In 2017 I wrote a blog for World Mental Health Day. I wrote about the increased societal openness about mental illness over my clinical lifetime, the impact of the widespread availability of talking therapies through IAPT (now renamed NHS Talking Therapies) and described some of the work we had been doing in Bristol and what we planned to do. I talked about research into treatment resistant depression and the threshold for starting antidepressant drugs. What’s happened since in our world, and have we made any progress?
It’s hard to escape the COVID pandemic, but it’s also hard to assess its impact on mental health. The COVID-19 Mental Disorders Collaborators concluded that throughout 2020 the pandemic led to a global increase of over 25% in cases of both depression and anxiety. Others have argued that such estimates may be over-inflated and that trauma research shows that negative life events are typically followed by resilience and recovery.
Indirect impacts are even more complex; COVID infection had neuropsychiatric sequalae for some; grief, loss and economic impacts were widespread. There is evidence that young adults and especially adolescent females experienced increased feelings of hopelessness, and that deaths related to drug overdose were higher. Educational and social development were interrupted for many young people, although older people were more vulnerable to the physical effects of the disease. I suspect that the psychological impact was as great or greater for the young. As the Chinese Premier Zhou Enlai was alleged to have said in 1972, when asked about the impact of the French Revolution: “It’s too early to say”. But I think that one impact of the pandemic is the sense of shared suffering across the world, and this may have shifted our perception of a need for equity in response to health crises, including mental health crises.
In our own work in the Centre for Academic Mental Health we have developed evidence on the management of treatment resistant depression through large randomised trials looking at both psychological and pharmacological treatments. We continue to work in this area and are participating in trials of drugs that have not been used to treat depression before now, such as pramipexole, a treatment for Parkinson’s disease. We have also expanded our work into the area of anxiety disorders. Anxiety has been relatively under-researched in the UK and, as well as looking at patterns of diagnosis and prescribing over time, we have begun a trial of treatment for anxiety that has not responded to usual drug treatments.
We are not only interested in getting more people onto more treatments; there is a growing concern about the effects of long-term treatment with psychiatric drugs, and we share that concern. For example, much of the huge increase in antidepressant prescribing over the last 20 years is driven by long-term prescriptions. We have published on the adverse effects of long-term antidepressants – there may be a greater risk of stroke and heart disease with longer term treatment – and we were part of a multi-centre trial looking at the recurrence of depression after withdrawal of antidepressants. In this study we found that while relapse rates were higher off the drugs after a year, the difference between those who stayed on the drugs and those who stopped was not large. Our aim in these studies has been to better inform patients and prescribers when they are making difficult decisions about whether to stop these drugs.
So, I finish with two thoughts. Perhaps the pandemic has made us think differently, not only about global equity, but also about how closely mental, physical and social wellbeing are related. And while no game-changing treatments for mental health are imminent, we continue to refine the care we offer by better understanding its risks and limitations and re-purposing treatments that we already use.
Today is World Mental Health Day – “Our minds, our rights”.