Mental Health Awareness Week has started, and the theme for 2023 is ‘anxiety’. Anxiety has often occupied a precarious space in discussions on mental health. This is perhaps because it is such a common human experience, and the point where ‘normal anxiety’ tips over into ‘abnormal’ or ‘clinical’ anxiety is disputed and hard to define. However, are anxiety, depression, and mental distress more broadly, medical problems – or political and social ones?
Anti-depressants: doctor’s go-to drug for mental health
Millions of people in the UK are going to their GPs with symptoms of anxiety, depression, and other common mental health issues. GPs then tend to prescribe anti-depressant medication: usually selective serotonin reuptake inhibitors (SSRIs) such as sertraline or citalopram.
Last year, doctors prescribed anti-depressants to more than eight million adults in the UK. That was the sixth consecutive year that saw an increase in both patients and prescriptions. Doctors were twice as likely to prescribe anti-depressants to women as they were men. This is despite a meta-analysis of clinical trials in the US over a 37-year period revealing that anti-depressant medication is substantially better than a placebo for only 15% of patients.
The conventional medical approach to mental health is based on an assumption that a person experiencing prolonged mental distress is suffering from a biological abnormality in their brain. This is the “chemical imbalance” theory. Doctors recommend a combination of psychiatric medication and talking therapy to treat this ‘illness’.
The medical model approach does not deny, however, that social and political factors, such as poverty or trauma, can trigger an episode of mental ill health. Instead, it frames prolonged and debilitating emotional distress as primarily a biological illness.
Is there a chemical imbalance?
In recent years this theory has come under a lot of scrutiny. There was a major scientific study in summer 2022, led by consultant psychiatrist Joanna Moncrieff and others. It found there to be “no convincing evidence” that low serotonin levels (the ‘chemical imbalance’ theory) are responsible for clinical depression. Moncrieff said:
Thousands of people suffer from side-effects of antidepressants, including (the) severe withdrawal effects… yet prescription rates continue to rise. We believe this situation has been driven partly by the false belief that depression is due to a chemical imbalance.
This research sparked significant public debate. Some professionals made the valid point that anti-depressant medication can save lives. Plus, even if we don’t fully understand how the medication works (just like we don’t fully understand how paracetamol works), the fact that it does work for some people is significant.
Research scientists have pointed to the fact that randomised controlled trials of thousands of people living with depression have shown that SSRIs are an effective treatment for depression. However, critics have highlighted the historical influence ‘big pharma’ has held in the development and design of these clinical trials.
The controversy around SSRIs runs parallel to a growing movement of experts and campaigners who question the nature, and even the existence of, mental disorders. Within this movement, there are many experts who feel the psychosocial elements of mental health conditions are being overlooked.
Sedated, due to capitalism
Meanwhile there are other, more radical voices who argue that mental health conditions do not exist. They claim the entire construct of mental disorders was designed to disempower marginalised social groups, particularly women, racialised minorities, and LGBTQ+ people.
Dr James Davies, psychotherapist and associate professor of medical anthropology at the University of Roehampton, is part of this movement. In 2021 he published a book called Sedated: How Modern Capitalism Created Our Mental Health Crisis. Davies maintains that most people who seek help for mental health issues:
aren’t suffering from internal dysfunctions in any biologically verifiable sense. They’re suffering from natural and normal, albeit painful, human reactions to difficult things they have become embroiled in.
In Sedated, Davies argues that changes in the modern workplace since the 1980s, including the rise of commuting, the ‘gig’ economy, and the normalisation of unpaid overtime, have led to huge numbers of people experiencing significant mental distress. He also found that nearly 40% of workers “feel their jobs make no meaningful contribution to the world”.
Davies maintains that materialism, a defining feature of capitalism, can be both a cause and consequence of mental distress. He says many people use material objects, like cars or designer clothes, as a coping mechanism for emotional issues.
Biology versus “social history”
Dr David Crepaz-Keay was previously diagnosed with schizophrenia. He is now a member of the genetics working group at the Royal College of Psychiatry. He is also Head of Applied Learning at the Mental Health Foundation. Crepaz-Keay argues there are biochemical and genetic predispositions that put certain people at elevated risk of developing a mental illness. However, he told the Canary:
there’s definitely a strong racial and gendered component to the way we address mental illness… if you look at who ends up using psychiatric services, it looks a lot more like social history than biochemistry.
Historically, gay and bisexual men, and unmarried young mothers, were vastly over-represented in the population of people detained under mental health legislation in the UK. Today, those groups are no longer detained in large numbers. However, Black people are. Crepaz-Keay told the Canary he puts this down to a combination of racism and social disadvantage:
We see such a strong divide by postcode and economic categories… what you might think of as ‘white privilege’ is a huge protective factor.
Crepas-Keay also noted that, while schizophrenia is “associated with a large number of genetic traits”, there are strong common social themes for people with this diagnosis. He said these include poor housing, not being in a stable relationship, low income, and poor education outcomes. Crepas-Keay noted that these social disadvantages often worsen over time:
Privilege or disadvantage reinforces itself in destructive cycles: they don’t tend towards an equilibrium, they tend towards more privilege or more disadvantage.
The medical model
Dr Ana Draper is a consultant systemic psychotherapist at an NHS Trust, and chief executive of Improved Futures. The systemic approach is quite removed from the medical model. It focusses instead on relationships, social difference, and individual identity. Draper emphasises the importance of recognising power differentials, even in the therapy room. She told the Canary:
Our role, as therapists, is to walk alongside people, to help them discover the things that are useful for them… if you’re ‘doing to’ people, rather than ‘being with’ them, I think that’s a very unethical thing to do.
Historically, people have criticised the medical model for labelling people with diagnoses. This can then lead to social stigma and an excessive focus on what’s ‘wrong’ with the person. Draper supports a movement away from this framing, and towards a more non-judgmental, therapeutic exploration of the person’s life experiences.
Draper notes that, while biology is an aspect of mental health, neuroplasticity has shown this can change over time. She gave the Canary the example of refugee children she has worked with:
When you experience extraordinary events that are life-threatening, your brain is going to be in hypervigilant mode, and it’s going to keep you there… The cognitive part of the brain gets affected when the primal part is constantly on overdrive… but those pathways can be repaired when there is an opportunity for the brain to function in a different way.
So, in a safe environment with healthy relationships, it is possible to heal and recover from even highly traumatic events. We should not consider biology an immutable factor. However, to make this a reality trauma-informed approaches need to be embedded across public life: in schools, the NHS, the criminal justice system, and so on.
The weaponisation of mental health
There is also a need to reexamine the concept of a ‘personality disorder’. Draper said the US diagnostic manual (the DSM) is “not scientific”, and women who have experienced abuse are far more likely to receive this controversial label in mental health services.
Dr Charlotte Proudman, a family law barrister and director of Right to Equality, is also critical of personality disorder diagnoses. She says perpetrators of abuse often weaponise them in the family courts to try and discredit their victim. Proudman told the Canary:
It’s not uncommon for mothers to be diagnosed with mental health conditions by experts in family law proceedings when they’ve had no previous diagnoses. This could include personality disorders – even a histrionic personality disorder, which is highly gendered in nature. Such diagnoses can cause all manner of problems for mothers who are then labelled as bad mothers… when in fact they are suffering trauma because of domestic abuse.
Hyper-capitalism: no recipe for peace of mind
There is clearly no escaping the social and political factors that influence who is diagnosed with a mental health condition or personality disorder, and who is detained under the Mental Health Act. However, a significant body of genetic research suggests that biology does play a role in our capacity to maintain good mental health.
As Draper summed up to the Canary:
We have a society that’s so unequal… and the cost is people’s mental health.
Whether it’s nature or nurture, what is clear is that a hyper-capitalist society with extreme income and wealth inequality isn’t a recipe for peace of mind. Instead, it’s possible that we need to reframe how we consider mental health. Whilst many people will find comfort in labelling expressions of mental health, that shouldn’t preclude incorporating a social model into our understanding. Mental ‘illness’ isn’t an aberration, it’s a measured response to a deeply unequal society.
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