As ‘taboo’ topics go, few are talked about more than mental health. It’s easy to see why- if diagnoses, drug prescriptions and surveys are to be believed, the number of people who are in some sense mentally unwell is staggering. It’s not the sort of thing which sufferers talk about often with their friends, but the media is frequently full of stories on the topic, especially this week, following the publication on 18th May of the American Psychiatric Association’s highly influential new Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Expert debates have made the leap from medical journals to popular newspapers, and the usual controversies have been repeated time and again. The expansion of diagnostic criteria is the most contentious. More people than ever now fall within the category of some sort of mental disorder.
More significant in the long term is the debate about the very nature of mental illness that flares up at times like this. The British Psychological Society has quite rightly raised concerns that under DSM-5’s new definition of a mental disorder, biological causes are given more weight than has previously been the case. This is despite the fact, critics point out, that we don’t yet know enough about the causes of mental illness; ‘biological markers’ remain elusive. Despite its subtle shift in stance on the topic, DSM-5 still relies upon checklists of external symptoms rather than chemical measurements.
The tone of this debate in the media is rarely set entirely by the facts. Instead, instinctive feelings and ideological positions are justified by bits of evidence in the firm knowledge that nothing is conclusive. It’s hard not to be persuaded that this is true of some of the experts too. Neither side yet has enough evidence to be proven right, and most experts seem to accept this; despite the tone of debate around DSM-5, some figures from the APA have stressed that social and cultural factors are still taken into account. Regardless of this, mental health treatment in this country and others remains obsessed with medicine.
DSM-5 is used for diagnosis only, and makes no recommendations about the best treatments for the disorders listed. However the shift to a more biological emphasis will reinforce the tendency to prescribe medication, despite the fact that medication does not work for a surprisingly high number of people.
SSRIs, the family of antidepressants to which the ubiquitous Prozac belongs, are not fully understood. Some reports claim that around one third of people taking Prozac don’t find it has any positive effect. They also have, in some people, the alarming side-effect of an increased risk of suicide. Dr David Healey, an outspoken critic of SSRIs, claims that these drugs kill more people than they save. He also argues that it isn’t simply because these people are depressed- when SSRIs are given to smokers, sufferers of OCD, or healthy people, the chance of suicide increases.
This isn’t to say that medication doesn’t work. For many people, drugs can be an effective way of dealing with mental illness, even if they aren’t fully understood yet. But at the same time, it’s clear that this isn’t the best approach for everyone.
Given that the topic is still surrounded by so much mystery, the hard ideological positions which many people take in these debates seem counterproductive. If mental health is to be combatted, it needs an approach which takes into account the problems of individuals, rather than attempting to apply a cure-all solution for which there is inconclusive evidence.
For those people who find drugs ineffective, the provision of therapy in this country’s health system can often be dire. It is highly dependent upon locality. Waiting times and lack of choice meant that in 2010 almost a third of people who tried to access psychological therapy eventually sought private provision. The overall picture is one of inadequate support for treatments other than the purely medical.
If access to psychological therapies is going to become the norm, a shift is needed in the tone of the debate. We need to accept that we don’t know enough about mental disorders to be relying so heavily on drugs which have very mixed effects. We need to be able to give patients the choice of receiving a form of therapy, regardless of where they live: the post-code lottery has to end. We need to be careful that DSM-5, despite its many merits, doesn’t prevent innovative thinking about mental health.
George Morris is a first year historian from Clare College