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A 50 year timeline – including the 1990s Defeat Depression Campaign.

Marion Brown is a retired psychotherapist, who in recent years accidentally found herself a campaigning for patient safety. Her late husband was a GP in Scotland. Marion shares here a personal record – which she hopes will be of interest to GPs.

Imet my late GP husband (Charles Brown 1953-2011) in the early 1970s when we were both students at St Andrews university. I had grown up in South Africa, my mother a 1951 St Andrews BSc Biology graduate. Mine was an active privileged rural and farming childhood. I remember our mother reading Silent Spring by Rachel Carson in the early 1960s and this having an influence on her thinking – certainly around environmental poisons and toxins. We visited the doctor when ill or injured or needing specific medical intervention.

My husband had grown up in Scotland within a well-respected medical family.  His father, grandfather and uncles were all practising doctors – and his brother still is.  Medicine was always very much part of family life – and indeed still is, now within a 4th generation.

My 1970s BSc had included Physiology, alongside medical students.  After graduation I worked for 3 years as a cancer research technician in Manchester, whilst my husband completed the clinical part of his medical degree there. I subsequently lived much of my adult life as wife of a Scottish village GP.  This included – especially in the 1980s and 1990s – the local GPs and spouses being taken out for meals by Pharma reps and having all sorts of branded items around the place. I was certainly aware of incentives for GPs to diagnose depression and prescribe antidepressants during the mid-1990s RCGP/RCPsychiatrists Defeat Depression Campaign,1 when there was much press and public education about ‘defeating depression’.

….the mid-1990s RCGP/RCPsychiatrists Defeat Depression Campaign, when there was much press and public education about ‘defeating depression’.

In the 2000s, with the establishment of NICE, the NHS introduced GP prescribing incentives including the Quality Outcomes Framework which included guidance and incentives for GPs to continue to diagnose – and treat – depression and anxiety. By then the use of the Pfizer-funded PHQ-screens,2 especially PHQ-9 were encouraged.3,4 McPherson and Armstrong comment that “The PHQ9 was entirely self-report, requiring no clinician involvement. The purpose was to create a measure that would detect depression in primary care, where the majority of mental illness had now come to be managed.”4

From around the early 2000s there was a growing trend to encourage GPs to recognise difficult-to-manage so-called heartsink patients, who kept visiting the doctor for all manner of physical complaints – but who, despite various tests etc., apparently had nothing physically wrong with them although tended to have a history of depression/anxiety.  I later learned that the PHQ-15, together with PHQ-9 for depression & GAD-7 for anxiety, had been developed specifically to help GPs to recognise patients with medically unexplained symptoms5 in order for them to be ‘managed’.

My husband elected in 2007 to do his annual required Continuing Medical Education over a one-week pharmaceutical-sponsored course in St Andrews and we stayed in the town.  I had by then embarked on the Human Givens Psychotherapy Diploma and was invited to sit in on the day that depression was the main topic.

I qualified as a Human Givens practitioner in 2011 and our training stressed that any issues around prescribed medicines that any client might be taking were entirely between a client and their prescriber. My psychotherapist role was to enable clients to figure out what unmet human needs might be causing them to experience symptoms of overwhelming stress and emotional distress, typically symptoms such as insomnia, anxiety, panic attacks, depression etc.. and to support them to discover what human resources they might be able to draw upon and/or learn, in order for them to return to ‘normal life’ – generally within a few sessions of Human Givens therapy www.hgi.org.uk.

Common ‘unexplained somatic symptoms’ overlapped strongly with the serotinergic effects … of SSRI/SNRI antidepressants.

It was late in 2016 that I first became aware that Medically Unexplained Symptoms (MUS) was being acquired in people’s medical records – and that MUS was a recognised DSM-IV diagnosis (now Somatic Symptom Disorder DSM-5).  By then the work of Fava et al6 on the ‘effects’ of antidepressants – and of antidepressant discontinuation/withdrawal – was raising questions.  It was striking that that the common ‘unexplained somatic symptoms’ overlapped strongly with the serotinergic effects – on all main body systems – of SSRI/SNRI antidepressants.  It has now become apparent that the many/multiple system somatic symptoms often experienced by patients are also known ‘effects’ of antidepressants taken as prescribed per guidelines, and that these symptoms are mostly being misdiagnosed as relapse, MUS, functional disorders, bodily distress and so on.

Now MUS is becoming increasingly referred to as Functional Neurological Disorder (FND), and it appears that many people suffering serious antidepressant (and indeed other prescribed drug) side effects and withdrawal effects are acquiring these ‘functional disorder’ labels ‘of unknown aetiology’ – with the result that patients are further misdiagnosed and disbelieved.  We wrote about this in our Patient Voice article for BJGP Life The Patient Voice: Antidepressant withdrawal, MUS and FND and an expanded version published by the Journal of Critical Psychology, Counselling and Psychotherapy JCPCP.7

Many people suffering serious antidepressant side effects and withdrawal effects are acquiring these ‘functional disorder’ labels.

One has to wonder whether the 1990s Defeat Depression Campaign1 (DDC) has inadvertently resulted in a long trail of chronic illnesses due to underestimation of the risks of SSRIs/SNRIs.  During the DDC GPs were encouraged to suggest or imply that the patients were suffering a chemical imbalance, in the brain, of low serotonin, thus reducing stigma, and to reassure their patients that the newer antidepressants were ‘safe and effective’, and ‘not addictive’.  Patients were told to not stop taking them as they would suffer ‘relapse’ of their condition.  Patients were also told that they may experience some mild side effects on starting, and might even feel worse in the first two weeks or so, but that after that the anti-depressant effects should ‘kick in’.  It might be that a switch to another antidepressant could be an option if the first one didn’t suit.  They should then take them for at least 6 months and then continue for at least 4-9 months after remission of depression to prevent relapse/recurrence.  By which time there would be some level of physiological dependence.  These messages are widely prevalent to this day and we now have many cases of treatment resistant depression where people have been tried on many different antidepressants – and are more depressed than ever.8

Stevie Lewis’s 2020 article for BJGP summarises her own personal patient experience, which began during the DDC. She introduces the Guidance for psychological therapists: information for GPs advising patients on antidepressant withdrawal.

In recent years growing evidence of actual patient experience has been added to the formally published research, for example this special collection by Therapeutic Advances in Psychopharmacology from Sage Journals. Some GPs have been raising concerns too, including Des Spence , Richard Byng and Sian Gordon .

Psychotherapy practice has become seriously complicated by what has happened as a consequence of the DDC. Seeing people who are not on antidepressants, and/or other psychiatric medications, is increasingly rare, and many people have now been taking them over decades. These drugs were specifically designed to be consumed orally, to pass through the digestive and circulatory systems, to penetrate the blood-brain-barrier and act on the subtle functioning of the brainstem, the very seat of the human autonomic nervous system, thus affecting homeostasis and  higher conscious thought. This is of course the brain area concerned with the most basic and essential autonomic fight/flight/freeze systems – which, by definition, impact on all the essential bodily systems and functions. When we ‘tinker with’ such essential brain functions – most especially those controlling vitally important sleep – we can impair the capacity for recovery and can cause harm. We are seeing increasing cases of development of akathisia – unbearable sub-cortical nervous system dysregulation, most commonly initiated when starting, changing, or stopping medications including antidepressants. Once developed, akathisia is very hard to resolve and is so excruciating that it leads inevitably to incidences of self-harm and suicide. See information from the Akathisia Alliance for Education and Research.

We are seeing increasing cases of development of akathisia – unbearable sub-cortical nervous system dysregulation.

The recent 2021 Cochrane Review of the evidence for antidepressant discontinuation and continuation concludes “All included trials were at high risk of bias. The main limitation of the review is bias due to confounding withdrawal symptoms with symptoms of relapse of depression. Withdrawal symptoms (such as low mood, dizziness) may have an effect on almost every outcome including adverse events, quality of life, social functioning, and severity of illness.”9

Patients have been disbelieved and ‘put down’.  This has had a detrimental effect on doctor-patient relationships and patients and doctors (who are also patients) have suffered and continue to suffer.  Even now, no-one seems to be ‘listening to patients’.  I have recently expressed alarm concerning the 2021 NICE guidance for Chronic Pain – and its recommendation of antidepressants.

My late husband’s case example is one of countless others.  In his case, in 1985 at age 31, he suffered complete Addisonian crisis following a particularly stressful work and life period, whist a junior GP partner in a busy small-town practice.  On his third emergency hospital admission within a week a Synacthen test confirmed the diagnosis of Addison’s Disease. He began to recover once started on lifesaving, lifelong medical treatment for this condition. Within a few weeks he had recovered well enough to take up a new position as GP in a small rural practice. He worked full-time as a GP for a further 25 years.  In the early 1990’s he was started on Seroxat for depression, commonly experienced alongside Addison’s Disease. He remained on 20mg Seroxat until after his retirement in 2010, when he was recommended by a psychiatrist to switch to Venlafaxine. This only lasted two months as the side effects were intolerable, and he went back onto Seroxat 20mg which seemed to suit him better. Just a few months later he developed almost complete insomnia, terrors, awful gut issues, severe arthralgia, chronic pain, loss of temperature regulation, paranoia, nightmares, agitation, cognitive issues and altogether felt terribly ill. No-one could seem to fathom what had gone wrong, despite various tests and investigations, adjustments to usual medications and a trial of Melatonin. His notes record an exchange between his GP and endocrinologist where they agree that he is probably ‘somatising’ and ‘just needed stronger antidepressants’. Of course, the Addison’s disease was a significant complication. He was increasingly deeply suicidal and utterly desperate, and acted upon this.

Having now learned of so many unsuspecting souls who have experienced the horrors of medication-induced akathisia, my husband’s ultimately fatal experience following 20 years on Seroxat probably was a form of catastrophic autonomic dysregulation and overwhelmingly intolerable akathisia.  He thought he had completely lost his mind.

My hope is that this article will encourage … caution about use of these commonly used so called safe and effective anti-depressant drugs.

My hope is that this article will encourage reappraisal and respectful caution about use of these commonly used so called safe and effective anti-depressant drugs, especially when considering starting people on them. Patients, and their prescribers, need to respect the risks and limitations of these medications so that genuine ‘informed consent’ can be reached before prescribing, or starting to take, any drug. Patients need reassurance that good sense and effective practical and psychological measures can often be taken at the outset to resolve the common symptoms of human stress, emotional turmoil and distress, sometimes without any need for prescribed mental health drugs (including the now emerging trend to develop and market synthetic medical psychedelics), or needing to resort to electrical or other invasive treatments.

Our brains are subtle, complex and precious.  We need, most of all, to give ourselves and others the very best chance of gently supported recovery from periods of physical illness/injury – and/or overwhelming overload or distress.

References 

  1. Priest R. 1996  Lay people’s attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch | The BMJ
  2. PHQ screeners   phqscreeners
  3. Kendrick A. 2015 Long‐term antidepressant treatment: time for a review? – Kendrick – 2015 – Prescriber – Wiley Online Library
  4. McPherson S. 2021 Psychometric origins of depression – Susan McPherson, David Armstrong, 2021 (sagepub.com)
  5. Burton C. 2013. ABC of Medically Unexplained Symptoms. BMJ books
  6. Fava G. 2015 Withdrawal Symptoms after Selective Serotonin Reuptake Inhibitor Discontinuation: A Systematic Review – FullText – Psychotherapy and Psychosomatics 2015, Vol. 84, No. 2 – Karger Publishers
  7. Brown, M. Lewis, S. (2021). The Patient Voice: Antidepressant Withdrawal, MedicallyUnexplained Symptoms, and Functional Neurological Disorders. Journal of Critical Psychology, Counselling, and Psychotherapy, 20 (4), 14-20    (1) (PDF) JCPCP v20 i04 Brown&Lewis (researchgate.net)  Contents – JCPCP, Vol. 20, No. 4, Winter 2020 (egalitarianpublishing.com)
  8. McLachlan G. 2018 Treatment resistant depression: what are the options? | The BMJ
  9. Van Leeuwen E. 2021 Approaches for discontinuation versus continuation of long‐term antidepressant use for depressive and anxiety disorders in adults – Van Leeuwen, E – 2021 | Cochrane Library

 

Featured photo by Vijendra Singh on Unsplash

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Marion Brown
Marion Brown
2 years ago

Thank you very much to BJGP Life for publishing this.
I had previously been asked by GP Bryan McElroy to do a recorded interview with him – for discussion with other GPs. This is now available here:

Sarah Preece
Sarah Preece
2 years ago
Reply to  Marion Brown

Thank you for your work, and ongoing contribution to this field Marion Brown

Marion Brown
Marion Brown
2 years ago

Here is a letter by Dr Charles Brown that was published late 2006 …. within this ‘timeline’. https://www.gponline.com/letters-calls-emails-coming-terms-new-age-technology/article/607949

Tom Todd
2 years ago

Thanks, Marion and BJGP Life. I hope Marion’s knowledge and opinions can be considered for incorporation into improved practices. I have experienced akathisia from use of (and sometimes enforced use of) ‘antipsychotics’, and it is devastating. I’m very glad to have had it eventually recede after my advance statement preferences (short term use of ‘antipsychotics’ only; to treat acute episodes of psychosis) were eventually respected. I’m presently working with a health care team (including a clinical psychologist) that I hope will continue to recognise that enforcing ‘treatments’ is not perceived by me to be therapeutic, and doesn’t remotely allow for wellbeing potential to be realised.

Marion Brown
Marion Brown
2 years ago

As 29 May is Addison’s Disease Awareness day (birthday of President J F Kennedy – who was diagnosed Addison’s disease at age 30), this recent publication of this article has proved timely. My husband found much useful information via the Addison’s Disease Self-Help Group AHSHG, ( He found very little awareness or understanding within the medical community.)
www,addisonsdisease.org.uk
https://www.healthawareness.co.uk/rare-diseases/think-addisons-disease-save-a-life/

Millie Kieve
2 years ago

Marion thank you for this detailed explanation of the ‘Disease Awareness’ campaigns created to ‘Sell Sickness” in order to promote sales of drugs promoted as ‘cures’.
My condolences for you seeing the suffering and tragic death of your husband. Like me, following the prescription drug harm and death if my daughter Karen, you aim to save others from the same fate.
My conclusion is we have to start with medical education. Independent seminars and tutorials need to be established.
Since the GMC removed Clinical Pharmacology & Therapeutics from curriculum guidelines ‘Tomorrow’s Doctors’ in favour of Integrated Medical curriculum, many medical students have been failed.

trackback
1 year ago

By Sam Gleadon, mental health worker

The ‘low serotonin’ hypothesis has been the backbone of the psychiatric approach to depression for the past 40 years. It claims that mental health issues are caused by a “chemical imbalance” of neurotransmitters, the brain’s chemical messengers.

But in July 2022, a controversial Umbrella analysis hit UK headlines, summarising decades of evidence; it showed conclusively that there was little scientific basis for the “low serotonin” theory of depression.

Yet surveys show that 80-90% of the population now believe that mental health issues are caused by these chemical imbalances and the spread of this idea has had huge sociological and political ramifications. Millions have been left believing they are genetically wired for suffering, while the overwhelming distress caused by modern capitalism is let off the hook.

Chemical imbalance and the medical model of mental illness

The chemical imbalance theory is linked closely to the medical model of mental illness, which states that there are specific biological mechanisms which cause discrete forms of psychological distress, akin to physical illnesses or diseases of the brain. The explanation for these ‘diseases’ mainly focuses on genetic differences, and the emphasis is on the biology and brains of individuals rather than their life histories or environments.

Although a number of studies have been made into other biomarkers(consistent biological evidence), the levels of the neurotransmitter serotonin, which is involved in mood, sleep and digestion, remain the most researched.

Yet six different measures, ranging from the number of serotonin receptors to evidence of serotonin in the bloodstream, have shown no clear link between the amount of serotonin and the likelihood of depression. What this research and the lack of evidence of other biomarkers for depression is making clear, is that the complexities of human suffering can’t be boiled down to quantities of a few basic neurochemicals.

This isn’t to say that our brains and biology are not important; in fact, they are involved in some way in all our experiences. However, our emotional well-being is dictated by a highly complex web of interactions, including our social environments, personal and cultural belief systems, the early ‘wiring’ of our nervous systems, genetic predispositions, and so on.

Promotion of chemical imbalance theory by Psychiatry and Big Pharma

So why has this incredibly oversimplified view been promoted in western culture for decades? This disease-based medical model of understanding depression has its roots in academic psychiatry from the 1960s.

In her book The Myth of the Chemical Cure, Joanna Moncrief outlines a shift in psychiatric attitudes to new medications being developed. Previously, medications used in mental health were seen in the same way that we might imagine sedatives working, by dampening our normal functioning to produce a temporarily useful altered state of consciousness.

Psychiatry, which throughout its history was keen to be seen as an empirical scientific profession much like medical doctors, started to present new medications differently. They were promoted as working on a specific underlying disease caused by a “chemical imbalance”, with psychiatrists as the guardians of the knowledge for these “diseases” of the mind.

Psychiatrists promoted this view in tandem with a growing pharmaceutical industry. With the discovery of new SSRIs (a group of anti-depressants) in the 1980s, big pharmaceutical companies went into overdrive to promote the disease-based “chemical imbalance” theory and the need for SSRIs.

Following deregulation, direct consumer advertising spending on drugs ballooned in the USA in the 1990s, going from $25 million in 1988, to over $1bn in 1996, with psychiatric medications being the largest share. Today, $5bn is spent on drug advertising alone.

With adverts like this, for Zoloft (called sertraline today), commercials were everywhere in the 1990s and early 2000s. In 1999, it was estimated that the average American saw nine adverts for drugs every day.

Pharmaceutical Industry control of psychiatry

In most countries however, direct advertising of drugs like this is illegal. Generally, the pharmaceutical industry has influenced the population through its staggering financial domination over the psychiatric profession globally. Many leading psychiatrists, some with huge authority in the field, are funded by big pharma. Their influence is used to promote certain medications through professional talks and by promotion in academic journals. Half of the biggest donations from all pharmaceutical companies to medical professionals went to psychiatrists alone.

Educational conferences for psychiatrists are now dominated by Big Pharma. Psychiatrist, Edward Torrey, explained that at the 7th World Congress of Psychiatry in 2001, $10 mn was spent by pharmaceutical companies on extravagant extras such as an artificial garden and circus acts, as well as airfares for all attendees and direct sponsorship of half the delegates.

In the UK, author James Davies has uncovered that many top UK universities are paid millions each year for research funding. Equally disturbing, BMJ (formerly the British Medical Journal) research found that clinical commissioning groups, which allocate NHS funding, are also being given millions by pharmaceutical companies, much of it hidden. The consequence of this has been a huge influence of medical practice. GPs for example, would regularly prescribe psychiatric medications and give the “chemical Imbalance” explanation as justification.

A tenth of the population take mental health medication

One clear side effect of this culture has been an explosion of the use of SSRIs and other psychiatric medications. Around 10% of the UK population iscurrently taking some kind of psychiatric medication with similar rises found globally. Meanwhile, evidence is increasingly showing that the prolonged use of such psychiatric medications can actually be harmful to those who take them.

To be very clear, this is not to say that psychiatric medication is inherently bad or that taking it is wrong. But there has been a complete lack of transparency from pharmaceutical companies about their long-term side effects and overall effectiveness.

Many investigations have now revealed that much of the research around psychiatric medications is biased in favour of medications. Inquiries have found either unconscious bias or straight-up malpractice are commonplace in the profession. This is unsurprising, given that most of the research on medication is done by psychiatrists with direct financial ties to the pharmaceutical companies themselves.

The other more subtle cultural effect has been the ‘internalisation’ of the disease-based understanding of mental distress, as a set of biologically driven “illnesses” rooted in the brain.

Research shows that when psychological distress is framed in a biological and individualised way, blame on the person is lessened; however, stigma about their chances of recovery, desire to befriend them, and prejudices around their behaviour, such as increased aggression, all worsen.

The paradox of our current culture around mental health is that although we are more understanding of people receiving treatment, the way we understand “mental illness” can increase the stigma and division between those with “mental illness” and those without. Rather than seeing mental health as a spectrum along which we all move back and forth, depending on life circumstances and life histories, our current “disease-based” framework can be divisive.

I’ve seen the danger of this in mental health services, whereby people only feel their distress matters if they have a diagnosis and are deemed “unwell”. On the reverse side, some of those who might need support will hesitate to access it, out of fear of being labelled as someone with mental health issues. This culture of otheringthose who are mentally ill is a repercussion of the wider ideological framework that benefits big business and the capitalist class.

Historically, with the rise of capitalism and the subsequent need for a hard-working labour force, asylums were part of a network of institutions created to deal with those deemed unfit for the workforce. Our modern welfare state system echoes this culture by focusing on getting people “well” enough to work again, rather than having a holistic focus on well-being.

Huge profits for “Big Pharma”

Big business makes huge profits by commodifying our distress. Not just with the $22bn anti-depressant market, but the whole $275bn well-being industry selling us fitness programmes, self-help books, and mindfulness apps. Although these products can be useful, they often trap us into believing that solutions to distress lies with individuals rather than collective political movements of liberation.

On top of the profitability, the idea of “mental illness” itself promoted through the “chemical imbalance” theory takes society’s focus away from our failed economic system and government policies. There is now a growing phenomenon of the “psychiatrisation” even of social problems such as domestic violence, child abuse, school failure, unemployment and so on. An example of this is the rapid rise in the numbers of school children – in overcrowded classes and under extreme exam pressure – being given labels of ADHD and anxiety disorders needing ‘support’ with medication.

In all these examples, the ideology of “mental illness” focuses on blaming and shaming the individual for issues created by society, disguising the oppressive role of big business and its economic system.

A new way forward?

More holistic models of human suffering, which move away from the medical model of mental health, are becoming increasingly popular within healthcare. Trauma-informed care (TIC) and the more controversial Power Threat Meaning Framework (PTMF) look at the context of people’s lives, and in particular, the role of challenging or traumatic life experiences.

PTMF puts our suffering in its social context by examining how power operates in society, such as the way our economic system traps people in poverty, or the consistent gaslighting of women in a society rife with sexism. These models of understanding mental distress can be best summarised by moving away from asking “what’s wrong with you?” to “what’s happened to you?”.

Although these ideas are growing in popularity within the mental health profession, and through various activists on social media, they will come up against the vested interest of big business. The worker’s movement can, and should, act as a mouthpiece to promote frameworks like these.

These new ideas can both liberate us from the blame and stigma that capitalist ideology creates, while also pointing a direction forward through the transformation of society via collective political struggle, rather than as isolated “chemically imbalanced” individuals.




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