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8 May 2011 • Vol 2 No 5 • British Journal of Wellbeing

I commenced my training as a nursein 1987, the year that Prozac waslaunched in the United States. The

year I quali ed, President Bush (the rst)proclaimed the 1990s ‘the decade of thebrain’. Rapid change was the one constantin my experiences of working in publicmental health services and a similar paceof change has occurred in relation tosocietal attitudes towards mental health

problems. Public health campaignsaround the world aimed to reduce thestigma associated with seeking help orhaving mental health problems. The mostpopular approach to this in the 1990s wasthe promulgation of the message that‘mental illness was like any other ’. Thiscaptured the zeitgeist of the time, and

many people expected con rmation of thebiogenetic basis of mental illness throughadvances in neuro-imaging technology and the soon-to-be completed unravelingof the human genome. However, ratherthan wait for the proof to arrive of mentaldisease or distinct disease processes, suchspeculation has been treated as fact by authoritative spokespeople in the mentalhealth industry.

Even a fairly cursory review of thepress releases and publicity that haveemanated from esteemed mental healthorganisations might lead one to concludethat widely known syndromes such asschizophrenia and bipolar disorder (if notthe entire taxonomy of mental disordersin the Diagnostic and Statistical Manual (DSM-IV TR)) are clear-cut, lifelong braindiseases. One might also be forgiven forbelieving that we are in the throes of aglobal pandemic of mental disease with

at least a quarter of the world (probably more) being likely to be mentally ill andin need of (pharmaceutical) treatmentat some time. However, a critical , carefuland scienti c reading of the evidence todate would lead one to be more cautious

about such claims. Despite a concertede ort on the part of researchers, no newbiological markers have been found forcommon mental health problems thatmight unequivocally con rm them asbiological diseases since syphilis was foundto be responsible for general paresis of the insane in the 19th century. Scientistshave tried to nd tangible evidence tocon rm the various chemical imbalancehypotheses and if anything these simplisticideas (e.g. that schizophrenia is a result of too much dopamine and mood problems

of not enough serotonin) have been found wanting (Whitaker, 2010). This is not tosay that e orts have been in vain as wenow know much more about how the brainis a ected by stress and trauma (Nutt andMalizia, 2004), but to characterise mentalhealth problems at this point as braindiseases is simply premature and belies theincredibly complex interplay between theenvironment, our relationships and ourbiology.

The message that people’s behavior isexplained by a disease may reduce the

sense that people are blameworthy fortheir behavior but it does little to reduceother people’s fear as people may be seento be out of control. People diagnosed withschizophrenia continue to be stigmatisedand feared in some places (Read et al,2006). Nevertheless, the idea of variousstates of mind being a result of some kindof ‘chemical imbalance’ has taken hold of the public imagination. In recent years theclass of drugs called selective serotoninreuptake inhibitors (of which Prozac is

Richard LakemanLecturer, Dublin City University

It’s time to rethink our thinking aboutmental health problemsRichard Lakeman questions perceptions of mental illness and our reliance on medication

Health professionals frequently assume that medication is a benign response

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British Journal of Wellbeing • Vol 2 No 5 • May 2011 9

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but one) have become the most prescribedand pro table drugs in the United States(Cohen, 2007) suggesting that people have

literally bought the message. This, it mightbe added, at a time when the e cacy of the so-called ‘antidepressants’ has beenfound to be only marginally better thanplacebo (and not clinically signi cant)in all but those with the most severeforms of depression (Kirsch et al, 2008).People are seeking help for depressionand unhappiness in primary care and thisis what many experts in my own area of interest, suicide, recommend that peopledo. Beautrais et al (2005) for example,assert that mental disorders (particularly

mood problems and substance misuse)play the strongest role in the aetiology of suicidal behaviour. It stands to reasonthat getting timely help for such problemsought to be an imperative and indeed de-stigmatising seeking help for depression isa part of every suicide prevention strategy.However, what isn’t quite as clear is what‘the’ aetiology of mental disorder actually is.

Health professionals frequently assumethat depression has a biological aetiology,or at least that providing medication is

a benign response. Up to 75% of peoplediagnosed as depressed (regardless of severity) receive a prescription for anantidepressant (Sleath and Tina Shih,2003). Whitaker (2010) has recently proposed that far from being benign,the indiscriminate long-term use of psychotropic drugs for common mentalhealth problems might actually makethings worse for many people and accountfor dramatic rises in disability from mentalhealth problems. It is now widely acceptedthat the once enormously popular anti-

anxiety drugs can lead to dependency anddangerous withdrawal syndromes, and

when used for long periods make treatingthe original or underlying problems moredi cult. Whitaker (2010) argues thatdrugs might have some positive e ectsin the short term but for many peoplethe long-term use may exacerbate andcontribute to illness and disability. A further concern I have regarding this turntowards biogenetic rhetoric and emphasisin academic circles, and emphasis on

medication and compliance in clinicalpractice, is that it might stop people fromidentifying and e ectively addressing their

problems.Prematurely concluding that a

problem is biological or communicatingto a patient that he/she has a diseaseamenable to medical treatment may suspend or foreclose on opportunitiesto explore, develop an understandingand nd a solution to people’s problems.Until relatively recently this suspensionof judgment has been at the heart of psychiatric practice as illustrated by MacNiven:

‘The conception of a mental illnessis very di cult for the ordinary person to grasp. To explain that the patient’s symptoms need not haveany demonstrable physical basis isnot always easy, even when one isdealing with well-educated people.The natural desire to nd somecause for the changes in the patient’s personality leads them to believethat the symptoms must be caused by ‘something on the brain’ or by‘poisoning his system’. Not infrequently

they have been encouraged in theseideas by the physician who treated thecase before it came to the psychiatrist.’ (MacNiven, 1928: 239)

How foreign these words appear today after a mere two decades of talking-upand normalising medicating (but notactually nding ‘something on …’) thebrain. The author goes on to discuss adetailed assessment and attempt to ndthe best way to formulate the person’sproblem through the formulations of the

person, their family, and other healthprofessionals. That so many people donow take psychotropic drugs and returnfor repeat prescriptions without any degree of coercion probably does indicatethat people feel better for taking them,but it does not mean that people havenecessarily found the best way to frameand resolve their problems. Cohen (2007)described a person who was depressed atleast in part because she and her par tner

were facing bankruptcy. Apparently she is

no longer depressed, but is bankrupt—thelatter outcome might have been avoidedif the problem was framed as a nancial

rather than a mental one. I suggest thatthe best route is not necessarily theshortest or the least painful. We needto rethink mental distress, illness anddisorder. As professionals we need torediscover the idea of complex caseformulation, as societies we need toacknowledge the complex socio-culturalcontribution to the distress of individuals,and as individuals and citizens we needto reject overly simplistic biogeneticexplanations for our behaviour and seekto account for our lives and understand

them. As Socrates is purpor ted to havesaid ‘An unexamined life is not worthliving’. Psychiatry and psychology o ersa secular way of examining ones’ life butour challenge is to make people’s life

worth living. The best way to do this, inmy view is to eschew simplistic biogeneticexplanations for human behaviour andrediscover bio-psycho-social-spiritualexplanations that were an illustrious partof the helping professions for the best partof the last century. BJW

Beautrais A, Collings SCD, Ehrhardt P, Henare K(2005) Suicide Prevention: A Review of Evidence of Risk and Protective Factors, and Points of E ectiveIntervention . Ministry of Health, Wellington, NZ

Cohen E (2007) Antidepressants most prescribeddrugs in US. CNN Health , 9 July 2007 http://tinyurl.com/6f4a3gg (accessed 18 May 2011)

Kirsch I, Deacon BJ, Huedo-Medina TB et al (2008)Initial severity and antidepressant bene ts: ameta-analysis of data submitted to the Food andDrug Administration. PLoS Med 5(2): e45

MacNiven A (1928) The formulation of psychiatriccases. Journal of Mental Science 74: 238–47

Nutt DJ, Malizia AL (2004) Structural and functionalbrain changes in posttraumatic stress disorder. J Clin Psychiatry 65(suppl 1.): 11–7

Read J, Haslam N, Sayce L, Davies E (2006) Prejudiceand schizophrenia: a review of the ‘mentalillness is an illness like any other’ approach. ActaPsychiatr Scand 114(5): 303–18

Sleath B, Tina Shih YC (2003) Sociological in uenceson antidepressant prescribing. Soc Sci Med 56(6):1335–44

Whitaker R (2010) Anatomy of an Epidemic: MagicBullets, Psychiatric Drugs, and the Astonishing Riseof Mental Illness in America . Crown PublishingGroup, New York

References

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