Another of our interviews with people working on providing alternatives to multinational corporations – this time in the health sector. Simon’s position is that the way we’ve organised society, especially the stressful nature of work and modern life generally, but specifically the breakdown of communities and the support networks they provide, has resulted in an epidemic of depression, and treatments are usually based on pharmacological models of distress that tend to be treated with corporate drugs, rather than by addressing the systems we live under. But he’s optimistic that we can turn this around.
Are you talking about mental or physical well-being?
Both. The two are inseperable. We have had to mend the damage caused by the idea, starting with Descartes, that the mental and the physical somehow reside in different realms. I might see a patient with chest pain, but it’s anxiety that caused the chest pain in the first place. Trying to work out if something is ‘physical’ or ‘mental’ is surprisingly unhelpful in a consultation, so we try to look at the whole person in terms of well-being, rather than focusing on one aspect of health.
I think that ‘well-being’ is the best umbrella term, because as soon as you start talking about mental health, you lose some people, because they don’t see themselves as having a mental health problem.
What’s the problem as you see it?
I don’t think we’re looking closely enough at the causes, or focusing enough on preventative medicine. In health we often use the analogy of a river, with drowning people floating by. Of course we have to fish the people out of the river and save them, but it would be absurd to keep doing that without looking upstream to see why there are lots of drowning people in the river in the first place, and try to prevent them from falling in.
Is depression becoming more prevalent?
Depression diagnoses have gone up about 100-fold since the 1950s. Of course, this doesn’t mean that there’s more depression – it could just mean that we diagnose it more. Before the development of the first antidepressants, only major depression was recognised, but having effective treatments means doctors pay more attention to symptoms.
Depression can be diagnosed with symptoms of low mood lasting as little as 2 weeks. A low mood after the loss of a loved one is normal, and the concern is that reaching for antidepressants is to medicalise life. A much more useful definition is around resilience – to see if people going through a bad time have the ability to pull themsleves out of it.
Essentially, people are diagnosed as depressed if symptoms respond well to antidepressants, whereas it used to be that responses to life problems weren’t described in terms of mental health. So for example, if someone loses their job, or is bereaved, they might go to the doctor with the assumption that they are depressed, whereas their condition could also be seen as normal sadness due to a negative life event. Both patient and doctor may subconciously frame the problem in terms of a mental disorder, whereas previous generations might have just talked with friends and family, and experienced the sadness until it went away or until circumstances changed.
Mental health problems carry much less of a stigma than previously – which is a good thing, but can very easily put people on a path towards taking medicines when talking to people might have been a better path.
Do antidepressants work?
Yes, although we don’t know how much is due to the placebo effect. SSRIs comprise one of the main families of antidepressants, (including Prozac) but we don’t actually know how they work. The evidence for the ‘serotonin hypothesis’ is actually pretty scanty, partly as it’s a very difficult thing to prove. Although these drugs, ‘Selective Serotonin Reuptake Inhibitors’, are designed to make the neurotrasmitter serotonin more available in the brain, we don’t actually know if this is why people get better.
I don’t mean to ignore talking therapies – these do help, and for some provide a drug free alternative, but NHS waits are long and you need to be motivated to engage with therapy. The NHS has invested in Cognitive Behavioural Therapy (CBT), but this doesn’t suit everyone and other therapies are much harder to access.
I’m hugely concerned about jobcentres pushing people towards CBT however, especially when threats of sanctions are used. The move towards defining joblessness as a mental illness is worrying, and therapy at the behest of the state draws parallels with the misuse of psychiatry in Russia under Stalin, when disagreement with the ruling party was defined as a mental illness. Therapy must always be something people enter into voluntarily.
Other drugs work for depression too – antipsychotics such as quetiapine also lift mood, and many people self medicate with cannabis, for example. The common factor seems to be taking the mind to a slightly different place – a bit like taking a holiday. It’s getting out of your normal rut, and seeing the world from a different perspective, that seems to be beneficial in terms of depression. If you can move someone sideways so that they can see their life and their problems from a different place – that’s a powerful therapeutic tool. It can get people ‘unstuck’ from their usual thinking. This may be what antidepressants are doing, and this may be why they work, rather than any effect they’re having on serotonin.
And strong, supportive communities work too – see below. Antidepressants can definitely work, and in some cases they’re life-saving. But a lot of people come in, talk over their problems with a doctor, leave with a prescription, don’t take the tablets, but get better anyway. Maybe a diagnosis and a prescription create a little badge for them, that encourages people close to them to look after them a bit better.
So instead of disparaging antidepressants, I’d like to step back and try to work out why there are drowning people floating by, and focus a bit more on preventative measures.
What do you think are the causes of depression?
I think it has a lot to do with people feeling disconnected from power – from having no control, no power to intervene in the things going on around them. This seems to be a strong factor in terms of people’s resilience. The current febrile and polarised political climate is not helping either. Depression is a reaction to this feeling of helplessness, by taking the position ‘you can’t hurt me any more – I’m hurt enough already’. At some level there can be a passivity or even a feeling of victimhood, and a narrative gets framed around that. Moving forward from this means finding an alternative narrative that celebrates and encourages enablement.
How did we get here?
The distancing of families and loss of community ties has had a lot to do with it – social media and TV can’t replace real live people in communities. There are fewer opportunities for local interaction. As a GP, I’m sometimes the only person a patient has talked to for weeks, and possibly the only person to have touched them for years.
When a spouse dies, some older people haven’t built up a local community that they can turn to, may not have family members nearby because they’ve moved away, and are looking at a very lonely and vulnerable old age. This isn’t meant to be a call for a reactionary ‘family values’ approach, just a reflection of the fact that we need to respond to changing patterns in society and encourage groups, which often can act as surrogate families.
Pfizer brought out a questionnaire called the PHQ9, which looks at the ‘biological features’ of depression, like poor sleep, low mood, loss of enjoyment, poor concentration etc. In order to standardise care for depression, it was incorporated into the GP contract. This left practices financially penalised if GPs didn’t do a PHQ9 for people with depression, and therefore it became inculcated into clinical practice. People with a high PHQ9 score tend to respond well to drugs – and remember that this is something devised by a drug company and pushed into clinical practice by the government. This helps to medicalise depression – i.e. if you meet these criteria, you’re depressed, and here are some drugs.
Is there pressure from drug companies to prescribe drugs?
Huge pressure – yes. In the States it’s worse, with direct consumer advertising of drugs and the medicalisation of distress, rather than looking for less-profitable alternatives. It used to be the case that opiates were only prescribed for severe pain, for example with cancer; but now opiate pain-killers are more frequently prescribed for musculoskeletal pain. We clearly need to try and reduce pain, and treating acute (recent onset) pain helps prevent loss of function and the development of ongoing pain symptoms. However, strong opiates bring a signifciant risk of addiction and / or overdose, and sure enough, opiate addiction is becoming a big problem. This may be because opiates also help anxiety, and this is actually the condition that the drugs are inadvertently treating.
In the UK, prescription medicines can’t be advertised directly to the public – only to doctors. There are ways around this for drug companies though – they can operate via charities, for example. Take prostate cancer – it is counterintuitive, but there’s very little evidence of survival benefit from looking for prostate cancer if you don’t have the symptoms; but people are regularly exposed to the idea it is responsible to ‘get yourself checked’, promoted by some prostate cancer charities. If you follow the funding of these charities, you’ll often find drug companies not far behind. Injections for prostate cancer cost around £1,000 per year. This represents significant income for drug companies, as, because we don’t know at diagnosis whether prostate cancer will actually shorten life of this patient, everyone gets treated.
There is a statistical fallacy called ‘lead time bias’ which makes survival rates look better by screening asymptomatic individuals. Supposing treatment for a condition makes no difference, the date on a death certificate will be the same, whenever it is diagnosed. If you screen for prostate cancer in someone without symptoms, the patient is usually incredibly grateful that something has been ‘picked up early’, but you may not be extending their life. Making a diagnosis earlier means the apparent length of time this patient ‘survives’ cancer is longer. Starting the clock earlier makes it look like survival rates have improved, but all that has happened is we are making someone into a ‘cancer patient’ earlier.
Drug companies don’t have to do much ‘pushing’ these days however, when people have got used to the idea of antidepressants, and believe that there’s a ‘pill for every ill’.
Another example is dementia. Only around half of people with dementia have been diagnosed as such, and Cameron introduced government targets for dementia diagnosis. You could see this as the government trying to do something to help people with dementia, but the target is only about numbers diagnosed – it doesn’t measure the experience of people with dementia, the availability of respite care, whether people can die in the place they choose, or any of the things that actually matter to people with dementia. This may be less about wanting to help people with dementia, and more about government being successfully pressured by drug companies to increase numbers, because dementia drugs are expensive to develop and a ready market helps offset costs. The health secretary meets with drug companies a lot more often than he meets with doctors. We could do much better as a society in looking after people with dementia, but making communities more responsive to needs is probably a more helpful way of achieving this.
The same is happening with tech companies by the way – a lot of the newly announced investment in the NHS will go on technology of uncertain benefit, rather than on much cheaper preventative care. Health care is in thrall to whizzy, expensive, high tech medicine, hence the huge spend on hospitals rather than primary care, which is a much more cost effective way to provide care. While politicians receive donations and sinecures from the corporate sector, and as long as there exists a massive corporate lobbying industry, these things will continue.
Industry funded research is another way care provision can be biased. The Seroxat / Paroxetine saga is a case in point. GlaxoSmithKline suppressed negative results of research into its use with children, and an internal document read “It would be commercially unacceptable to include a statement that efficacy [in children] had not been demonstrated, as this would undermine the profile of paroxetine”. They were fined, but no-one went to jail. There have been, and continue to be, plenty of other corporate offenders too.
This pressure from drug companies has made health care much more expensive for fewer lives saved. Cost-effectiveness is best served by preventative measures, but they are sidelined in favour of expensive corporate products. The government produced the Cancer Drugs Fund in 2011 to fund expensive cancer treatments not deemed cost-effective by the National Institute for Health & Care Excellence. The most cost effective thing I can do as a GP to save a year of someone’s life is to invest in services to help stopping smoking – it costs around £700 to save one year of someone’s life (actually, one QALY, a ‘quality adjusted life year’, an attempt to recognise that survival and quality of life may not be the same thing). Doing the same thing using statins to lower cholesterol costs up to £20,000, and some cancer drugs costs nearer £100,000 for a year of life. Far more life-years can be saved for the same amount of money by encouarging smoking cessation, but the money gets spent on cancer drugs. When even the Daily Telegraph says ‘This mechanism for diverting taxpayers’ money to enhance, to little or no purpose, the profits of Big Pharma might be more aptly named the Drug Company Fund’ you know that it’s really all about corporate bungs.
Is ‘insanity’ just a sane response to an insane world?
I mentioned this concept to a patient recently, and she had what doctors describe as the ‘flash’, a moment of insight. She understood that maybe the problem wasn’t with her but in the society around her. When she came in, her attitude was ‘I can’t cope – I need to change’, and when she left, her attitude was more ‘no wonder I can’t cope – I need to help change society’.
[NB: the seminal book on this subject is ‘The Sane Society’ by Erich Fromm.]
How can we change direction?
We can realise how much strong communities can be a preventative factor when it comes to depression, and a strong restorative factor when people are unwell. So if someone has supportive friends and family nearby, and a job that allows them to take time off and come back to work slowly, they might be able to avoid antidepressants. The NHS is doing the best it can to help people get well again, but there’s not enough happening to strengthen communities to stop people getting ill in the first place.
The trick is to build community for everyone.
Doctors can think about de-medicalising some forms of depression, anxiety etc. I often suggest people join some of the community activities we have locally – like the ‘men’s shed’, or poetry or flower-arranging or yoga or gardening, before I’ll think about antidepressants. Often the problem is loneliness – which requires people, not pills. The exercise from getting an allotment will help high blood pressure and raised cholesterol just as much as tablets.
‘Social prescribing’ is the term used for this kind of approach, and it’s on the up. I think it will slowly become more available – it’s being supported by local commissioning groups, and it’s extremely cost-effective in NHS terms, after all, because being part of a community doesn’t cost the NHS anything, and it not only helps people with mental health issues, it makes those issues less likely in future.
Doctors like it too – the only thing that’s stopping them getting more involved is lack of time. Some places like Bromley-by-Bow are doing great things, and it is spreading across the country. It’s not some sort of new, magic answer – I was suggesting people recovering from illness spend time volunteering in charity shops rather than launching straight back into work, a long time before I’d heard the phrase social prescribing. It’s often just common sense.
What can individuals do?
I mentioned above that it’s seeing things from a different perspective that is really useful in overcoming depresssion. But it’s not only drugs that can give people this different perspective – other people are good at that too. So just sitting down with someone and having a coffee and a chat might be just as effective as antidepressants, without the potential side-effects. And of course it’s free, and it helps to build community – plus it’s usually by putting things into words that people actually get to understand how they’re feeling.
People who are most at risk are those who don’t have anyone they can have these kinds of conversations with, or worse, are surrounded by people who might frame their symptoms in negative terms. If people around you are telling you that your situation is awful and hopeless, it will be more difficult to pull yourself out of it. In some ways, the old attitude of ‘plenty more fish in the sea’ or ‘look on the bright side’, delivered in a loving way, is not that far from what talking therapies like CBT provide, in a much more long-winded way!
The view from evolutionary psychology is that when thinking about yourself, the ‘pull yourself together’ attitude is protective, in that it can prevent you from slipping into depression. It’s not a helpful narrative for people who already have depression though, because if you could snap out of it, you would. It’s important to remember that depression isn’t your fault, and if you beat yourself up when you’re unwell, it’s not going to make you any better. You have to forgive yourself, because as long as you see it as your fault, it reinforces the blame, making it very hard to move forward.
If you’re suffering from mental health issues yourself, then work out what it is that keeps you well (for me, it’s gardening, for example), and then find a local group that will allow you to do it with other people. Of course your job might not be helping. I spoke to someone recently, working in a call centre for the kind of company that sends fliers to people telling them they might have won £10,000, and to call a premium rate number to check. He was profoundly depressed, and although it was a difficult subject to broach, in the end he realised that his job was making him ill. Believing in what you do for a living is enormously beneficial for mental health.
In terms of building community, then people can join or start groups focusing on an area of personal interest – whether it’s singing, art, poetry, sport, DIY, gardening or whatever, you can be sure that there will be other people locally who are interested in it too. Anything that brings people together is good.
Are you optimistic?
I am, because there’s been a huge change in attitudes, perhaps especially in the UK. It’s not about having a stiff upper lip any more – we’re all encouraged to talk about our feelings. I believe that social prescribing will become more prevalent, and allow us to sidestep corporations more easily.
At the moment, if the only response doctors have is antidepressants, then any distress starts to look like depression. If we have other ways of addressing issues, we can offer an alternative to medication. Basic antidepressants aren’t expensive, but lack of community might mean mild problems become worse, and for major symptoms, the drugs become much more expensive.
There are a growing number of organisations providing community care – for example, Orchard Origins in Herefordshire, who take people with mental health difficulties and they go out and prune old orchards. They maintain orchards, and make cider in the autumn. It works. There are hundreds of suitable activities that can have the same effect, depending on personal interest. Having a range of options seems to be the important factor – a sense of shared purpose is what makes a group & ultimately helps build communities.
I hope that in 10 years time, antidepressants will only represent a small percentage of the options available for treating depression or anxiety. Drug companies will continue the search for profits, but we’ll have to deal with that as well.
Is the problem systemic, rather than just in the health sector?
Yes – it’s the corporatisation of everything, although of course I’m looking at it from a health perspective. For me, Huxley’s ‘Brave New World’ provides a useful warning, where everyone ends up taking ‘soma’, because it allows you to put up with a crappy society. It’s the same message historically peddled by the church, and more recently the National Lottery – put up with a bad situation now & things will get better one day. Don’t make a fuss and aim to go to heaven / win the lottery / marry a rich footballer. In the meantime, it’s a very potent way to discourage attempts at change.
At the moment, we have a situation where close to 50% of teenage girls in the UK will self-harm to some extent. I can’t see any way to avoid the conclusion that there’s something wrong with a system in which that happens. I don’t believe that this would happen at such scale in a healthy system.
What can we do about that?
PSHE (personal, social and health education) classes in schools are important in building resilience; and actually, resilience is a bit of a buzzword at the moment. It basically means being able to cope with bad stuff – but how about not subjecting people to these stressors in the first place? So focusing on resilience might distract us from looking at the cracks in our society, and how we might change it.
Talking of young people, possibly the most important thing they need is a support system – and maybe a resurrection of the old idea of apprenticeships – mentoring by adults outside the immediate family help to teach them how to become adults. An adult role model that a young person can look up to is extremely helpful in producing healthy young adults and a healthy society.
Building community is vitally important. I think the NonCorporate position is right – that multinational corporations take wealth out of communities, and prefer people to live in nuclear families so that each unit has to buy all the kit they need to operate properly. Sharing things and doing things for each other within communities doesn’t suit corporations, whose existence is predicated on a need to make as much money as possible, competing with other corporations for market share.
So I think that the current crop of community land trusts, community energy and community-supported agriculture schemes, and all the other new kinds of institutions that build community are really important. NonCorporate.org is a useful tool to help people disengage with the corporate world and to help these new institutions to flourish.
Dr Simon Lennane is an NHS GP in a market town on the Welsh borders, with an interest in mental health and wellbeing.