1. When the architects condemn their own building.
If like me you’ve seen the lives of friends and family ended, ruined or dogged by mental illness and if you too have despaired about the lack of effective help, it can seem obvious that the answer is to just put more money into our current mental health services. It also seems obvious that it’s not a laughing matter. But let’s start with a Woody Allen joke from “Annie Hall”:
“Two elderly women are at a Catskill restaurant. One of them says, ‘Boy, the food at this place is just terrible.’ The other one says, ‘Yeah I know. And such small portions.’”
Thomas Insel used this joke last year to question why the mental health debate has fixated on the quantity of medical services, when actually the quality and the outcomes of the services are so enduringly poor. Until 2015, Insel was Director of the National Institute for Mental Health (NIMH) . In that role he was the US Government’s top psychiatrist and the world’s largest funder of psychiatric research. When he said that modern psychiatry needed to be re-invented, he spoke with authority and shook the establishment. But he was not alone. The most influential architect of modern mental health services was Robert Spitzer. He literally wrote the book, chairing the task force who wrote the ‘bible of psychiatry’, the third version of the Diagnostic and Statistics Manual (DSM) published in 1980. This has determined the West’s approach to mental health ever since. (Once an American bible, the DSM became the global bible when it colonised the World Health Organisation’s manual for mental health). Yet in 2011, Spitzer despaired that a system designed to treat three to four per cent of the population had “medicalised thirty per cent of the population as mentally ill”. Allen Frances led the updating of Spitzer’s DSM in the 1990s. But he too has now condemned the building he helped design. In 2013, Frances publicly called for the US Congress to urgently investigate “a diagnostic system that is far too loose, a drug industry that is far too unregulated and a mental health system that is badly broken”. He issued a high profile mea culpa for “diagnostic inflation” and the “shrinking realm of the normal”:
“Diagnostic decisions that seemed to make sense were exploited by drug companies in aggressive and misleading marketing campaigns. They sold the idea that the problems of everyday living are really mental disorders, caused by a chemical imbalance and cured with a pill.”
Two groups have benefited financially from this system: medics have had a codified system that grants them exclusive rights and payment for meeting a wide variety of public needs; drug companies have had a global opportunity to match a “pill for every ill”. Rather than blaming the drug companies, Frances laid the blame on himself and his fellow doctors. Ninety per cent of people with mental health problems are treated by general practitioners (GPs). Frances despaired of how within a ten minute consultation under-trained doctors used a checklist of symptoms to diagnose a condition and prescribe a pill to deal with it. In the UK, for example, less than half of GPs have been trained in mental health and yet it is a diagnostic issue in a third of their consultations. But the problems with our current approach to mental health are more profound than poor implementation. When the DSM was updated in 2013, Thomas Insel caused a great stir by rejecting the bible outright. He said “Biology never read that book.” He stressed that very few psychiatric diagnoses are “real medical conditions”. Unfortunately, we just don’t know that much about the brain, an electro-chemical machine with a hundred billion neurons and a thousand trillion possible connections. Undaunted by the lack of science, psychiatry has defined hundreds of conditions. But these conditions are diagnosed simply by a checklist of symptoms. Historically, this used to be true in physical medicine where, for example, dyspnoea or “shortness of breath” was a common diagnosis. Today’s medicine knows it is not a disease but an important symptom of an underlying condition in the heart, lungs, blood or brain. These are the real medical conditions and we increasingly have effective therapies to treat them. In mental health, we are still largely diagnosing “shortage of breath”. Worse still, Insel and other have proven that there is very little reliability, validity or consistency in the mental health diagnoses given by doctors, even for the most common or most serious conditions.
The absence of science is not only a problem for diagnosis. It also holds us back from improving the poor range and the limited effectiveness of the therapies we currently have on offer. When it comes to science and therapies, mental health is forty or fifty years behind oncology. Insel states it starkly:
“Current treatments are not effective enough. While there have been important innovations in the behavioural treatment of borderline personality disorder and family interventions for anorexia nervosa, for many disorders we have little to show after four decades of pharmacologic research except reduced medication side-effects. In spite of exuberant sales of medications and broader use of psychosocial treatments, we are faced with outcomes that are just as unacceptable for serious mental disorders as they would be for cancer. Briefly stated: in many cases patients receiving the best of current care are not recovering. We can blame the mental health care system, the absence of insurance or providers, or stigma, but the inconvenient truth is that our treatments are not good enough”.
2. It’s not the first existential crisis for psychiatry.
If the architects have condemned the building, we ought to be discussing psychiatry in terms of an existential crisis. Unfortunately when it comes to existential crises in psychiatry, as Yoggi Berra would say, “It’s like deja vu all over again.” The only way to understand our current crisis is to look at the history of psychiatry and how we got where we are today.
The first crisis for psychiatry came at the end of the nineteenth century. Since the 1840s, hundreds of thousands of people in western countries had been moved into newly built asylums, based on psychiatry’s promise of a medical regime to make them better. But people didn’t get better. Two-thirds of people never left the asylums and the numbers, and cost, grew inexorably. The only real medical science was Alzheimer’s discovery of dementia. By 1907, the then President of the American Psychiatric Association (APA) publicly pronounced that “Our therapeutics are simply a pile of rubbish”. Psychiatry argued itself out abolition by inventing three new systems of mental healthcare. These systems lasted until the 1960s and 1970s. By then public, and wider medical, opinion had turned against them. The first system treated mental illness as contagious and socially corrupting, reinventing the purpose of asylums as isolating the ill to protect the healthy and often allowing eugenicists to sterilise them protect future generations. For example, between 1907 and 1974, some sixty thousand Americans were compulsorily sterilised, mostly because of perceived mental issues. The second system was the biological movement. From the 1920s to the 1960s, the biological psychiatrists introduced operating theatres and turned the asylums into hospitals, attacking the infections they believed were the cause of mental illness. On an industrial scale, they removed potential sources of infection (teeth, cervixes, spleens, sinuses and colons ), triggered immune system reactions by introducing fevers (with, for example, malaria) and tried to kill poisonous cells in the brain by inducing comas with insulin shock therapy. In the 1950s, they expanded their treatments with the hammering of an icepick into the head to lobotomise the brain. The third system of psychiatry was psychoanalysis. Based on the teachings of Freud and others, the analysts eschewed physical medicine and focused on invisible diseases of the mind. By the 1960s, they dominated US university medical schools and the world’s psychiatric textbooks. Personality traits were illnesses and eccentricities were deviant. For example, most analysts saw homosexuality as a curable disorder, produced by a domineering mother and a weak father. They saw addiction to food, drink and drugs as a reaction to being deprived of breast-feeding. Their Psychosomatic School saw lots of diseases (e.g. schizophrenia, autism and even asthma) as the product of dysfunctional parenting, best addressed by life-long, expensive therapy sessions. The analysts had a profound impact on popular culture and general medical training, although relatively few people were treated by them. By the early 1970s, it was evident to those outside psychiatry, including most other medics, that all three of these systems of psychiatry were pseudo-science, ineffective and abusive.
In 1976, the APA President declared, “Our profession has been brought to the edge of extinction”. Psychiatry was being mocked in the newspapers as a fraudulent pseudo-science. Insurance companies were less willing to pay for treatments. Across Western countries, the asylums were being rapidly emptied and closed. Social workers and psychologists were providing twice as much outpatient support as psychiatrists. After more than a hundred years as a profession and having consumed vast amounts of public spending, psychiatry was humiliated and short of friends. Its diagnoses had been exposed as arbitrary and unreliable. This was destroying its credibility. It didn’t appear to be able to make people better. This was destroying its legitimacy. It couldn’t explain any science behind even the few (accidentally-discovered) drugs which helped people manage their conditions. This was destroying its claim to be medicine. In 1977, Melvin Sabshin, the medical director of the APA, led the fightback, stating that “A vigorous effort to remedicalize psychiatry should be strongly supported”.
3. How we ended-up looking through at society the wrong end of the telescope.
From this nadir in the 1970s, medical psychiatry fought back. And it won. The victory came with the APA’s publication of DSM III in 1980, masterminded by Robert Spitzer. This was a political power play by the psychiatrists. They vanquished the opposition they faced from other professionals, regulators and funders. They also defeated internal resistance from the psychoanalysts, who went from dominance to oblivion in quick order. The World Health Organisation’s International Classification of Diseases (ICD) has been gradually colonised by the DSM, giving it global domination. The Spitzer battle entirely shaped our current approach to mental health, how we define it, discuss it and deal with it. But that system was myopically designed around the self-interest of one group of psychiatrists, not the interests of society at large. If we now want to improve mental health, we have to grasp this point. Our current system was designed from the wrong end of the telescope, focusing on the provision, funding, demarcations and organisation of a particular set of professional services for one in twenty people, regardless of how they became ill. This design ignored the fact that one hundred per cent of people have mental health and that, as with physical health, they are on a spectrum from the super-fit, through the healthy, the unhealthy and the moderately ill to the severely ill. The new psychiatry just focused on this latter group, ignoring the mental health risks, opportunities and challenges faced by the other ninety-six per cent of the population. This had three immediate consequences:
Consequence No 1: We created a binary distinction between normal and ill, and just focused on the ill
Whereas psychoanalysis saw mental health as a continuum, with everyone suffering some form of neuroses, the new psychiatry draw a hard boundary between three to four per cent of people who were defined as medically ill for apparently biological reasons and the great majority who were “normal”. The “normal” were not differentiated. The new psychiatry had nothing to say about, or offer, the “normal” majority. This boundary was explicitly designed to please health insurers who resented paying for professional help for people who were finding life hard and to deny non-medical professionals (e.g. social workers, psychologists and counsellors) the right to treat (and/or the right to third-party funding for) those the psychiatrists defined as medically ill.
Consequence No 2: We became obsessed with diagnostic labels for people’s symptoms
Instead of trying to identify and treat the causes of mental illness (be they social or physical), the new psychiatry focused exclusively on symptoms. DSM III gave the appearance of science, in that it categorised hundreds of allegedly distinct conditions. It focused on the rapid diagnosis of these conditions by verifying the presence of various symptoms. It did not match the condition to a cause or to a treatment. The explicit goal of this system was to achieve more consistent diagnoses. But it had a more profound impact on society as a whole. A medical diagnosis of these conditions became the exclusive access code to health insurance / public health payments for treatment, disability benefits and other public services. People needed, and wanted, these new labels.
Consequence No 3: Only doctors can give out drugs, so we just gave out drugs.
Having dismissed non-medical professionals (like talking therapists, counsellors, social workers or neuroscientists), the new psychiatrists were keen to maintain their exclusive privileges. Only medical doctors, like them, could dispense drugs. So the new psychiatrists were keen to focus on drugs. The pharmaceutical companies obliged, creating drugs for particular conditions. Relieved of the need to prove cause-and-effect and with a near monopoly on treatment, they grew a huge, global industry with drugs that provided symptom-relief. Other treatments were largely neglected, until psychological therapies like CBT became more popular in the last decade.
4. The five accidents that became an emergency.
The intended consequences of the 1980 DSM on our approach to mental health were profound. But actually, there have been a series of accidents since then whose unintended consequences have been even more influential.
Accident No. 1: The new psychiatry became a largely GP-based service.
Although the psychiatrists asserted medical supremacy, they did not manage to gain exclusivity amongst doctors. Very few mental health patients get to see a psychiatrist. That’s partly because the DSM III was designed for outpatient care, based on the application of a diagnostic manual and treatment with a branded drug. GPs found that they could deliver that system without recourse to psychiatrists. Given the constraints of their appointment system, they formed rapid conclusions based on a list of patient-described symptoms and, in most cases, felt able to treat the patient directly with a drug, marketed to match one of the DSM conditions. This had profound consequences for how western countries dealt with mental health issues:
- Whereas the new psychiatry expected three to four per cent of people to fall within the DSM categories, GPs found that the diagnoses covered ten times as many people. For example, in Denmark, four out of ten women and three out of ten men will be medically diagnosed as mentally time during their life. In the US, NIMH found that one in two people will meet the criteria for mental illness at some point in their life. One of the new DSM conditions was ADHD. Originally it was envisaged that, perhaps, one in two hundred might have this condition. In the US, however, one in five boys is now diagnosed with ADHD by the time they leave high school. Two-thirds of them are on permanent medication. A quarter of middle-aged American women currently take anti-depressants.
- Even a high quality outpatient service has limited traction on the life of a person with mental illness. Whereas inpatient care designs and controls every hour of the patient’s life, an outpatient system directly controls only a few hours of their life, when people attend their outpatient appointments. For mental health specialists, these hours rely on highly-skilled therapy to change people’s thoughts and to help them find self-help skills. A GP-based outpatient service directly controls only a few minutes of people’s life. That isn’t enough time to be therapeutic, even if the doctor had the skills. In this context, the only tool left is medication and the time available is just enough to prescribe and re-prescribe drugs.
- The medicalisation of mental health assumed that doctors can solve medical problems on their own, in the way that they do for physical illness with biomedical testing, drugs and surgery. That is rarely true in mental health where getting better relies significantly on the patient’s own therapeutic actions and their interaction with their friends, family and colleagues. Outpatient psychiatric care rarely works with the other people in the patient’s life, dealing with the patient one-to-one. Worse still, medical ethics prevent doctors discussing their adult patients, even vulnerable eighteen year olds, with their family and friends.
- The authority of the DSM system and the fact that almost everybody in western countries has access to a GP have combined to make the GP the mandatory interface for millions of people with mental health concerns. For many of them, a GP diagnosis is the obligatory gateway to the time they need off work, to sickness and disability benefits or access to non-medical support. For others, they are sent to the GP by other professionals (e.g. teachers, HR managers, counsellors) who defer and refer to medical authority on what they perceive to be mental illness. For example, in the last twenty years there has been a thirty-five fold increase in the number of American children classified as disabled by mental disorders.
Accident No. 2: The alternative to inpatient care was often even worse than the old asylums.
Inpatient care was the baby thrown-out with the bathwater when the asylums were closed. A small number of people need indefinite inpatient care, whilst many more need short-bursts of it. There isn’t enough of it. For example, England, like other countries, has only ten per cent of the inpatient places, per head of population, that it had in the 1950s. The US has even less. It wasn’t just the asylums closing. England has halved the number of inpatient places it still had in 1998. Community-based crisis services have not worked well. Only fourteen per cent of English patients who’ve experienced a mental health crisis felt they had appropriate care and there are no English community services rated as good. In the absence of appropriate inpatient care, people who are severely ill are labelled, and dealt with, as non-medical problems, as criminals, as homeless, as addicts, as a public nuisance and as suicides:
- A lot of people with serious mental illness have ended-up in prison. About a fifth of prisoners are seriously mentally ill. When they are released, they are likely to return to prison. For example, ninety per cent of the seriously mentally ill prisoners in Los Angeles have been in prison before and a third have been imprisoned more than ten times. Forty per cent of all Americans with serious mental illness have been, or are, in prison.
- A quarter of the people living on the streets in western countries have severe mental illness. English police forces spend twenty per cent of their time dealing with people who are seriously mentally ill, often for their own protection.
- Huge numbers of people are self-medicating for their mental illness with alcohol, illegal drugs, painkillers and nicotine. Severely mentally ill people are three times more likely to be alcoholic. Nearly half the men who kill themselves in the UK have long-standing drink problems. Significant numbers of people with mental health issues diagnose their problem as chronic fatigue and/or pain, often taking powerful painkillers throughout the day. The opioid crisis has ravaged swathes of middle-aged, middle class America.
- People in crisis desperate for medical care present themselves in growing numbers in Emergency Rooms in hospitals or volunteer for involuntary commitment to psychiatric care. Ironically, their best hope of medical treatment is for the physical illnesses which are a consequence of their mental illness, like diabetes and cardiovascular disease. But even here, the system is failing, with seriously mentally ill people dying fifteen to twenty years earlier than others due to their worse physical health.
- More bleak still is the horrifying numbers of suicides where, in the absence of appropriate care, people take their own life. Globally, suicide is one the biggest killers of young people. In America there has a recent upsurge in “baby boomer” suicides.
Accident No. 3: The reactive approach of GPs (and community services) created a mental health service which waited for people to present themselves as mentally ill, often very ill.
The right strategy would have anticipated the predictable risks to mental health which people face in life, proactively helping them to manage those risks and responding rapidly when illness occurs:
- We know that people have a higher risk of mental ill-health around certain stages of life and key events. This includes: adolescence; having a baby; bereavement; relationship breakdown; becoming chronically ill or disabled; having financial problems; retirement; loneliness; being physically abused; unemployment. These were just the sort of “everyday living problems” the new psychiatrists and the health insurers wanted to exclude from mental health services. They were also the causes of mental illness which were deemed irrelevant in the DSM’s pseudo-biological approach to mental health. By the time these events caused people to see the GP, the symptoms of mental illness had often set in and it was these symptoms which were treated.
- The lack of a proactive public health strategy around the risky events in life has been profoundly harmful. We can see this most starkly with children and young people. Half of all mental health problems have manifest themselves before the age of fourteen and three-quarters of adults with mental illness had their first symptoms before the the age of twenty-four. Yet, in the UK for example, children only benefit from six per cent of mental health spending. Young people struggle to get referred by GPs to specialist help and those who do get referred wait an average of ten months to start treatment. Similarly, we know that up to one in five women are at risk of perinatal mental health problems, yet only fifteen per cent of communities in the UK have even an “adequate service” for these risks and forty per cent have none. Only fifteen per cent of people in the UK who would benefit from psychological therapy receive it . Of course, many people never make it to even the GP, a major reason why three-quarters of British people who the DSM defines as having depression or anxiety receive no treatment at all.
Accident No. 4: Everyone bought the “chemical imbalance” theory and ten per cent of people ended-up on anti-depressants.
The drug companies retro-fitted a theory to their serendipitous discoveries that certain drugs had some beneficial effects on some people. They claimed that depression, and other common illnesses, result from a chemical imbalance in the brain and that their drugs correct this balance, e.g. increasing serotonin to tackle depression. The drug companies used this theory to build a massive global business. GPs adopted it because it fitted their apothecary-style practice, narrowing a psycho-social illness into a bio-chemical condition that can be corrected with tablets. For understandable reasons, the anti-stigma movement of mental health campaigners welcomed the theory and promoted the mass use of these anti-depressants. This is perhaps the biggest of the accidents:
- Today about one in ten people are currently take anti-depressants in the US, UK, Canada, Sweden and Australia. In most western countries, the proportion taking antidepressants has doubled or more since 2000. Some countries, including France, South Korea and the Netherlands, take much less and have resisted these rates of growth. Japan has only adopted anti-depressants since 2000, having previously resisted the concept of depression of an illness, seeing it as a personality type instead.
- Unfortunately, there is no scientific proof of the chemical imbalance theory, in spite of a massive and expensive effort to prove that it is true. That shouldn’t prevent doctors prescribing these drugs so long as they are effective and safe. Unfortunately, the evidence for this is weak.
- Doctors tell people that anti-depressants have a positive effect on half of the people who take them. That is true, but misleading. Even drug companies only claim that their drugs have a positive impact on one in eight people who take them. A further three in eight people benefit from a placebo effect. Indeed, even the one in eight who appear to benefit from anti-depressants may just be experiencing a ‘super-placebo’ effect from the side-effects they suffer from the anti-depressants. Placebos which induce these side-effects have been show to have the same efficacy as actual anti-depressants.
- The degree of improvement enjoyed by the half of people who benefit from anti-depressants is limited. To be fair, drug companies only claim a “moderate” reduction in depressive symptoms. Independent research shows the impact to be even less than that. For example, for adolescents the “effect size” for people who do benefit is 0.25, whereas a moderate effect would be 0.5. Drug companies are also clear that the beneficial effects of the drugs take two to six months to kick-in. Without medication, a third of people with depression are better after three months and two-thirds are better after six months. For the people who do benefit, these drugs are probably best compared to a band-aid, increasing the natural healing process a little.
- There is a small minority who appear to be greatly harmed by taking anti-depressants, with a doubling of the suicide rate for peole with depression and the triggering of psychosis in significant numbers of people. But the biggest harm of the anti-depressant accident is that their domination of psychiatric care has crowded out better and more varied solutions to common disorders and left millions unable to get well again.
Accident No. 5: Episodic and one-off illnesses were systematically turned into permanent and chronic disabilities.
This had been one of the biggest criticisms of the asylums, where people whose illness ought to have been temporary or infrequent were indefinitely removed from society and pharmaceutically incapacitated. Unintentionally, Care in the Community has created similar problems, with people becoming permanently ill, dependent on drugs and economically excluded:
- The first problem lies in the system of disability benefits. In the UK, for example, half of all claimants of these benefits have a mental disorder. Two-thirds of them claim for depression and anxiety. The UK number has doubled in the last twenty years, driven largely by people with depression. The numbers have grown even more sharply in the US. Thirty years ago, only one in fifty US disability payments were for mental disorders, now it is a third of them. These mental disorders, which ought to be temporary or infrequent have been treated as a permanent and continuous disability. For example, the UK numbers receiving disability benefits for mental disorders for more than five years have doubled in the last decade. Intended to be kind, the benefits often have the perverse consequence of keeping people out of work, when we know that work is one the most therapeutic activities. GPs have no incentive to either assertively reach out to people in these circumstances or to provide therapeutic support to get back into work.
- The second problem is the way that GPs prescribe drugs. For example, in spite of the evidence that drugs only have a short-term impact for depression, many people are taking them for extended periods. Two-thirds of Americans on anti-depressants have been taking them for more than two years and one in seven has been taking them for a decade or more. It is undisputed that these drugs have debilitating side-effects, like fatigue, obesity and mania, which reduce people’s ability to participate in society. There is also evidence that long-term use induces chronic depression, which simply doesn’t go away. Most perniciously, it seems that rather than treating a chemical imbalance, these drugs create an imbalance where there wasn’t one to start with. This imbalance makes it hard to come-off the drugs, as there are serious withdrawal symptoms and, for half of people, psychological problems arise, as the brain continues to fight the drug’s effects even after it is withdrawn. Both of these problems can make people feel resigned to taking the drugs indefinitely. For many people taking one drug is the first step to taking many drugs. Unguided by real science, doctors try a drug and as most of them don’t work for most people, they try another one and as many suffer serious side-effects, they prescribe a compensating drug, like a mood-stabiliser for the mania induced in some by anti-depressants. For some conditions, the medical protocol is to prescribe drugs for life. That’s true, for example, with antipsychotics, even though the best research shows that forty per cent who discontinue these drugs recover their health, compared to seventeen per cent who continue to take them. But coming off anti-psychotics is hard, as dopamine levels can surge as the brain continues to compensate for the now withdrawn drug and this surge can cause immediate relapse into psychosis.
This combination of indefinite out-of-work benefits and drugs can leave many people feeling they are living in a ‘virtual asylum’, rather than recovering from their illness, managing their condition and living a full life.
5. Seven steps to turn around the telescope and focus on society’s mental health.
For the last four decades we have looked at mental health through the doctors’, and the wrong, end of the telescope, reducing our field of vision to the detail of the medical services available to those who are already mentally ill. We need to seize back the telescope and turn our view to society as a whole and explore a wide range of strategies, going well beyond medicine, to maximise everyone’s mental health.
Step No 1: We should focus on mental health, rather than just illness.
Everybody has mental health, in that they have a brain, they have emotions and they have cognitive skills. Instead of worrying about whether five, ten, twenty or thirty per cent of people have mental health issues, we need to sell the message that one hundred per cent of people need to improve, protect and repair their mental health. At any one time, we can all be ranked on a mental health spectrum as super-fit, healthy, unhealthy, moderately ill or severely ill. There is a normal distribution across this spectrum and people can move up and down the scale over time. We should have a public health strategy that mirrors our approach to physical health. That would mean a big focus on the unhealthy, trying to ensure that they consciously work towards good health and avoid sliding into ill-health. It would mean a big push to tackle early signs of illness and to prevent moderate conditions becoming severe.
Step No. 2: We should link mental health to success in life, rather than failure.
Most of the world’s most successful people (be they in business, sport, entertainment, the professions or the military) spend a lot of time self-consciously improving, protecting and repairing their mental health. In sport, for example, it is commonplace to say that the success, or failure, of top tennis players, footballers and golfers is all in the mind. The British Cycling Team which has dominated world cycling for the last decade attributes much of its success to its psychological coaches. At the more mundane level, we know that good (or improved) mental health is vital to our progress in education, employment and family life.
Step No. 3: We should educate people about the key components of mental health.
Most people actually have a lot of knowledge of physical health. They know the importance of cardio-vascular exercise, the genetic risk of certain cancers, the risks of being over-weight, the harms of alcohol and tobacco, what to do if they get the flu, etc. However, few people know much about mental health. But if we want to empower people to understand and look after their mental health, we shouldn’t just wait to educate them when they, or their loved ones, are so ill that they are being treated by a doctor. People need to understand and think about their genetic inheritance, in terms of genetic risks (e.g. schizophrenia) and their inherited character traits (e.g. being introverted, conscientious, open to new experiences, etc). They need to understand the powerful evolutionary instincts which can take over our brain (e.g. the rejection of new-born babies or the overwhelming desire to fit in). It is important to understand how the way that we live influences our mental health, for good and bad. Our habits can adapt our character traits. We can get stuck in the past or fearful of the future, making it hard to deal with the present. We can get into virtuous or vicious circles with our mental health, where problems lead to problems or success leads to success.
Step No. 4: We should re-define mental illness as either “Emotional Health” or “Neurological Health”.
Modern psychiatry has led us to define mental illness as one thing. We haven’t done that in physical medicine for a few hundred years. Even within particular parts of the body, physical medicine is specialised. For example, we don’t lump together ophthalmology and ENT (ear, nose, throat) specialisms because they are both focus on the head. Given our limited scientific understanding of the brain and of the biological causes of illness, I think that, currently, it’s best to define mental illness in terms of its effects. Firstly, we can divide those effects into two broad categories of illness: emotional distress and cognitive problems. If either of these effects endure, they need attention. Both can range from mildly disruptive to fatal. Emotional distress occurs when we struggle to regulate our emotions and it includes stress, anxiety, depression, trauma, compulsive disorders and a range of behavioural problems. Given the lack of neuroscience insight, our main tools to tackle “Emotional Health” are self-awareness, talking-therapies, social support, self-help techniques and lifestyle changes. Cognitive problems are related to learning, memory, perception and problem-solving. They relate to dementia, autism, learning disabilities and most types of schizophrenia. “Neurological Health” for historical reasons already deals with some of these areas and should be expanded as a discipline to cover all cognitive problems. For neurological problems, the main therapeutic hopes lie in imitating the life science breakthroughs in oncology.Unfortunately, science has not yet produced significant treatments for cognitive problems. Therefore, the current focus is ensuring that people have sufficient personal care, in addition to what they can get from their friends and families.
Step No. 5: We should distinguish between “dysfunction” and “malfunction” in Emotional Health.
With a dysfunction, our mind works but is poorly maintained and prevents us dealing with the world appropriately. Emotional dysfunctions can be rooted in a mix of evolutionary instincts, our genes, our character, our experiences and our habits. The dysfunction impedes how we want to live our lives. Negative emotions undermine our quality of life: fear, stress, sadness, low self-esteem, anger and dark thoughts. Everybody is dysfunctional to some extent, sometimes in very minor ways, other times in very significant ways. The effects of a dysfunction are likely to be that we are mentally unhealthy or mildly ill, although some people find ways to manage a dysfunction and live a mentally healthy life. The point about a dysfunction is that we can do a lot on our own, or with lay help, to reduce or remove the dysfunctionality and, critically, to prevent a malfunction. We should stop over-medicalising dysfunctionality and empower people to help themselves and others, as well as accessing non-medical professionals. However, with a malfunction, our mind stops working, as the illness is overwhelming, we can’t function and we can’t fix ourselves without very skilled help. A malfunction can quickly become a vicious circle in which people go from bad to extremely bad and where there can be fatal consequences. We see this in the levels of death from suicide, addiction, eating disorders, self-neglect and violence to others. With malfunctions, immediate and intensive expert support is vital. Half measures and delays are the enemy.
Step No. 6: We should connect good mental health with good physical health.
When it comes to physical health, public health campaigns tend to focus on what everyone can do to maximise their good health, including diet, exercise, abstention from drugs, sleep and relaxation. The good news is that these are also essential features of protecting and improving our mental and emotional strength. These are not just prophylactic effects. We know, for example, that exercise compares favourably with both drugs and talking therapies in treating mild to moderate depression. We also know that the most pressing issues in physical health, like obesity and addiction, are rooted in mental and emotional health.The physical solution to obesity is easy – eat less, especially less bad things. The only barriers to this solution, for most people, are mental and emotional. If a new approach to mental health did no more than inspire people to follow existing lifestyle advice for physical health, it would make a big improvement in society’s mental health. And that in turn could transform the lifestyle-driven problems in physical health.
Step No. 7: We must recognise that the way our society chooses to live has a big impact on mental health, for good and bad, and can be changed.
The medical model has over-emphasised the individual and the biological. Our mental and emotional strength is heavily influenced by our social interactions. And therefore, we are all responsible for our impacts on other people’s mental health. The good news is that being altruistic and caring for others is one of the best things we can do to improve our own mental and emotional strength. Mental illness and poor health are often based on underlying feelings that one has lost autonomy and/or community-connectedness, experienced as helplessness, hopelessness, passivity, boredom, fear, isolation and dehumanisation. These are social problems which have medical consequences. The best solutions are, often, therefore social rather than medical. In terms of physical health, many of the biggest achievements in have come from non-medical solutions. We live longer and better in large part due to clean air, safe water, better vehicle and workplace safety, less tobacco smoking, more and better food, fluoridated water. We could need a similar public health approach for the social causes of mental health issues. For example:
- We know that loneliness causes both physical pain and mental distress. It’s an evolutionary reaction, warning us of the dangers of social isolation. We know that it’s at the root of many young and old people presenting with depression and other mental illness. It also causes physical harm, as much damage as smoking fifteen cigarettes a day. It’s both extensive (e.g. one in five Americans is chronically lonely) and growing rapidly (having trebled on some measures in the last two or three decades).
- Whilst doctors are busy putting children in the US, UK and Germany on lifelong medication for ADHD, we know ADHD-labelled children are indistinguishable at school from other children when they have chosen their learning activities and are interested in them. Children with this label do worst in environments which they find boring, repetitive and overly-controlled.
- However, ADHD-labelled children are not alone in being disengaged from school. For example, only forty per cent of American high school students feel engaged by school, down from eighty per cent at elementary school. Significant numbers of them are prescribed anti-depressants and others are mentally unhealthy.
- Similarly, only thirty per cent of American workers feel engaged by their jobs, twenty per cent hate their work and fifty per cent are disengaged. At least a third of sickness absence from work is due to mental and emotional issues. The biggest causes of work-related stress are the relationship with one’s boss and colleagues, performance management, work/family conflicts and unclear or unsatisfying roles.
- A quarter of UK university students say that they have mental health problems, including a third of female students. They see their academic work as the biggest cause of their mental problems, followed by concern about their future career and relationship issues.
- It is clear that social media have introduced new risks to mental health. For example, it has made bullying easier and potentially more intense. It has increased the pressures of social comparison. Some teenagers find it hard to switch it off and get the rest and recuperation they need.
- Money problems cause mental health problems and poor mental health is more likely to led to money problems. Debt is a major underlying cause of mental illness, and vice versa. We know, for example, that ninety-four per cent of British women with mental health problems say their spending increases when they are unwell, mostly as “comfort spending”.
- Regular access to green and tranquil spaces, especially naturalistic areas, is very beneficial to mental health. However, many people lack easy access to these areas and the growth and densification of many cities is failing to improve this.
- Career paths have become less predictable and pay progression harder to achieve. A lot of people feel economically insecure and feel they lack personal agency to improve their future. Many of the economically elite deal with these issues by finding and working with mentors, who help them chart the best course, solve problems and improve their personal effectiveness. But the most economically insecure who could gain most from such mentoring the most tend to be excluded from it and suffer the consequences.
Whether it’s schools, colleges, workplaces, online communities, neighbourhoods or banks, the design of these institutions and how we use them are entirely within our control. Whilst many people thrive in these social institutions and enjoy positive mental health, there is at least a large minority who do not. Making things work better for them would transform society’s mental health.
8. An eight point policy plan for the future.
Once we have taken these seven steps and turned the telescope around to look at society’s mental health as a whole, we can focus on the policies to fix our current broken system. I have suggested eight policies that I think would make a big difference across western countries.
The first four policy proposals are to urgently deal with the broken system for adults who are mentally ill and should be in place by 2020:
Policy No 1: General practitioners (GPs) should no longer be able to prescribe drugs for mental illness.
This is essential to turn our backs on the excessive and ineffective medicalisation of moderate mental health issues. It also the disruptive action which will force countries, against a deadline of the closure of this service in 2020, to urgently put in place a new approach to mental health. Of course, all doctors including GPs will be free and encouraged to identify mental health issues, including serious illness. But we do not expect a GP who suspects cancer to start immediately administering chemotherapy. Instead, they refer the patient for rapid specialist diagnosis and treatment. That’s what we need to build for mental health. Whilst there is no urgency to most of the mental health drugs, as their effects, such as they are, take months, rather than days, GPs should still be able to prescribe an urgent anti-psychotic, but only very short-term.
Policy No. 2: Inpatient places should be, at least, trebled to offer more safe refuges for people whose care cannot, for periods of time, be secured in the community.
A trebling would provide a bed for one in a thousand people in the UK or one in two thousand in the US. That’s not a return to the 1950s, but a humane steam-valve for people in acute crisis. However, they should not be hospitals or hospital-style facilities, which are an unnecessary hang-over from the biological days of the asylums. Instead, we need small-scale, compassionate and peaceful refuges, close to people’s homes. In addition to these in-patient facilities, we need to accept that a significant number of people will need residential care for long periods of time. This has happened for older people with dementia, who now dominate residential care homes. As a minimum we need to offer long-term residential support for the seriously mentally-ill who are currently ending up in prisons or living on the street. But we can also think more imaginatively. For example, the Shared Lives scheme in the UK places adults with learning disabilities into family homes, who are paid like foster parents would be for young children. Similar schemes could work for other adults.
Policy No. 3: Adults should be able to directly access CBT (and other accredited psychological therapies) whenever they want, face-to-face or online/mobile, without delay, the need for approval or worry about the cost.
There are too many barriers and delays to people helping themselves to proven therapies as soon as they need them. Where people’s emotional health is dysfunctional, they should be able to directly and immediately access accredited therapies and therapists, without delay or intermediaries. Indeed, that is what people do now when they have the triple luck to know that such therapies exist, to have the money to pay for them and to find a highly skilled therapist. Too many people lack this triple luck. With a good therapist, the diagnosis is part of the therapy and they will quickly identify where an individual is suffering a malfunction which requires more intensive or medical support. Government and health insurers should invest in training a lot more therapists and creating a stronger system of accreditation and ratings by patients. Most critically, they should ensure that everybody can access the therapy, irrespective of income. In countries like the UK that means making it free-as-you-go on the NHS. In others like the US, it means that insurers do the same. In some cases, it maybe means-tested, in the same way that other health services would be. Or employers and universities may choose to fund their own services. In the scheme of things, these therapies are inexpensive and short-term. We should encourage people to use them freely and worry about the net cost if it becomes a big problem. I suspect it won’t and will instead reduce other current costs considerably.
Much of the investment in this area should be in online and mobile services. There is clear evidence that written therapy, by text and online, and telephone/video therapy both work as well as face-to-face therapy. They reduce the barriers to access and the stigma of medical appointments. They also reduce travel and time constraints for both patient and therapist, as well as creating a more natural conversation for many people. However, the investment should go further and create automated services, as well as professional help. This should include online courses to train people in CBT skills to improve their own help, like This Way Up which has had outstanding results in Australia. It should also accelerate the new AI-based bots which provide therapeutic conversations and intervene with therapeutic suggestions when their passive monitoring detects unhealthy behaviour on smartphones and other devices. Similarly, people should be offered automated initial diagnosis, given that AI can use the same checklists as GPs, but also has facial and audio recognition that can detect and diagnose mental illness better than most doctors. For example, we have voice-recognition software which can predict psychosis in the next thirty months with one hundred per cent accuracy.
Policy No. 4: Adults whose lives are dominated by poor mental health should be offered a new, all inclusive health service through a specialised Accountable Care Organisation (ACO).
There should be a new type of care-provider for people with long-term conditions. This includes both people with severe mental illness and those whose moderate conditions have become chronic disabilities. Their support is currently fragmented across GPs, community mental health services, addiction services, justice services, public housing, employment services and welfare agencies. Instead, they should be offered the chance to opt-into a dedicated ACO, which provides all of their health needs, both physical and mental, from GP services through rehabilitation to crisis support. A variety of ACOs should be set-up and patients would be offered a choice, of whether to switch to an ACO and which one. Some might be specialised by disorder, e.g. for eating disorders or for chronic depression/anxiety. They should all bring together a mix of professional skills, both medical and non-medical (e.g. debt management, personal trainers, etc). The ACOs should rationalise the current fragmented and hierarchical professional mess (doctors, nurses, social workers, psychologists, occupational therapists, etc) and define new types of professional based on patient need and efficiency, not old intra-professional battles. They would have full accountability for the person’s health and picking-up the pieces when other agencies like the police, a court or a homeless charity are dealing with their patients. Some people would opt to stay with the specialist ACO indefinitely because their of condition, but for most people the goal would be to return to mainstream provision. The various current funding streams would all be merged to create a single, capitation fee paid to the ACO to meet all the need of a cohort of individuals. They would also be rewarded for getting people better and improving their participation in the community, including working. These rewards would be funded out of anticipated savings to Governments and health insurers. However, this model is more about improving quality and ending the fatalism of the current system, than it is about trying to save money. Top priorities would be reverse the trend for people with depression and anxiety becoming permanently ill and unemployed and to introduce global best practice therapies. For example, Finland’s Open Dialogue therapy has meant that after five years of treatment eighty per cent of people who had psychosis are living without symptoms, the same percentage are in employment and only a third still take drugs. This contrasts with the UK where after five years, eighty per cent still have psychotic symptoms, very few work and nearly everybody is still on drugs.
The next four policy proposals are to improve the future mental health of our population:
Policy No. 5: There should be a high-profile education and social action programme for Emotional Health that actively engages the majority of the adult population.
There is a big remedial job to do on adult education, to ensure that people understand at least as much about mental health as they do about physical health. There is also a pressing need to empower people to improve their own emotional health and to actively support other people to do the same. Each country should tackle this in an ambitious and sustained programme, that has the high profile given to other campaigns like smoking, AIDs, cancer and obesity. The key to this campaign is creating a digital platform in each country (a website and/or an app) and encouraging every adult to go there to learn about emotional health and what they can do about it. It should be sold in two ways, “Be A Great Mate” (learning about emotional health issues and how to support people you know) and “Check On Your Emotions” (assessing, and re-assessing, yourself on an emotional health scale and working out what you can do to improve things, and then whether they are getting better or worse). People should be encouraged to take an accredited test for both of these things to show what they’ve learnt, and to keep it updated. The digital platform should give them to chance to drill-down and find-out more about particular health issues and solutions, once they are engaged or when they revisit. The platform could curate and offer links to useful resources and support, including clicking through to therapy or joining a support group. People could be offered a more intensive education about high risk events, e.g. pregnancy or divorce, as well as being inspired by people, famous and not, who are mentally superfit and/or who’ve recovered from big setbacks. These are not pie-in-the-sky aspirations. For example, in the UK the Alzheimer Society is already training four million people to be Dementia Friends. And around the world, hundreds of millions of people are using self-help health sites, taking quizzes or using wearables to monitor their health and fitness. The problem for mental health is not demand, but supply.
There should also be high profile social action opportunities. Every country should have days like Australia’s “RU OK?” day, which captivates the country every September. They should inspire people to train and volunteer to offer emotional health support to others. This could, for example, replicate the success of Crisis Text Line in the US, or create a wider supply of education and employment mentors, or recruit and train support group leaders. It is essential to nurture and fund more peer-to-peer online platforms, which are accredited by health regulatory bodies as meeting minimum ethical and safety standards, but which recruit as many volunteers as people who need help.
To have a successful, sustained campaign over many years, there should be a common language and a standard core approach to emotional health that is widely shared across society. The more this is standardised, the more it will be socially reinforced and the more it will change norms and behaviours. There are currently lots of different approaches to emotional health and little standardisation. It is a Tower of Babel. There are no doubt a range of good options, but one approach should be chosen. Personally, I would choose Steve Peters’ “Mind Management”, set out in his book “The Chimp Paradox”. Peters has combined the latest neuroscience with a lifetime’s experience of clinical psychiatry to create a comprehensive, but simple and brilliantly communicated approach. It’s been lapped-up by elite sports and business people, with some distinguished celebrities crediting their Olympic Gold medals to Peters.
Policy No. 6: There should be a new national “Best Minds Service” for young people, which replaces all existing services, which educates all young people about emotional health and allows those who are ill to self-refer to immediate and better help.
Investment in the mental health of young people is probably the most important of all the investments that can be made. Adolescence is a high-risk period, but also a highly malleable period when the brain is being shaped and character is being adapted. There is a need for a new service focused on the needs of 12-22 year olds. The new Best Minds Service has two key priorities. Firstly, to shift the debate and attention from illness to health, from a small minority to everybody. Secondly, to bring a fresh approach to the services for young people who are dysfunctional or who malfunction.
In shifting the focus to health, rather than illness, the Best Minds Service needs to put in place a youth version of the adult education and social programme set out in Policy No. 5 above. That would include a digital platform with a tailored version of “Be A Great Mate” and “Check On Your Emotions”. It would also include further age-related modules like “Healthy Social Media Use”, and “Starting University”. Young people would be accredited for successfully completing these programmes. All young people would be obliged by their school, college or university to produce their accreditation and to update it at least every two years. This would be a legal requirement on the institution, as part of its statutory duty of care.This would mirror the way that, for physical health, people are expected to produce vaccination certificates or certificates for safety training. Over and above this basic standard, all educational institutions would be offered the chance by the Service to be accredited as a “Best Minds” institution. To achieve this, they would be required to monitor, improve and report on the collective emotional health of their students, increasing the numbers who are super-fit and healthy, reducing the unhealthy numbers and having timely responses for those at risk or becoming ill. The challenging accreditation would be for the successful outcome, with the institutions free to find the best way to achieve it. That might include mental training programmes, lessons on emotional health, peer support, pastoral care and parental involvement. There should be social pressure for all institutions to gain the accreditation and report on their annual progress.
In terms of starting again with services for young people who become ill, the starting points are the same as for adults. That means no GP prescriptions, sufficient inpatient places for young people in crisis and unfettered digital access to psychological therapies like CBT. The Best Minds Service should be the national provider of all services, although it may choose buy some of them from both national and local third-parties, working through contract and under the Best Minds brand. All young people should be guaranteed these four services, with Governments or health insurers making sure that there are no financial barriers to universal access:
- A new primary care service, based on the successful Headspace model in Australia. These centres, backed by online and telephone help, are staffed by a mix of professionals, including doctors, and are designed with young people to be attractive and welcoming places. Young people, and their families, can turn up when they want to get help with depression, anxiety, stress, addiction, sexuality issues, relationship problems and bullying. Whilst young people and their families should access the centres directly, the Best Minds Centre is where a concerned GP would send a young person. These Best Minds Centres (and their online and phone equivalents) should not just focus on people with problems, but also advise young people on general fitness (like a gym would do for physical health) and handling everyday challenges (e.g. exams, relationship breakdowns). The philosophy of Best Minds would be, by default, to include family and friends in their relationship with the young person, rather than exclude them for medical ethical reasons.
- A national online Peer-to-Peer service, where young people can anonymously both give and receive support from other young people on emotional health issues. This should be well-funded and regulated so that a well-moderated service can be recommended safely to young people. The platform would automatically monitor young people’s use and discussions to offer them confidential prompts for self-help and for professional help, which should be accessible by clicking through from the site.
- Immediate access to therapies, without the need for referral, allowing the therapist to judge the self-diagnosed problem and guide the next steps. As with adults, this should include unfettered access to CBT (and similar) therapy and teach-yourself-CBT skills. It should also allow for immediate self/parent-referred access to specialist and rigorously accredited therapy for eating disorders, psychosis and personality disorders.
- Self-referral to immediate inpatient care when young people are experiencing a malfunction and they, or their family, feel that a community service is inadequate during the crisis. Inpatient care should be small-scale, local and non-hospital-like.
Best Minds should also meet the needs of parents and teachers, who often feel unable to deal with young people’s emotional health issues and who are frightened-off by the current over-medicalisation. This could be done by offering an online platform, with an accredited learning experience to “Be A Great Parent”, backed-up by an online peer-to-peer parent site and online resources to deal with reducing their children’s unhealthiness, dealing with high-risk events and supporting young people through illness. The focus for teachers should be about actively promoting good mental health for all children, training teachers in positive programmes to measure and improve each child’s emotional health during their school and college life.
Policy No. 7 : There should be a new statutory duty on certain services and employers to actively promote good mental health.
Most western countries have legislated to place a statutory duty on certain services and employers to actively avoid discrimination against certain groups. The scope of this duty varies across countries, but typically it guards against discrimination by disability, race and gender. As a minimum, it should be clarified that, for these purposes, disability includes mental illness, both moderate and severe. However, a more transformational version of this policy would place a duty on certain services and employers to actively promote good mental health. This duty could be placed selectively, e.g. it might be placed on services with involve a higher-risk to the emotional health of consumers (like financial services) or on larger employers, who have the resources to be proactive. It could also be placed on key government services, like urban planners to ensure that they are obliged to mitigate risks to emotional health, like the lack of green, naturalistic space or safe places to walk or cycle.
Policy No 8 : There should be a bold new international, publicly-funded research and development “Mind Programme” to discover new therapies.
A new “Mind Programme” needs to emulate how cancer research, at its best, has organised itself in the last twenty years or so. We may not know much about the mind today, but we can be optimistic about what we are about to learn. As Thomas Insel says, “What the EKG did for cardiology, the bacterial culture did for infectious disease, and molecular biology did for oncology, neuroscience should provide for the study of mental disorders”. We do now have better tools to understand the brain, like high resolution imaging, connectomics, high-throughput sequencing for DNA/RNA and whole genome epigenetic analysis. The programme needs to be publicly-funded (and/or Not-for-Profit funded) as the drug company incentives (and current investment plans) are not aligned to what’s needed. It should be genuinely international, to deeply share resources and collaborate on R&D activities. Whilst neuroscience will be key, we should guard against jumping from “brainless psychiatry” to “mindless psychiatry”. So, the “Mind” programme should be as multi-disciplinary as possible, bringing together neuroscientists, psychological therapists, evolutionary psychologists, educationalists, urban planners, data scientists, sports coaches, social workers, etc. The programme should be entirely open-minded about whether the right therapies are drugs, counselling, lifestyle changes, social support or self-help techniques. All solutions should be trialled to clinical standards.
9. Conclusion.
In conclusion, I agree that more money will have to be spent on mental health. But I have tried to show that money on its own will not be enough. We have to recognise what’s gone wrong in our approach to mental health in the last forty years and how, sadly, we can’t just trust the current professionals to sort it out. Instead, we need to shift our focus to society as a whole and radically raise our ambitions about what can be done. I am not an expert in mental health and I have probably not got the analysis or the solutions entirely right. However, I hope my attempt at both will at least stimulate others to produce something better. I am keen to ally with anyone who cares enough to imagine and bring about a new approach.
Paul Kirby 