Licence to Pill


There’s a joke from Samuel Goldwyn that goes: anyone who sees a psychiatrist should have their head examined. It sums up the transactional nature of power – how in some ways psychiatrists are like any other guru – that is, they have power because you give it to them. If you’re feeling helpless, here’s someone you can imagine has all the answers you seek.

Unlike your average guru though, psychiatrists – and mental health services in general – also have another kind of power, one you can’t easily revoke when you decide you want to find help some place else. As part of the medical establishment, they have a great deal of institutional authority, including the power to suspend your human rights, and to force you to receive treatments against your will.

If you disagree with your psychiatrist, that’s just another sign you’re crazy, right? But what if that’s not true? What if over time, our insistence that ‘doctor knows best’ has become a barrier to understanding madness? These aren’t easy questions to answer, but they have far-reaching implications for how we view mad and distressing experiences in general, whether you’re at the pointy end of the system, or picking up your first script of antidepressants.

Some say we’re on the cusp of a collective, global mental health crisis. The prestigious Lancet journal called the worldwide rate of mental health issues “a striking and growing challenge” to health systems (Whiteford, et al, 2013). New Zealand’s Mental Health Commission says we need to increase access to mental health services over the next decade, even as funding will become “tighter and more difficult” (Mental Health Commission, 2012). Perhaps some breakthrough in medical science will solve this looming mental health dilemma? That’s certainly the promise of each new antidepressant or antipsychotic on the market: more benefits, less side effects.

At the same time, however, there’s something of a crisis within psychiatry itself, and some are starting to question the basis of its authority. Indeed, amidst the dire projections, the Mental Health Commission says our best hope is a society-wide approach to mental wellbeing. Following their lead, perhaps it’s not a medical breakthrough we need, but a social one.

Let’s look at the main tool in the psychiatric toolkit: medications. Recent studies show that drugs are no more effective than placebo for treating depression, and this applies both to the mild and severe ends of the spectrum (Andrews, 2001; NICE, 2009; Fournier et al, 2010). Take that in for a moment. Stick to the sugar pill, and you’ll likely get the same outcome.

As for the things we call ‘severe mental illness’ – hearing voices, delusional thinking – a whole series of trials has found the effects of drug treatments to be “disappointingly limited” (see Bracken et al, 2014). Then consider the catastrophic health effects of long-term antipsychotics, including heart disease, liver failure, and a host of other issues. What happened to ‘first do no harm’? In the case of ECT – shock treatment – one study found that “sham ECT” was actually more beneficial than the real thing (Rasmussen, 2009). Without the risk of memory loss to boot.

Now, this isn’t to say these treatments don’t work, per se. People on the real pills and people on the placebo both got better – just not because of what’s in the pill. Pat Bracken, one of the founders of the Critical Psychiatry Network, has an interesting take on this. I cornered him at a conference last year, after his keynote completely shook my smug, preconceived notions about his profession. We talked about this placebo thing – how maybe it’s the sense of hope you get from receiving treatment, or maybe the benefit of a good relationship with your treating team. And how maybe people get better because, well, people get better.

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