The use of antidepressants rose significantly in England during the financial crisis and subsequent recession, with 12.5m more pills prescribed in 2012 than in 2007, a study has found.
Researchers from the Nuffield Trust and the Health Foundation identified a long-term trend of increasing prescription of antidepressants, rising from 15m items in 1998 to 40m in 2012. But the yearly rate of increase accelerated during the banking crisis and recession to 8.5%, compared to 6.7% before it.
The report also found that rises in unemployment were associated with significant increases in the number of antidepressants dispensed and that areas with poor housing tended to see significantly higher antidepressant use.
Nick Barber, director of research at the Health Foundation, said that the report, published on Wednesday, was the “most accurate and insightful study of medication in this area in this country” and raised questions about whether people were being treated appropriately.
“The rate of increase in prescribing had been still for some years and does seem to have increased from 2008 so it would suggest that recession and some of the associated problems such as unemployment could be part of it,” he said. “If depression has increased as well as the prescribing the question is: ‘Is it being treated properly?’ There’s also an economic question at the time of recession as to whether we’re using our medicine resources as well as we could be.”
The report says a rise in unemployment and in the cost of living during the recession “could have an impact on the prevalence of mental health problems and require changes in the service delivered”, although it does not specify what those changes should be.
The increase in prescribing was despite the coalition government providing extra funding for the Improving Access to Psychological Therapies (IAPT) programme, introduced by Labour in 2008 to help people in distress access talking therapies. “The question is whether that is just because it’s a relatively young service or whether it reflects that there are delays [in accessing IAPT],” said Barber. “If you’re a prescribing GP with a distressed patient, if you know there’s a delay in this service, I am sure you will be more likely to prescribe antidepressants.”
An NHS report published in January found that while GPs made 883,968 referrals for psychological support in England in 2012-13, only 49% of them led to someone suffering from mental health problems starting treatment.
The Focus on Antidepressants prescribing report, part of the Nuffield Trust and Health Foundation’s QualityWatch programme, which is tracking the quality of health and social care in England, found that over the 14 years covered by the report, the increase in prescription of antidepressants outstripped the rise in depression.
Dr Cosmo Hallström, a fellow at the Royal College of Psychiatrists, said that while the figures were likely to raise concern in some quarters about over-prescription of antidepressants, he saw their increased use as a positive development on the whole, reflecting increased awareness of depression and how to treat it. “There needs to be a spectrum of treatments available,” he said. “Whereas antidepressants won’t be the best treatment in all cases they are of proven benefit and shouldn’t be denied to people who are waiting for something else.”
But he cautioned that they should not just be prescribed without follow-up. “You should review over a few weeks to see whether they are really working or not,” he said.
The researchers also observed wide variation in prescriptions between areas and different GP practices. For example, Blackpool residents were prescribed more than four times as many of the tablets each month per 1,000 people as Brent, in north London.
The report found that areas with more white people, more women, and more people over the age of 65 had the heaviest use of antidepressants, while GPs who prescribed more antibiotics also tended to prescribe more antidepressants, which Barber said “confirmed that some doctors are more inclined to reach for the prescription pad”.
London had a lower level of prescribing, which the authors put down to its younger and more ethnically diverse population, while the north-east, which has high rates of unemployment, had higher levels.
Adam Roberts, senior research analyst at the Nuffield Trust, who was one of the report’s authors, said: “The variation isn’t explained by rates of depression, which is what you would think. Someone with more expertise should look at defining what the appropriate rate is and how the variation is explained. We tried to explain it to a certain extent but we couldn’t fully explain it.”
The authors have created a modelling spreadsheet for GPs and clinical commissioning groups to calculate their expected level of prescribing of antidepressants, based on factors such as the profile of patients in their area and socioeconomic indicators, and compare that with their actual prescriptions.
Researchers also discovered that a 1% rise in unemployment over time typically meant one and a half more tablets were given out per person on a GP list per year. By contrast, comparing practices in different geographical areas, rather than analysing trends over time, did not show clear links to unemployment, although areas with worse housing tended to see significantly higher antidepressant use.
As Jennay Ghowrwal and her brother prepared to leave their mother’s house in Bethesda, Maryland, in March 2011, they got ready for an ugly conversation.
For nearly two years, the Ghowrwals’ 65-year-old mother had been living alone with untreated schizophrenia. She refused medication. She wouldn’t see a doctor. The Ghowrwals’ Sunday visits were a critical part of the makeshift care system they’d created around their mother. And it was when they gave her a weekly allowance.
“That was the worst part,” says Jennay Ghowrwal, 28. “She always asked for more than she was going to get.”
But that spring afternoon, their mother’s demands were more extreme than usual. She demanded $2,000 because, she said, she needed a haircut. Frustrated, and weary of her mother’s emotional instability, Ghowrwal refused. “I said, ‘No, Mom. I’m sorry. We can’t give you that.’”
Her mother went quiet.
When she started to talk, her speech was quick and difficult to decipher. The CIA was after her. Her kids were out to get her.
“If I can’t have control over my life, then they can’t either,” she screamed through tears. Then she grabbed a box of matches from the kitchen table, and lit one. As the match burned in her mother’s fingers, Ghowrwal remembers being relieved, thinking:
“Finally. The moment we’ve been waiting for.”
In the last several years, national tragedies like the shootings in Newtown have put pressure on the government to improve access to mental health treatment in the US. This weekend’s violence in Santa Barbara has reignited the issue. But behind these headline-grabbing mass killings, there’s a much broader crisis.
The most publicised reform came in November 2013 when the Obama administration issued regulations directing all private American insurance plans to cover mental health care equally to other kinds of medical care. These regulations mean, among other things, that co-payments and caps for mental health-related treatment cannot be more expensive or restrictive than for any other type of medical care.
There’s just one problem: while Obama may have expanded access to mental health benefits, the reach of the services those benefits theoretically provide hasn’t kept up. The availability of mental health care in the US remains woefully inadequate to handle current demand, never mind a potential influx of new patients.
Paul Appelbaum, a Columbia University psychiatrist and expert on legal and ethical issues in medicine and psychiatry, used a simple phrase to sum up the biggest problem facing US mental health care.
“Right to care does not mean access to treatment,” he said,adding that “tens of millions of people who did not have insurance coverage may now be prompted to seek mental health treatment. And the capacity just isn’t there to treat them.”
“There really is no mental health system in the US,” Appelbaum said.
“A system requires a vision. What we have is a shapeless void.”
Appelbaum’s blunt assessment was echoed by dozens of doctors, patients and caregivers withwhom the Guardian spoke for an investigation into the US mental health care system. Inadequate access to treatment services and providers all over the country, has left families of the mentally ill picking up the burden, and the cost, of providing care.
The Ghowrwals are one such family.
Jennay Ghowrwal’s mother hadn’t always been sick.
In 1976, she came to the US from Afghanistan on a prestigious Fulbright scholarship. She first settled in Ohio, where she met her husband. In the early 80s, Ghowrwal and her brother were born.
When Ghowrwal’s mother got a job in DC working for the government, the family of four relocated to Virginia. There, they lived an uneventful life, until 1994, when their father died following a series of strokes.
Over the next few years, Ghowrwal’s mother poured herself into her work and rose through the ranks in the Defense Department, and eventually gained a high security clearance position at an intelligence agency. “Nothing seemed to throw her off,” Ghowrwal says.
Though she lived in the US for years, Afghani culture was always a vital part of her mother’s life. While in Virginia, she became a fixture in the Afghan community. “She was always taking on new challenges,” says her daughter. She started a non-profit Afghani women’s organization and even hosted her own public access television show about Afghani culture. In fact, inretrospect, one of the first signs something was wrong, Ghowrwal says, was that she stopped doing her show. But not everything was so obvious.
Passing comments about ever-present government surveillance were justifiable, Ghowrwal reasoned, because her mother worked at an intelligence agency. When her mother complained of workplace harassment, it again made sense; the Ghowrwals were Afghan immigrants living in post-9/11 America.
But her mother’s behavior at work soon became stranger, harder to ignore. She started having crying fits at her desk. She lashed out at colleagues. It didn’t take long before her co-workers reported her to their supervisor, and her employer began investigating her, eventually assigning a psychologist to review her mental state.
“Personality disorder,” the psychologist wrote on the report, and recommended treatment if she wanted to keep her high-security clearance – and her job.
At first, Ghowrwal sided with her mother. “I read the report with the sense that her employer wasn’t being honest – and less with a suspicion that any of that was true. I don’t know why I was so skeptical other than I had never had a sense that my mother was detached from reality,” she says.
Still, although Ghowrwal didn’t yet believe that her mom was ill, she encouraged her to seek treatment for the sake of getting her job back. “But when we talked about it, she laughed and said ‘I’m not doing that,’” Ghowrwal remembers.
After she refused to follow the psychologist’s instructions, Ghowrwal’s mother was fired. She’d been making a six-figure salary, and had premium health insurance. Both were now gone.
Ghowrwal, who had just returned from a semester abroad in Chile, was now faced with an unemployed, unstable mother and burdened with the task of finding out what was wrong – and how to deal with it.
She moved out of her dorm on campus, and back into her childhood bedroom. Without an income, Ghowrwal’s mother was blowing through her savings. Ghowrwal took a job and helped with mortgage payments, bought groceries and paid utility bills. She cooked, she cleaned, she tried to keep her mother calm. Her life as a carefree college student was over.
“I don’t think I realized how messed up I was. I was emotionally unstable and angry all the time,” Ghowrwal says. “I would blow off assignments and my grades really suffered. I failed a few classes. And yet I was unaware that at the center of all this confusion was something truly life-changing.”
Living at home, Ghowrwal watched as the woman who raised her became someone else entirely. She was obsessed with finding a job, but would make up excuses for why she couldn’t follow through on her applications. She demanded her children spend time at home, but her unpredictable behavior made their time together untenable.
“Everything was becoming about the delusions. She started to throw plates during arguments. She once threatened to kill my brother if he married a woman she didn’t approve of,” Ghowrwal says. As their mother became more unstable, Ghowrwal and her brother realized they needed to get her help.
“There wasn’t a single moment of horror,” Ghowrwal says, describing her mother’s deteriorating mental state. “It was kind of like a slow burn, building up to a flame of terribleness that eventually did reach a breaking point.”
First, they tried a tactical approach, asking their mother to seek treatment for their sake. “We told her seeing a therapist might help her be ‘less stressed’”, Ghowrwal says. “We didn’t even bring up medication.” But her mother refused. Time and time again. “We kept asking her, but eventually she started to get angry with us for bringing it up. There was no use,” Ghowrwal says.
Eventually, Ghowrwal and her brother looked into other options. “We started to realize that she needed to be forced into treatment.”
“Involuntary commitment was just sort of a thing we thought logically existed in society for people who needed it,” Ghowrwal says. She and her brother went to court to try and get an order for their mother’s hospitalization. But because of high commitment standards, their petitions were refused.
“The judge basically told us she would have to be wielding a knife in someone’s face at the moment that the petition was made. Or, alternatively, dying of hypothermia in her car.”
Appelbaum says the “dangerousness” standard, which means a patient must be at risk of hurting themselves or others before they can be hospitalized against their will, makes it difficult for the families of seriously mentally ill people to get them into treatment. In order to get their loved ones the help they need, they often have to stand by and watch them spin out of control.
“The most agonizing calls I get are from family members who clearly are very worried about a loved one with a serious mental illness,” he says. “I have to tell them that unless you can make a case that your loved one is likely to harm themselves, or likely to harm other people, or you’re willing to throw them out on the street, there’s no way to get them into the system. The involuntary system is very tightly constrained by these dangerousness criteria.”
Dangerousness was not always the standard for involuntary treatment. Up until the 1970s, a mentally ill person only had to be “in need of care” in order to qualify for involuntary hospitalization. But as the deinstitutionalization movement gained momentum, attitudes toward mental health care evolved. One by one, states found “need of care” to be unconstitutionally broad, and unconstitutionally vague, and narrowed their standards to dangerousness. At the time, it made sense.
“These decisions were issued in an era when a majority of people were being hospitalized in large state institutions, which were typically underfunded understaffed and provided poor care,” Appelbaum says. “The courts were responding to that as well as the more theoretical constitutional argumentation.” One consequence of this change is that today, families have to wait for their loved ones to reach, as some call it, “rock bottom” before they can receive the care they need.
For help understanding the intricacies of the mental health system (and why it was so difficult to get her mother hospitalized) Jennay Ghowrwal turned to her local chapter of NAMI’s Family2Family support group, for people with mentally ill loved ones.
“Hitting ‘rock bottom’ was a theme people would raise [in the group],” Ghowrwal says. “That’s what it takes. ‘Let them fall hard enough and then they’ll get treatment’, they’d say.” For many of these families, this meant letting their loved ones become homeless, suicidal or homicidal.
When Ghowrwal watched as her mother stood in her kitchen, burning match in hand, she knew it was her chance. She picked up the phone and dialed 911.
After she lit that match, Ghowrwal’s mother was, as Ghowrwal had hoped, admitted to a hospital. But two weeks later, she was out again.
“All the doctors agreed with us that she needed to be there,” Ghowrwal says. “I couldn’t understand how she could be let out.”
With the match incident, Ghowrwal’s mother had finally met the dangerousness standard, which was enough to get her committed. But it wasn’t enough to get her treated.
In Maryland, at the time Ghowrwal was hospitalized, a patient had to be deemed dangerous in his or her community to be admitted involuntarily. But, to be medicated involuntarily, a patient had to be deemed dangerous a second time, while in the ward itself. And, of course, a patient who might be very dangerous on the street could potentially pose no issues while hospitalized.
The problem with this, Rebecca Birnbaum, a clinical researcher at the Lieber Institute for Brain Development in Baltimore, notes, is that anti-psychotic medication is critical to treating schizophrenia.
“Without medication and therapeutic sessions, patients and families endure a lot more suffering,” Birnbaum says.
Recognizing the barrier to treatment that the law presented, officials in Maryland finally changed it this year.
Even with treatment, however, some experts say that patients need to be spending more time in the hospital than wards permit.
“In the 1980s, average length of stay was probably 20-30 days, whereas today it’s a week or less in most places,” Appelbaum says. “That’s not a lot of time to stabilize somebody in a psychotic condition or somebody with severe depression.”
For the 15 days Ghowrwal’s mother was held in the hospital, she did not exhibit acts of aggression considered dangerous enough to merit medication. Without the medication necessary to treat her delusions, she was released in essentially the same state that she was in when she was admitted.
Appelbaum says the fall in the length of stay on inpatient units is driven by two important factors: one, a drastic drop in inpatient beds over the years, and two, as demand for beds has increased, psych wards haven’t expanded.
“The public sector in this country has shrunk to just a mere ghost of its former self,” Appelbaum says. “In the mid 1950s there were over 555,000 people at any given time in psychiatric hospital beds. There are fewer than 55,000 [beds] in service today.”
Moreover, psychiatric wards lose money. Their patients are, more often than not, on Medicaid, which has a very low reimbursement rate for care providers. “The returns are just not enough to cover the cost of care,” Appelbaum says. According to him, no matter how many patients cycle through the beds, or how long the waiting line is behind them, psychiatric wards are rarely, if ever, expanded. As a result,patients are let go too early, making it even more likely that they’ll cycle through the system again.
When Ghowrwal went to pick up her mother at the hospital, she says the doctors understood her predicament. “They were like: ‘We get it. It sucks. Here’s what we can offer.’” They sent her mother away with prescriptions for antipsychotics and referrals for community mental health centers.
“We asked our mom, ‘Are you planning to do any follow up treatment?’ and she laughed it off,” Ghowrwal says. Left without any other option, Ghowrwal drove her mother home, which is where she remains today. “As far as I know she threw the prescriptions in the trash,” Ghowrwal says. It’s been three years since she was released, and she hasn’t seen a psychologist or a psychiatrist since.
Faced with few options, and unwilling to watch their mother bottom out again, the Ghowrwal children have taken matters into their own hands.
Jennay Ghowrwal and her brother have, at great personal expense, created a world in which their mother can live on her own and be safe. They check in on her regularly. They pay all her bills. They’ve learned to handle her delusions. It has not been easy.
Her persistent distrust of the government means she refuses to accept any assistance from it. Attempts to relieve some of the financial burden have included tricking their mother into signing up for food stamps. “We got her to sign a random piece of paper, just so we could get her signature,” says Ghowrwal.
Ghowrwalestimates that in the last six years, she and her brother have spent upwards of $140,000 on her care. “Each month, my brother and I spend about $2,000 on her.” she says, adding that her mother has been relying on those funds for about six years. “She’s our mother. I don’t want to imagine what would happen if she was living on the streets.” Throughout her years caring for her mother, Ghorwhal has become passionate about improving mental health care. Just this year, she took a job working for the Treatment Advocacy Center.
If the Ghowrwals lived in one of the 45 states that offer outpatient commitment (also called Assisted Outpatient Treatment), things might be different. Outpatient commitment is a policy in which certain patients are ordered by a court to continue treatment, like visiting a psychiatrist or taking medication, while living outside the hospital. Connecticut, Massachusetts, New Mexico, Tennessee and Maryland are the outliers.
Paul Appelbaum says studies of outpatient commitment programs shows that they do a lot of good for the people who need them. “The data suggests that with that sort of structure, with a court order in place and the services made available, people are much less likely to be re-hospitalized, they are much less likely to end up in jail and less likely to be homeless. All of the major outcome measures that you’d wanna look at for this group are moved significantly in the right direction by outpatient commitment.”
This year, the Maryland House defeated a bill proposing outpatient commitment. But according to Jeffrey Janofsky, director of the Psychiatry and Law program at Johns Hopkins University in Baltimore, making it law wouldn’t be enough to guarantee the program’s success anyway.
“There’s no point in passing legislation if you’re not going to provide the funds to back it up,” he said. “New York has a particular kind of outpatient civil commitment law, but that law comes with millions of dollars of funding for necessary services. The real question in Maryland is, are we as a society going to spend the money to treat patients with significant mental disorder? And we’ve decided, ‘No, we are not.’”
This fifteen minute interview about caregiving for severely mentally ill relatives may have some useful advice for newcomers these problems.
Forget your expectations for the mentally ill person. Take any ideas about the potential for that person’s life and flush them down the john.
Forget your expectations for your family members. Don’t waste your time talking to family members about caregiving if they’re trying to distance themselves.
The interview is from Healthy Place, and features the expertise of a Cindy Nelson works part-time for NAMI Massachusetts and volunteers as a NAMI Family to Family Education Program teacher. She has been helping her schizophrenic sister for several decades.
Canada is the only G8 nation lacking a national mental health strategy and that fact became painfully obvious after a 2006 Senate report. Entitled Out of the Shadows At Last it was a hard look at the way Canadians with mental illness often slip through the cracks in the various systems across the country …health, justice, education et cetera. It called for a more organized approach and a structure to manage it. A little later Canadian Prime Minster Stephen Harper, whose sanity is often questioned by onlookers, agreed to create the Mental Health Commission of Canada and named the co-author of the Senate report Liberal Senator Michael Kirby as its first Chairman.
Cross Country Check-Up is broadcast weekly on Sunday Afternoons on CBC Radio One. It is a nation-wide phone-in program for a country five and a half time-zones wide, and spanning three oceans.
Host Rex Murphy heared from individuals and families who have been touched by mental illness and their thoughts and experiences as callers and experts discussed the state of metal health care in the dominion, and the new national mental health strategy that has been proposed. A plan is obviously the first step …implementation brings its own set of challenges especially in a system that is somewhat fragmented by different approaches in ten provinces and three territories.
Caregivers of people with bipolar disorder may experience a different quality of burden than is seen with other illnesses. A better understanding of their concerns is necessary to improve the training of professionals working with this population. Conceptualizing caregiver burden in a conventional medical framework may not focus enough on issues important to caregivers, or on cultural and social issues. Perceptions of caregivers about bipolar disorder have important effects on levels of burden experienced. It is important to distinguish between caregiversÕ experience of this subjective burden and objective burden as externally appraised. CaregiversÕ previous experiences of health services may influence their beliefs about the illness.
Caregiver burden is associated with depression, which affects patient recovery by adding stress to the living environment. The objective burden on caregivers of patients with bipolar disorder is significantly higher than for those with unipolar depression. Caregivers of bipolar patients have high levels of expressed emotion, including critical, hostile, or over-involved attitudes. Several measures have been developed to assess the care burden of patients with depressive disorders, but may be inappropriate for patients with bipolar disorder because of its cyclical nature and the stresses arising from manic and hypomanic episodes. Inter-episode symptoms pose another potential of burden in patients with bipolar disorder. Subsyndromal depressive symptoms are common in this phase of the illness, resulting in severe and widespread impairment of function. Despite the importance of assessing caregiver burden in bipolar disorder, relevant literature is scarce. The specific effects of mania and inter- episode symptoms have not been adequately addressed, and there is a lack of existing measures to assess burden adequately, causing uncertainty regarding how best to structure family interventions to optimally alleviate burden.
The relatively few studies into caregiver burden in bipolar disorder may largely reflect experiences in the US Veterans Affairs health service, but the findings may be limited in their generalizability. Nevertheless, available data suggest that caregiver burden is high and largely neglected in bipolar disorder. Clinically effective, well-targeted and practically viable interventions are needed. However, services cannot be enhanced on a rational basis without an improved understanding and capacity to measure and target caregiver burden the impact of any change in services be evaluated.
Ogilvie AD, Morant N, Goodwin GM. Bipolar Disord 2005: 7 (Suppl. 1): 25–32. a Blackwell Munksgaard, 2005
All in the Mind is a BBC Radio 4 programme dealing with the limits and potential of the human mind in relation to psychology, neuro science, mental health and the law and is presented by the immensely bone-able Claudia Hammond.
You can listen each week on Tuesday, on demand or subscribe to the podcast. The archives in the first link is worth exploring as there are nearly 100 episodes on file. Three episodes may be of particular interest to you.
Schizophrenia and caregiving — Tim Salmon’s son developed schizophrenia after college and the past twenty years have been a desperate struggle to secure him the care and support he needs. In this episode, Tim tells about the daily reality of living with this little understood illness and criticises the woeful inadequacies of provision in our society for those with mental illness.
Dementia — We don’t know the cause, there is no treatment or cure, and it is fatal. Dementia is the health challenge of this generation. This show also examines what is to be expected in the forthcoming UK Dementia Strategy
Siblings with Mental Health Problems — While parents often care for young people with mental health problems it can also raise issues for their siblings. They might have fears for their own mental health or worry about the change in their relationship to their brother or sister. How easy is it to share worries about your own mental health if you feel it’s minor in comparison to your brother or sister? And what of the future and the responsibilities you may one day inherit from your parents. Listen to hear about these and other issues.
How do you co-ordinate mental health services in a country wider than the Atlantic Ocean when it’s not your responsibiliy?
A forthcoming report in Canada addresses how to intervene early with emotional disorders in other to reduce the severity of the impact on the victims. This new report from the Mental Health Commission of Canada hopes to persuade the dominion’s federal government to take a lead role on mental health care even though health administration in this country is a provincial (which is to say regional) matter. Listen to this interview on on CBC Radio One’s The Current.