Human beings are living longer and better lives. Medicine has managed to wipe diseases off the face of the Earth, greatly reduce the severity of others, and treat many that were once incurable. The majority of these advances were made in the second part of the 20th century. But there is still one field that has not improved over the last 50 years, and is actually seeing things get worse: mental health. More and more people are suffering from conditions in this field and the drugs being used to treat them have not advanced for decades.
Research has shown that the majority of antidepressants are better than a placebo only for that small proportion of patients who suffer the most serious illnesses. At the same time, more people use all kinds of psychotropic drugs for longer than is recommendable, something that can make mental illnesses worse, as well as causing other health-related problems.
James Davies, a Reader in medical anthropology and psychology at the University of Roehampton in London, has just released a Spanish-language edition of his 2021 book Sedated: How Modern Capitalism Created our Mental Health Crisis. In it, he makes a prescient review of this reality, pointing to factors he believes to be key: the medicalization of problems; the obsession of the system to create productive consumers, rather than make people happy; and an approach to mental health that seeks to alleviate symptoms rather than address the source of the conflict, which is often related to precarious jobs, low wages and a lack of free time. The native Londoner, who opted not to supply his age, spoke to EL PAÍS via videoconference.
Question. One of the main theses in the book is that the problem of mental health in the West does not come from biological causes, but material ones. Are people’s work situations the biggest cause of mental health issues?
Answer. There are a whole host of different issues that can lead large swathes of the population to manifest what gets reframed as symptoms of mental health disorders. Working life is indeed just one of them. And that obviously depends upon the particular working conditions you’re subjected to. But what we have seen in the contemporary West, since the 1980s, are increasing levels of worker dissatisfaction and worker disengagement. And these levels of distress obviously are rooted in the structural determinants of our modern working economy. But the most dissatisfying jobs in our working economy tend to be the jobs located in the service sector. And indeed, this is the sector that has rapidly expanded since the 1980s.
We’ve also seen a whole suite – which I outlined in the book – of employment policies that have made working life less tolerable for more and more people. The removal of unionized working protections, the increased need for dual working households, we’ve seen flatlining wages, we’ve seen an increase in precarity and short-termism within the employment market... We stay for far less longer in any given occupation than we did 30 years ago, which interrupts our ability to build sustainable social relationships. But what we’re doing is rather than embracing and seeking to identify and reform some of the structural drivers of distress and dissatisfaction, we are beginning to reframe that dissatisfaction as a kind of medical problem, the solution for which resides in medical interventions, rather than social intervention.
Q. Does our society resemble the one portrayed by Aldous Huxley in Brave New World?
A. Huxley is obviously talking about the extent to which, as a society, we’re being managed chemically. I think when we look at the figures, it’s quite clear that we’re really at a point where his prophecy so to speak, has almost come true. In the UK, approaching 25% of the adult population were prescribed one kind of psychiatric drug or another last year. This is a quarter, with the figures rising by about 7% each year. So we’re not going to see a reverse in this trend anytime soon. And that’s not just the case for the UK. That’s the case for the US, for Spain, for most Western economies, where psychotropics are widely used. And in the book, I argue that this growing medicalization and medicating of our emotional lives is essentially distracting us from some of the more structural and systemic problems that are generating high levels of distress in contemporary society.
As far as Keynes is concerned, by 2020 we would be in a situation where we’re only working on average for 15 hours a week
Q. Do you think that a reduction in the working day or a reduction to four days of work a week would result in better mental health?
A. Well, yes. In the book, I refer to that now-famous article by [John Maynard] Keynes where he seeks to predict how the economy would look by now, in the 2020s, if Keynesian principles are allowed to reach fruition over a period of 60 years. And as far as he’s concerned, we will be in a situation where we’re only working on average for 15 hours a week. And this was, for him, a very desirable state of affairs, because what it would mean is, we could spend the rest of our time on what he referred to loosely as cultivated leisure: the activity of cultivating the self, cultivating relationships, building our communities, creating a world that was facilitative, and that was good for the soul. And that should be the primary occupation of life. So I think insofar as we spend the time we have available by cutting down the working day in useful, meaningful pursuits, absolutely. This would be to the advantage of all of our mental health. One of the interesting things about the first lockdown in the pandemic was that there was a lot of coverage on how the pandemic exacerbated poor mental health. But what was far less regularly reported was the extent to which the first lockdown in particular actually boosted mental health for a large section of the population, about a third of people reporting that they actually felt better as a consequence of lockdown than they had before. And only 7% of people in the UK reported that they wanted life to return to normal post lockdown. And the reason, again and again, cited as to why people felt a boost in wellbeing and why they didn’t want to return to business as usual post-pandemic was because of work.
Q. You focus on social causes for mental health issues. But aren’t there biological and genetic causes for these issues?
A. Well, for the vast majority of mental health conditions, there have been no biological markers found. This is why we don’t have any biological tests to verify any kind of psychiatric diagnosis. So in the absence of that, I think it is it is very problematic to assume that these are biologically rooted problems. There’s no evidence to support that. And in fact, when we look at the interventions we offer patients, they seem to prefer most of the more social and psychological interventions over the biological ones.
We’ve not seen an increase in the efficacy of psychiatric drugs
Q. It doesn’t seem that psychiatry has been helping people very much, if you look at the overall results. As a psychiatrist, are you frustrated by that?
A. Yes, absolutely. I think that the most damning critique of our mental health sector is derived from looking at his clinical outcomes. So in pretty much all areas of general medicine, we’ve seen outcomes rising since the 1980s. Overall, that’s what we have seen. And we’ve seen that in all areas of medicine bar one, the area in which I work: the mental health area, the area of psychiatry. In that area since the 1980s, not only have clinical outcomes broadly flatlined during that time period, but according to some measures, they have actually got worse. So the prevalence of mental health problems has increased fourfold over that time period. We’ve seen mental health disability rates treble over that period, and most worryingly, in the places where psychiatric medications are most aggressively prescribed, we’re seeing the gap between their life expectancy and everyone else’s widen from about 10 to 20 years over that time period. Also, we’ve not seen an increase in the efficacy of psychiatric drugs over that time period, according to the research, and these very dire statistics exist, despite the fact we’ve spent in the UK at least around a quarter of a trillion pounds [$327 billion] on mental health services and research since the 1980s. I would argue that the situation is so dire because we’ve essentially adopted the wrong approach: the over-medicalizing and medicating approach, which hasn’t got to the social and psychological drivers that sit behind most people’s difficulties.
Q. What is the role that you think psychiatrists should have?
A. I think there is a role for psychiatric medication. I think we know from the research that the most severely distressed members of society can benefit from certain kinds of medications over the short term in particular. So there is a role for doctors in that respect, there is a role for psychiatrists in determining whether or not the problems a person is going through are related to some other medical problem that they may have. Medical doctors are uniquely equipped to do that investigative work. So there is a role for psychiatric drugs, and they would be facilitated by medical doctors. But I would say it’s a greatly reduced one, and a greatly more regulated one than the one we have today.
Q. Should general practitioners be able to prescribe antidepressants, for example?
A. I think we need far tighter regulation of prescribing in primary care. We’re seeing huge percentages of these drugs prescribed to people who should not really be taking them, who are in the mild and moderately depressed categories. The only area where we see some benefit beyond placebo is in the most severely, very severely distressed patients. But these aren’t the majority of people going into primary care, and getting treated with antidepressants through primary care. I think one of the reasons we’re seeing huge levels of prescribing in primary care is because there’s simply a deficit of alternatives. The doctors by instinct want to help the patient. They’re suffering, and they feel morally obliged to do something. And when there’s an absence of alternatives, what ends up often happening by default is that a nice depressant is prescribed, even though the doctor may have reservations about doing so.