What Disability Benefit Trends Tell Us About Psychiatric Treatments and the Economy

Joanna Moncrieff, MD
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Sickness and disability benefits are a hot topic in the United Kingdom at the moment. The government’s new system means that everyone’s benefit entitlement is being reviewed, and this is causing huge stress and anxiety for many people, including my patients. Some people have suggested that for this reason, I should not have published the recent paper on trends in sickness and disability benefits that I published with a colleague, Dr Viola.(1) It was unethical and should not have been allowed, apparently,(2) even though almost all the data is already in the public domain – on the Department for Work and Pensions’s website – in the name of transparency.

But we cannot simply ignore or suppress such a seismic shift in social trends. When I looked at benefit statistics in the 1990s, musculo-skeletal disorders (principally back pain) were overwhelmingly the biggest and fastest growing cause of receiving what were then called incapacity benefits, and cardiovascular disorders were the second most common cause in men. In 1994-1995, mental disorders accounted for just 20% of days on which benefits were claimed.(3)

Since that time, mental disorders have far outstripped all other types of medical conditions and become the leading cause of claiming sickness and disability benefits. While the number of people claiming benefits for other medical conditions fell by 35% between 1995 and 2014, the number of people claiming benefits for mental disorders more than doubled. In 2014, 47% of all claims for disability benefits – almost half- were made by people whose primary condition is a mental disorder. 1.1 million people in the UK, or 2.7% of the working age population, claim disability benefits due to a mental disorder.(4) The costs to the individuals who are unable to support themselves, and to the society as a whole, are huge.

These figures are important for what they tell us about the success or otherwise of current approaches to helping people with common mental health problems, and for what they say about the economy, and the nature of modern work.

I started looking at disability benefits back in the 1990s in order to find some objective measure of the performance of people diagnosed with depression Depression and anxiety disorders account for the majority of disability claims by people with mental disorders. In 2014, almost half (44.2%) of disability benefits awarded to people with a mental disorder were for depression and two thirds were for depression or anxiety (66.8%).(1) These proportions have not changed much since the 1990s.

In the early 1990s, campaigns like the Defeat Depression Campaign publicised the message that large numbers of people were depressed without knowing it, and that they should go and get the new and wonderful antidepressants that had just come onto the market (the SSRIs of course!). Since that time, the use of antidepressants has increased four times! In England, prescriptions have risen over 10% a year since 1998.(4)

If antidepressants are effective, and people with depression are more likely to be prescribed them, then you would expect the consequences of depression to start to lessen. One of those consequences, according to government statistics, is being out of work. But what we see is quite the opposite: Increasing use of antidepressants correlates with increased numbers of people with depression who are out of work and claiming benefits, and increasingly on a long-term basis. And this is at a time when disability due to other medical conditions has fallen.

The idea that conditions like depression and anxiety can be quickly and effectively treated with medication or short courses of therapy that re-adjust your thinking is not borne out by the evidence. Rather than helping people improve their lives and get on their feet again, this approach seems to create ever rising numbers of people who are viewed, and may come to themselves, as chronically sick. Far from helping people towards a meaningful recovery, taking an antidepressant may simply be a daily reminder of the idea that you are permanenelty flawed.

One of the ways our current approach is wrong is that we are looking for the problem in the individual- inside the brain. Instead we need to ask what it is about our society that means that so many people feel too unhappy, worried or mentally frail to work. Having a ‘decent’ job is an incredibly important part of people’s lives, and most people want one. Research shows that even people with severe mental disorders would like to be in work, if they could.(5,6) A good job is a source of satisfaction, purpose and camaraderie. People without work easily lose confidence and become socially isolated.

Fewer and fewer ‘decent’ jobs exist, however, especially at the unskilled end of the jobs market. Most jobs, even fairly menial ones, have become increasingly competitive and demanding, with performance targets and micro-management. I heard one radio journalist describe how he had attempted to apply for a job as a local petrol station attendant. He had to complete complex questionnaires designed to assess his levels of motivation and dedication, as if the application were for a high flying executive position. Despite his University education, he failed miserably to qualify, and wondered how anyone without a degree in management consultancy was able to get shortlisted.

Unskilled jobs have either gone altogether, or have become increasingly casualised. With the increase in agency work and zero-hours contracts, there are fewer jobs with paid sick leave and holidays. For these reasons, some analysts have referred to the problem of ‘disguised unemployment,’ indicating that many disability claimants are willing and able to work if suitable employment opportunities existed.(7) But they need jobs that will accommodate the fact that they might not always be performing at 100% efficiency (like everyone, of course), and they might need to take time off occasionally. They need understanding employers, who respect and value their contribution, not agencies which can simply hire someone else.(8)

Working in a highly pressured, insecure and competitive situation is bad for everyone. Rising disability benefits are a sign that we need to do something about modern employment conditions. We need to provide more opportunities to work in a supportive and accommodating environment. This is especially important for people with mental health problems, but it would benefit us all.

* * * * *

References:

  1. Viola S, Moncrieff J. Claims for sickness and disability benefits owing to mental disorders in the UK: trends from 1995 to 2014. BJPsych Open 2016;2:18-24.
  2. http://www.philipfthomas.com/index.php/blogs/28-un-critical-psychiatry
  3. Moncrieff J, Pomerleau J. Trends in sickness benefits in Great Britain and the contribution of mental disorders. J Public Health Med 2000 Mar;22(1):59-67.
  4. Calculated using figures from ONS: deducting population of Northern Ireland (since disability benefits data do not cover Northern Ireland), and assuming working age pop is 64% of population, as given by ONS data
  5. Ilyas S, Moncrieff J. Trends in prescriptions and costs of drugs for mental disorders in England, 1998-2010. Br J Psychiatry 2012 May;200(5):393-8.
  6. Boycott N, Akhtar A, Schneider J. “Work is good for me”: views of mental health service users seeking work during the UK recession, a qualitative analysis. J Ment Health 2015 Apr;24(2):93-7.
  7. Marwaha S, Johnson S. Views and experiences of employment among people with psychosis: a qualitative descriptive study. Int J Soc Psychiatry 2005 Dec;51(4):302-16.
  8. Beatty C, Fothergill S, Macmillan R. A theory of employment, unemployment and sickness. Regional Studies 2000;34:617-30.

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27 COMMENTS

  1. We’ve got the same problem here in the states, at least, we will have it soon. People have been pushing for mental health parity (parody I like to call it). This is the idea that “mental illnesses” are medical conditions requiring the same financial allowances as other medical conditions and, therefore, they should be treated as such by insurance companies. The problem is that you end up with a growing population of people on disability and out of work. There is no escape clause. Eventually the economy has got to feel the pinch.

    Bernie Sanders in a debate recently, talking about his medical welfare plan, specifically alluded to people with “mental health conditions”. You’ve got a growing un and under-employed population in that very category. A pretty sizable percentage of the US population is taking SSRI anti-depressants. Medical coverage packages and insurance parity are only going to increase the size of this population. Getting people in the mental health system, or the social disability system, back to work is not a big priority. When the tab starts coming in, taxpayer thoughts on the subject are bound to change as there is only so much that burro can haul without breaking his back.

    Jobs screen for “mental health”, that is, they subtly discriminate against people who have any sort of admitted psychiatric history. The Americans with Disabilities Act (ADA) doesn’t adequately cover people with “mental illness” labels. Because of the employment situation, and because jobs are seen as beneficial (duh), the mental health system itself is hiring people from within the patient ranks as paraprofessionals. This is very problematic terrain because it is another one of those ways in which the mental health system expands, that is, it in this process picks up both more staff and more patients. This isn’t the same thing as getting people jobs outside of the mental health system, and in this fashion, helping them leave the system (i.e. recover). It provides the mental health system with more employees, and encourages the netting of more patients, potential employees, and further expansion.

    If the light isn’t there suddenly, it is going to arrive in time. You can’t, in other words, do certain things without there being consequences. Building this disability system is one of those things. There is no thought of countering this disability system by putting some of these technically disabled people to work. Eventually the absurdity of the whole thing is going to catch up with us. As I’m trying to say, some of these people are only disabled technically, and there is that piper waiting for his fee. Someday somebody is going to have to pay, and that somebody is going to be somebody who is not paying today. Unemployment is depressing, sure, but there is a cure to that depression, should anybody manage to get the idea that it is not such madness as one might have supposed.

  2. Great article, Joanna, with many good insights into the intersection of economic/work factors and emotional problems. Thank you! The fact that longer term psychosocial treatments of emotional problems, which permit lasting reintegration into the community/workforce, actually save money in the long-term is often misunderstood or missed by those focusing on short-term profit, i.e. drug companies and some psychiatrists, plus government officials that they lobby.

  3. Thank you for this article and your recent paper.

    Robert Whitaker’s thesis of course is that it is the massive overprescribing of the drugs themselves which is, in large part, causing the epidemic of mental ill-health, and consequent increasing numbers of disability claimants.

    Do you agree with this?

  4. Wonderful to see employment practices linked to mental and emotional suffering! It is way past time we started recognizing that our society itself is a crazy-making environment and that we need to take some action to address the constant low-level anxiety and hopelessness that pervades many of the well-integrated members of our society. Those on disability are the “canaries in the coal mine” that should warn us that we are on the wrong track!

    —- Steve

  5. Don’t pretend to know what’s best for mentally ill people who can’t work, let them tell you. Yes the goal is getting them off the handouts as the taxpayers aren’t compassionate when they are told these are the lazy ones. Let the benefits be a stepping stone, don’t use the logic that encouraging them back to work means taking away their money with reviews. Encourage work by increasing the incentive with more already receiving help, and most of all don’t judge the sick judge the rich who aren’t creating good high paying jobs that make people happy to begin with. No one wants to flip burgers and be oppressed by minimum wages, and don’t force people to do those jobs that don’t want to do them by coercive measures of taking their benefits away.

    • I agree that simply “having a job” (such as flipping burgers) doesn’t do anything for anyone’s self-esteem; it’s often the prospect of such alienating labor that makes people crazy in the first place. I support a guaranteed minimum wage for everyone, take the whole “disability” angle out of the equation.

  6. One of my former economics professors wrote a good book explaining what the problem is, having society controlled by enormous multinational companies, rather than maintaining family owned businesses and competition, is the problem.

    http://www.amazon.com/The-Bigness-Complex-Walter-Adams/dp/0394547217

    Plus, there’s a lot more job satisfaction when you are the boss, and compassion if you personally work with the boss. The Walmarts have destroyed this country. Not to mention the “too big to fail banks.”

    • Actually, there’s a lot more to the problems than just that. Shipping all the manufacturing jobs off shore so the corporations can have stuff made cheaper. Exchange rates are a problem, I know I can buy a Chinese made painting in a US store, for less money than I can purchase a plain canvas. Those in charge (and it is the same bankers who are screwing over both England and the US), who I’ve read think competition is a sin, are really destroying the entire world with their greed.

  7. I tend to think that while psychiatry and its meds are crazy-making, the basis of the problem lies also in an economic system that is focused on profits and productivity at the exclusion of all else…it is crazy-making.

    Companies (and their shareholders) demand ever increasing profits and dividends, and to get these are willing to shed workers and place ever greater pressures on those who remain to deliver more and more with less and less. Unskilled/low skilled jobs are disappearing…robots are more efficient and cost less and don’t involve messy human interactions. Governments are following the “corporate ” model in efficiency drives, reducing staffing and expecting more with less. The rich get richer and everyone else can go to hell on a prescription for psych meds.

    Workplaces are now very brutally competitive and it is survival of the fittest in the extreme…and not everyone can be the fittest.

    I think it really is a socio-economic-political issue and to look at it as just a “mental health” issue in isolation is to ignore the serious causative factors and place more blame on the people who are unable to do a lot about it.

    I can understand that your patients are upset with you….the government response will be to blame these people and label them “malingerers” (and not support them in getting off highly addictive and destructive meds prescribed by DOCTORS), tighten eligibilty for benefits, and demonise and throw these “mentally ill malingerers” into more desperate circumstances without actually doing anything to address the underlying issues.

    Pharmaceutical companies will not be forced to contribute to cleaning up their mess in any significant way – that would decrease profits and profits are all that matters….and the drugs ARE approved for use by governments, after all, and so they must be safe and effective (psychiatrists say they are) and so it must be the fault of the “mentally ill”…as defined by (highly paid) psychiatrists.

    ….and around and around we go.

  8. Create jobs , create jobs …. Non sense !

    The whole problem is that survival is overly dependent on money.

    When you do get a job the government takes a big cut right from the start then in many places in the US the education mafia is so out of control the property taxes on a home cost more then the mortgage . The joke is you don’t own your home , no, you rent it from town hall.

    Of course they push “create jobs” they want more slaves.

    I live somewhat “off grid” I don’t get many bills. I have a great antenna for snagging WIFI , batteries and inverter system , water tank shallow well pump. I am going to leave the rest out for the sake of internet anonymity but damn I would hate to have to live the traditional get screwed with bills and rippoffs coming in from every direction. Money I earn is mine.

    I love watching that show “extreme homes” so many cleaver ideas and tons of outside the box thinking. My next place is going to be really kick ass. The whole trick is finding a location that tolerates freedom.

    Just as the U.S. solar industry is surging, with record sales last year, Florida is attempting to outlaw off-the-grid living altogether. The move marks a trend towards government interference in our private lives, as more and more of us make a commitment to a more sustainable way of life.

    Off the Grid Living Is Deemed Illegal in Florida http://thelibertarianrepublic.com/off-the-grid-living-is-deemed-illegal-in-florida/

    Off-grid living is being attacked from coast to coast.

    “Most jobs, even fairly menial ones, have become increasingly competitive and demanding, with performance targets and micro-management.”

    Sounds stressful.

    Bottom line is stress causes mental illness and the system itself causes most of it. Make money work work work or be outside !!! Your crappy “illegal” apartment is $1,200 a month cause the homeowner has a $15,000 tax bill courtesy of the education mafia.

    Do you sort of get it people in favor of the liberal “utopia” ?

    Create jobs… All they really want is more slaves. They hate self sufficiency.

    So if anyone out there is “disabled” meaning your struggling with anxiety and depression from they struggle of working crappy jobs and renting a crappy places like millions do check out http://www.off-grid.net/category/off-grid-101/

    Its no easy escaping the crap jobs and crap apartments situation but half the battle is making the plan and then actually getting started.

    • Ok no one liked my post.

      I guess what I am trying to advocate is we need an absolute right to housing. I don’t mean socialistic public housing that more than often than not gets over run with problems but a right to shelter yourself, I am having trouble naming it but its a right. The right to build and live in your own shelter. It should be law.

      Tiny House Movement: Affordable Housing Revolution http://tinyhousetalk.com/tiny-house-movement/

      Go ahead , look at all the super clever ideas on these tiny do it yourself build a home webpages. Like what you see and think you can do that. Go ahead and try. Tell me how far you get before you run into a major bureaucratic hassle and likely get shut down.

      I guess if we can “create jobs” maybe we can get neo-feudalism to work even for disabled people who can’t do the 9-5 thing instead of letting the serfs have the right to build own home and be left alone.

      Neo-feudalism, whats that ? Click here http://www.zillow.com/homes/for_rent/

  10. Dr. Moncrieff has posted an excellent description of how psychological and emotional difficulties have such complex and interactive causes. If a person gets a physical illness, and misses work they will soon lose their job. This leads to the person becoming discouraged and frustrated.

    That kind of emotional upset will soon put them in a psychiatrist’s office where they will be offered medications, which may sedate them but won’t change the situation. If they seek therapy, they may learn to understand their difficulties from a different perspective. But even then, their therapist has very little power to help them find work.

    If they are out of work and have a family to support, the stress mounts and often the family relationships become strained due to financial pressure, loss of status and loss of a sense of competence..

    Added to this is the pressure that comes from many in our highly competitive, highly capitalistic society that labels the person not only as crazy, but lazy.

    To turn this around, to help a person begin to feel competent and human again takes many people. A good therapist can be a help, but there needs to be a support network of family and friends. It would also be most helpful if there is an understanding community that offers a path to a meaningful life.

  11. I hate everything about this conversation.
    I hate that anybody can think it’s acceptable to publish this without even mentioning the wave of suicides among people being declared “fit to work”
    http://www.buzzfeed.com/tomchivers/disability-benefit-assessments-linked-to-suicides-study-find
    I hate that being economically-productive is being held up as the measure of people’s worth, their ethics, their participation in community, I’m disgusted to hear workplaces being referred to as communities rather than the points of conflict and alienation that they are.
    http://prole.info/wcpw/intro_4.html

    • Excellent, I completely agree.

      I’m once again reminded of the Krishnamurti quote. It’s so relevant to all of this, continually, and especially to your statement, lily.c–

      “It is no measure of health to be well-adjusted to a profoundly sick society.”

      I believe lily.c is correct, that workplaces tend to be toxic, more and more, and people put up with it because they perceive no choice in the matter. I will argue that this is merely a perception based on feelings of powerlessness to create what we need and want for ourselves. That can shift, with good healing work.

      Social change would mean that we put this into perspective and make appropriate changes to our social, professional, and healthy systems, and this will challenge us into a new way of life. It’s the only way, imo, if we want a balanced society that will positively affect our health and well-being and be supportive, rather than challenge it relentlessly to the point of making it practically impossible to be “successful” (as per mainstream definition) and healthy, grounded, and generally at peace. For starters, the cut throat competition alone leads people to be all kinds of underhanded and back-stabbing, it’s a way of life for some very ambitious people of the mainstream culture. And sadly, it seems to work for them, at least it has been. I’m counting on the idea that people are finally waking up and taking a stand against this kind of unjust and unhealthy daily oppression.

      A ‘decent job’ is most definitely not the key to happiness of any kind, it’s merely something we do to pay the bills, and so often we are forced to work with people we don’t necessarily care for, up to and including employers that can be hard to respect, due to their power issues.

      Being able to create what we most desire is what brings us joy and inner peace. Working for others who give us a paycheck merely keeps us enslaved and drained of energy. Everyone should be their own boss, that would be the first step toward a healthy society. Then, of course, that means taking responsibility for ourselves, which is a whole different matter. Change comes layer by layer.

  13. This is such an interesting discussion. Thank you to everyone who has contributed. It has been very enlightening.

    In answer to the question about whether psychiatric drugs are responsible for rising benefit rates, I think the massive prescription of psychiatric drugs contributes by confirming to people that they are sick, and through the apathy-inducing effects of many drugs. I do not think that the drugs are the ultimate cause of this situation, however.

    I agree that a job is not the be all and end all of life, but I think that most people benefit from being able to contribute to society in some way, and by being rewarded and respected for their contribution. This does not need to be through paid work, I acknowledge, but it would be nice if there were more jobs out there that gave people a sense of satisfaction and pride.

    • “I agree that a job is not the be all and end all of life, but I think that most people benefit from being able to contribute to society in some way, and by being rewarded and respected for their contribution. This does not need to be through paid work, I acknowledge, but it would be nice if there were more jobs out there that gave people a sense of satisfaction and pride.”

      Dr. Moncrieff, on the surface, I would agree with this statement. However, there are a lot of phrases here which I feel are significant in their various interpretations.

      How many ways are their to be contributing members of society? So, so many, and not all of it involves even remotely some kind of ‘work,’ but more so, a way of life. Someone who is committed to providing a daily random act of kindness certainly contributes greatly to society. And usually, people that do this prefer anonymity, and feel their own sense of self-respect and self-reward, from an internal space.

      Respected and rewarded by others? In a competitive society, that can be hard to come by for anyone, but certainly a population treated second class will be hard pressed to avoid exploitation, as marginalized citizens are so rarely treated with respect, and as well, can have a hard time feeling self-respect, as a result.

      Healing is considered to be one of the highest contributions to society, yet there is rarely respect and monetary reward; and of course, “disability” can be prolonged regardless, because healing doesn’t necessarily mean meeting society’s criteria for how ‘to be,’ and most often, it is the opposite. Healing often means individuating from society, and finding one’s own path on one’s own merit, not as defined by a ‘society.’ That’s true freedom.

      I believe a lot of people receive disability benefits not because they are unable to create, produce, and contribute, but more so, simply from savvy and sound self-care of not wanting to drain their energy by working to ‘fit in,’ (which is great effort we don’t even recognize often). I think respect and reward come from our sense of power to create on our own terms, rather than to go through life working for others.

      Were workplaces to be more just, class-less, and conducive to unity and truly working toward a common goal while being able to balance employee needs, then yes, that could be quite rewarding and fulfilling. But the sad truth is that this is most often not the case, and instead, employees are left to fend for themselves, if they are not into appeasing ego after ego, in order to survive. That’s not at all healthy, and, in fact, is chronically stressful, yet it is commonplace.

      I can’t think of a more prevalent cause of baseline distress in society, at large, than having to rely on employment by others, if they are to feel satisfied, respected and rewarded in life. That is really giving away our power.

      What I feel would be nice, and quite healthy for people, is to find life rewarding and fulfilling, through the power of knowing our freedom to create what we most desire, and of course to me, that would always include for the greater good, given that we are part of a global collective. I, at least, feel we are all connected, whether we like it or not.

      If we’re doing it ourselves, our way, that alone is fulfilling and rewarding, regardless of outcomes. It’s the process of our own creativity that is most rewarding. In turn, we, ourselves, generate that self-respect and satisfaction we crave as humans, without having to rely on others (give them our power) to provide this for us.

      Respect and reward are best served by our own sense of it for ourselves, not on dependence on others to provide this for us.

      Thank you for this very stimulating discussion.

      • I wanted to add briefly, from my own lived experience, that I feel that prolonged disability is more a issue of stigma for the sake of getting away with corruption than anything.

        I had healed and worked hard to transition from disability for a long time, and each time I was making strides and about to cross over that bridge, my transition was literally sabotaged by a tangent of the very system from which I was trying to transition.

        Eventually, I’d be alienated one way or another, first, through a wrongful termination for which I rightfully won a legal mediation, proving blatant discrimination (I had a successful caseload, but being client-centered was not their agenda, which was unacceptable to me, and of course who was I–a person on disability–to offer a perspective?); and then at other agencies, simply through gossip.

        I was moving along well each time, and quite humble about it as I had been through quite a bit up to this point and was not looking for trouble, but my truth about the system and what I knew about healing was terribly threatening to the system and status quo–even though I was working for an advocacy agency eventually, but that was in name only I discovered down the road, the corruption continued–so they’d find a way to give me quite a hard time, despite my obvious and sincerely dedicated contributions to the agency at hand. Who needs that??

        Point is, I got stuck on disability a lot longer than I had planned and intended–thanks to corruption and incompetence on the part of the system and its ‘transitional’ services–and I made the best of it, furthering my training as I healed–including healing from betrayal and sabotaged from the system–doing trade for healing work, teachings and a healing internship when I could not afford it, and eventually creating a healing business from scratch, along with a no-budget film about the destructive nature of social stigma and marginalization, all of it on faith and trusting my process and hoping for the best. I made leap after leap of faith, embracing the uncertainty of it all. Thankfully, it all worked out.

        What else was I to do, if I wanted to be happy and fulfilled in life? Sit around all day complaining and wringing my brain about how life had dogged me? No way. A time came when it was vital to seek new perspectives, so that I could move forward rather than getting stuck in my own quagmire of victimization.

        The world doesn’t change for us, we have to change the world by changing ourselves. Change means letting go of the old to allow for something new. That’s very challenging, although it’s quite an adventure of living. Only way to know how to receive it is with trust, one step at a time.

        Change is also inevitable, that is the nature of things.

  14. Here. I need to bring this up again because this just happened. Hundreds of disabled people blockading thoroughfares in London, because the government wants to let snoops into FUCKING SURGERY UNITS to try to declare people “fit to work.”

    https://johnnyvoid.wordpress.com/2016/03/06/just-the-start-say-claimants-and-disabled-people-as-blockade-brings-traffic-chaos-to-central-london/

    This blockade and the organizing it’s part of is part of an urgent, desperately-needed strategy by vulnerable people, to draw SOME KIND of line in the sand, to stop the abuse and disposability that capitalism throws them into. Look. This is what’s happening.

    “The British government has just published statistics revealing that thousands of people seeking welfare benefits DIED WITHIN WEEKS of being found “fit to work” and having their benefits cancelled.”
    http://www.dailydot.com/politics/uk-welfare-benefits-death-statistics/?tu=gav

    This is NOT “such an interesting discussion,” DOCTOR. This is what the work ethic does. It fucking kills people.

  15. Thanks for sharing. Europeans are so exponentially more conscious and organized than people in the U.S.; we should be paying more attention to what’s going on in the world beyond our borders.

    Do you know anything about this “Mental Health Resistance Network”?