT be possible that Ireland is experiencing a hidden epidemic of mental illness? It sounds unlikely. There have been no screaming headlines or siren voices on TV warning about it. But judging by the numbers alone, the rise in the number of people suffering from mental ill-health is chilling.
Take illness-benefit payments for mental health problems. They have jumped by more than 80 per cent over the past decade, up from 9,884 in 2001 to 18,173 last year. And look at the use of drugs. Over the past five years, prescriptions for antidepressants, benzodiazepines and sleeping pills on the medical-card scheme increased by more than 25 per cent.
All of this comes with a heavy economic cost. The three-million-plus prescriptions for mental health drugs on the medical-card system and the Drugs Payment Scheme in 2010 cost the State in excess of €100 million. In addition, mental health problems are estimated to cost the Irish economy around €2.5 billion a year through lost employment, absenteeism, lost productivity and early retirement, according to recent research by the Mental Health Commission, the State’s independent watchdog for psychiatric care.
So, what’s going on? Is the prevalence of mental illness really climbing? Or are we simply learning to recognise and diagnose mental disorders that were always in the community? And what about the drugs that play such a prominent role in treatment: do they work? And if they do, shouldn’t we expect the prevalence of mental illness to be falling, not rising?
These are urgent questions that go to the heart of a growing debate on the efficacy of antidepressants, and about whether we are medicalising common distress. They also pose fresh challenges for a mental health system that, for decades, has been built on the foundation of a “medical model” approach to treatment.
The drugs under challenge include many of the main medicines used to treat anxiety, depression and schizophrenia.
Critics – including patients’ groups and some high-profile psychiatrists – say that fresh scrutiny of scientific literature suggests the benefits of many medications have been exaggerated and that in the long term they might even exacerbate a person’s illness. Further, they say, the medicalisation of distress is serving only the interests of drug companies, which don’t care who is prescribed antidepressants as long as they are prescribed in great quantities.
It’s a challenge hotly disputed by the representative groups for the psychiatric profession, who see mental disorders mostly as diseases of the brain that can be treated effectively with medication. They argue that critics make too much out of often minor technical matters and then ignore an overwhelming body of data supporting the effectiveness of medication.
IN THE 1950s, psychoactive drugs transformed the face of psychiatry. The first was Thorazine, which was used widely in mental hospitals as a tranquilliser for psychotic patients. It was followed by a host of other drugs, aimed at tackling anxiety and depression. In the space of a few years, there were tablets to tackle what were regarded as the three main categories of mental illness: psychosis, anxiety and depression.
According to medical card figures for 2010, the medications most prescribed for mental health problems were Valium (500,550 prescriptions) and Xanax (432,000), both of which are benzodiazepines or sedative-type drugs that can be highly addictive, and the antidepressant Effexor (323,000).
There are many who attest to the benefits of these drugs. Many say they couldn’t survive without them, or that they play a vital role in keeping conditions such as schizophrenia or depression at bay. Lisa, a mother of four, is one of them. She says she experienced severe postnatal depression after the birth of her second child, and she didn’t know where to turn. “It was very scary, and I was worrying about harming my baby,” she says. “I was prescribed an SSRI [an antidepressant] and I began to feel better after two weeks. Everyone is different, but for me, I feel they did work. It cleared my head.”
Set against this backdrop, the increase in the numbers taking medication shouldn’t be seen as something alarming, according to the College of Psychiatry of Ireland, the professional representative body for psychiatrists.
“[Prescriptions] are increasing for lots of medicines, such as anticholesterol drugs for heart conditions,” says Dr Anne Jeffers, a spokeswoman for the college. “When it’s to do with the heart, it’s seen as something good. And it’s time we started to see drugs for treating mental illness in similar way . . . We see people every day who benefit hugely from the mental health system. There is a need to ensure that those prescribing drugs are accountable, but it’s also important to get the message out there that medication does work.”
Far from being over-treated, psychiatrists feel that not enough people, especially young people, seek help soon enough, given the benefits that can follow early intervention.
But recent research is posing a fresh challenge to the notion of how effective these drugs are in the long term, and in the process it is asking unsettling questions about the very foundation of psychiatry.
When Prof Irving Kirsch of the department of psychology at the University of Hull in the UK, and his colleagues in the US and Canada, obtained complete data for all drug trials submitted to licensing authorities in the US, their findings sent a jolt through the medical community. They found that Prozac, Seroxat and other antidepressants of the same class performed no better than dummy pills – or placebos – in the earliest trials. No such analysis had been done before because of the reluctance of the pharmaceutical companies to hand over the full trial results.
In his recent book Anatomy of an Epidemic, investigative journalist Robert Whitaker has found that questioning the efficacy of some psychiatric drugs is not a new phenomenon. He points to an article in the 1976 American Journal of Psychiatry co-authored by Jonathan Cole, regarded as the father of American psycho-pharmacology, titled “Is the Cure Worse Than the Disease?” In the paper, Cole reviewed all the long-term effects the drugs could cause and observed that studies had shown at least 50 per cent of all patients with schizophrenia could fare well without medication. “Every schizophrenic outpatient maintained on antipsychotic medication should have the benefit of an adequate trial without drugs,” Cole wrote at the time.
Whitaker maintains that the psychiatry profession, in effect, shut off further public discussion of this sort. In the 1970s, he says, psychiatry was fighting for survival. The two main classes of drugs – antipsychotics and benzodiazepines such as Valium – were increasingly regarded as harmful, and sales declined.
At the same time, there was a dramatic increase in the number of counsellors and psychologists offering talk therapy and other non-drug-based approaches. “Psychiatry saw itself in competition for patients with these other therapists, and in the late 1970s, the field realised that its advantage in the marketplace was its prescribing powers,” he says. “It consciously sought to tell a public story that would support the use of its medications, and embraced the ‘medical model’ of psychiatric disorders.”
In fact, he goes so far as to argue that the natural history of mental illness is changing. Where once conditions such as schizophrenia and depression were episodic and shorter, now they are more likely to be chronic and lifelong. This, he believes, is due to the damaging long-term effects of some drugs.
However, Kirsch’s and Whitaker’s findings and assertions are challenged by many psychiatrists who say they distort the vast body of wider research which shows these drugs can be very effective, especially in the short term.
This debate over medication and how best to treat mental health problems comes at a time when the voices of patients and advocates, especially those critical of the system, is growing louder. Groups such as Mind Freedom Ireland, Mad Pride and many others are rejecting the labels and language of psychiatry, which views mental ill-health as a bio-medical problem.
Instead, these organisations tend to see mental health problems as forms of emotional distress or an underlying vulnerability, and are demanding a much greater emphasis on choice and on being involved in their route to recovery.
For people such as Dr Terry Lynch, a Limerick-based GP and psychotherapist, it is time our debate on how best to treat mental health problems focused more on developing a genuinely recovery-oriented approach. While he says he is not “anti-medication or anti-psychiatry”, he says the process of recovery requires therapy and time.
“The mental health system doesn’t sufficiently understand the emotional and psychological aspects of mental health problems, nor the importance of exploring in detail the individual’s experiences, whatever they may be.”
This failure, he says, is not due to limited resources, but to an ideological blind spot within the medical approach to mental health problems. In his experience, successful treatment involves becoming an “accompanier” with a person on their journey of life and creating a relationship based on trust, equality, safety, acceptance and positive regard.
Despite the public perception of the psychiatric profession as enthusiastic supporters of a medicine-only approach to care, consultants on the ground say the reality is very different.
For example, Dr Anne Jeffers of the College of Psychiatry says the profession is fully behind the State’s mental health policy, A Vision for Change, which advocates a recovery ethos where psychiatrists work in partnership with patients to support them on their own journey.
The reality on the ground, according to many, is that while this approach is practised in some areas that offer a wide range of services, often due to the influence of individual consultant psychiatrists, many others are still rooted in the more traditional medical approach.
Continuing to invest in the mental health system will be crucial to modernising it. The roll-out of community mental health teams, to be staffed by psychiatrists, therapists and social workers, will be key to giving patients more options.
The attitude of GPs is also crucial. Many say they feel forced to prescribe drugs as the only solution, because they don’t have access to “talking treatment” such as cognitive behavioural therapy.
Meanwhile, the debate about whether drugs work or not seems set to rumble on. It’s a reminder that, despite all our scientific advances, our basic understanding of how mental illness affects the brain is evolving slowly.
The lack of biological markers – for example, there is no blood test for depression – leads to theories about how various treatments work. And as long as the inner workings of the brain remain a mystery, there are likely to be precious few definitive answers.
Dylan Tighe: ‘Instead of relieving my distress, I felt the drugs were compounding it’
The first time Dylan Tighe, who is 34, attended a psychiatrist was at the age of 18, after experiencing a prolonged bout of depression.
“I just felt listless. There was a complete lack of desire and absence of joy that was overwhelming. It was an experience that would be repeated again,” says the award-winning theatre director.
After a brief consultation, he was prescribed Seroxat, an antidepressant, for the best part of a year.
It was the beginning of several years of being prescribed a range of antidepressants and mood-stabilisers which, he says, had often severe side effects, such as an increased heart rate, short-term memory loss and sexual problems.
In the meantime, he felt other options weren’t being made available, such as talk therapy, which might helped him resolve underlying issues.
“Drugs were always the first port of call. There was a dismissive attitude towards talk therapy . . . instead of relieving my distress, I felt the drugs were compounding it.
“My engagement with the service and lack of choice disempowered me to the point where I’m sure it was a factor in the depression itself.
“I found the relationship between the psychiatrist and patient quite patronising. They are the ones with the knowledge and power. Yet, all the assumptions on which I was being prescribed medication were very challengable – but it’s difficult to do so when you’re at a very vulnerable point.” He says he would have liked to have been listened to about what he felt would work in his case – but says there was little leeway outside of the medical approach.
After exploring options on his own, he found psychotherapy “infinitely more helpful”.
“The most helpful therapists were those with the most empathy. That was almost totally absent from psychiatry, in my experience.”
Tighe hasn’t used drugs for about two years. He has serious reservations about psychiatric medication, but accepts that some people find them helpful. “You can’t generalise. Everyone’s different. In my case, I was told I may have to take them for the rest of my life, so I feel an enormous sense of relief now that I made a choice to stop taking them.”
Tighe is now putting the finishing touches to an album and stage production called Record, which will draw on his experiences of the mental health system. It will premiere at the Cork Midsummer Festival on June 25th and will go on to tour nationally.
“The material uses my starting point of diagnosis and examines the area of emotional distress and ideologies around psychiatry, and looks towards a new way of conceptualising emotional distress . . . I feel I’ve made huge progress in coming to my own understanding of my experiences, which has been very empowering and enlightening.”
Catherine Mannion: ‘You’re labelled. I was a “manic depressive”. It depersonalises you’
After giving birth to three children in quick succession, Catherine Mannion felt exhausted. The babies were born prematurely and needed extra attention. But she was losing weight and felt physically and mentally drained.
“I was burnt out, looking back,” she says. “I just didn’t have any energy.”
Her GP advised her that she needed a rest or “deep sleep” to recover, she says, and suggested a brief stay in a psychiatric hospital for a few days.
After being discharged, Mannion decided to go for marriage counselling due to the strain her exhaustion was having on the relationship.
After explaining how she felt to a psychiatrist, she says she received a diagnosis on the spot: manic depressive psychosis.
“It took me completely by surprise. I’d never heard anything like it. When the psychiatrist started describing the symptoms – mood swings, extremes of emotion, indecision – I just didn’t recognise it. It didn’t sound like me.”
Mannion says she was told Lithium – a drug used to treat manic depression – was the answer: it would correct the chemical imbalance in her brain. She would receive it under supervision, along with anti-depressants, and be discharged from hospital after a few weeks.
Instead of a brief involvement with psychiatric services, she says it was the beginning of a “lost decade” in which she felt ignored by specialists and was given little option other than taking often heavy doses of medication.
“It was clear to me that I wasn’t getting better,” she says. “I was just getting worse. The side-effects were just numbing. I started questioning what was happening, but then I’d be told that if I didn’t take them I was in danger of being locked up.”
In all, she had four stays as an inpatient, ranging from a few weeks to a few months. At one point, she recalls refusing to take tablets she was prescribed. She says she intravenously injected anti-psychotic drugs and received several doses of electro-shock therapy.
“It made be feel that I couldn’t function as a person. If felt like my life was on hold. I didn’t have spontaneity or joy in life. It just desensitised me.”
A key moment of validation for her, she says, was reading a letter in a newspaper by Dr Michael Corry, a critic of the forced administration of treatment.
Outside the system, she sought independent diagnoses from Dr Corry and a psychologist: both, she says, concluded she did not have a mental illness.
“A long time has passed. I don’t think many psychiatrists realise the profound effect they can have on a person’s character. You’re labelled. I was a ‘manic depressive’. It depersonalises you,” she says.
“As far as medication is concerned, we need to discuss both sides, the for and against. I don’t doubt they help some people. But in my case, they turned out to be my worst enemy.
“And I lost 10 years of my life on medication which I feel I never needed at all.”