THINKING ABOUT A DRUG-FREE FUTURE FOR MENTAL HEALTH SERVICES
In the hotly contested field of belief about mental health and distress, we all bring our life experience, politics and personal philosophies into a debate that is rarely as much about objective facts as we sometimes pretend.
And so I will start this chapter about the possibility of a drug-free mental health service by briefly sharing something of the experience and beliefs that have taken me to the point of making this proposal.
I first encountered psychiatric drugs at the age of five or six. After several episodes of extreme anxiety, I was to put on sedatives for a few weeks. I don’t recall being asked anything about what I thought was going on or what I needed.
Then, when I was 19, and dropping out of university, I found myself taking tranquillisers and anti-depressants. I ended up stuck in despair, institutionalisation and a drug-induced stupor. It only ended when I refused ECT and went to live in a therapeutic community. I was required to come off my medication and immediately became more alive – also, angry, scared and confused, but at least I was in touch with my feelings and had the energy to start to rebuild my life. That was nearly thirty years ago and I haven’t taken a psychiatric drug since then.
In these times when the political map is continually being redrawn, I don’t have a neat name for my beliefs. But when I see somebody struggling, I want to know what is wrong with the situation they are in rather than what is wrong with them. I think advanced capitalism has alienated people from themselves and each other. I have a strong belief in the brilliance of the human mind, and our ability to take charge of our lives and heal from painful experiences.
My own experiences and beliefs about life in general have profoundly affected my views on psychiatric drugs and I think there is also plenty of evidence to back them up.
Drugs and the self-advocacy movement of mental health system survivors and service users
For many years, I have been involved in organisations and networks of service users and survivors, while working as a consultant, trainer and writer on mental health issues.
This movement has achieved a great deal, in some respects. Above all, we have demonstrated that whatever our personal histories as recipients of psychiatry, we still have something to offer. It is a movement that has given hope to many people who have felt written off. In the UK, we have been a broad movement. People with fundamentally different beliefs about mental health and distress have managed to work alongside each other, by valuing inclusion above ideology.
To the extent that we have found a consensus position on psychiatric drugs it is this: mental health services are over-reliant on medication, we should be given more information about unwanted effects, and alternatives such as counselling should be more widely available. It is a position that suggests there is too much reliance on psychiatric drugs but that some people feel that they benefit from taking them. It emphasises individual choice as a key principle.
But it is a position that has its limitations. In a harsh world, where trends in mental health are driven by the profit motive and political expediency, service users and survivors have been powerless to prevent drugs from becoming even more dominant as the established response to human misery and distress.
If we are to reverse this trend, those of us who are critical of psychiatric drugs, including our many allies who work in mental heath services, need to take a clearer and stronger stand.
I suggest that it is practical and desirable to get rid of psychiatric drugs entirely. There are better alternatives available and mental health services that place human connection, support and relationships at their centre will have better outcomes than our current drugs-based system.
I realise this proposal will alarm some people who currently feel dependent on medication. I wish to make it clear I am not advocating that anyone currently on medication should have it withdrawn against their wishes. I suggest, instead, that over a period of 10 or 15 years, better solutions can be put in place for people new to mental health services. Current, long-term users of psychiatric drugs should be given support to come off them but only if they want it. .
The problem with medication
Whether we choose to talk about mental illness, mental distress or psychological disturbance, psychiatric drugs do not cure it. The best they ever do is relieve unpleasant thoughts and feelings, and modify behaviour for some of the people who take them. I do not underestimate how important that can be for someone who has no hope of a better solution.
But this is the best they can do. All too often, symptom relief is marginal or non-existent. And any benefits have to be weighed against the vast array of unwanted. effects that can range from the unpleasant to the unbearable to the downright dangerous.
A generally unacknowledged effect of psychiatric drugs is the way they interfere with our ability to heal through the natural and spontaneous release of emotion. I have facilitated many groups in which users and survivors have talked about this. It is common for people to agree that emotional release through, for example, crying, laughing or angry raging is a natural and healthy way of dealing with painful feelings, and then to report that their medication subdues this ability.
Every now and again a new class of psychiatric drugs is developed. It is marketed as being more effective, safer and with less unwanted effects than the drugs it is designed to replace. (Drug companies, the Royal College of Psychiatrists and the Department of Health are always more willing to acknowledge the limitations of the drugs they have been promoting for years when they think something better has turned up.) However, these drugs inevitably turn out to be less wonderful than we are led to believe.
The most recent so-called ‘anti-depressants’ illustrate this point well. These Serotonin Specific Reuptake Inhibitors (SSRIs), of which Prozac is the best known, were introduced in the late 1980s and succeeded in capturing the public imagination. At last there appeared to be a perfect drug – a ‘clean’ drug - that would make you feel better, be completely safe and have no unwanted effects.
Ten years on, a different picture had emerged. They did not turn out to more effective than other anti-depressants. The British National Formulary (the standard reference for medication) says that they should only be used in preference to other anti-depressants if there is a significant risk of deliberate over-dosing or if the side effects of other anti-depressants cannot be tolerated.
But a long list of possible side effects of SSRIs is given. It includes gastro-intestinal effects such as nausea, vomiting, abdominal pain, diarrhoea and constipation, and also dry mouth, nervousness, headache, anxiety, insomnia, tremor, dizziness, hallucinations, drowsiness, convulsions, sexual dysfunction, sweating, mania and many others. It is also recommended that SSRIs are used with caution with people who are pregnant or breast-feeding, have epilepsy or cardiac disease, a history of mania and several other conditions.
Nor are they as safe as was originally claimed. Dr David Healy, a psychiatrist and expert on SSRIs has investigated incidents in which they have caused a condition called akathisia – a state of extreme disturbance that can lead to violence and suicide. His best estimate is that they has caused 250,000 people, worldwide, to attempt suicide, of whom 25,000 have succeeded. (1)
Further problems have emerged with withdrawal from SSRIs. Although the manufacturers claim otherwise, many people experience serious and distressing symptoms when they attempt to come off the drugs.
Prozac and the other SSRIs have proved to be far from the universal panacea that was promised. Psychiatric patients continue to be given treatments that are often ineffective, unpleasant and dangerous.
Trends in use of psychiatric drugs
But, despite these drawbacks, use of psychiatric drugs escalates as more and more people become convinced they need them, are told they need them or are made to take them. Use of anti-depressants has more than doubled in ten years. In England, there were nine million prescriptions in 1991 and over 22 million in 2000 (2). Children have become a new market for psychiatric drugs. Prescriptions of Ritalin – given to so-called hyperactive children – went from 3,500 in 1993 to 158,000 in 1999, in England (3). This is following a trend in the USA where one in 30 children are now on Ritalin. Here, children as young as three are being given Prozac (4).
And still the belief persists that the chemical reactions in our highly complex and delicate brains can be precisely manipulated by medication.
Malcolm Lader, Professor of Psychopharmacology at the Institute of Psychiatry claims that: ‘Over the next 20 years, normal, healthy people will become able to manipulate their mood using drugs without side-effects, it’s going to happen. The only question is how much normality we allow to be treated with drugs.’ (5)
Non-psychiatric mood-altering drugs
It is not just psychiatric drugs that we use to change the way we feel and function, and experience and respond to the world around us. Alcohol, heroin, nicotine and cocaine are among the many other substances that people reply on.
We like to think of them as falling into distinct categories, such as social drugs or street drugs. Some are considered safe and acceptable, others dangerous and unacceptable. They are put into arbitrary categories that have very different legal status. It is not hard to make a case for ecstasy being safer than Largactill, and yet use of ecstasy is illegal while the law is used to force people to take Largactill.
Whatever the real and imagined differences between all the mood altering drugs, we take them because we want to feel and behave differently. In particular, we use them to dull emotional pain – to stop ourselves feeling scared, angry, bored, alienated or depressed. And all mood altering drugs are limited in their effectiveness, have unwanted effects and can be dangerous.
When the total use of mood altering drugs is put together, it is not unrealistic to talk about the mass drugging, or numbing, of the population.
When looking at the bigger picture of why we are so reliant on psychiatric drugs we need to speculate about why so many of us are so dissatisfied with ourselves and our lives and why we so readily turn to chemical solutions. In thinking about this we need to consider who benefits from our society’s addiction to mood altering drugs.
Whether your drug comes in the form of champagne, cocaine, Closarill or coffee, it will have been pushed, promoted or prescribed for profit.
Is this what we want? Is this what we need? Is there a better way?
Is it possible for mentally distressed people to receive effective drug-free help?
The arguments in favour of medication hinge on effectiveness. Undoubtedly, medication can be effective in removing or reducing symptoms for some people. For some of this group, it can occur with no or few obvious unwanted effects.
But what is really going on when we take medication? We are led to believe that it is all about a reaction between the drug and the chemicals in our brains, such as serotonin or dopamine. We are led to believe that this occurs quite independently of our own attitudes or expectations. This is supposedly established by trials in which some people are given the drug that is being tested and others are given an inactive substance which is called a placebo. They don’t know which they have been given. If those receiving the active drug experience a greater reduction in symptoms than those receiving the inactive placebo, the drug is deemed to be of value.
Placebo is interesting. It is consistently found that people who are given this inactive substance, experience a reduction in symptoms. This is generally treated as simply an inconvenient aspect of human behaviour that has to be eliminated in order produce accurate results in drug trails. But looking at it another way, doesn’t it demonstrate a capacity to self-heal that could be directly harnessed to bring about changes in the way we think, feel and behave?
This speculation becomes even more interesting when you question the assumptions and validity of drug trials involving placebo. For example, people taking part in these trials can usually tell whether they have been given an active substance or not and this may affect the outcome. They can, instead, be given what is called an active placebo, that gives the feeling they are taking a drug but does not have the direct effect of the drug being tested. When this is done, much of the difference between taking the drug and the placebo is eliminated.
An examination of the biases of drug trails led the authors of From Placebo to Panacea (6) to conclude that ‘no-one is in a confident position to tell patients how effective psychiatric drugs truly are. Paradoxically, the only confident stance is one of uncertainty’.
In other words, if you are experiencing apparent benefits from your medication, the cause may well be your own ability to change your feelings and thoughts, simply because you expect them to change. Isn’t that a hopeful explanation, suggesting that the supposedly faulty mind of a ‘mentally ill’ person has powers that psychiatry has not even considered?
But while this phenomenon remains largely unexplored, at least in advanced capitalist countries, realistic and preferable alternatives to medication have been tried and tested, and there are many others for which the hard evidence of effectiveness is lacking but have been found to be beneficial by people who have experienced them.
In the first category come various varieties of talking treatments. For example, one study looked at the relative effectiveness of psychotherapy and psychiatric drugs in the treatment of depression. It concluded that of every 100 people with major depression, 47 would be expected to recover successfully if given psychotherapy but only 29 if given medication (6).
Another form of talking treatment is called Cognitive Behaviour Therapy (CBT). For people with a diagnosis of schizophrenia who participate in CBT, a 25% reduction in ‘symptom severity’ has been reported, similar to that produced by the medication Clozapine. Studies suggest people tend to continue to improve after the CBT has ended (7). And yet, people with this diagnosis have frequently been told that talking treatments are not for them.
But the alternatives to drugs are not limited to conventional talking treatments, which don’t suit everyone. As the authors of Your Drug May Be Your Problem: How And Why To Stop Taking Psychiatric Drugs put it: "The choice is not between psychiatric drugs and some other ‘therapy’ but between psychiatric drugs and all the resources that life offers us." (8)
Service users and survivors have developed and adopted imaginative self-help approaches to overcome mood swings, self-harming, hearing unwanted voices and depression. There are countless stories of people who have been told they will never be able to achieve anything because of their so-called mental illness, battling to create good lives for themselves despite the gloomy predictions of alleged experts in their care.
Others have made huge strides by getting involved in the user/survivor movement. Fragile confidence has been rebuilt, dormant talents regained, and hope rekindled.
These alternatives are not mere substitutes for medication. They offer the possibility of a much broader range of interpretation of the various conditions that collectively are called mental illness and they offer the potential for more fundamental transformation than symptom reduction.
If we abandoned the distracting quest for chemical solutions and, instead, invested our time, intelligence and money in discovering and uncovering human solutions, who knows what we might achieve?
Is it possible to have a society in which people can live happily without drugs?
There are many studies that demonstrate social inequality causes health problems, including mental heath problems (9). Perhaps more surprisingly, it is possible that greater wealth actually causes unhappiness. The psychologist, Oliver James, makes a convincing case in his book, Britain on the Couch (5).
If this becomes accepted as the truth, it could trigger a revolution in our attitudes towards money. Imagine if everyone lost interest in acquiring more wealth than they need to live modestly. The whole basis of advanced capitalism would collapse. We would have a more equal society, and a more mentally healthy society.
A World Health Organisation survey found that people with ‘schizophrenia’ have better recovery rates in Third World countries than the First World. The psychiatrist, Julian Leff, suggests this is because of the stronger social networks, opportunities to work and relative lack of stigma. You don’t have to be convinced that ‘schizophrenia’ is a valid diagnosis to see the significance of these findings. Perhaps, as a psychiatrist, Julian Leff was reluctant to acknowledge that psychiatric drugs are difficult to obtain in these countries where recovery rates can be more than twice as high as in England (10).
The notion that happiness can be obtained by spending money, distracts us from thinking about more sophisticated and ultimately more satisfying routes to personal fulfilment. There is a wealth of ancient and more recent wisdom about training our minds to overcome negative emotions and patterns of thought. Perhaps if we learned to value and utilise the brilliance of our minds, we would be more reluctant to mess them up with mood altering drugs of any description.
Undoubtedly, a society that put relationships, co-operation and care at its centre would enable many more people to lead satisfying lives, fewer to become mentally distressed, and more of those who do to be able to use the experience positively to change their lives for the better.
Can a drug-free mental health service be achieved?
It may seem like an impossible dream but that is because we tend to under-estimate the possibly of change. In fact, the one thing that is certain in this world is nothing stays the same.
When I was a mental patient, in the 1970s, there were quite a few dubious psychiatric treatments that have since ceased to be used. Patients were being given the hallucinogenic drug, LSD, others were being drugged into sleep for several days at a time; and insulin shock treatment was still in use. Lobotomies were commonplace but are now strictly controlled. All these treatments disappeared or declined without a great deal of fuss.
This era has also seen the great reconstruction of mental health services, with the closure of the old institutions and their replacement with community care. Despite all the difficulties, few people want to go back to the old system. And yet the prospect of moving out of the asylums was disturbing for many of the patients – and staff.. When that is all you know, it is difficult to believe that there is something better. No doubt, the prospect of a drug-free mental health service will also frighten people. A programme of replacing chemical treatment with people helping each other will also provoke anxiety and resistance among staff and recipients. But I predict it will fall away once the benefits of a more imaginative and hopeful approach become apparent. And a difference between this and the hospital closure programme is that it does not need to be imposed on people who have no wish to change their situation.
The people who will lose out are the shareholders in drug companies. The big difference between drugs and other treatments is their profitability. And that, more than effectiveness, accounts for their massive sales. Change is possible but multi-national companies will do their best to resist it. That doesn’t mean they will succeed.