Towards a social understanding of mental health

The UK has begun to open up about its mental health problems – one in four of us will experience a mental health problem each year – but does the way we treat mental health need updating? Prof. Peter Kinderman, Professor of Clinical Psychology at the University of Liverpool, makes the case that our understanding of mental health issues and the way we treat them must move away from pathologising the issue to seeing it as a response to social and environmental factors

Prof. Peter Kinderman

Mental health is now a mainstream political issue. The links between our mental health and political decisions are profound, and psychological science suggests that we need to do much more than merely argue for increased resources. We need wholesale and radical change in how we understand mental health problems, and in how we design and commission mental health services.

We urgently need substantial improvement in our mental health care system. The 2013 Chief Medical Officer’s report estimated that the direct costs of mental health problems to the UK economy are between £70–100 billion per year (4.5 per cent of gross domestic product, and ten times the annual cost of EU membership). Taking into account reduced quality of life and loss of productivity, the annual indirect costs of mental health problems in England alone are estimated to be around £105.2 billion ($2.5 trillion worldwide in 2010). The personal costs are even higher. In the UK, around 6,000 people take their own lives each year, and (partly as a result of advances in the treatment of infection) the most common cause of death in women in the first year after childbirth is now suicide.

Despite the expertise and dedication of NHS staff, our current mental health services (in the words of the ‘Schizophrenia Commission’) are ‘badly letting people down in every area of their lives’. 20 per cent of the adult population in the UK takes a psychiatric drug on any given day, and the numbers are rising. While many people report benefits of such medication, many also report serious adverse effects, both immediately and on discontinuation. There is also evidence that increased use of psychiatric medication is associated with increased (not decreased) disability rates, and prescriptions are highest in areas with greater socio-economic deprivation.

For me, at least some of the reasons that we struggle so much to offer citizens the kind of mental health care that they deserve come from the ways in which we understand the issue. The idea that our more distressing emotions such as grief and anger can best be understood as symptoms of physical illnesses is pervasive and seductive. But it is also a myth, and a harmful one. Our traditional approach to helping vulnerable people in acute emotional distress is severely hampered by old-fashioned, inhumane and fundamentally unscientific ideas about the nature and origins of mental health problems.

In my book, A Prescription for Psychiatry, I argue that mental health problems are fundamentally social and psychological issues. Our thoughts, our emotions, our behaviour and therefore our mental health, are largely dependent on our understanding of the world, our thoughts about ourselves, other people, the future and the world. We all differ in the ways we respond to events, and there are many reasons for those differences, but fundamental to our mental health is how we are shaped by our experiences, how we build up our sense of who we are and the way the world works.

I find support for my perspective in a recent United Nations report by Special Rapporteur Dainius Pūras, a psychiatrist from Lithuania, which contains powerful recommendations for reform. The UN Special Rapporteur’s report condemns the neglect of what he calls ‘the preconditions of poor mental health’, including violence, disempowerment, social exclusion, and harmful conditions at work and school. The report emphasises the need for a ‘paradigm shift’, stating: ‘The crisis in mental health should be managed not as a crisis of individual conditions, but as a crisis of social obstacles which hinders individual rights. Mental health policies should address the ‘power imbalance’ rather than ‘chemical imbalance’’.

This has profound implications for mental health policy.

We need appropriate funding of mental health and social care, but we should avoid the ‘more of the same approach’, which would merely see increasing funding for services with poor outcomes. Nor should we assume that current models of leadership, management, governance, and service commissioning are always preferable.

We need to challenge and change the way that we think about mental health problems – moving from a biomedical paradigm to a psychosocial one. While biological research has great value, we must reject claims that overstate or misrepresent the evidence base. This means no longer treating mental health issues as predominantly caused by brain pathology, but rather embracing evidence that mental health issues are usually responses to social and environmental factors. We should therefore replace ‘diagnoses’ with straightforward descriptions of our problems, and base the services offered on shared, co-produced ‘formulations’. We should radically reduce use of medication, and use it pragmatically rather than presenting it as a ‘cure’. These changes will reduce stigma, more accurately capture the nature of distress, de-pathologise our mental health discourse, and promote the research and implementation of more effective non-biomedical alternatives.

As a practical example, one simple change that could make a real difference would be to adopt the use of psychosocial codes, which are already part of both ICD-10 and DSM-5 (the diagnostic manuals used worldwide). These quasi-diagnostic codes document neglect, abandonment and other maltreatment, homelessness, poverty, discrimination and abusive life events in childhood. They are officially recognised by the World Health Organisation as appropriate as the basis for healthcare planning and remuneration, but are almost never used or reported in clinical practice or academic publications. The vast majority of people simply do not have the root causes of their problems recorded. And ignoring these social determinants of mental health problems can only serve to locate the blame not in those unacceptable social circumstances, but – unjustly – in the individual. Broadening routine data capture within UK NHS records could establish more inclusive, social, systemic and psychologically comprehensive patterns of difficulties, which could target information regarding established social determinants of mental health problems, such as inequality, poverty and trauma.

We also need to reform our approach to the prescription of medication. Psychiatric drugs are now prescribed to over 20 per cent of the adult population, costing the NHS around £800 million per year. Antidepressant use has doubled over the past ten years, as has the average duration of antidepressant use. The use of opioid painkillers has risen by 80 per cent over the same period, while the latest research shows that these drugs do not work in 90 per cent of cases. We recognise the role drugs can play, but we demand reform of excessive as well as unnecessary long-term prescribing due to the associated harms of dependency and withdrawal. As recent research also shows that long-term use leads to worse outcomes (and can be linked with rising mental health disability), doctors should prioritise short-term prescribing, always with a plan for coming off. Additionally, patients must be properly informed regarding potential harms as well as benefits, and must no longer be misled by unsubstantiated rationales for prescribing, such as notions of brain chemical imbalances.

Instead, we need to commission and invest in services that people demand and would help them. Our services are fragmented, under-resourced and do not deliver what people want. Many people want access to psychological therapies, but are offered only medication, and avoid other mental health services, leading to avoidable harm. Current mental health services fail to invest sufficiently in alternative yet more effective provision, including psychological therapies, psychosocial care as well as support in the community. Good examples are the services offered by the Maytree charity or the NHS’s own Drayton Park Women’s Crisis House, offering people in an emotional crisis a safe place to stay and access to therapy and help. These kinds of cost-effective psychosocial alternatives to expensive long-term hospitalization are far more appropriate and also increase the chances of people being able to rebuild their lives. But they are also currently under-resourced, difficult to access and poorly integrated with other health and social care services.

Because mental health problems are, in many cases, intimately connected to social and environmental causes, including abuse, bullying, poverty, insecure employment or insecure housing, mental health services must be more closely integrated with both physical health services (particularly community and GP services) and local authority social and educational services. We should shift funding from ill-coordinated and fragmented bio-medical services to services that prioritise prevention and early intervention, psychological therapies and psycho-social support, and which work more closely with services such as housing, education and the criminal justice system.

Finally, we must reform those institutions that uncritically maintain and promote the current unsuccessful approach to mental health provision. This will involve substantial transfers of power, from individual clinicians to teams, and from professionals to service users. We must ensure that there is proper representation of service users on expert groups, and promote a person-centred approach to mental health care, which emphasises fundamental human rights and personal autonomy. This will require changes to mental health legislation, reform of the Royal Colleges, clinical guidelines reform, the implementation of a UK ‘Sunshine Act’ and wider regulatory reform.

A humane, rights-based, intelligent, scientific, psychological position on mental health is a social-determinist approach. This clearly identifies mental health as a political as much as a clinical issue. It also provides a solid, evidence-based, foundation for the development of radical but humane mental health policies.