Beyond Pills: UK Parliament Must Support Social and Psychological Services Instead

13
2010

Editor’s Note: The following speech was delivered by James Davies to the UK Parliament on December 5, 2023 as part of the Beyond Pills All Party Parliamentary Group Launch.

Most people in this room will have experienced, at some point in their life, poor or very poor mental health. But if you are one of the fortunate ones who hasn’t, you’ll certainly know someone who has—a friend, a family member a close associate. And around half of those who’ve suffered a mental health problem will have at some point consulted the NHS for support.

Plenty of capsules and pills laying on a flag of Great Britain. Concept of medicine and heath care in the UK.

So, what kind of support do they invariably get?

Well, when we look at the data, we learn that the majority will receive a drug prescription, and beyond that, little else. For example: In England last year around 8.5 million people were prescribed an antidepressant compared to around 1.5 million who were prescribed a psychological therapy. And this huge imbalance in provision isn’t because most people would prefer the drugs. On the contrary, we know from research that most people presenting at primary care would prefer a psychological or social provision. But that is not what they get, and it’s not what they get because, in large measure, we as a society have significantly under-invested in social, psychological, community-based intervention over recent decades. And this has created a vast gap in what we offer, which ever increasing prescribing has come to fill.

For instance, antidepressant prescriptions have almost doubled in England in the last decade, rising from 47 million in 2011 to over 85 million in 2022/23, and these figures are set to continue to rise. Furthermore, the average duration of time a person spends on an antidepressant has also doubled over the last 15 years or so, with around half of patients now classed as long-term users. Finally, if we take all the psychiatric drugs we prescribe—the anxiolytic, antipsychotics, stimulants, antidepressants—approaching ¼ of the adult population is prescribed one of these drugs in any given year.

But you may ask, what’s wrong with that—what is wrong with more people seeking help; what is wrong with more people receiving support?

Well, what is wrong is that more people are not getting better. In other words, this rising tide of prescribing (antidepressant prescribing) is not associated with an improvement in mental health outcomes at the population level. In fact, according to some measures, outcomes have worsened as antidepressant prescribing has risen (and this correlation we witness not just in the UK, but everywhere where these drugs are being most aggressively prescribed—the US, Australia, Canada, Sweden, Iceland, etc.).

Now while, of course, there may be many variables contributing to this worrying correlation, one variable occupying the concerns of a growing number of international researchers and clinicians is that such worsening outcomes are being fuelled by our over-reliance on pills, to the exclusion of much else: the social and psychological support; the community-based interventions that people need and want.

This is an especially pertinent concern when considering the efficacy of these drugs. As multiple meta-analyses have shown, antidepressants have no clinically meaningful benefit beyond placebo for the vast majority of people taking them—for all but the most severely depressed patients. However, unlike placebos, antidepressants have side and adverse effects for between 40-70% of patients, depending on the study you consult. They also have withdrawal effects for around half of users who stop them, with up to half of those reporting those effects and severe, and a significant proportion experiencing withdrawal for many weeks, months or beyond.

So when we factor in the adverse effects, the poor efficacy for most people, as well as the common sense clinical observation that most people who present at primary care with mental health problems aren’t suffering from brain dysfunctions in any biologically verifiable sense, but from natural and normal albeit painful human responses to difficult lives they are living—to difficult circumstances in which they have become caught up; circumstances that their pills were never designed to treat.

We are here today to launch the Beyond Pills All Party Parliamentary Group. A group which understands that as critical and as lifesaving medications can be, there will never be a pill for every ill (contrary to what our prescribing habits appear to imply), not just in psychiatry but across our health professions. Pills can’t save broken marriages; they can’t erase a painful past or build community. They can’t bring a loved one back. They can’t solve poverty or poor housing, or right the wrongs of inequality or discrimination, or resolve any other well-evidenced social determinant of poor health. They are what they are; they have their place. But they also need to stay in their place.

Today, we ask all of you attending to support this call to move beyond pills were appropriate; to support this parliamentary group in its activities and aspirations going forward; to challenge the institutional silos that so often inhibit change from happening, and not to stymie every good idea with the declaration: ‘but we are already doing that’ or ‘there’s already a committee for that’. The reality is that on the ground things are not changing fast enough—and we need to address that now.

As a first step to advancing change, APPG members and experts have today published a piece in the British Medical Journal, making an evidence-based call to reduce antidepressant prescribing and setting out how this can be done. In this call we align with the World Health Organisation, which only last month published its new depression guidelines. These guidelines, for the first time, demote antidepressants as a first line treatment for depression, to a subsidiary treatment, and instead put social and psychological provision first. They are calling for us to move beyond pills. We urge you all to help make that change happen.

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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.

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James Davies, PhD
Dr. James Davies is Associate Professor of Medical Anthropology and Psychology at the University of Roehampton, London. He is also a practicing psychotherapist (Reg. UKCP). He graduated from the University of Oxford in 2006 with a PhD in social and medical anthropology and is author of the books Cracked: Why Psychiatry Is Doing More Harm Than Good, and Sedated: How Modern Capitalism Created Our Mental Health Epidemic.

13 COMMENTS

    • I love the linked piece.

      That being said, absent causality the explanation of the similar failure rate of all forms of psychotherapy fall pray to multiple fallacies, the most relevant I think is confirmation bias.

      To illustrate, the linked piece speaks of rapport, which according to wikipedia is “… a close and harmonious relationship in which the people or groups concerned are “in sync” with each other, understand each other’s feelings or ideas, and communicate smoothly.”

      But, precisely because causality is absent I can claim with the same confidence, by analogy not with friendship but with cost, that many people claim to enjoy or benefit from something, meassurably so, after they payed for it, despite intialliy claiming they didn’t.

      I have a coarse crass personal example of that, but in the abstract, after paying top dollars to go to the opera, despite I never liked it, I might claim, afterwards I enjoyed it. Specially if peered pressured by an esteemed friend, even acquaintance.

      As many people claim they enjoyed their childhood, their college, their marriage or past relationships, despite at some point sometimes vociferously stating otherwise. And very rationally about it. We all already payed the cost and at least we will try to benefit from the memories… even if false ones…

      So, that 30% at best benefiting from psychotherapy, any form, might be putting lipstick on a pig if the therapist is amenable to be labeled beneficial. Otherwise the barrier to claiming benefit after psychotherapy’s expense might not be feasible, so it might require a friendly therapist for the patient to put lipstick on psychotherapies’ pig, so to speak.

      The psychotherapist as a non repudiable mannequin, he or she only needs to be there are not be offensive to the patient’s senses for incurred cost to be labeled, even felt beneficial, even meassurably so.

      I would love someone to do an experiment on that! with a human psychotherapist of course, sham psychotherapy, as per hypothesis, might be offensive to the senses in it’s own unique way!. Disprove that researchers!.

      And the confirmation bias comes from identifying, finding or just claiming the benefit comes from an analogy, not a reason: friendship and the “rapport” it involves. When in fact, in reality, it could be a lot of things, it might even be different for any and all individuals involved and therefore, tatarara!, outside current scientific methodology… you know, averages, sums, standard deviations do not explain individuals, only aggregates.

      Now, in my individual, personal experience, I have only had rapport with a single individual. And that did not make the rest of my human interactions non-beneficial. I don’t need to be in sync to enjoy friendship or romantic partnership, let alone interacting with a pompous practitioner as a all clinical psychologists I interacted with were. Mere sharing and agreement in doing so was more than beneficial to me.

      Then, precisely because of the lack of causality, there is the underknown phenomenon that if we were to meassure something with a broken watch, that runs in thirds instead of halfs, three times a day it would measure correctly the hour. An hourly watch would do so 24 hours a day. Disprove that researchers of psychotherapy. That is not in yer models I bet…

      So research about the benefit of all forms of psychotherapies might be explained by the methodology of meassuring “mental disorders” improvement, not because any other form of non-trivial causality. And I am not the one that has to explain that, why it should work, it’s the researchers that have to do that BEFORE even planning experiments.

      And although that will be claimed as ludicrous by believers in clinical psychology, the sad fact is that in science causality is everything. One cannot claim effectivenes of an intervention without a tested beyond doubt model of it. It only adds to the confusion and the mass, the molasses of worthless unreproducible research.

      It would be like trying to disprove the paranormal, the espiritual, angelical or demonical, without knowing how it works. Scientifically strictly speaking cannot be done, that’s why it’s called outside science, just like clinical psychology and it’s therapies are, hence the use of a friendship and rapport analogy, instead of a causal explanation.

      Clinical psychology and it’s therapies belong into the humanities, not in the sciences, next to literary analysis, hermeneutics, rhetoric, poetry and saddly critical and social studies. Music, art, estethics, ethics, philosophy, etc. Those human intelectuall, enjoyable and beneficial activities, for individuals and the aggregate have no causal model: they don’t need one, they are either enjoyable or they are not. No one is seriously, scientifically claiming, that Dostoievsky’s writings cured my paranoia, even if they illuminated for me what paranoia is not, as was not the case for Raslkolnikov, the police was really after him…

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  1. I think this piece omits a crucial fact:

    SRRIs and SNRIs do make depression worse, recurrent and longer lasting in the long run.

    It’s not merely that for the vast majority of consumers antidepressants are not effective beyond “placebo”, aware antidepressants are more nocebos, or active placebos than mere “placebos”. Like ethanol, cocaine, stimulants and designer drugs: short term might make the consumer enjoy or feel better, but longer term the consumer is worse, way worse off, than if he or she never used such psychotropics, including antidepressants.

    So, I think it is worse: it increases suicidality across ALL age groups, it makes depression harder to come off, i.e. “resistant to treatment”, more severe, longer lasting, and worse yet: recurrent.

    So, suming up: it makes many consumers dependent on pharmacotherapy because the original problem: depression, is worsened by the pharmacotherapy in the long run.

    Whereas depression as understood before SRRIs and SNRIs was monoepisodic, i.e. it tends to happens once in a lifetime, except in some not so frequent sufferers. Before, it was severe enough to disable many sufferers, and now it can be “mild”, with little disability beyond “I feel bad/sad/blue”. Or worse yet: “I can’t enjoy my relationships, my parenthood, my motherhood, my childhood, my work, my community”, etc.

    There is no biological mandate that commands a human has to enjoy it all. It is to me as solid an empirical observation as “All humans are mortal”.

    Not enyojing an aspect of life, or worse yet: many or ANY aspect of life is part of the human existence. No one, I imagine, enjoys ANYthing. We can’t honestly expect we ALL are supposed to enjoy the same than literaly everyone else: the aggregate of what apparently we are supposed to enjoy, which is what EVERYONE in the aggregate enjoys. That is ludicrous, ridiculous and severly misguiding.

    And in itself, by creating a false expectation of the reality of human existance a cause of suffering in it’s turn. As a trivialized example: I would not suffer for not having a career, or a partner, a child, etc., that I don’t know it exists. Or never will.

    But if I am peddled that somewhere out there there is a perfect partner for me, that will most certainly cause me not only pain, but grief at never having met her. Big, small, transitory, permanent, depends.

    Expectation can be a source of pain, sorrow and misery, particularly when it is false, and therefore unachievable. That’s why, I think many religions and philosophies embrace some form of acceptance. “The way things are” without embracing renunciation: “I can’t change that”.

    And there it lies a balance that in itself can cause anguish, pain, sorrow, etc. That is life for emotional beings, let’s get over with it.

    Now, another thing not considered in this piece is that perhaps many members of society are expecting life to be absent of pain, sorrow, suffering or misery.

    I am not minimizing nor denying anyone’s suffering, pain or struggles, just trying to provide context, hopefully insight, to the proposal against widespread, happy trigger pharmacotherapy…

    Poverty, for example, is understood and defined vastly different in the first world than in the “third world”. Several social metrics correlated with well being, correlated, are very different in Africa than in the US, UK, Australia, Sweden, etc. Even in latin america or the middle east.

    So, if the hardship of existence probably necessarily is heavier in the “third world”, why do members of society of the first world not only expect, but DEMAND a pill for their ailments, suffering, misery, etc.?. And worse yet: Why practitioners in the first world push them?.

    The I deserve better does not work for everyone, let’s at another place think about that…

    Human life has never been absent of that, never.

    At the same time the first world is enjoying, inequality included, the most prosperous period in ALL of human existence.

    And yet, members of those societies feel, apparently or possibly worse than ancient hunter gatherers?. Worse than early neolitic societies?. Worse than during ancient times?. Worse than during the middle ages, the renaissance, the reformation, or the industrial revolution?. During the two past world wars?.

    How so?, first worlders?. How so?.

    Aren’t you folks, respectfully, expecting too much from a place in time and planet that for YOU already has given TOO much?. Without feeling bad about THAT, to me, misconception.

    Another thing that I want to complement is that those are first world problems, at least my country Mexico, experiences on top of that severely increased criminality, governmental/public servants’ corruption, ineffective and corrupt crime investigatory set of agencies, climate change, relative scarcity of drinkable water, poor education, superstition of the religious kind.

    Foreign exploitative models of international economic exchange, forced internal displacement/migration, an exodus of foreign refugees that has in the past turned into hecatombs, lack and loss of public health services, corruption in the medical community, a huge set of bussinesses with models that demand and depend on cheap labor that is inneficient, insufficient and oppresive for workers, a vociferous conspiranoic comander in Chief with vitriolic rhetoric against his imaginary “opponents”, and a big etcetera.

    Including hunger and death by starvation of minors in marginated native communities. Poorly addressed by the current federal administration.

    So, to try make it less gloomy:

    “May all OUR delulus become trululus, because being delulu is OUR only solulu”.

    Ironically, because the rhetoric of depression, it’s pharmacotherapy and even psychotherapy looks more delulu to me, than, well, seeing human existence, not how society wants us to see it, but how it always has been…

    As an advice, admitting I can’t advice or suggest anyone antyhting without knowing their peculiar situation, but as always, if it sounds harmfull or offensive please take it from another delulu:

    Many of us, proud to be mad, became oligo or monothematic, precisely because no one can enjoy ANY and ALL the riches of the world, even if one had them at the graps of our paws…

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  2. I would like to see more reporting on the horrific side effects of psychotropic medication. Why would anyone want to take mind numbing medication, knowing that they will cause weight gain, diabetes, lethargy, depression, frightening movement disorders, breathing problems and cardiac disorders? I’ve seen all this with my son’s treatment.

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    • But would more reporting on the negative effects of psychiatric drugs (I know many of those effects can be horrific, even for those who say they benefit from the drugs) necessarily reduce their use? From what I gather, cigarettes are making a comeback, at least, in the u.s. in spite of the many campaigns against them.

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  3. This was a beautiful statement and thx for sharing on this forum.

    Dr. Davies book “Cracked”…was instrumental, with a handful of others in 2014, in clawing back my voice, health, & autonomy following the carnage resulting from a bipolar disorder diagnosis (2004) during the peak “BD Gold Rush” years…and the unspeakable ‘treatment’ damages done.
    I appreciate this public opportunity to express my gratitude for his book, helping me believe that what had, & was currently happening to me wasn’t novel and it was intentionally targeting and exploitative.
    Thanks again for all you continue to do, Dr. Davies.

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  4. Thank you for the attempts to go through Parliament. I am grateful for making the government sit up and listen. Maybe these aren’t perfect solutions but it’s a start. I am happy that the UK is seeing there needs to be medication reckoning.

    I love in the US and I don’t see this happening anytime soon. If one country becomes more vocal and signing on to the UN/WHO treaty becomes one step more to pressure the US government to admitting the truth.

    Thank you for your effort

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