Free associations

Free associations

Does more mental health treatment and less stigma produce better mental health?

Mental health problems continue to carry a heavy stigma. People who experience them are often feared, excluded, shamed and discriminated against. Overcoming that stigma is a high priority, not least because it’s a barrier to engaging people in treatments that might help them.

People suffering from mental health problems are not the only ones to experience the stigma of mental illness, however. Those who treat them sometimes share the burden. Just as the shadow of death falls on workers in the funeral industry, psychiatric stigma casts a shadow on the public image of mental health professionals.

Psychiatrists in particular have been concerned they are held in low esteem by the public and within the medical profession. This negative view of the field has significant consequences, such as making it difficult to recruit students into psychiatric training. The chronic under-funding of mental health research and treatment arguably reflects the same devaluation.

Two articles published this week shine a revealing light on how the general public views mental health care and its practitioners. Their findings appear paradoxical, but on closer inspection they tell an important story.

Public views of mental health treatment

The first article takes a close look at how laypeople perceive mental health treatment, and how their perceptions have evolved. The authors review 162 surveys, conducted around the globe between 2000 and 2015, that explore how the public views treatments of depression and schizophrenia. Their findings are surprisingly optimistic.

First, large majorities of survey respondents recommended psychiatrists or psychologists as sources of help. Although these specialists were recommended for the treatment of depression to a similar degree as general practitioners, they were clearly preferred for treating schizophrenia. Australia was an exception to the global rule: there, general practitioners were favoured over mental health professionals for depression and seen as equally appropriate for schizophrenia.

Second, most survey respondents had favourable views of standard mental health treatments. Medication was recommended by half of them for depression and by two thirds for schizophrenia, with more than three quarters recommending some form of talk therapy. Again, Australia stood out for not showing the otherwise universal preference for psychotherapy.

Finally, the study authors examined changes in treatment recommendations over the period 1990 to 2011. They found both psychiatrists and psychologists enjoyed steadily rising levels of endorsement as treatment providers. Psychotherapy and especially medication also rose in public estimation, the latter gaining in popularity by 15% each decade.

These findings suggest hand wringing about the stigma attached to mental health professionals may be unwarranted. The public appears to have a generally positive view of them and the kinds of help they dispense.

By implication, people should now be increasingly willing to seek mental health treatment when they need it, confident public opinion supports that course of action. And because more people seek professional help, the population’s mental health should be improving.

Does more treatment lead to better mental health?

The second article offers some evidence for this optimistic scenario, but then gives it a sharp twist. Its authors examine whether increases in the provision of treatment for common mental health problems have delivered reductions in their prevalence. They compare developments in the USA, the UK, Canada and Australia.

One consistent finding is rates of mental health treatment have indeed risen, sometimes sharply. A higher proportion of people experiencing mental health problems are now receiving help, narrowing the so-called “treatment gap”. In particular, antidepressant prescription rates have skyrocketed.

Taking Australia as an example, the authors report government expenditure on mental health care has climbed steeply in real terms. Antidepressant use more than quadrupled from 1990 to 2002, then almost doubled again in the following decade. The proportion of people experiencing a mental health problem who receive treatment for it was 46% in 2009-2010, up a striking 9% in just three years.

Crucially, though, these rising rates of treatment have not been accompanied by falling rates of diagnosis. There is no good evidence in any of the four countries that common mental health conditions are becoming less prevalent or that average levels of psychiatric symptoms in the population are dropping. Instead, they are either static or on a gentle upswing.

How to explain this puzzle of more mental health treatment without more mental health? The authors dismiss the possibility these treatments do not work, noting many have established their efficacy through tightly controlled clinical trials. They propose a few alternative explanations.

Increased treatment might have a positive impact that is masked by other factors. Perhaps improvements in population mental health due to the greater uptake of treatment have been counteracted by declines due to rising levels of adversity or other risk factors. The authors dismiss this too: there is little evidence life in high income countries has become steadily harder in recent decades.

Alternatively, real improvements in mental health might be obscured by a growing tendency for people to report mental health problems. Ironically, the public’s mental health may appear to be worsening – or at least not improving – precisely because the stigma of mental health problems is eroding. If disclosing psychiatric distress is no longer a source of shame, more people will disclose.

The ‘treatment gap’ and the ‘quality gap’

The authors of the article find little evidence for this explanation but consider it credible. However they prefer another. Rising rates of treatment may have disappointing effects on population mental health not because those effects are masked, but because the treatment is poorly implemented.

Too much mental health treatment is not evidence-based. Too much treatment does not target the right people, and too much is inadequately delivered. Insufficient attention is paid to preventing mental health problems in the first place.

Take rampant antidepressant use as an example. As the authors of the article argue, these medications are commonly prescribed for mild depressions, or for people who do not even merit a diagnosis, when they are more suitable for severe cases. Prescribing practice disproportionately targets older adults, who have relatively low rates of depression. Prescriptions are often too short or they are abandoned prematurely.

The message of this research is clear and urgent. In addition to closing the treatment gap and ensuring that more affected people receive treatment, we must close the “quality gap” and ensure treatment is sound. Part of the solution surely lies in advancing evidence-based psychotherapies which, as we have seen, the public tends to prefer to medication.

We still have a way to go with reducing stigma. We may have even further to go with implementing effective mental health treatments.