Shameless exploitation of antidepressant placebo effect

I wasn’t going to blog about Carmine Pariante’s recent New Humanist article, as it just repeats what he has already published. But he has been promoting it as a balanced view on antidepressants (see eg. his tweet), which it isn’t.

I’ve questioned Carmine’s scientific credibility before (see previous post). I think the Royal College of Psychiatrists may even have appreciated that he overstates his case (see another previous post). For example, he wrongly sees critical/relational psychiatry, which has produced the critique of antidepressants he rebuffs, as dualist (see yet another previous post).

Carmine does need to take the critique of antidepressant efficacy more seriously (see previous post). I told him this several years ago (see another previous post). No one’s disputing what he says that many people report benefit with antidepressants. But the question is whether that means that antidepressants work (see yet another previous post), which he says it does. Actually, people’s experience of antidepressants is more complex than mere benefit (see even another previous post). 

Carmine will not like my sceptical argument about the overstatement of psychiatric medication efficacy because of biased clinical trial methodology (see previous post). He worries people are being shamed for taking antidepressants (see another previous post). But he seems to fail to realise that doctors have always exploited the placebo effect. Why he’s being so overdefensive could be because he fears that antidepressants may be another example. The overmedicalisation of society has created too much antidepressant prescribing (see yet another previous post). If psychiatry carries on in the way Carmine wants it to then I anticipate there are going to be serious problems (see last post).

The myth of massive psychiatric need

I want to start this post with a quote:-

There has been a massive growth in mental health services during the past 20 years as psychiatry has extended its boundaries to include an ever-widening array of human problems.

Don’t assume this is a recent quote, although it could be! It was actually written in 1988 in an article entitled ‘More and more is less and less: The myth of massive psychiatric need’.

The article goes on:-

Psychiatric manpower, facilities, and programmes have been vastly increased. However, as more resources are provided, more are perceived to be needed: more and more is less and less.

The article’s warning that the myth of massive psychiatric need was being used to justify additional resources for existing services, rather than solving current problems, has still not been heeded all these years later (see eg. recent post). That’s not to deny requirement for additional investment, but need for services should be prioritised rather than demand.

As supply of services increases, demand also continues to increase. Resources therefore fail to meet that demand. Merely increasing the numbers of professionals doesn’t solve the problem. If treatment is so effective at reducing need, then demand should decrease over time as that need is met, rather than increase. This situation is made even worse by broadening the boundaries of what counts as mental disorder over recent years (see my article referred to in this post).

As the article says, the problem with all this development is that resources are diverted from the most seriously mentally ill. The NHS, including mental health services, has become too fragmented and dysfunctional. We must stop  seeing mental health services as a panacea for society’s difficulties (eg. see previous post). We’re being oversimplistic about what psychiatry can achieve (see eg. another previous post).  Psychiatry, and health services in general, needs to redefine its role.

Preparing for Mental Health Act reforms

Wes Streeting, Shadow Secretary of State for Health and Social Care, has said that one of the first pieces of legislation he would bring forward in government would be on reforming the Mental Health Act (MHA) (see Guardian article). The current government did not include reform of the MHA in the King’s Speech for the current parliamentary session (see eg. Community Care article).

Reforms need to be taken forward in line with the Parliamentary Scrutiny Committee recommendations (see previous post) and recent WHO/OHCHR guidance (see another previous post). The Centre for Mental Health has produced a helpful document on A Mental Health Commissioner for England, a new role proposed by the Scrutiny Committee. I would like to see the opportunity taken, in the time available before legislation comes back again to parliament, to consider further:-

• prohibiting civil detentions to secure facilities
• improving advocacy by creating an integrated service of Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts 
• extending the role and powers of the Mental Health Tribunal (MHT) to treatment as well as detention decisions, thereby making the role of Second Opinion Approved Doctors (SOADs) redundant

See my submission to the Scrutiny Committee for further details.

Too much antidepressant prescribing reflects the overmedicalisation of society

As the BMJ reports (see article), a group of politicians, experts, and patient representatives has called for the UK government to reverse the rate of antidepressant prescribing. Their BMJ letter comments on both the increasing rates of prescribing (see previous post) and the increasing duration of time on antidepressant treatment (see another previous post). Long-term outcome for depression is not necessarily good (see yet another previous post). There is even evidence that treatment can create a vulnerability to relapse, meaning that people may do better over the long-term by working through their problems without medication (see previous post). The net ingredient cost of antidepressant drugs is not insignificant, and, in the 2022/3 financial year in England, it was over £235 million (see NHS Business Service Authority data).

This call to reduce antidepressant prescribing needs to be understood in the context of the overmedicalisation of society in general. Such overmedicalisation needs to be reversed in the interests of the country’s health as a whole, as the NHS has become unsustainable (see eg. previous post). The cultural process of creating panaceas for emotional and other mental health problems doesn’t always work and may create more problems than it is worth (see eg. another previous post). This may be particularly obvious with the ever increasing demand for mental healthcare for children and young people over recent years (see eg. yet another previous post).

The letter marks the launch of the Beyond Pills All Party Parliamentary Group (APPG) (see Guardian article), which joins the forces of the former APPG for Prescribed Drug Dependence (see eg. previous post) and the College of Medicine Beyond Pills Campaign (see previous post). A cultural change to reduce the reliance on medication and to support shared decision-making is needed, not least for mental health services. The BMJ itself has recently called for a reset in its campaign against too much medicine (see eg. post on my personal blog).