The limits of psychiatry

Abstract

Growth in mental health service activity and technology Despite the reduction in psychiatric beds in England over recent years (fig 1), mental health service activity has increased considerably. The annual number of antidepressant prescriptions, for example, has more than doubled over the past seven years (fig 2). Similarly, the number of consultant psychiatrists has more than doubled over the past 22 years (fig 3). View larger version: In this window In a new window Fig 1 Average daily number of available mental illness beds in England (excluding beds for children and elderly people). Source: NHS hospital inpatient data View larger version: In this window In a new window Fig 2 Annual number of prescriptions for antidepressants in England. Data from NHS prescription cost analysis View larger version: In this window In a new window Fig 3 Number of consultants in psychiatry in England over past 25 years. Data from NHS medical workforce statistics As the number of psychiatric beds has decreased, the number of people in prison with a mental disorder has risen, with a higher proportion of women inmates having mental health problems than men.7 Authors in the United States suggest that prisons are replacing mental hospitals, but the data could be explained either as the “psychiatricisation” of criminality or as the increasing diagnosis of mental illness in prisoners not previously recognised as being mentally ill. As more resources have been provided for mental health services, more resources are perceived to be needed.8 Disillusionment is inevitable in a system of mental health care where an increase in professional staffing cannot completely resolve the perceived unmet need of the population. Demand is unavoidably high as mental health problems are common. The proportion of men and women with a neurotic disorder in a given week was found to be 12.3% and 19.5% respectively in the psychiatric morbidity survey, the largest epidemiological study of the prevalence of psychiatric disorders conducted in the United Kingdom.9 As the expectation of solutions to mental health problems rises through the increasing availability of the mainstay psychiatric treatments (psychotropic drugs and “talking” therapies, such as counselling), the traditional boundaries of psychiatric disorder have broadened. Everyday problems regarded as the province of other social spheres become “medicalised” by psychiatry. Mental health care may function as a panacea for many different personal and social problems. The diagnosis of attention-deficit/hyperactivity disorder in children, for example, has increased dramatically over recent years, paralleled by an increase in the prescription of stimulant drugs in the United States.10 This trend is also apparent in England and is likely to be reinforced by recent guidelines from the National Institute for Clinical Evidence.11 The behaviour of children in whom attention-deficit/hyperactivity disorder is identified overlaps with behaviours commonly displayed by children when they feel frustrated, anxious, bored, abandoned, or in some other way stressed. The obvious critical view is that the social phenomenon of mass drugging of children indicates not a genuine increase in mental disorder but rather a displacement strategy for the difficult task of improving family and school life. It is indeed likely that recourse to drug treatment discourages self responsibility and thereby exacerbates the underlying difficulties that it is supposed to remedy. Attention-deficit/hyperactivity disorder has also become established over the past 10 years as an adult disorder, and it is now regarded by some as the most common chronic undiagnosed psychiatric disorder in adults.12 The expansion of psychiatry is also reflected in the marketing of selective serotonin reuptake inhibitors for neurotic conditions other than depression. Paroxetine, the drug with the greatest net ingredient cost to the NHS in England in 2000, is now approved in the United states for use in multiple disorders: depression, generalised anxiety disorder, social anxiety disorder, panic disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. Selective serotonin reuptake inhibitors have even been promoted and used as lifestyle drugs.13 Two disorders illustrate further the process of medicalisation. Firstly, social anxiety disorder could be seen as the process of medicalising shyness. The disorder is characterised by a marked and persistent fear of social or performance situations in which embarrassment may occur. It is said to be the third most common psychiatric disorder in the United States, after major depression and alcohol dependence. Lifetime prevalence has been estimated at 13.3%.14 Some claim that the condition is not just ordinary shyness and that it is a common public health problem.15 None the less, although definitions of the syndromes of shyness and social phobia may differ, the distinction is difficult to make empirically. Furthermore, we should be sceptical about the potency and benefits of drugs for this condition. Secondly, the diagnosis of post-traumatic stress disorder was officially recognised after an essentially political struggle to acknowledge the suffering of the Vietnam war veterans. Subsequently, the diagnosis has become increasingly associated with less extreme experiences, encouraged by compensation claims for psychological damage. However, medicalisation of traumatic human suffering runs the risk of reducing it to a technical problem. Providing debriefing and counselling, for example, may not be the most appropriate focus of humanitarian relief operations in wars and other disasters.16 Box 1: Nine beliefs summarising the perspective of the neo-Kraepelinian approach19 Psychiatry is a branch of medicine Psychiatry should use modern scientific methods and base its practice on scientific knowledge Psychiatry treats people who are sick and need treatment...