3.1 Mental health as business: introducing the debate

Dr Harvey Gordon is a Forensic Psychiatrist who has been a Consultant for eighteen years at the Broadmoor High Security Hospital and is currently a Consultant at the Maudesley Hospital in London and Jim Read has worked for many years in organisations and networks of mental health service users and survivors as a Consultant, a Trainer and a Writer. Jim, if I could start with you. Perhaps you could just give us some idea of your personal experience?

Yes. It is many years ago, starting when I was five years old when I was put on sedatives by a child doctor, I believe at the request of my parents and then mainly in a period when I was a young adult in the early 1970s when I had a period of time when I was in one of the old psychiatric hospitals on medication and I guess at that point seen as a long term patient, except I managed to get out of that situation, spend some time in a therapeutic community, and for many years now haven’t had anything to do with psychiatry as a service user or patient.

Although you are working with people who do have those experiences?

Absolutely, and my entire incentive to be involved in this came from my own experience. I felt that there were a lot of people who were kind of languishing, if you like, in the mental health system as it was then, who, if they had some breaks, could get out and have a decent life and I wanted that to happen. So about twenty years ago I kind of made that decision, ‘this is what I want to do with my life’.

And Dr Gordon, of course you are involved in the delivery of mental health services. To what extent do you feel that those mental health services are delivered as a business, using business as a model. Are services actually delivered in that way?

Well there has been an increasing trend over the last ten to fifteen years in that direction, but it creates a certain tension because certainly since the establishment of the National Health Service in 1948, the main principle whether it was physical ill health or mental ill health, was that a patient should receive the treatment that he or she requires irrespective of any financial factors. At the same time the Health Service has to work within a budget, and of course in that regard one can say it is affected by financial factors. I’d be reluctant to think of myself as working as a businessman. I don’t wish to operate in that way. The National Health Service is still a public service run largely according to patient need. It is not run according to business principles.

But isn’t there an argument that we get a postcode lottery when it does come to delivery of services because of budgets?

Yes, and I think that the current government have made efforts to try and begin streamlining of services with various organisations such as the National Institute of Clinical Excellence which now advises on prioritisation of treatments and that advice, although it is not binding on every region, there is an expectation that it will be taken fully into account.

Jim, what do you think about the service delivery as a business?

I don’t think budget constraints is the key issue in mental health and it strikes me that people often have better outcomes in countries where less is spent on mental health in poorer countries. What I do notice is that the governments are always reorganising the National Health Service endlessly and that managers seem to spend most of their time reorganising rather than actually thinking about the service that they deliver. But if you are a patient, what really matters is where you have to go for treatment and what you’re given. The major change that has happened in the last decade about that is that increasingly people are treated in the community and that’s the sort of thing that actually matters to patients, not whether this one’s purchasing from that or this one’s delivering this service or what inspection systems you have. To be honest they don’t make a whole lot of difference other than they preoccupy people.

But isn’t there something to be said for standardisation across the board?

Well, standardisation, I think, is an interesting issue in mental health because the two things that are never standard are the patients and the practitioners. One of the things the government’s introducing at the moment is things like home treatment and assertive outreach teams across the country. Now I think there are some very good home treatment and assertive outreach teams, but that doesn’t necessarily mean that they are the ones that are being reproduced, because actually so much in mental health depends on the people who are providing the service and their attitudes and their skills and their orientation and you can put someone who doesn’t relate well to a service user in any team and give it any name and any function, it won’t be any good. You put someone really good in the worst ward or give them any job title, they would do a good job, so you can’t standardise people.

You can’t standardise people, but are people getting a choice?

No. I think there is some limitation of choice in regard to mental health. The system is largely arranged by catchment area and it’s not impossible, but it is almost impossible to be treated by a psychiatrist and his or her team outwith that catchment area unless you go privately. So in a sense there isn’t a great deal of choice. The second problem about choice is that we have to face the tension of where a doctor feels that the right treatment for a patient is X and the patient thinks it is not X but Y. What do you do then? Is there an expectation that the psychiatrist must operate according to the patient’s preference?

Jim?

I think choice can be overrated, I think one of the problems of modern society is there is often too much choice. The fact is that the first time you have a mental health crisis, you are not an expert on the range of treatments that are offered and you want someone to guide you and tell you and to be an expert and to offer you what’s best. So to that extent, I don’t think choice is always the thing that we should go for. I think where choice is applicable particularly is people who use services over a long period of time often do become knowledgeable, first of all about treatments and services in general but also often about what particularly suits them or works for them. So I think that’s where I would like to see more choice and one of the ways you can also do that I think, is by people having direct payments, as is much more widespread with disabled people, with physical impairments. You get a budget that’s assessed as being appropriate and then you determine how it is used and have the flexibility to do that. That really puts you in the driving seat in a way that you’re not with the kind of monolithic NHS type services where basically you go there and see that doctor or forget it.

Patients put in the driving seat, but where do the pharmaceutical companies come in?

The drug companies they are a business, I think they openly say that they market their medicines for financial gain but at the same time they have to produce medications which doctors are willing to prescribe and which patients are willing to take, so it is a market but it’s one which is dependent on the professionals and the public who become mentally unwell finding those medications helpful.

But isn’t there a question of them as businesses creating a market?

That has been argued that certain mental conditions are not really mental conditions at all, but socially constructed. I’m really not convinced that just changing the words for what at the end of the day is considerable subjective distress and whether one calls it a disability, a condition or an illness, these things tend to change historically. I suppose one could argue that the distress is engendered by particular societies thinking that something is a disorder and then twenty to thirty years later the same thing is under reconsideration, is no longer regarded as a disorder. I suppose the best examples of that might be some of the sexual disorders, homosexuality which would have forty years ago both been regarded as a mental disorder in the international classifications and as a crime and now is neither. So it is true that societies themselves can alter what they think is or is not a mental disorder over time.

But can’t that work in the opposite direction too, in that something that people would simply have lived with and addressed within the community, then gets a label and becomes treatable?

I suspect that people’s expectations of happiness and contentment have risen possibly beyond what is realistic so that people are kind of demanding to be helped when perhaps they might have suffered you know and you can argue about which is the best deal there and that partly perhaps depends on the effectiveness of the help. I also suspect that we’re creating more discontent and unhappiness by kind of having a more fragmented and individualistic society, which is more unequal, so I think probably actually the levels of distress in society, in kind of what people usually call advanced capitalist societies, are rising anyway.

But let’s look at the kinds of drugs that are prescribed. For instance antidepressants, isn’t there a danger of an over prescription because of what you have said about people’s expectations of help as opposed to suffering, but isn’t there a danger that drugs are used and not necessarily the underlying cause of that distress examined?

Well it is always possible but that’s why there are national and international definitions of what depressive disorder actually is and its variants. Now even if you can identify certain stresses within the person’s life or in the environment which has contributed to the person feeling depressed, it doesn’t necessarily follow that you can’t help to relieve what has been engendered by that stress by biological means. In addition to any environmental assistance, helping with any family conflict, if there’s financial problems trying to help with housing issues, all these things are part of modern mental health care in addition to, where appropriate, the medication being prescribed.

I’m not saying that people are going to doctors with minor things and getting antidepressants, when people talk about the “worried well” or something I think that is insulting to the level of distress which people experience. But the fact is that the use of antidepressants over the last ten or fifteen years has escalated and you have to think why is this? What are we doing wrong? What are we doing wrong in either GP surgeries or in society in general? There has to be a big problem if that’s happening, but no one seems to be that interested and of course the drug companies are in a sense delighted. I‘m not convinced about any form of medication actually, I think that it can be quite beguiling because for some people they will experience symptom relief as a result of taking medication, but often once you start taking it, it stacks up problems for later. I was interested to just come across quite recently a review of fifty years of research into neuroleptics which are the drugs that are given for example to people who have a diagnosis of schizophrenia and the conclusion was that overall, the widespread and long term use of neuroleptics with these people has caused more harm than it has helped.

You have also said that in some countries where less money is spent on treatment, the results are, I can’t actually remember how you put it, but what is your argument for less money being spent on treatment?

I am not arguing for less money being spent, but what I am saying is that the World Health Organisation found that actually outcomes for people who qualify if you like, for a diagnosis of schizophrenia, which is a very dubious diagnosis anyway as far as I’m concerned, are actually much better in poorer countries than they are for example in countries like England. There may be a whole load of factors there. One of which is that less psychiatric drugs are used there and that may be the key one, you also have to say that without kind of resorting to cliché and stereotyping, that perhaps people experience less stigma and alienation as a result of having those sorts of distresses in those countries than they do here. Which would then point the way to a much more community based mental health service than the one that still, I think, predominantly looks to drugs as the main form of treatment. I think there are many different ways of dealing with distress and there’s plenty of evidence that the sorts of ways that you can research, like psychological therapies are more effective and also much less likely to be harmful or dangerous or dammed unpleasant, all of which can be said about psychiatric drugs. But beyond that in a sense there is everything that the world has to offer, if only we could find a way of bringing that into people’s lives and then of course a medically based NHS service isn’t going to do that.

My experience respecting Jim Read’s views that he has just expressed on this, are that in many of the cases that reach hospital, and my practice is both in the community and in hospital, the degree of debilitation to the person and not only to the person but to those he’s living with, the people that are looking after him are sometimes worn out. In fact sometimes they complain that we don’t admit the patient when they don’t know any longer what to do with him. The longer that the person remains untreated or under treated, the more likelihood there is of much more serious developments. The experience I think uniformly of psychiatrists who work in this field, that we are called upon all the time to intervene preferably with the patient and the carers agreement, regrettably from time to time without it and that’s unfortunate but it’s a repercussion of the fact that mental illness is not always the same as physical illness, the person as they get more and more unwell they lose the objectivity of their judgement and they do things which in their normal state of mind they wouldn’t do.

But once that intervention is made, how important is it to get the balance right between treating the condition with drugs and treating with alternatives?

Well, I think Jim’s right that throughout the whole drug era, since the early ‘fifties, we’ve used cognitive therapy, we’ve used behaviour therapy, we’ve used dynamic psychotherapy, which indeed started before the drug era, and all these things are used now usually in combination with medication, sometimes instead of. But the argument simply does not conform to my experience, which is not to say that Jim is wrong, but it is simply out with my experience that in all cases, non- medication type interventions results in a successful resolution of all this distress and symptomatology.

What changes would you like to see to the delivery of mental health services in the next five years? What do you think is the key thing that you’d like to see changed and why?

I suppose I’d start with things not getting worse and that means the government getting rid of this ridiculous mental health bill, which they keep kind of threatening us with, which would mean more people being forced to take medication that they don’t want. I think it would mean let’s stop giving amphetamines to children which is a kind of current new trend and do something about the escalation of antidepressants. That would be a good start. I’d like to see far more staff trained to use psychological therapies and I’d like to see the knowledge and wisdom of people who have had a diagnosis of mental illness and find ways out of the role of being long term service users, to be really made use of and this whole business of what expertise people do have because they’ve been in the system, being used properly, not as a kind of tokenistic add on user involvement exercise that everyone has to tick a box to say that they’ve done, but as something that actually drives and forms a new mental health service which is not reliant on psychiatric drugs.

Dr Gordon?

I certainly entirely support the view that the mental health professionals need to listen. At the end of the day I think it’s our obligation to use our training and experience which does at the moment include a prominent role for medication, I would be defensive of that. In fact, I would say that if you said tomorrow that the psychiatric profession can carry on treating mentally ill people, but you cannot use medication anymore, you have to use other means, then I think we would be considerably disadvantaged and so would the patient population and I don’t think that anyone would thank us for that at the end of the day. If you would to say to me, ‘you cannot use medication anymore’, I would feel that I would not have enough confidence that many of my patients would recover sufficiently. Because I see everyday, I see these treatments working. Now I think Jim is quite right to say that there are side effects, in fact if you have cancer as a life threatening condition and we shouldn’t forget that mental illnesses can be life threatening conditions, there can be suicides, there can be accidents, rarely there can be homicides and there is quite morbidity associated with mental ill health. So I think it is vital that we recognise that these illnesses are very powerful and in order to combat them we have to have powerful means to do so.

They’ve not been very successful have they? We seem to be kind of focusing at the moment on what the government will call long term and serious mental illness. Drugs never cure anything, people often do not like taking them, they’re often pretty dangerous, they can kill people, people kill themselves while on medication and people relapse on medication.

Well, I have no doubt that the relapse rate is far lower when a person who is suffering from a mental illness is on the appropriate medication. All of the studies on suicides, completed suicides, have shown that the patient was either not on antidepressants at the time or was on a very inadequate dosage. It is true there are some suicides who are on ordinary doses of antidepressants, but not many.

Well, it’s true that people use their antidepressants to kill themselves and it’s also true that people, who have used the so-called modern antidepressants, have sometimes actually developed suicidal symptoms as a result of taking them.

There, unfortunately, we have to leave it, gentleman. Jim Read and Dr Harvey Gordon, thank you.