A modern approach to mental health

Does psychoanalysis have a place in modern medicine? Peter Fonagy and Alessandra Lemma do their best to make the case that it does. They argue that evidence of its usefulness is “on its way,” that it continues to enhance therapeutic relationships, that it’s central to our understanding of the influence of early life experience, and that it is the basis for cognitive behavioural therapy (doi:10.1136/bmj.e1211). But for my money they are outflanked by Paul Salkovskis and Lewis Wolpert (doi:10.1136/bmj.e1188). Psychoanalysis has had its day, these critics say. It should be given credit for establishing a new paradigm over a century ago, but it has now been supplanted by other concepts that better explain and improve people’s mental state. Continuing to act on such outdated theories would not be tolerated in cardiology or oncology, they say.

More than this, they suggest that psychoanalysis carries dangers for modern healthcare, calling it a pseudoscience whose claims can’t be tested or refuted. They say it has always resisted the idea of evaluating outcomes and of diagnosing and treating symptoms. And it’s expensive. They contrast this with the real improvements in mental healthcare that have come from greater accountability on both the outcomes and costs of treatment through bodies such as the UK’s National Institute for Health and Clinical Excellence.

Helen Lester and Simon Gilbody confirm this progress, with caveats. In their editorial on bmj.com (doi:10.1136/bmj.e1014), they remind us that it’s now 25 years since the first SSRI, fluoxetine, was licensed. Patients and clinicians now have available to them a potentially confusing array of second generation antidepressants. Since evidence suggests that little difference exists between them in effectiveness, decisions should now be made on the cost and side effect profiles of different drugs.

Importantly, the authors stress that the latest systematic review of 234 studies in people with major depression shows that second generation antidepressants do work. This evidence counters widely publicised claims made in a meta-analysis, published in PLoS Medicine in 2008, that they had little or no effect except in people with the most severe depression. Such claims may well have dissuaded patients and some clinicians from considering or continuing antidepressants. It’s good to see them countered here.

Efforts to change attitudes towards people with mental health problems continue. A new campaign in the UK says “It’s time to talk.” But Stephen Ginn and Jamie Horder spot difficulties with the much quoted figure that one in four people experience mental health problems (doi:10.1136/bmj.e1302). Is this a lifetime, yearly, or point prevalence? The evidence in fact suggests a higher figure and several prevalence studies point to a lifetime prevalence of nearer 50%.

Whatever the true burden of poor mental health in the UK and internationally, it is certainly considerable. And it is concentrated among poor and marginalised groups. While acknowledging important progress in modern treatments, we should remember the dangers of adopting a strict medical model. Poor mental health is often rooted in inequality, conflict, overcrowding, lack of rights, lack of financial security, and poor living conditions—which tablets don’t treat. Unless social and economic determinants are addressed (a very big task), poor mental health and the stigma it attracts will continue unabated.