Whatever an individual’s view regarding the best model with which to understand and respond to emotional and mental distress, it is clear that since the mid-2000s there has been growing professional and public criticism of the utility and validity of the ‘biomedical’ model and associated interventions – a model in which distress has been assumed by some to be rooted in an underlying disease mechanism or organic pathology. It is important to note, however, that such criticism has been advanced not only by non-medical professionals. Indeed, many of its proponents stem from the medical and psychiatric community itself, where today there is a diversity of views regarding the utility and validity of this model. In short, the lines of debate cut through all mental health disciplines, and so can no longer be framed in disciplinary polarised ways. Furthermore, such debates now resonate beyond the disciplines themselves, in ever larger sections of the academic, political, media and service-user communities, and similarly stem from increasing concern that our mental health services are not just failing due to lack of investment, but owing to peoples’ emotional and behavioural difficulties being over, unduly and unhelpfully medicalised. It has been argued that over-medicalisation has led, in turn, to the consequent over-prescribing of psycho-pharmaceuticals,12,13 rising mental health stigma,14 the proliferation of unnecessary and harmful long-term prescribing, and the crowding out of effective alternatives that people both need and want.15,16 These arguments have dovetailed with others that pertain to the medical model, such as the value or otherwise of psychiatric diagnosis more broadly17–21; the role of conflicts of interest between the pharmaceutical industry, prescribers and drug-researchers22–24; the lack of biomarkers for ‘mental disorders’ or evidence for the chemical imbalance theory of mental distress 25,15; the evidence that antidepressants may yield no clinically significant benefits over placebos for most people despite ever-rising prescriptions30–33; the expanding knowledge of withdrawal problems34,4,5, and the growing understanding that long-term use of psychiatric drugs is often associated with poor outcomes and increased harms3. These concerns, criticisms and areas of debate have been articulated, advanced and engaged with not only by psychologists, academics and therapists, but also by many psychiatrists who have seen in the psychiatric perspectives and treatments once championed in the 1990s, many promises left unrealised.
Each individual involved in the composition of this guidance will have a particular view on these separate debates and criticisms, as will its readers. As no guidance can ever be written in a vacuum, and as many contributors have been involved in some of the above debates, it is important to be explicit about how these criticisms may have informed the content of this guidance.
The first obvious influence is that this guidance departs from the increasingly contested belief, both within psychiatry and beyond, that psychiatric drugs ‘cure’ mental ‘illnesses’ that are rooted in brain pathologies. Rather, it takes the view that psychiatric drugs, like all other psychoactive substances, alter states of mind in ways that may or may not be experienced as helpful by the individual in question. Also, like many other psychoactive substances, psychiatric drugs can cause side, adverse and withdrawal effects that can complicate a person’s recovery, certainly if not acknowledged as such.
The second influence concerns the language used in this guidance. Medical terms such as ‘illness’, ‘disorder’, ‘pathology’ and ‘dysfunction’ do not merely describe the suffering they depict but shape how it is understood, managed and perceived. Medical language imports meanings that may not always accord with how many psychological therapists frame distress. A common view in the psychological community is that medical language broadly assumes what it should rather demonstrate: that the suffering it describes is in fact medical ‘illness’, ‘disorder’ or ‘pathology’. Rather than seeing suffering as an illness, many therapists would understand it as a rational reaction to hurt, trauma or impairment. In many cases it may be a call for change or an instance of what may be termed ‘social suffering’ – namely, a non-pathological, distressing, yet understandable human response to harmful social, political, relational and environmental conditions (past or present).
Given that medical language carries meanings that extend well beyond the way in which many therapists understand psychological distress, including meanings that assume, rather than demonstrate the biological causes of mental distress, this guidance will avoid medical terminology where possible. Instead, it will adopt non-medical descriptors, such as those recommended by the British Psychological Society.36 There are occasions, however, where the meaning of alternative words is not clear and so some language has been retained for the sake of simplicity and readability, but this should not be taken as an acceptance of its full medical implications. Quotation marks have been used in some places to denote a disputed term.
3. Royal College of Psychiatrists (2019). Position statement on antidepressants and depression. (Accessed July 2019) Website: https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/position-statements/ps04_19—antidepressants-and-depression.pdf?sfvrsn=ddea9473_5.
4. Davies, J., Read, J. (2018). A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence based? Addictive Behaviors. pii: S0306-4603(18)30834-7. doi: 10.1016/j.addbeh.2018.08.027. [Epub ahead of print].
5. Horowitz, M.A. & Taylor, D. (2019). Tapering of SSRI treatment to mitigate withdrawal symptoms. The Lancet Psychiatry.
12. Dowrick, C. & Frances, A. (2013). Medicalising and medicating unhappiness. BMJ,14(347). Website: https://www.bmj.com/bmj/section-pdf/750417?path=/bmj/347/7937/Analysis.full.pdf.
13. Rice-Oxley, M. & Fishwick, C. (2013). Medicalisation of misery to blame for soaring use of antidepressants, say GPs. (Accessed July 2019). Website: https://www.theguardian.com/society/2013/nov/21/prescribing-culture-blame-rise-antidepressants.
14. Loughman, A. & Haslam, N. (2018). Neuroscientific explanations and the stigma of mental disorder: A meta-analytic study. Cognitive Research: Principles and Implications 3(43). Published online 14 November 2018. doi: 10.1186/s41235-018-0136-1.
15. Bracken, P., Thomas, P., Timimi, S. et al. (2012). Psychiatry beyond the current paradigm. British Journal of Psychiatry, 201, 430–434.
16. Davies, J. (2013). Cracked: Why psychiatry is doing more harm than good. London: Icon Books.
17. Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, Big Pharma, and the medicalization of ordinary life. New York: William Morrow.
18. Davies, J. (Ed.) (2017). The sedated society: The causes and harms of our psychiatric drug epidemic. London: Palgrave Macmillan.
19. Johnstone, L. (2014). A straight talking introduction to psychiatric diagnosis (Straight Talking Introductions). London: PCCS Books.
20. British Psychological Society (2011). Response to the American Psychiatric Association DSM-5 Development. Leicester: Author.
21. Allsopp, K., Read, J. & Kinderman, P. (2019). Heterogeneity in psychiatric diagnostic classification. Psychiatry Research 279, 15–22.
22. Campbell, E.G., Weissman, J.S., Ehringhaus, S. et al. (2007). Institutional academic-industry relationships. The Journal of the American Medical Association, 298(15), 1779–1178.
23. Cosgrove L., Krimsky, S., Vijayaraghavan, M. & Schneider, L.
(2006). Financial ties between DSM-IV panel members and the pharmaceutical industry. Psychotherapy and Psychosomatics, 75(3),154–60.
24. Timimi, S. (2008). Child psychiatry and its relationship with the pharmaceutical industry: Theoretical and practical issues. Advances in Psychiatric Treatment, 14, 3–9.
25. Harrington, A. (2019). Mind fixers: Psychiatry’s troubled search for the biology of mental illness. New York: W.W. Norton and Company.
30. Ioannidis, J. (2008). Effectiveness of antidepressants: An evidence myth constructed from a thousand randomized trials? Philosophy, Ethics, and Humanities in Medicine 3,14.
31. Kirsch, I. & Jakobsen, J.C. (2018). Correspondence: Network meta-analysis of antidepressants. The Lancet, 392(10152), P1010. doi: https://doi.org/10.1016/S0140-6736(18)31799-9.
32. Hengartner, M.P. & Ploderl, M. (2018). Statistically significant antidepressant-placebo differences on subjective symptom-rating scales do not prove that the drugs work: Effect size and method bias matter! Front Psychiatry, 9, 517. Published online 17 October 2018. doi: 10.3389/fpsyt.2018.00517.
33. Munkholm, K., Paludan-Müller, A.S. & Boesen, K. (2018). Considering the methodological limitations in the evidence base of antidepressants for depression: A reanalysis of a network meta-analysis. BMJ Open, 9:e024886. doi: 10.1136/bmjopen-2018-024886.
34. Fava, G., Gatti, A., Belaise, C., Guidi, J. & Offidani, E. (2015). Withdrawal symptoms after selective serotonin reuptake inhibitors discontinuation: A systematic review. Psychotherapy and Psychosomatics, 84, 72–81.
36. British Psychological Society (2015). Guidelines on language in relation to functional psychiatric diagnosis. Available online: https://www1.bps.org.uk/system/files/user-files/Division%20 of%20Clinical%20Psychology/public/Guidelines%20on%20 Language%20web.pdf. (Accessed January 2019.)