Mental health articles

OF mental health care and mentally ill

Antidepressants have been associated with disabling effects

Antidepressants have been associated with a number of disabling effects, including tiredness, dry mouth, loss of libido and impotence, blurred vision, constipation, weight gain and palpitations. The tricyclic version of this type of drug was implicated in around 10 per cent of deaths from self-poisoning in Britain in the early 1980s. Tricyclics have now been superseded by the selective serotonin re-uptake inhibitors (SSRIs), which are less toxic. In older people a decline in suicide has been directly attributable to prescribing this type of anti-depressant.

However, as these drugs have gradually superceded the tricyclics, new issues have emerged which suggest that the newer antidepressant drugs carry serious risks that may outweigh any benefits. This is particularly the case when prescribing these drugs in the treatment of depression in childhood and adolescence and warnings have been issued regarding the increased risk of suicide-related behaviour. The prescription of antidepressants for a range of psycho-social problems and their associated distress (reduced diagnostically and monolithically to ‘clinical depression’ is shaped by a number of factors. These include patient and professional characteristics, the interaction between them, the type of treatment setting and form of healthcare system. Sleath and Shih (2003) found in the USA that insurance status is influential in determining which type of antidepressant is prescribed. Patients belonging to a health management organization that had capitated visits were four times more likely to receive older rather than newer antidepressants.

As with the newer ‘anti-psychotics’ discussed above, the regular use of newer antidepressants has met with accusations of another false dawn, as new iatrogenic problems are identified and initial hopes of curative power are queried. For example, reviews of studies of antidepressants versus psychological therapies in randomized controlled trials suggest that both are clinically effective in the short term, separately and combined, but no treatment is good at preventing long-term relapse in those who have had a depressive episode in their lives).

Initially it was claimed that the SSRIs were not dependency forming. This has now proved to be a false claim. Moreover, and more dramatically, they have been linked to claims of raised risk of both homicidal and suicidal behaviour (Healy 1997). SSRIs have also played a role in extending the medicalization of a range of ordinary experiences of distress. For example, Metzl and Angell (2004) examined an increasing range of female experiences, which have been medicalized by their treatment with the newer antidepressants. These include ‘pre-menopausal dysphoric disorder (PMDD)’, ‘post-partum depression’ and ‘peri-menopausal depression’. Moreover, categories of depressive illness have expanded to incorporate what were previously considered normal life events such as motherhood, menstruation and childbirth. These points about antidepressants indicate that medications have complex life cycles, with diverse actors, social systems, and institutions influencing who they are prescribed to and how they are used. Cohen et al. (2001) point to the way in which a medication life cycle evolves and mutates with social and technological change. The drug companies, the medical profession and patients themselves contribute to these changes in prescribed drug use.

Psychological therapies As far as the psychological therapies are concerned, it is not self-evident that they are benign, simply because they are physically non-invasive and generally preferred by service users. Two types of iatrogenic problems arise in psychotherapy. The first is the so called ‘deterioration effect’ – where symptoms get worse during the normal course of therapy (Bergin 1971). The second set of problems is to do with the personal abuse suffered at the hands of unethical practitioners who exploit the power discrepancy existing, under conditions of privacy, to gain emotional or sexual gratification from their clients (Jehu 1995; Pilgrim and Guinan 1999). By the mid-1990s over half of the malpractice suits taken out by people with mental health problems about their treatment at the hands of psychiatrists and clinical psychologists in the USA involved the distress created by sexual abuse by therapists (Schoener and Lupker 1996). Such has been the crisis of confidence thrown up by evidence of these iatrogenic effects of psychotherapy that some previously committed therapists have recommended the abandonment of therapy in favour of some type of self-help or have issued strong warnings to patients about the risks, as well as of the potential benefits, of psychotherapy.

Nonetheless, users of in-patient services still ask for talking treatments, complaining that these are on offer less frequently from psychiatric services than physical treatments. Exclusion from such treatment seems to reflect a tendency to treat neurotic patients more readily in this way. There is mixed empirical evidence on this issue. On the one hand, psychotic patients seem to be more prone to deterioration effects than less disturbed patients (Bergin and Lambert 1978). On the other hand, there are claims of significant positive effects of psychotherapy with psychotic patients (allowing the latter also to avoid the problems associated with major tranquillizers) (Karon and VandenBos 1981). Just as medication use and the professionalization of psychiatry are interconnected (see earlier) professional questions also surround the differential use of psychological treatments. During the early professionalization of clinical psychology, its bid for therapeutic legitimacy centred on the behavioural treatment of neurosis. Psychologists tended to leave the treatment of madness to biological psychiatrists (Eysenck 1975). However, in the past 20 years psychologists have taken an increasing interest in the treatment of psychosis (Bentall 2003). As a consequence, the costs and benefits of physical and psychological treatments now need to be considered for all groups of patients as the unstable division of labour between psychiatrists and clinical psychologists has shifted. Despite the user disaffection about bio-medical treatments in psychiatry and an expressed preference for talking treatments, given the risks of the latter, this does not imply that they are more cost-effective than drugs and ECT. Indeed, it could be argued that in some ways drug regimes are more open to public accountability than are the talking treatments (Pilgrim 1997b). For example, provided that clinicians cooperate with them, drug protocols can make prescribing practices amenable to audit (by managers or even service users). By contrast, the effective elements of talking treatments largely relate to ‘nonspecific’ effects of the therapist or therapist–client interaction.

Good outcomes in psychotherapy are not linked to particular models but to these benign, supportive or inspirational practitioner variables, or the synergies for change created by some client–practitioner interactions but not others (Lambert and Bergin 1983). It is much more difficult to audit such inter-subjective factors than it is to set down guidelines about good drug-prescribing practice. Also drug-prescriptions are public and impersonal, whereas psychotherapy is private and personal. The latter features seem to be linked to user preferences (to have their idiosyncratic experiences taken seriously). However, these are the very reasons why talking treatments are liable to create deterioration effects because incompetent or abusive practitioners are shielded from public view. Talking treatments, as their name indicates, rely on talk as a resource for personal change. In doing so, they professionalize ordinary human processes: the production and coproduction of human narratives.

Psychological therapies professionalize narrative work and then generate expert metanarratives. The latter then inform the preferred model of the practitioners through illustrative and justificatory case studies. Psychotherapeutic expertise implicitly or explicitly privileges these preferred meta-narratives, with competition existing between professionals about which one is superior. Thus, this professionalization of narratives could be criticized for undermining the legitimacy and effectiveness of ordinary relationships, which when working well contain elements of clarification, reflection and social support. Indeed, the ‘non specific’ effects indicated earlier from psychotherapy outcome research suggest that the main elements of change are common to any helpful conversation between human beings such as rapport, empathy, trust and support. Forms of lay and professional talk are on a continuum with shared characteristics. The professionalization of talk may obscure this continuum when privileging therapeutic narratives. One way of viewing psychological therapies is that they provide the opportunity for helpful conversations which, for contingent reasons, are missing from a client’s personal and social context.

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