Un-Critical Psychiatry?
A paper just published in British Journal of Psychiatry Open has met with criticism and anger in some quarters. The paper, co-authored by Sebastião Viola and Joanna Moncrieff, prominent members of the Critical Psychiatry Network, analysed trends in claims for sickness benefits from 1995 to 2014 using data from the Department of Work and Pensions (http://bjpo.rcpsych.org/content/2/1/18 ). They examined changes in the prevalence of claims attributable to mental disorders compared with other major categories of medical condition and changes in long-term claims. They found that the number of people claiming benefits for more than 5 years had increased since 1995, largely because of a rise in long-term claims for mental disorders. In contrast, claims for other disorders such as musculo-skeletal conditions fell, with the result that mental disorders are the largest single medical cause of benefit claims, accounting for almost half of all claims in 2014.
Critical comments appeared on the Council for Evidence Based Psychiatry’s website (see http://cepuk.org/2016/01/25/new-study-shows-disability-claims-for-mental-disorders-in-uk-has-doubled-over-past-20-years/ ), where a link to the paper appeared, and on the anti-austerity critical mental health survivor Face Book page Recovery in the Bin (RitB). For example, one commentator notes that the paper ‘…isn’t helpful in the current climate where MH claimants are being targeted with impunity & the problems that people have are also rooted in the society they live in, as for “less stigma” [an argument developed in the paper] you have to be joking you really have taken your eye off the ball to state that.’ (my emphasis) A comment on Recovery in the Bin (RitB) observes that ‘…when social justice is at an all time low…all social support demands people are on meds at least on paper, and our govnt [sic] is targeting people with a mental illness dx [sic] who are claimants. They won’t look at this and think maybe we should fund different sorts of services, it will just be another stick to beat people with.’ A person with disabilities and mental health problems points out that ‘It seems that there is a campaign against the idea of people with mental health problems being classed as disabled under the Equality Act and therefore receiving ESA and PIP. Unfortunately it all seems to result from underlying stigma of mental health problems and the idea that we are not *really* unwell or disabled in the same way that people with more visible health conditions or illnesses may be.’ Another person comments that ‘An economist at the Kings fund said to me once pompously [sic]… the key to being able to provide more services (he meant health care) was to increase productivity in the economy. So I asked him “what if the things that increase productivity… longer hours and more work… are the things that make people sick?” He went glassy eyed and wandered off to spead [sic] more of his productivity gospel…’
These comments raise a number of questions. First, why was this study undertaken? The authors say that since the changes to the benefit system introduced by the last Labour government in 2008 there has been no systematic study of the impact of these changes, aimed at encouraging long-term benefit claimants back to work, in the UK. Indeed the paper’s opening sentence refers to the cost of benefit support for long-term sickness being an international concern.
The subjects of this study, those who experience long-term unemployment because of disabilities and mental health problems, are people who are despised, reviled and detested (see, for example http://www.theguardian.com/society/2012/feb/05/benefit-cuts-fuelling-abuse-disabled-people ). They are attacked in the tabloids and broadsheets, in so-called ‘poverty porn’ on television (see, for example Channel 4’s Benefits Street) and by leading politicians. Indeed, there is anecdotal evidence that welfare reforms are jeopardizing the mental health of claimants (see http://www.theguardian.com/society/2012/feb/05/benefit-cuts-fuelling-abuse-disabled-people )
This raises the question of power. The mighty, the privileged, and those who have a voice are seen to be bearing down on and pointing the fickle finger of morality at those who are powerless, under-privileged, and who are voiceless. I am certainly not accusing the authors of this paper of making moral judgements about the subjects of their study, but it is important to recognize that the wider context is one in which others are already doing so.
This raises another issue. The NHS has an extensive system of ethical checks and balances through Multi-centre and Local Research Ethics Committees, who scrutinize research on NHS patients to safeguard their interests and safety. There is however no reference in this paper to ethical scrutiny (there usually is in papers published in medical journals). The authors will doubtless argue that NHS ethical scrutiny was unnecessary because their data originated not from NHS sources but from the DWP (though a freedom of information request). If that’s so, then perhaps the NHS needs to consider extending its ethical scrutiny to such work.
What worries me most of all about this paper is its failure to contextualise the study politically. Here, I’m referring to the impact of government austerity policies on income and other forms of inequality. We know that the UK has the second highest levels of income inequality in the Global North, second only to the USA. We know that income inequality is very closely related to a broad spectrum of physical and mental health problems, indices of family and social dysfunction, and long-term unemployment. Yet there is no reference in the paper to austerity and inequality. Instead it argues tamely and unconvincingly that the increase in the proportion of benefit claimants with mental health problems arises from the success of anti-stigma campaigns making it more socially acceptable for claimants to admit to mental health problems. Yet they adduce no evidence to support this.
Maybe those of us who are critical of this study are mistaken. I’d like to imagine it’s the first in a series of well thought out papers from critical psychiatrists criticizing the benefits system, and that next the authors will turn their attention to the ideology of neoliberalism that many of us consider to be the principle author of inequality and the widespread social injustices that spring from this. Joanna Moncrieff’s work is rightly highly regarded. In the past she has demonstrated great integrity and courage by publishing important papers and books that challenge and question what in my view is the harmful dogma that masquerades as psychiatric theory. She has also published thoughtful critical papers on neoliberalism, biomedical psychiatry and the pharmaceutical industry in the past.
This paper is an aberration, but perhaps this is what happens when you try to publish your work in a mainstream psychiatric journal. The British Journal of Psychiatry would after all be most unlikely to publish a paper analyzing trends in benefit claims from people with mental health problems against the context of neoliberal austerity. But then consider the implications of this paper as it stands; how will it be interpreted by policy makers, politicians and government? This is another reason for more careful ethical scrutiny of research undertaken by NHS employees on NHS patients using data that has not originated from NHS sources. Sadly, in my opinion, it would appear to be a case of un-critical psychiatry.
© 2016 Philip Thomas
What disability benefit trends tell us about psychiatric treatments and the economy
joannamoncrieff / January 29, 2016
Sickness and disability benefits are a hot topic in the United Kingdom at the moment. The government’s new system means that everyone’s benefit entitlement is being reviewed, and this is causing huge stress and anxiety for many people, including my patients. Some people have suggested that for this reason, I should not have published the recent paper on trends in sickness and disability benefits that I published with a colleague, Sebastiao Viola (1, http://bjpo.rcpsych.org/content/2/1/18.) It was unethical and should not have been allowed, apparently (2, http://www.philipfthomas.com/index.php/blogs/28-un-critical-psychiatry), even though almost all the data is already in the public domain – on the Department for Work and Pensions’s website – in the name of transparency.
But we cannot simply ignore or suppress such a seismic shift in social trends. When I looked at benefit statistics in the 1990s, musculo-skeletal disorders (principally back pain) were overwhelmingly the biggest and fastest growing cause of receiving what were then called incapacity benefits, and cardiovascular disorders were the second most common cause in men. In 1994-1995, mental disorders accounted for just 20% of days on which benefits were claimed (3, http://jpubhealth.oxfordjournals.org/content/22/1/59.long).
Since that time, mental disorders have far outstripped all other types of medical conditions and become the leading cause of claiming sickness and disability benefits. While the number of people claiming benefits for other medical conditions fell by 35% between 1995 and 2014, the number of people claiming benefits for mental disorders more than doubled. In 2014, 47% of all claims for disability benefits – almost half- were made by people whose primary condition is a mental disorder. 1.1 million people in the UK, or 2.7% of the working age population, claim disability benefits due to a mental disorder (4). The costs to the individuals who are unable to support themselves, and to the society as a whole, are huge.
These figures are important for what they tell us about the success or otherwise of current approaches to helping people with common mental health problems, and for what they say about the economy, and the nature of modern work.
I started looking at disability benefits back in the 1990s in order to find some objective measure of the performance of people diagnosed with depression Depression and anxiety disorders account for the majority of disability claims by people with mental disorders. In 2014, almost half (44.2%) of disability benefits awarded to people with a mental disorder were for depression and two thirds were for depression or anxiety (66.8%) (1). These proportions have not changed much since the 1990s.
In the early 1990s, campaigns like the Defeat Depression Campaign publicised the message that large numbers of people were depressed without knowing it, and that they should go and get the new and wonderful antidepressants that had just come onto the market (the SSRIs of course!). Since that time, the use of antidepressants has increased four times! In England, prescriptions have risen over 10% a year since 1998 (4, http://bjp.rcpsych.org/content/200/5/393.long).
If antidepressants are effective, and people with depression are more likely to be prescribed them, then you would expect the consequences of depression to start to lessen. One of those consequences, according to government statistics, is being out of work. But what we see is quite the opposite: Increasing use of antidepressants correlates with increased numbers of people with depression who are out of work and claiming benefits, and increasingly on a long-term basis. And this is at a time when disability due to other medical conditions has fallen.
The idea that conditions like depression and anxiety can be quickly and effectively treated with medication or short courses of therapy that re-adjust your thinking is not borne out by the evidence. Rather than helping people improve their lives and get on their feet again, this approach seems to create ever rising numbers of people who are viewed, and may come to themselves, as chronically sick. Far from helping people towards a meaningful recovery, taking an antidepressant may simply be a daily reminder of the idea that you are permanenelty flawed.
One of the ways our current approach is wrong is that we are looking for the problem in the individual- inside the brain. Instead we need to ask what it is about our society that means that so many people feel too unhappy, worried or mentally frail to work. Having a ‘decent’ job is an incredibly important part of people’s lives, and most people want one. Research shows that even people with severe mental disorders would like to be in work, if they could (5,6). A good job is a source of satisfaction, purpose and camaraderie. People without work easily lose confidence and become socially isolated.
Fewer and fewer ‘decent’ jobs exist, however, especially at the unskilled end of the jobs market. Most jobs, even fairly menial ones, have become increasingly competitive and demanding, with performance targets and micro-management. I heard one radio journalist describe how he had attempted to apply for a job as a local petrol station attendant. He had to complete complex questionnaires designed to assess his levels of motivation and dedication, as if the application were for a high flying executive position. Despite his University education, he failed miserably to qualify, and wondered how anyone without a degree in management consultancy was able to get shortlisted.
Unskilled jobs have either gone altogether, or have become increasingly casualised. With the increase in agency work and zero-hours contracts, there are fewer jobs with paid sick leave and holidays. For these reasons, some analysts have referred to the problem of ‘disguised unemployment,’ indicating that many disability claimants are willing and able to work if suitable employment opportunities existed (7). But they need jobs that will accommodate the fact that they might not always be performing at 100% efficiency (like everyone, of course), and they might need to take time off occasionally. They need understanding employers, who respect and value their contribution, not agencies which can simply hire someone else.
Working in a highly pressured, insecure and competitive situation is bad for everyone. Rising disability benefits are a sign that we need to do something about modern employment conditions. We need to provide more opportunities to work in a supportive and accommodating environment. This is especially important for people with mental health problems, but it would benefit us all.
(1) Viola S, Moncrieff J. Claims for sickness and disability benefits owing to mental disorders in the UK: trends from 1995 to 2014. BJPsych Open 2016;2:18-24. http://bjpo.rcpsych.org/content/2/1/18
(2) http://www.philipfthomas.com/index.php/blogs/28-un-critical-psychiatry
(3) Moncrieff J, Pomerleau J. Trends in sickness benefits in Great Britain and the contribution of mental disorders. J Public Health Med 2000 Mar;22(1):59-67. http://jpubhealth.oxfordjournals.org/content/22/1/59.long
(4) Calculated using figures from ONS: http://www.ons.gov.uk/ons/rel/pop-estimate/population-estimates-for-uk–england-and-wales–scotland-and-northern-ireland/mid-2014/sty—overview-of-the-uk-population.html, deducting population of Northern Ireland (since disability benefits data do not cover Northern Ireland), and assuming working age pop is 64% of population, as given by ONS data
(5) Ilyas S, Moncrieff J. Trends in prescriptions and costs of drugs for mental disorders in England, 1998-2010. Br J Psychiatry 2012 May;200(5):393-8. http://bjp.rcpsych.org/content/200/5/393.long
(6) Boycott N, Akhtar A, Schneider J. “Work is good for me”: views of mental health service users seeking work during the UK recession, a qualitative analysis. J Ment Health 2015 Apr;24(2):93-7. http://www.ncbi.nlm.nih.gov/pubmed/?term=boycott+and+akhtar
(7) Marwaha S, Johnson S. Views and experiences of employment among people with psychosis: a qualitative descriptive study. Int J Soc Psychiatry 2005 Dec;51(4):302-16. http://www.ncbi.nlm.nih.gov/pubmed/16400906
(8) Beatty C, Fothergill S, Macmillan R. A theory of employment, unemployment and sickness. Regional Studies 2000;34:617-30. http://www.tandfonline.com/doi/abs/10.1080/00343400050178429
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