Why We Worry

Where anxiety comes from—and what we can do about it

Overprescribing Drugs to Treat Mental Health Problems

10 reasons why drugs shouldn't be a treatment of choice for mental disorders

We hear so much these days about how psychotherapies can help people with mental health problems. But the most recent figures tend to suggest that as many as 57% of people with mental health problems are being treated solely with medications without any form of psychotherapy. And that figure is not going down—it’s going up!—up from 44% to 57% between 1998 and 2007. In addition the pediatric use of SSRIs has risen significantly between 1994 and 2000, largely to treat childhood anxiety and depression, and has often occurred without regulatory approval.

 So is drug treatment alone an effective way to treat mental health problems? To be sure, there are at least some people who benefit from some drug treatments—especially if they suffer from acute mental health problems that they are likely to recover from relatively quickly.

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 However, there are numerous good reasons why drugs alone should not be the reflexive treatment of choice for many mental health problems, and I’ve listed some of these reasons below.

 1.       In the case of some mental health problems, such as depression, between 50-60% of individuals taking anti-depressant drugs do show improvement, but in many cases, drug treatments are associated with an increased risk of subsequent relapse, and a more effective treatment might be to combine drug treatment with psychological therapies.

 2.       Treating some common mental health problems with drugs from the outset may effectively “medicalize” them, turning what might have been short-term acute bouts into a longer-term chronic problem. For example, almost everyone knows someone who has been on antidepressants for most of their life. Good business for the pharmaceutical industry, but are those drugs having any significant effect on symptoms over the long-term?

 3.       Prescribing drugs at the onset of a mental health problem perpetuates a medical model of mental health that may lead many sufferers to believe their recovery is now out of their hands and in the hands of medical experts. This is akin to labeling a mental health problem a “disease”, and this can have very significant negative effects on the sufferers ability to self-regulate and self-help. For example, studies show that recent attempts to label obesity as a “disease” actually has a significant negative effect on self-regulation of obesity symptoms.

 4.       Unfortunately, most current diagnostic criteria for mental health problems are categorical rather than dimensional. That is, the criteria indicate that you will either be diagnosed with a mental illness or you will not (the categorical approach). In contrast, the dimensional approach suggests that mental health symptoms are on a dimension from mild to severe. The current categorical model is perfect for conceiving of mental health problems as "diseases" that have a diagnostic ‘cut-off’ point, and this conception brings with it all the problems described in point 3. In addition, it is also a perfect scenario in which pharmacological companies can promote the use of drugs to treat mental health problems as "disease categories."

 5.       Drug companies need to sell drugs to survive, so will have an incentive to invent new disorders to generate a market for new drugs. Very often this may lead to the medicalization of perfectly normal emotional processes, such as bereavement. A good example of the way in which normal psychological processes can be surreptitiously medicalized and made to appear ‘abnormal’ in order to create markets is in the example of the female menopause.

 6.       One obvious—but important—downside to many drugs used to treat mental health problems is that they often have significant and distressing side-effects. These side effects can be physical and include fatigue, blurred vision, gastric disorders, headaches, dizziness, sexual dysfunction, risk of cardiac disorders, and weight gain. In many cases (such as antipsychotics) these side effects are significant enough to make up to 50% of those taking medication stop taking them. But apart from medical symptoms, some pharmacological treatments can also increase psychological symptoms such as anxiety, suicidal ideation, and even increase suicide attempts (especially in young adults).

 7.       A number of studies have suggested that there may be a significant publication bias in randomized controlled trials (RCT) reported by drug companies. For example, RCTs assessing the effectiveness of drug treatments are significantly more likely to report a positive effect if the study was funded by the pharmaceutical industry than if funds came from non-industry sources. This tends to suggest that drug companies may not publish studies that show that their drugs are ineffective! And this bias is also likely to significantly over-estimate the effectiveness of drugs for mental health problems.

 8.       While prescribing drugs for mental health problems may have a short-term palliative effect, drugs don’t obviously help people to change the way they think or change the socioeconomic environments that might be a root cause of their psychological problems. We know that negative and biased ways of thinking can maintain common mental health problems such as anxiety or depression—these important factors need to be addressed with psychotherapy—not drugs. Helping an individual with mental health problems to rise above difficult socioeconomic conditions is challenging within any kind of treatment approach, but multidisciplinary teams of mental health professionals are increasingly able to help clients with a broader range of psychological and socioeconomic problems.

 9.       Sadly, many of those health professionals (GPs and family physicians) at the first point of contact with people suffering mental health problems are poorly trained to identify psychological problems in their patients, and have little time available to devote to dealing with these types of problems. This increasingly makes medication prescription an attractive option for doctors whose time-per-patient is limited—an outcome which will have all the potential negative effects of medicalizing the problem into a "disease."

 10.     At present we don’t have any wealthy "multinational psychotherapy conglomerates" to match the financial clout of the pharmaceutical industry, so when it comes to "selling" treatments for mental health problems, drugs will always have the marketing advantage regardless of whether they are more or less effective than psychological therapies. That’s an uneven playing field that needs to be addressed.

 These are just some of the reasons why we should be wary of the increasing trend of treating psychological problems with medications, and in many cases medications without accompanying psychological help and support. There are certainly attempts being made in many countries to increase access to psychological therapies for those who need them, but while mental health is still viewed primarily as a medical problem within health care systems promoting medical models, little is likely to change rapidly.

Graham C. L. Davey, Ph.D. is an expert in anxiety and a professor of psychology at the University of Sussex, UK.

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