The Royal College of Psychiatrists and the media routinely state that there is an “epidemic” of mental disorder—1 in 4 people in the UK, with 3 in 4 said not to get the treatment they need. These disease-mongering assertions have been recycled for so long that they have become unexamined societal truisms. We are apparently wading knee deep in “mental disorder,” yet psychiatry has not confronted the philosophical problem of defining just what we mean by “mental disorder.” Barring categories arising directly from physical disease (for example, dementia), there is no conceptual agreement about when a person “really” has a mental disorder, only the constructed agreement inherent in the methodologies that psychiatry has adopted. [1] If there are sufficient phenomena, at sufficient threshold, a mental disorder is declared to exist. This is a kind of alchemy. If to have a mental disorder is to have some measure of incapacity, how could 1 in 4 UK citizens be thus afflicted and society still keep going as it does? [2] The psychiatric field is making knowledge claims it cannot justify. I am not talking about a minority with undoubtedly severe or recurrent psychiatric problems, often needing inpatient care.

When the medicalisation of everyday life and the commodification of “mind” is professionally endorsed and taken up by wider culture, the language of psychological deficit is inserted into the public imagination. People come to see themselves not as normally stressed, but as “ill,” with negative emotion recast as a mental health problem. [3] As more resources for mental health services are called for and provided, more are perceived to be needed, an apparently circular process, a dog chasing its tail. It was clear when I was an occupational psychiatrist that the psychiatrization of the problems of living frequently perpetuated them.[4]

The more that the mental health field promotes its technologies, such as anti-depressants, as necessary interventions in potentially any area of life, the more there is a downgrading in collective assumptions about the resilience of the average citizen. Ivan Illich called this “cultural iatrogenesis.” [5] To coin an aphorism, the average citizen is as vulnerable or as resilient as the society he is living in expects him to be. To culturally endorse a much thinner-skinned version of a person than previous generations recognised does not seem a good idea if we look ahead to the huge challenges facing the world. Society needs to talk less, not more, about “mental health”.

Can anyone seriously argue that UK society is healthier and happier as a result of our epidemic of antidepressant prescribing: 64.7 million in 2016, up from around 9 million in the 1990s? [6] Antidepressants cost the NHS £266 million in 2016, and these are only the direct costs. In an age of medicalisation no diagnostic category is more indiscriminately applied than “depression.” David Healy describes the idea that abnormal levels of the neurotransmitter serotonin were connected to depression as the “marketing of a myth.” [7] No consistent defining biological abnormality has yet been found in the brains of people with a diagnosis of depression. Thus the very term “antidepressant” denotes a false specificity. Antidepressants have non-specific sedative effects, but so far that is all that can be said. Meta-analyses of research data suggests that antidepressants struggle to demonstrate clinical superiority over placebo. [8] Regarding a recent review in The Lancet, it is telling that psychiatric academe considers that ratings only one third above placebo, with assessment limited to eight weeks, settles the case for mass prescribing. [9]

My patients’ presentations frequently bear out the reality that life in the UK is getting harder: the fortunes of the haves and have-nots are diverging, the fabric of the welfare state thins, employment entitlements grow precarious. The Archbishop of Canterbury calls our economic model “broken.” Many people receiving a diagnosis of “depression” might be more authentically seen as carrying generic social suffering. The doctor can do little about the patient’s social predicament, but feels he must do something and so prescribes an antidepressant by reflex. This “epidemic” of depression lets the neoliberal political and economic order off the hook.

“Depression” has become the dominant idiom of distress in contemporary culture, eclipsing time-honoured and more nuanced descriptors—sorrow, unhappiness, despair, gloominess, bitterness, misery. In the process we have lost something that cannot be compensated for by this epidemic of anti-depressant prescribing. [10] Some re-balancing would be realistic: it could start with the psychiatric field being more honest and less self-aggrandising about the truth claims it advertises to wider society. “Depression” is the case in point.

Derek Summerfield is an honorary clinical senior lecturer, Institute of Psychiatry, Psychology & Neuroscience, King’s College; formerly research associate; Refugee Studies Centre, University of Oxford.

References:

1. Ingleby D. Understanding ‘Mental Illness’. In: Ingleby D. ed. Critical psychiatry. The politics of mental health. London: Free Association Press 2004. 23-45.
2. Summerfield D. Proposals for massive expansion of psychological therapies would be counter-productive across society. Brit J Psychiatry 2008:192(5);326-330.
3. Summerfield D. Cross-cultural Perspectives on the Medicalization of Human Suffering. In: Rosen G. ed. Posttraumatic Stress Disorder. Issues and Controversies. Chichester: John Wiley 2004: 233-45.
4. Summerfield D. Metropolitan Police Blues: protracted sickness absence, ill-health retirement, and the occupational psychiatrist. BMJ 2011;342:d2127.
5. Illich I. Limits to Medicine. Medical Nemesis: The Expropriation of Health. London: Marion Boyars 1975.
6. Summerfield D. Depression: epidemic or pseudo-epidemic? J Royal Soc Med 2006:99;161-2.
7. Healy D. Serotonin and depression. The marketing of a myth. BMJ 2015:350;h771.
8. Kirsch I, Deacon B, Huedo-Medina T, Scoboria A, Moore T, Johnson B. Initial severity and anti-depressant effects. A meta-analysis of data submitted to the Food and Drug Administration. PloS Medicine 2008:e45. doi 10-1371/journal.pmed 0050045.
9. Cipriani A, Furukawa T A, Salanti G, ‘Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis’ The Lancet, 2018, DOI: https://doi.org/10.1016/S0140-6736(17)32802-7
10. Wakefield J, Horwitz A. The loss of sadness: how psychiatry transformed normal sorrow into depressive disorder. New York: Oxford University Press 2007.