Treatment for mental illness works, if people get it

Many people, even some doctors and psychiatrists, say treatments for mental illness are ineffective and may even make things worse. Such mis-quoting and mis-reading (or maybe its no-reading) of the clinical trial literature must represent the biggest failing of mental health professionals to engage with the evidence and the public.

Hundreds of randomised controlled trials over half a century have shown that antidepressants, lithium and antipsychotics usually reduce the symptoms of depression, bipolar disorder and schizophrenia respectively.[1-6] Patients in these trials are more likely to stay on treatment than placebo, despite adverse effects, presumably because they find them helpful overall. Treatments also reduce relapse rates by about 40% if sufferers carry on taking them. These benefits cannot be simply dismissed as down to pharmaceutical industry sponsorship of the trials.[1,6] In clinical practice, psychiatrists try to tailor drug doses to the individual, to optimise benefit and minimise adverse effects, and slowly phase the drug out once patients are well again.

The psychotherapies get a less hostile press than psychotropic drugs. Although less well established, they can be as effective as drug treatments, have fewer adverse effects and many patients prefer them, but they take longer to work and can be difficult to obtain.   Generally, a combination of drug and talking treatments is better than either alone, which is why both are used in most clinical settings.[7]

Treatments for mental illness are as effective as medical treatments

On average, the amount of benefit these treatments have, [8] and the proportion of patients with mental illness who receive interventions based on clinical trial evidence, [9,10] is about the same in psychiatry as in the rest of medicine. Stefan Leucht and colleagues [8] compared recent systematic reviews on the efficacy of drugs compared with placebos for common medical and mental conditions. They found 94 meta-analyses covering 48 drugs for 20 medical illnesses and 16 drugs for eight mental illnesses. The mean effect size was about the same and if anything slightly higher for mental illness treatments. Overall, therefore, drug treatment for mental illness is as effective as it is for medical conditions.

About two-thirds of people respond to initial treatment with antidepressant or antipsychotic drugs.[1-6] The majority of the remainder will respond to other treatments, and relapse rates are reduced (not increased!) by staying on treatment. Indeed, antidepressant or antipsychotic maintenance treatment to avoid relapse are amongst the most potent treatments in all of medicine.[8] Statements that these treatments are addictive and make underlying problems worse are not evidence-based and are completely alien to practising clinicians who actually see patients.

Psychiatric treatment can save lives

It is even true that many treatments for mental illness can be life-saving. Systematic reviews of clinical trials and large-scale population based studies show that lithium reduces death by suicide in depression, [4] and that antipsychotic drugs reduce all-cause mortality in schizophrenia in both the short and long-term. [11,12]

It is difficult to avoid the conclusion that stating drug or talking treatments for mental illness don’t work reflects ignorance and bias. Perhaps they also reveal the very same stigmatisation of mental illness that affects the people getting the treatments.[13,14]

REFERENCES

[1] Leucht, C., Huhn, M. & Leucht, S. Cochrane Database Syst Rev 12, CD009138 (2012).

[2] Geddes, J.R., et al. Lancet 361, 653-61 (2003).

[3] Geddes , J.R., et al. Am J Psychiatry 161, 217-22 (2004).

[4] Cipriani, A., Hawton, K., Stockton, S. & Geddes, J.R. BMJ 346, f3646 (2013)

[5] Leucht S, et al. Lancet 379, 2063-71 (2012).

[6] Adams CE, Bergman H, Irving CB, Lawrie S. Cochrane Database Syst Rev 15 CD003082 (2013).

[7] Huhn, M., et al. JAMA Psychiatry 71, 706-15 (2014).

[8] Leucht, S., Hierl, S., Kissling, W., Dold, M. & Davis, J.M. Br J Psychiatry 200, 97-106 (2012).

[9] Ellis, J., Mulligan, I., Rowe, J. & Sackett, D.L. Lancet 346, 407-10 (1995).

[10] Geddes JR, et al. Qual Health Care 5, 215-7 (1996).

[11] Khan, A., Faucett, J., Morrison, S. & Brown, W.A. JAMA Psychiatry 70, 1091-9 (2013).

[12] Tiihonen J, et al. Lancet 374, 620-7 (2009).

[13] Nutt, D. Lancet Psychiatry 1, 102-4 (2014).

[14] Lawrie, S.M. Advances in Psychiatric Treatment 21, 85-7 (2015).

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