Transforming mental health services

Pullman et al (2025) consider how social work could contribute to the transformation in mental health services from a predominately medical approach to a balanced, evidenced-based biopsychosocial approach to care, as recommended by the World Health Organisation (WHO) (see eg, its 2022 World Mental Health Report). Services need to provide person-centred, human rights-based and recovery-orientated care.

As Pullman et al say

Critical Psychiatry stands as a minority movement within contemporary psychiatry, providing a critical analysis of the Medical Model. Its primary focus lies in addressing the inclination of a reductionistic Medical Model to dehumanize care …. In contrast, Critical Psychiatry advocates for a relational, recovery-oriented, and multi-cultural treatment approach, operating within the framework of a comprehensive biopsychosocial paradigm 

Pullman et al conclude by advocating several practical strategies to support the transformation agenda:-

(1) Consistent advocacy for the biopsychosocial model within mental health policy and educational curricula. 

(2) A renewed emphasis on teaching, training and supervising biopsychosocial approaches within professional education. The Biopsychosocial model has a long history but has struggled to gain a consistently prominent position within mental health work often in the face of bio-medical hegemony within psychiatry.

(3) To prioritize the voices and experiences of those with lived experience of mental ill health and mental distress, either directly or as part of families and social groups. Too often, mentally ill people have experienced inadequate treatment and, at times, abuse and oppression. This situation has not improved adequately, despite the inception of modern psychiatric practice.

Stuck on antidepressants

A Sunday Times investigation found that a quarter of women in their fifties and sixties take antidepressants, and 15% of women over 50 have been on them for longer than five years (see article). As the article also says, some people on antidepressants also experience emotional blunting and difficult withdrawal symptoms.

James Davies, who I have mentioned before (see eg. previous post), is quoted as saying, “[T]he evidence base [for antidepressants] suggests they’re no more effective than placebos. But unlike placebos, they have side-effects”. I pointed out to him in a tweet that placebos do have side effects, which are called nocebo effects. 

Antidepressants are inadvertent placebos. They are not usually intentionally prescribed for their placebo effects. Instead doctors tend to believe in antidepressants and that their efficacy has been proven, whereas this is at least open to question (see eg. previous post). Patients have also been encouraged to take them by the myth that the serotonin imbalance theory has also been proven, which is not the case (see eg. another previous post). 

Patients may therefore acquire attachments to their medication more because of what they mean to them than what they do. Many patients often stay on psychotropic medications, maybe several at once, even though their actual benefit is questionable. Any change threatens an equilibrium related to a complex set of meanings that their medications have acquired. No wonder they may have withdrawal symptoms. They have been made dependent on antidepressants and may well be frightened to try to manage without them. It’s easier to stay on antidepressants rather than upset any apparent equilibrium their medications have seemed to create.

Such nocebo effects also apply to emotional blunting. Antidepressants can tend to leave people feeling that there is a sense in which their psychosocial problems, which caused the depression, have not really been solved (see eg. previous post).  However much they may feel that antidepressants may have helped stabilise their mood, they may, therefore, also feel emotionally flat and not back to their real self. 

I am, of course, not saying that antidepressants do not block reuptake of catecholamines, such as serotonin, in the synaptic cleft between neurones. But how much the side effects of withdrawal symptoms and emotional blunting may well be due to nocebo effects remains to be determined.

Universal remedies for mental health problems

I’ve mentioned the problems with mental health services in Greater Manchester before (eg. see previous post). Mental health workers in Manchester have recently called off their strike having obtained more funding for services (see Big Issue article). As I’ve said before (see eg. previous post), the problem isn’t just about more funding. 

The fundamental problem is the management of demand for mental health services. The trouble is that services themselves have exaggerated that demand by selling panaceas for mental health problems, both medication and psychological therapies (see eg. previous post). 

As the Big Issue article points out, the problem with coping with demand is not just in Greater Manchester Mental Health NHS Foundation Trust. I used to work at Norfolk and Suffolk NHS Foundation Trust (NSFT), and as I have said on my personal blog (see eg. previous post), it also has had its institutional difficulties over the last 10 years. It has managed to correct problems in its Trust Board over recent years but services on the ground are still struggling to cope with demand. As far as beds are concerned, this is reflected in the endemic problem across the whole country of out of area placements. NSFT board recognises there is more to do to improve services but there also is a need for national direction. We are waiting to see how specific the new NHS 10-year Health Plan, postponed from June to July 2025, will be as far as mental health policy is concerned.

How we have been misled about the nature of depression

Joanna Moncrieff’s abstract for her Sowerby Project 10 year anniversary public lecture, ‘Changing our minds: How we have been misled about the nature of depression and mental disorder’, emphasises that most people generally have come to accept that it’s reasonable to believe that depression is a brain disorder which is specifically targeted by antidepressants (see lecture information). But they are being misled about the nature of depression and functional mental disorder in general (see eg. previous post). Depression has psychosocial not neurobiobiological causes. Antidepressants can tend to leave people feeling that there is a sense in which their psychosocial problems, which caused the depression, have not really been solved. However much they may feel that antidepressants may have helped stabilise their mood, they may, therefore, also feel emotionally flat and not back to their real self (see eg. another previous post). In fact there is a sense in which taking antidepressants can be identity altering, because reducing people to their brain does not help them to recognise and deal with the personal situation in which they find themselves. They are instead indoctrinated into believing the biomedical myth that they have a brain disorder. But their brain is only part of them, not their whole self. However difficult dealing with emotional problems may be, blaming the brain is not the right solution.

There can, nonetheless, seem to be advantages in taking on the biomedical myth. Not that people should necessarily be blamed for what has happened to them or who they are. But by believing that their problems have been caused by their brain, their difficulties may then be seen as out of their control and not their responsibility. However much that may well be the case, it’s still wrong to do so for biomedical reasons and cannot justify such speculation. Psychiatry has always had a tendency to encourage biomedical thinking because it seems to simplify reasons for depression and other mental disorders (see eg. previous post). Understanding reasons for such problems can be difficult and can never actually be proven, whereas the biomedical myth offers an apparent underlying physical scientific cause.

The biomedical myth will therefore survive. People will continue to wish that the cause of functional mental illness will eventually be found in the brain. But the disadvantages, not just the truth, of the biomedical myth need to be considered. People are being made too dependent on antidepressants. Withdrawal problems are common and can be severe if only because of what antidepressants have come to mean to people. Psychiatric patients often stay on medications, maybe several at once, even though their actual benefit is questionable. Any change threatens an equilibrium related to a complex set of meanings that their medications have acquired. People are being made to think that they need a pill and become fearful about trying to manage without the drug. These issues of dependence should not be minimised, yet commonly treatment is reinforced by emphasising that antidepressants are not addictive. 

There’s no point looking to mainstream psychiatry to resolve the increasing use of antidepressants, because the profession exists currently to defend the use of psychotropic medication. This is not likely to change soon. Psychiatry may have had phases of being more open minded and pluralistic in its approach, but it has always been attracted to biomedical understandings of mental illness. People find it difficult to accept there are limits to our understanding of human nature, which they think should be explicable in physical terms. Powerful vested interests in defending this belief mean psychiatry does not really want to change.