Throughout medicine, therapeutic preferences are evident. Certain treatments may predominate, but they coexist with lesser-used alternatives. They also wax and wane in popularity with clini- cians. They have also been subjected to wider social and cultural influences. The media and ‘pub- lic opinion’ have been influential in changing the regulatory frameworks and provision of drugs.
Mental health work is no different in this sense. However, it has been controversial for particular reasons, which go beyond the pattern of fads and fashions typical of wider curative medicine:
1 There is still a broad and unresolved tension between somatic and conversational modes of treatment. The overwhelming dominance of the first of these, especially in response to madness, has led to disaffection among service users and the growing popularity of non-drug based treatments. The latter are increasingly adopted by the state in the form of short-term talking interventions (e.g. CBT).
2 All therapeutic approaches have been attacked for their iatrogenic effects. Iatrogenic effects are those caused by the treatment itself; the term ‘side effects’ is a common version of this notion when talking about drug therapy. It is more accurate to speak of ‘unwanted effects’ or ‘adverse effects’, rather than ‘side effects’.
3 Each approach has received critical scrutiny for its ineffectiveness in ameliorating distress.
THe TreaTMenT of PeoPle WITH MenTal HealTH ProbleMs 127
Why have physical treatments tended to predominate?
From those on the receiving end, the fact that psychiatric treatments are indeed biased more towards drugs and ECT is indeed a problem. Not only do patients (understandably) expect their subjective sense of well-being to improve as a result of psychiatric treatment, they have higher expectations of the helpfulness of psychological and combined treatments than physical interven- tions alone (Noble et al. 2001). In most mental health services physical treatments have predomi- nated as the only form of treatment offered or imposed. However, this picture has changed with the state-sponsored use of talking therapies, particularly CBT, in service responses. Bio-medical professional preferences at the expense of user choice have effectively been affected by the intro- duction of treatments in primary care settings. This shift in ‘place’ is discussed more towards the end of this chapter.
Six mutually reinforcing contributory factors can be put forward to suggest why a bio-medical bias in treatment has existed in modern mental health interventions provided in health service settings.
1 The medicalization of psychological abnormality in the nineteenth century entailed a biological emphasis. For doctors to ensure their jurisdiction over madness they had to assert or prove that it arises from some sort of physical pathology. Accordingly, the use of physical treatments is consistent with a bio-deterministic aetiological theory. If such a position is not persuasive, then arguably mental illness is actually a sort of social, edu- cational or existential, not physical, problem. As an indication of this, psychoanalysis, the prototype of the modern talking treatments, became divided in its early years about whether analysts needed to be physicians.
2 During the 1960s, when large mental hospitals came under attack from a variety of sources, an opportunity was created for psychiatrists to shift their site of operation into mainstream medicine. Their preferred service delivery model was that of the DGH psychiatric unit. Baruch and Treacher (1978) point out that this allowed psychiatrists to make a bid to rejoin mainstream medicine and thereby compensate for the low status traditionally enjoyed by their medical specialty. Whether this has actually led to an improvement of their status within medicine is uncertain. However, aligning itself with general medicine was made more credible by the content of its interventions being like other medical procedures. In the USA Kleinman (1986) also noted that medication use and the professional image of psychiatry as a poor relation trying to improve its medi- cal reputation were intertwined.
3 Physical treatments are legitimized and encouraged by the profit motive. Drugs are a well-known source of profits for their producers. In addition to the profits accruing from the sale of psychotropic medication, these companies also sell drugs to offset the side effects of major tranquillizers (e.g. induced Parkinson’s disease). Drug companies pro- mote their products through expensive advertising campaigns and sponsored events.
These are orientated to professionals, but direct marketing to potential consumers is also increasing.
4 Although millions in each international currency are spent yearly on psychotropic drugs, they are still arguably cheaper to deliver than labour-intensive talking treatments. For instance, minor tranquillizers are a cheap and quick way of disposing of emotional prob- lems in the surgery. Likewise, a reliance on major tranquillizers to dampen down the agitation of psychotic patients, older people and those with learning difficulties has been a cheap alternative to crisis intervention, intensive family support and psychological pro- grammes.
128 a socIology of MenTal HealTH and Illness
5 If psychiatry exists, among other things, to control disruptive and unintelligible conduct, then physical treatments are highly suited to this purpose because they can be imposed in the absence of co-operation. Medication, psychosurgery and ECT can, in certain circum- stances, be imposed on people against their will, whereas it is very difficult to conduct talking treatments with resistant subjects. Indeed, most psychotherapists argue that con- sent is a necessary precondition for any form of their treatment and that this condition of free choice is clearly compromised by a client being captive (Pilgrim 1988).
6 Although discoveries about the behavioural impact of psychotropic drugs have often been a result of accident rather than design, once the effects are demonstrated, and they are patented and marketed by drug companies, they provide a spurious illusion that bio- determinism has been proven (bringing us back to point 1 above). The drive for pharma- ceutical companies to produce both innovative and ‘me too’ compounds for profit has entailed their stimulation of biological psychiatric research both directly via research funding and indirectly. In the latter regard, Healy (1997) noted that even the patient who is drug ‘treatment’ resistant becomes a curious conundrum for neuropsychiatric research- ers to solve using expensive medical technology to scan (live) and slice (dead) brains.
The very use of that expensive technology then confirms the legitimacy of biological reductionism within psychiatry.
Minor tranquillizers
Benzodiazepines are a class of psychoactive drugs, which have been used at various times for treating depression, anxiety, insomnia, agitation, seizures, muscle spasms and alcohol withdrawal, and as a type of premedication for minor surgical procedures. The effects associated with these drugs include the induction of sleep (hypnotic), the reduction of anxiety (anxiolytic) and muscle relaxation (Olkkola and Ahonen 2008). In recent years there has been a significant reduction in the use of benzodiazepine drugs largely as a result of the sustained criticism they have received (see below). A question has arisen about what should replace them as a strategy for managing anxiety-based mental health problems. Nonetheless, despite criticisms, they are still prescribed albeit ambivalently by doctors, and they remain a quick and relatively cheap response to some psycho-social problems in primary care settings.
The benzodiazepines have mainly been discredited for their addictive qualities. They are only effective in symptom control for around 10 days, with 58–77 per cent of recipients reporting sedation effects of the drugs (drowsiness, lethargy and memory disturbances). Thirty per cent of those taking these drugs for more than a few weeks will develop withdrawal symptoms, including panic attacks, insomnia, tremor, palpitations, sweating and muscle tension (Tyrer 1987). In a small percentage (under 5 per cent) more severe problems, including epileptic seizures and paranoid reactions, might occur. During the 1980s, the scale of iatrogenic addiction prompted a popular protest movement which led to litigation against the drug companies supplying minor tranquilliz- ers (Lacey 1991). When they are used in older patients, minor tranquillizers can also lead to mental confusion and falls, necessitating emergency medical treatment.
Sociologists have illuminated the role and impact of wider social influences, institutions and processes on the use and acceptability of minor tranquillizers. Bury and Gabe (1990) demonstrated the role of the media in legitimizing the social problem status of minor tranquillizers. The same authors presented an analysis of events surrounding the suspension of the licence, by the British Licensing Authority in 1991, for the widely used sleeping tablet Halcion (triazolam) (Gabe and Bury 1996). They identified four elements within these events: the claims-making activities of med- ical experts, legal challenges, the role of the media and the response of the State. Together these have made a contribution to minor tranquillizers becoming a public and governmental issue rather than a purely clinical matter.
THe TreaTMenT of PeoPle WITH MenTal HealTH ProbleMs 129
In relation to the same controversy about Halcion, micro-sociological factors within organiza- tions such as the Licensing Authority have been offered as an alternative to the account by Gabe and Bury (Abraham and Sheppard 1998). These micro-factors include professional interests and the internal organizational arrangements and processes within institutions for reviewing and pre- senting data. Abraham and Sheppard suggest that these are more important than broader extra- organizational social influences in determining whether or not a drug remains widely available or is withdrawn from use (cf. Gabe and Bury 1996). It may well be that both accounts are applicable – it seems likely that social processes at both micro and macro levels are likely to sway the extent to which drugs are viewed as acceptable by authorizing bodies, the medical profession, the public and the State.
Despite criticisms of the drugs they are still prescribed, although in primary care this is restricted to short-term use for phobias and they are no longer used as a widespread quick and cheap response to complex psycho-social presenting problems. The impact of campaigns against the drugs and criticisms about poor cost-effectiveness from services commissioners have impacted on GPs’ prescribing and so they are no longer habitually prescribed. A recent study suggested a sensitivity to previous criticisms and a much more restricted view of the GP’s role. This includes greater awareness of risks and addiction (Rogers et al. 2007).
Antipsychotics
The first generation of antipsychotics, which with the advent of a ‘second generation’ have come to be known as typical antipsychotics, were first introduced in the 1950s. The second generation, known as ‘atypical antipsychotics’ were developed and introduced into clinical practice in the 1970s, and since the 1990s have been increasingly used in routine practice. Both ‘typical’ and ‘atypi- cal’ medication block receptors in the brain’s dopamine pathways. Negative effects are common and include weight gain, white and red blood cell disorders (e.g. agranulocytosis), tardive dyski- nesia and tardive akathisia (movement and feeling disorders), and neuroleptic induced psychoses.
The iatrogenic problems of Parkinsonism (trembling), akathisia (inner restlessness) and tardive dyskinesia are a group of disabling and disfiguring movement disorders, including pronounced facial tics, tongue flicking and jerking limbs. Estimates of their prevalence in those prescribed major tranquillizers vary from 0.5 per cent to 50 per cent with a mean of 20 per cent (Brown and Funk 1986). The probability of the iatrogenic effect occurring increases the longer the drug is prescribed, the larger the dose and the more other drugs are given in a ‘cocktail’ (technically called ‘polypharmacy’) (Hemmenki 1977; Warner 1985). When larger doses are given (‘megados- ing’) fatalities are also risked, warranting the invention of a new diagnosis for iatrogenic death from phenothiazines – the ‘neuroleptic malignant syndrome’ (Kellam 1987).
Given the serious negative effects associated with neuroleptics, until recently the perceived degree of complacency about their use on the part of professionals has attracted sociological interest. Brown and Funk (1986) traced how the evidence about tardive dyskinesia was avail- able to psychiatrists in the late 1960s. And yet, throughout the 1970s and 1980s major tranquillizer prescription rates were undiminished (they actually increased in frequency and in dose levels).
Active and passive forms of professional resistance to the recognition of tardive dyskinesia as an iatrogenic epidemic were evident in this period. Some clinicians acknowledged its existence but challenged data on its claimed prevalence or argued that the therapeutic benefits outweighed the iatrogenic risks. Others simply failed to change their prescribing habits without comment.
Brown and Funk claim that two theories (professional dominance and labelling) have some merit in accounting for this professional resistance to change. Both acknowledge the importance of the powerless social position of patients. The labelling theory account suggests that the power- less position and low social status of psychiatric patients renders them both unimportant and invis- ible. Consequently, their treating psychiatrists do not take their complaints about ‘side effects’, or
130 a socIology of MenTal HealTH and Illness
their concerns about the debilitating effects of the drugs, seriously. Instead, doctors tend to be concerned only with the effectiveness of the drugs in symptom reduction (assessed by them, not the patients themselves).
The professional dominance theory focuses on the relationship between the status of psychia- try as a medical specialty and the role of physical treatment (see earlier). Brown and Funk endorse a similar picture, with psychiatry tying itself to physical medicine and its attendant biological trappings. Given this preoccupation with collective professional status, unfortunate consequences of biological treatment (like tardive dyskinesia) are ignored, denied or rationalized by clinicians.
According to this theory, the needs of patients are ignored in favour of the political needs of their treating psychiatrists. A study of psychiatrists and recipient views of major tranquillizers (Finn et al. 1990) showed that both groups concur on the risks and ‘bothersomeness’ of side effects.
However, ‘psychiatrists saw side-effects as significantly less bothersome than symptoms when considering costs to society’ (Finn et al. 1990: 843). It is, perhaps, not surprising that patients who experience the side effects of antipsychotics are often reluctant to comply with the regimen. In its depot form this type of medication results in an even more disempowered perception of the treat- ment process (Kilian et al. 2003). What is, perhaps, more surprising is that given the range and severity of side effects, non-adherence rates for major tranquillizers are the same as for other types of non-psychiatric medication.
The problems associated with traditional major tranquillizers (the phenothiazine group of drugs) purportedly applied less to the second generation of drugs. When introduced the claim was that these ‘atypicals’ were more efficient at symptom reduction and less liable to create movement disorders in patients. However, there is the risk of life-threatening blood disorders with some ver- sions of the new antipsychotics. A range of new problems and adverse effects have become appar- ent as they have been used on a more routine basis, Indeed, some psychiatrists comparing the use of old and new antipsychotics are now querying these purported advantages of the newer drugs. They argue that the older drugs in low doses are as good as the new ones (Lewis and Leiberman 2008).
Within psychiatry a sharper focus and use of ‘evidence-based’ practice has resulted in a more reflexive view about the traditional use of antipsychotics suggesting a greater alignment with both user views and the critique previously made by sociologists such as Brown and Funk.
This new view emanates from recognition of the results of clinical trials, which failed to show a superior outcome when the new atypical drugs were compared with the older generation drugs.
(Tyrer 2008) Others have gone as far as to suggest the possibilities of non-prescribing, as suggested by Morrison et al. (2012: 83):
Given that mental health services appear to have overestimated the strength of the evidence base for antipsychotic medication, while underestimating the seriousness of the adverse effects, it seems sensible to re-evaluate the risk–benefit ratio of such drugs. This risk–benefit profile may be a factor in the high rates of non-adherence and discontinuation of medication found in patients with psychosis; thus, some decisions to refuse or discontinue antipsychotic medication may represent a rational informed choice rather than an irrational decision due to lack of insight or symptoms such as suspiciousness. Given accurate and honest assessment of both risks and benefits, it should be possible to prescribe antipsychotics in a more thoughtful and collaborative way, and these considerations should involve explicit discussion of the pos- sibility of not prescribing at all.
The sociological significance of the prescribing of and compliance with antipsychotics extends beyond the issue of the adverse effects and practices of the profession of psychiatry.
THe TreaTMenT of PeoPle WITH MenTal HealTH ProbleMs 131
Psychiatric patients’ ‘non-compliance’ with medication has emerged as a significant social prob- lem. Images of deinstitutionalization, often promoted via the media, have become synonymous with the occurrence of socially unacceptable behaviour by ex-psychiatric patients living in the community. Within this oft-publicized scenario, medication has been depicted as an unambigu- ously valid means of managing and controlling people who are viewed as a potential threat to the social order. Compliance with these drugs has come to be seen as an indicator of the success or failure of ‘care in the community’. In this sense, the need for patient compliance derives not only from public pressures about managing psychiatric patients appropriately but it is also a central tenet in the management of mental health problems more generally.
The closure of mental hospitals was predicated on the assumed effectiveness of major tran- quillizers. The introduction during the late 1960s of depot medication can be seen as an early attempt to devise a strategy for the more efficient control of patients’ behaviour in the commu- nity. (It involves patients being injected with long-acting drugs in their home or at a clinic.) Depot medication was uniquely marketed as a means of ensuring the receipt of medication, which did not rely on the patients’ daily consent to treatment on their reliability in self-administering daily pills.
The effectiveness of antipsychotics has been assumed by professionals, politicians and rela- tives’ groups who emphasize the importance of treatment compliance for discharged patients. This has extended to legal proposals to enforce medication compliance in community-based patients in Britain – a policy already implemented in some parts of the USA (Dennis and Monahan 1996). How- ever, the effectiveness and acceptability of major tranquillizers have been strongly challenged. For example, Cohen (1997) notes that:
• only one in three medicated patients fails to relapse;
• chronic use of the drugs leads to a reduction in social functioning;
• to date, few researchers have attended to user views of being medicated.
The reviewer concludes that ‘the overall usefulness [of neuroleptics] in the treatment of schizo- phrenia . . . is far from established’ (Cohen 1997: 195). In relation to their iatrogenic effects Cohen concludes that the ‘neuroleptics’ near-sacred reputation as ‘antipsychotics’ is equalled only by their record as one of the most behaviourally toxic classes of psychotropic drugs’ (1997: 201).
Extending the point about assumed utility of the drugs, major tranquillizers have been viewed as the principal means of preventing ‘the revolving-door patient’ phenomenon. They are a central plank of ‘outreach’ care, case management, the care programme approach, supervised discharge and the management of those with ‘a severe and enduring mental illness’. However, the centrality of medication to mental health policy has been problematic. The iatrogenic effects of medication have also become a focus of critical scrutiny and this has received greater publicity than at the time when Brown and Funk were discussing the topic in the 1980s.
The negative effects of major tranquillizers have been the focus of criticism from campaign- ing and mental health user organizations. Policy-makers are now faced with balancing the need to maintain medication adherence, with the risks of iatrogenesis (Rogers and Pilgrim 1996). This dilemma has become increasingly difficult for policy-makers to manage in a cultural context of high sensitivity to risk, the emergence of a consumerist philosophy within the health service, and the growing acceptance of the legitimacy of lay perceptions and assessment of medicine within modern health care systems.
The receipt of major tranquillizers occurs in a context of the wider meaning and symbolic significance that ‘schizophrenia’ has for patients in their everyday lives and of a policy context which stresses the need to survey and control the behaviour of people living in the community. For this reason, self-regulatory action in this group of patients has been found to be less evident, and the threat and application of external social control is greater than in relation to other groups of patients taking medication for chronic conditions (Rogers et al. 1998).