More treatment,but what kind of treatment? A response to Mulder,Rucklidge and Wilkinson

To the Editor

Mulder et al. (2017) raise an important concern about possible harm our current mental health systems may be causing. I believe we must consider whether the tremendous increase in the provision of one form of treatment, namely the prescription of psychiatric medications, is actually one of the reasons why mental distress in the population isn’t decreasing. This unpopular proposition has been repeatedly made in the past, and we ignore it at our peril.

Psychotropic medications may recruit compensatory brain processes that oppose the initial, positive effects of the drug. For this reason, prolonged use of medications may worsen, at least in some cases, the patient’s long-term clinical and functional outcome. Depressed patients treated with medications do not fare any better in the long run compared to those who are not medicated, and there is now evidence from a 9-year follow-up study that they may actually fare worse (Vittengl, 2017). Similarly, schizophrenia patients maintained on antipsychotics may experience more frequent and severe relapses, be more disabled and more socially dependent compared to those who are medication-free. Many schizophrenic patients disengage from psychiatric services, but when followed-up over decades, many of them fare remarkably well without medication (Harrow et al., 2012).

Alternatives to our excessive reliance on medication do exist. Improving Access to Psychological Therapies (IAPT) is an English initiative to increase the provision of psychotherapy for anxiety and depression by primary care organisations. The latest annual report found an average recovery rate of almost 50%. The Finnish Open Dialogue approach to first-episode psychosis is based on psychotherapeutic treatment for all patients within their natural support systems, with minimal use of antipsychotics. After 5 years of follow-up, 82% of patients had no symptoms and 86% had returned to their studies or full-time employment.

Yet in most other healthcare systems, antidepressants are routinely offered as first-line treatment for patients with even mild depressive symptoms, with no good evidence of benefit. Antipsychotics are offered to all psychotic patients and maintained indefinitely in schizophrenia almost without exception. Only a minority of patients receive psychotherapy. With such a rigid and mechanical approach that fails to fully consider the harms our medications may cause, and with our lingering failure to embrace more holistic, highly effective approaches, perhaps we shouldn’t be surprised that at a population level, the treatments that we provide simply don’t seem to work.