Pictures are worth a thousand words. They can distill mountains of detail into essential understandings. So I’ve chosen pictures to distill the mountain of mental health research I’ve examined over the last eight years. Three infographics summarize research on psychiatric drugs, and one asserts why I think Integrative Mental Health is the best path available for mental health recovery.
The FDA1 and meta-analyses2 tell us that the advantage of antidepressants over placebo for treating depression is razor thin; so small, in fact, that most people can’t tell the difference. To gain this small advantage people must accept antidepressants’ side effects, risks, and limitations which can be significant. Even more startling, at milder symptom levels — representing about 85% of people taking these drugs for depression — antidepressants have no advantage over placebo.3
For many people, antipsychotics reduce psychosis. But less than a quarter of those with chronic psychosis see even a 50% reduction in symptoms when using them.4 And this partial symptom relief often comes with life-altering side effects. Additionally, evidence suggests that antipsychotics may do more harm than good in the long term.5
Benzodiazepines can reduce anxiety, often quickly. But prescribing guidelines say their use should be restricted to very short durations. There is good reason: significant cognitive decline and potentially life-threatening withdrawal make them a questionable solution beyond episodic anxiety.
Psychiatric drugs, the big picture
These infographics paint a troubling reality of psychiatric drugs. It isn’t surprising that most carry the strictest FDA warning, a black box. But there is another reality: some people find meds indispensable.
This hit home with me last fall at the Massachusetts Psychiatric Rehabilitation Association summit. After I presented these infographics I received nods of recognition as people saw their own experience in the numbers. But at the break, a peer support specialist spoke with me. “I’ve been on Clozapine for years,” she said. “It’s the only thing that works for me. It’s what allows me to do my job.”
So these infographics don’t suggest a mass exodus from drugs. Rather, they suggest exercising informed caution if you choose to use them. The risk/reward profiles of these drugs are much more questionable than their ubiquitous prescribing might indicate.
The infographics contain another message: look beyond drugs to other approaches that give more avenues for recovery. Thankfully, many such options exist.
Integrative Mental Health and the web of causation
Integrative Mental Health is an emerging paradigm that provides a diverse set of evidence-based options that include, but go well beyond, medication.
Unlike conventional psychiatry which focuses on symptoms and prescribes drugs to reduce them, integrative practitioners seek to understand and treat the causes that lie beneath the symptoms. They probe for markers of biological, social, environmental, and habitual factors unique to the individual.
They see these factors interacting in a dynamic web of causation. Some people have one factor that strongly predominates. Others strain under the accumulated weight of many smaller issues. And sometimes a minor incremental stressor can be the straw that breaks the camel’s back and ushers in a crisis of mental distress.
Here is a conceptual view of the web of causation, highlighting factors shown in research to be associated with mental distress.
Integrative practitioners perform biomedical testing, psychosocial evaluation, and probe personal history to understand this web. They address suspected causative factors, selecting from a menu of 27 evidence-based non-drug options. These include diet, exercise, digestive care, calming practices, nutrient supplements, herbs, psychological therapies, and much more. Nearly all these options have very low or no side effects and can be used with drugs. This is good news since drugs can be a part of the equation as well.
In thousands of cases, these customized interventions have significantly decreased symptoms, allowing drug dosages and associated side effects to be greatly decreased. In some cases, symptoms are completely eliminated without drugs.
Although Integrative Mental Health is showing great promise, it isn’t a silver bullet. We don’t know all the factors that influence mental distress and we can’t fully address all those we know. They also can take weeks or months to show full benefit and practitioners are hard to find.
But there is good reason to be hopeful. People who live in recovery overwhelmingly report that a combination of approaches was needed,6 and the growing number of integrative practitioners can help provide them.
There is significant work ahead if we are to reap the benefits of Integrative Mental Health. It starts with communication.
We must communicate the risk/reward profile of psychiatric drugs, so people know to look beyond them. But we must also communicate that some people find drugs necessary.
We must communicate the full menu of available recovery options, so people and their practitioners can craft the best path forward. We must communicate the remarkable stories of recovery to give hope to those in distress. And we must communicate that recovery is not only possible but should be expected.
That’s a lot of communication.
To make it easier, let’s use pictures. They’re worth a thousand words.
- Laughren T, Treating Depression: Is there a placebo effect?, CBS News, 60 Minutes broadcast, 2012, https://goo.gl/ug78Av. ↩
- Khan, A et al, Antidepressants versus placebo in major depression: an overview. World Psychiatry, 2015, PMCID: PMC4592645. ↩
- Fournier JC et al, Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA, 2010, PMCID: PMC3712503. ↩
- Leucht S et al, Sixty Years of Placebo-Controlled Antipsychotic Drug Trials in Acute Schizophrenia: Systematic Review, Bayesian Meta-Analysis, and Meta-Regression of Efficacy Predictors, 2017, Amer J of Psychiatry, https://goo.gl/bndxBq. ↩
- Insel T, National Inst of Mental Health Director’s Blog: Antipsychotics: Taking the Long View, Aug 2013, http://goo.gl/LFmP0V. ↩
- Duckworth K, Science Meets the Human Experience Integrating the Medical and Recovery Models, NAMI Advocate Magazine, Winter 2014, https://goo.gl/iF6EWy. ↩
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.