Mental health policy and practice across Europe: an overview

Psychopharmaceuticals in Europe 181
and not by GPs. At the same time the UK’s National Institute for Clinical Excellence
(NICE) advised that while those adults diagnosed with moderate depression
in primary care should be offered generic forms of SSRI antidepressants, the
risks had to be carefully explained and monitored, and that those with mild
depression should be treated initially with ‘watchful waiting’, perhaps advising
exercise, self-help and cognitive-behavioural therapy, but not the use of an
antidepressant, as the risk-benefit ratio was considered to be poor (National
Institute for Clinical Excellence 2004). By that time, criticisms were mounting,
not only of the reliability of published evidence of risk-benefit ratios for SSRIs,
but of the difficulties of withdrawing from this medication – not dependency as
is often suggested, but the severe and unpleasant physical effects – pains, sweating,
nausea and much more – which occur when patients who have been taking
these drugs for a while cease to take them, no doubt caused by the fact that
the molecules act very widely in the body, and the artificial raising of the levels
by the drugs leads to a down-regulation of the body’s own production of, or
sensitivity to, the molecules in question. 24 These cycles of enthusiasm, doubt,
scandal and warning are familiar from the history of the introduction of other
psychiatric drugs, notably the minor tranquillizers. They are usually followed by
routinization of the uses of these drugs at lower but stable levels, out of the glare
of publicity. And, while such public controversies may reshape the details of
prescribing practices and the populations to which different drugs are directed,
they are unlikely to challenge the basic presuppositions of biological psychiatry,
its rise to dominance, and the value, both cognitive and therapeutic, that it
accords to neurochemical explanations and pharmaceutical treatment of mental
health problems.
Conclusions
In one sense, developments in psychiatric drug use are merely one dimension of
a new set of relations between ideas of health and illness, practices of treatment
and prevention of bodily malfunctions, and commercially driven innovation,
marketing and competition for profits and shareholder value. But they take a
specific character in relation to mental health. As we all know, in the second half
of the twentieth century, psychotherapy and counselling became big business.
But psychiatry itself – in the mental hospitals, the clinics, the GP surgeries and
the private psychiatric consulting room – also became a huge and profitable
market for the pharmaceutical industry. These developments have continued
into the present century. It would be misleading to claim that all ways of understanding
mental health problems are ‘biological’ in the way I have described in
this chapter. Indeed, recent developments suggest some reconciliations between
bio-medical and social frameworks for understanding mental health problems,
notably through the mediation of the versatile idea of ‘stress’. But even where
practitioners adopt different understandings of the aetiology of such problems,
in almost all cases treatment involves the use of drugs.
Because contemporary psychiatry is so much the outcome of developments in
psychopharmacology, commercial decisions are actually shaping the patterns
of psychiatric thought at a very fundamental level. Most pharmaceutical