To reduce the rising burden of mental disorders around the world, the Lancet Commission on Global Mental Health and Sustainable Development has declared a need to increase psychiatric services globally, which should include an effort to “reduce the cost and improve the supply of effective psychotropic drugs for mental, neurological, and substance use disorders.”
While reducing the burden of mental disorders is certainly a laudable goal, we believe that implementing this plan will increase the global burden of mental disorders rather than decrease it.
Following the American Psychiatric Association’s publication of the third edition of its “Diagnostic and Statistical Manual” (DSM III) in 1980, there has been a remarkable expansion of the psychiatric enterprise in the United States and other developed countries. That expansion, which included dramatically increasing the use of psychiatric drugs, offers a lesson from the past that helps predict the effect of a planned “global” expansion of psychiatric services.
After DSM III was published, the main models of depression and other major mental disorders held that they were brain illnesses caused by chemical imbalances, and that psychiatric drugs could help fix these imbalances. The antidepressant Prozac, the first serotonin-specific reuptake inhibitor (SSRI), hit the market in 1988. It was touted as a wonder drug, and our society’s use of antidepressants and other psychiatric drugs soared. Today in the United States, more than one in five adults — and more than one in 20 children and adolescents — take a psychiatric drug on a daily basis.
Yet even as more and more people have been getting medical treatment for psychiatric disorders, the number of adults on government disability due to these disorders has more than tripled since 1987. The number of children so disabled by psychiatric disorders has increased more than 30-fold during this period.
The same correlation is seen in country after country that has adopted widespread use of psychiatric drugs and, in particular, the regular use of antidepressants. These countries have all seen sharp increases in disability due to mental disorders.
While this rise in disability may be due to many factors, there are two ways that increased use of antidepressants can contribute to it. Although antidepressants may provide a small benefit over placebo over the short term, there have now been a number of studies concluding that these drugs increase the risk that a person will become chronically depressed over the long term. Researchers have dubbed this drug-induced worsening “tardive dysphoria,” meaning that SSRIs are causing a biological change that often leads to persistent dysphoria, a state of profound unease or dissatisfaction.
In addition, one of the risks of taking an antidepressant is that it can trigger a manic reaction. When this occurs, the individual may be diagnosed with bipolar disorder, which is seen as a more serious illness than depression. A large study done by Yale investigators found that taking an SSRI antidepressant more than doubles the risk that a depressed person will convert to bipolar disorder.
Much of the Lancet report focuses on expanding psychiatric services in less-developed countries, where the “treatment gap” — the gap between the number of people suffering from a disorder and the number getting treatment for it — is greater than it is in developed countries. However, for the past 20 years, there has there has been an ongoing effort to “globalize” mental health care, which has led to the increased use of psychiatric drugs in these countries. We have already seen the impact of that expansion. As the Lancet report acknowledged, the burden of mental illness has been rising in “all countries.”
In short, there has been an expansion of psychiatric services globally over the past 35 years, which has led to a dramatic increase in the use of antidepressants and other psychiatric drugs. At a public health level, that approach has not worked. The Lancet report, in fact, acknowledges this failure. “A recent analysis of data from 1990 to 2015 from four high-resourced countries (Australia, Canada, England, and the U.S.) show that the observed prevalence of mood and anxiety disorders and symptoms has not decreased, despite substantial increases in the provision of treatment, particularly antidepressants, and no increase in risk factors.”
The changing outcome for schizophrenia in developing countries provides another example of the perils of exporting Western ideas about psychiatric diagnosis and treatments to other parts of the globe. In the decades before 1990, the World Health Organization conducted two studies that compared outcomes for people with schizophrenia in three developing countries (India, Nigeria, and Colombia) with outcomes in the United States and five other developed countries. In each study, the WHO found that outcomes in the developing countries were better — so much so that the investigators concluded that living in a developed country was a strong predictor that a person diagnosed with schizophrenia would not have a good outcome.
One of the big differences between developing and developed countries was that patients in the developing countries used antipsychotic medications only for short periods, while those in developed countries used them long term. Only 16 percent of patients in the developing countries took antipsychotics long term.
About 20 years ago, however, pharmaceutical companies began marketing atypical antipsychotics around the world. The results of that effort are now becoming clear. In a recent study funded by Eli Lilly, in which patients with schizophrenia in 37 countries were maintained on antipsychotics for three years, the better outcomes in the developing countries disappeared. They were now as poor as in the developed countries.
Any call for improving global mental health needs to recognize two facts: First, there are commercial forces at work in this enterprise, which urge more access to psychiatric drugs. Second, as the globalization of mental health has unfolded over the past several decades, the burden of mental disorders has increased in tandem. Without such recognition, proposals for closing the global treatment gap risks further exporting a failed paradigm of care.
The fatal flaws in the report could have been avoided if it had been created by a more diverse group that included international leaders with lived experience, including people from Asia, South America, and Africa. It should have included academics and researchers who have critically examined the scientific evidence regarding the merits and long-term effects of psychiatric drugs. And it should have included leaders of international recovery movements, such as the Hearing Voices Network, in order to incorporate their thoughts on what has been most helpful.
While the Lancet report is to be commended for acknowledging the importance of social and economic factors on mental health, the fact that it doesn’t investigate the public health failure of the past 30 years, which has unfolded even as the global market for the use of psychiatric drugs has expanded, puts it into the category of a potentially harmful document. It promotes more psychiatric treatment on a global scale without making the case that this will lower the burden of mental disorders worldwide. Indeed, it is easy to make the case, as we have sought to quickly do here, that “closing the treatment gap,” when treatment includes increased use of psychiatric drugs, will likely make things worse.
Robert Nikkel is director of Mad in America Continuing Education and a former state mental health commissioner. Robert Whitaker is a journalist, author of three books about the history of psychiatry, and publisher of the Mad in America webzine.