Almost one in four adults are being prescribed antidepressants, but this proliferation of pills is not only a waste of money but also prevents patients finding and addressing the real cause of their depression, writes Lucy Kenningham
I was 20 the first time I was prescribed antidepressants. I had gone to the doctors during January in rainy, miserable Manchester complaining of flu. Somehow, I came out of the appointment having been diagnosed with depression and prescribed a course of SSRIs. But in fact I didn’t have a mood disorder, and I didn’t need to go on medication.
Over the past decade, antidepressant prescriptions have doubled in the UK. More people than ever are taking these drugs – a number equivalent to almost one in four adults. They’re also doing so for longer – the average duration of time spent on them has doubled since the 2000s. . While this may be in line with increasing concern and focus on mental health, it is important to note that the vast majority of studies of SSRIs drop off after a year – meaning long term users are involved in a mass psychological experiment.
Despite the extra pills, mental health outcomes have worsened since the 1980s. “The evidence is overwhelming that the way we’ve gone about trying to understand and solve mental health problems for the last 30 years has failed,” says Dr James Davies. “We’ve not managed to improve mental health outcomes in that period, despite billions spent.” The gap in life expectancy between individuals with severe mental health issues and the general population has doubled since the 1980s and the mortality rate for those experiencing severe and sustained emotional distress is now 3.6 times higher than that of the general population.
That’s despite nearly a quarter of a trillion pounds having been allocated to mental health over the last four decades. The current system is not economically efficient. Doling out unnecessary pills is a waste of NHS money. Recent research reveals that the cost to the NHS of 5.4m people in England being unnecessarily prescribed psychiatric drugs is £560m a year. Societal costs have spiralled.
At the same time, the total cost of poor mental health is estimated to be around £300bn in England alone in 2022, which might explain why society and the NHS might see £560m as a reasonable investment.
The report, released today, proposes a radical rebalancing of the way we do things away from the traditional biomedical model towards a more holistic, person-centred approach that more fully recognises and addresses the social, economic and psychological determinants of mental health.
However, money, or rather money spent on drugs, is not necessarily the answer. The problem, according to Davies and the Beyond Pills All-Party Parliamentary Group (APPG), has been the dominance of the biomedical model in mental health care. This approach considers mental distress to be a medical illness and thus treatable with medicine like psychiatric drugs. That’s why in Davies’s report in conjunction with the Beyond Pills APPG, released today, they call for an overhaul in the state of the UK’s mental health system. Their assessment echoes those made by the World Health Organisation and United Nations. Their proposal? “A radical rebalancing of the way we do things away from the traditional biomedical model that has presided over poor clinical outcomes and the overmedicating of distress, towards a more holistic, person-centred approach that more fully recognises and addresses the social, economic and psychological determinants of mental health.”
How did we get here? Pharmaceutical companies have had far too much influence and have benefitted accordingly, Davies says. During a psychiatric drug boom of the 1980s, 1990s and 2000s, big pharma allocated substantial financial resources to promoting psychopharmaceuticals in the media and throughout public, professional and political communities, leveraging finances in unwieldy ways amounting to what Davies terms a “systematic entanglement of psychiatry with the pharmaceutical industry”. In fact, “our collective knowledge about mental health [has] become tainted” according to the United Nations in a report that said industry has corrupted research.
The second time I was diagnosed with depression I was 22 and was handed a prescription. It was for sertraline, a popular SSRI, and I took it. In large part, my consent was due to what medical friends assured me. Depression is a chemical imbalance in the brain, they said. Your problem is biological, a drug will fix it.
What I didn’t realise at the time was that this was in fact not gospel, but a mere theory – “at best a reductionist oversimplification” according to American pharmacologist Joseph Schildkraut. At worst, a lie by Big Pharma.
In the 1960s, the theory was formed and over the next two decades, selective serotonin reuptake inhibitors (SSRIs) were touted on the world stage and marketed with yet another unproven myth written into pill packets far past the time those profiting from the uptake of SSRIs knew it to be tenuous. Pfizer, one of the biggest firms, accepted in the 1980s that the chemical imbalance theory was an “inappropriate” inclusion on a medical leaflet for Sertraline. Yet the phrase remained on at least half of all SSRI leaflets. A UCL review in 2022 showed how the theory was considered to be fact in both the public imagination and amongst the medical establishment largely due to carefully crafted marketing.
“The theory of the chemical imbalance, which had become widespread by the 90s, has survived for so long perhaps because the reality – that mental illness is caused by an interplay between biological, genetic, psychological, and environmental factors – is more difficult to conceptualise, so nothing has taken its place.”
Rachel Aviv
“The theory of the chemical imbalance, which had become widespread by the 1990s, has survived for so long perhaps because the reality – that mental illness is caused by an interplay between biological, genetic, psychological, and environmental factors – is more difficult to conceptualise, so nothing has taken its place,” writes Rachel Aviv in her book Strangers to Ourselves which probes the murky parameters that border the definition of mental ill health.
For half a century scientists have been looking for a biological or genetic cause for depression but have largely been unable to find a definitive cause. Yet one in four adults are prescribed psychiatric pills in the UK annually. Often, they are on waiting lists for talking therapy but the wait can be as long as three years. Psychiatric drugs are brought to market in around 12 weeks – in fact, few studies have ever lasted more than a year.
The benefits of these drugs have undoubtedly been overegged. Multiple meta-analyses have shown antidepressants to have no clinically meaningful benefit beyond the placebo effect for all patients except those with the most severe depression, writes Davies. Plus, there are the potentially life-altering side effects. These include headaches, nausea and sexual numbing or an onset of asexuality – as documented in a much-discussed Panorama programme of 2023 which for the first time validated patients who had for a long time been struggling to taper off SSRIs. Wendy Burn, then head of the Royal College of Psychiatric Health, issued an apology to patients regretting that the severe and long-lasting effects of SSRIs weren’t recognised sooner. It was a rare case of a so-called patient movement, where patients, rather than doctors, were the ones to raise such a serious medical issue. Many felt let down by an NHS that failed to warn them of the side effects they were to suffer – and in many cases, keep suffering as they struggled to ditch the dependence-forming drugs.
Looking beyond pills: a radical solution to mental health treatment
“Mainstream biomedical thinking in mental health has broadly championed a different perspective, for example the chemical imbalance theories of depression (which have now been disproven) supported the idea that there’s something in you that needs to be corrected with drugs rather than something in your environment. The trouble with this overmedicalised view is that it exonerates social circumstances from bearing responsibility,” says Davies.
That’s why he is suggesting the introduction of a new narrative about what we need to do to put things right. “It’s a very ambitious report and you’re absolutely right this isn’t just about the health service. What we argue is that a lot of the distress in contemporary society isn’t a medical issue, it’s a social issue, a political issue. It’s poverty, inequality, discrimination, social injustice. All these things generate distress.”
His report for the Beyond Pills APPG proposes a paradigm shift in the UK’s approach to mental health. It suggests that mental health problems are mostly about circumstances, relationships and social environments – the most common although by no means the only one being poverty – rather than biological or genetic factors. “For example, a single mum on a council estate during Covid was three times as likely to get depressed as a middle class mum with a garden. This has got nothing to do with biology. This has got everything to do with the social predicament you are subject to.”
“A single mum on a council estate during Covid was three times as likely to get depressed as a middle class mum with a garden.
This has got nothing to do with biology. This has got everything to do with the social predicament you are subject to.”
Dr James Davies
A holistic approach to mental health understands that relationships, formal and informal, are central to healing and must be the core focus of all service provision. The consensus now is that people have never been lonelier or more disconnected from each other. A reformed approach understands that often mental health problems are symptoms of broader social issues. What, practically, can be done? “We need to start intervening in socially informed ways to these problems,” he says. Investing in financial, social and material support for families, schools and communities would reduce distress and thus the need for referrals.
Social prescribing is shown to help. An evaluation of a social prescribing service in Shropshire showed a 40 per cent reduction in GP appointments for people who had accessed social prescribing after three months. A study by the University of Sheffield showed a social return of £3.42 for every £1 invested.
“We need social policy interventions if we’re going to start tackling population level distress,” Davies says. “We need to think about emotional problems in a very different way to the last 40 years – they are not indicators that something’s wrong with you but a signal that something’s happening to you – be that in the workplace, family, community or home. They could be economic problems, social justice, discrimination. As a system we have not focused on this as much.”
And it is true that for me at least, luckily not being a victim of poverty, it was a change in life circumstances that led to my temporary depression – a phenomenon known as ‘reactive depression’. This term is helpful because it avoids suggesting to people that they have a long-term disease or ascribing them an identity as a ‘depressed person’. Most people with depressive symptoms will recover within a few months without drugs – it is important that this is kept in mind.
The truth is that these pills can work and should not be discouraged when suitable – but their potency has been overstated partly due to the strong historical influence of pharmaceutical companies. If one in four adults are now on psychiatric pills, surely it makes sense to question the sanity of the society that surrounds them.