# Shifting the Balance Towards Social Interventions: - **Original-PDF (den gällande versionen):** https://beyondpillsappg.org/wp-content/uploads/2024/05/Beyond-Pills-APPG-Shifting-the-Balance-Report-2024-1.pdf - **Licens och upphov:** Licens: se originalet. Författare: se originalet. - **Citera som:** Shifting the Balance Towards Social Interventions:. - **Den här kopian:** webbsida https://kmr.clearagency.ai/docs/beyond-pills-appg-shifting-the-balance-report-2024-1 · PDF https://kmr.clearagency.ai/docs/beyond-pills-appg-shifting-the-balance-report-2024-1.pdf (34 sidor) > Omvandlad till Markdown för tillgänglighetens skull; originalet är den gällande versionen. Original: https://beyondpillsappg.org/wp-content/uploads/2024/05/Beyond-Pills-APPG-Shifting-the-Balance-Report-2024-1.pdf ## Shifting the Balance Towards Social Interventions: ## A Call for an Overhaul of the Mental Health System ### Beyond Pills All-Party Parliamentary Group May 2024 This is not an official publication of the House of Commons or the House of Lords. It has not been approved by either House or its committees. All-Party Parliamentary Groups are informal groups of Members of both Houses with a common interest in particular issues. The views expressed in this report are those of the group. Preface .......................................................................................................................................3 Executive summary ....................................................................................................................5 Why we need an overhaul of our mental health system ..........................................................7 The WHO/UN call for mental health reform .............................................................................9 Six principles for mental health reform...................................................................................13 1. Mental health problems are mostly about our circumstances and relationships.........13 2. Mental health problems arise within our social environments.....................................13 3. Mental health problems are exacerbated by societal messages...................................14 4. Positive narratives and language are needed for recovery ...........................................14 5. Psychiatric drugs should be used with caution and over-prescribing reduced .............14 6. Research should focus on better psychosocial provision ..............................................15 Calls for action .........................................................................................................................16 Services ................................................................................................................................16 1. Boost provision for social interventions, including social prescribing and community-based resources ...........................................................................................16 2. Fund and deliver community-based mental health hubs for people of all ages.....17 3. Fund and deliver a national 24-hour prescribed drug withdrawal helpline and website.............................................................................................................................18 4. Reverse the rate of unnecessary antidepressant prescribing .................................19 Regulation ............................................................................................................................20 5. Reform the MHRA, the regulator of medicines in the UK .......................................20 6. Implement a UK Sunshine Act to improve transparency of financial conflicts of interest.............................................................................................................................21 Education and training.........................................................................................................21 7. Integrate Social Emotional Learning (SEL) into the national curriculum.................21 8. Improve the education and training of health professionals ..................................23 Public and professional awareness......................................................................................24 9. De-medicalise mental health language in both public and professional spaces.....24 Conclusion................................................................................................................................27 ### Preface This report points the way to a higher quality and more effective approach to mental health, which will improve the lives of millions of people and strengthen the UK economy. Its recommendations align with recent calls from the World Health Organisation and the United Nations for systematic mental health reform. The report begins by describing the current mental health crisis, which affects around a quarter of adults and children in the UK and has enormous individual, societal and economic costs. This is happening despite increased investment in traditional approaches to mental health. These existing approaches are simply not working. Shifting the Balance Towards Social Interventions calls for radical change with a shift towards more social interventions and away from pharmaceutical and other purely biomedical ones. This may seem counterintuitive in a country accustomed to think about mental illness as an individual problem requiring medical treatment. The report, however, points to the evidence of the impact on individuals of toxic relationships, family dysfunction and breakdown, abuse, bullying, violence and other traumatic events and to the role of wider societal factors such as economic insecurity, poverty, poor housing, inadequate nutrition, and damaged communities. It goes on to set out six principles for mental health reform. The emphasis throughout is to move away from focusing purely on health services aimed at treating individuals to concentrate much more on prevention through tackling the wider causes of mental ill-health and, as importantly, on creating health by providing the conditions for people to be healthy and, where appropriate, helping them to be so. Implementation will be difficult. It requires major changes in clinical practice and professional training as well as shifts in public perceptions. Equally importantly, as the report describes so well, pharmaceutical companies have had far too much influence and have benefitted accordingly. Medicines will still be needed for some patients, but the existing levels of over-prescribing must be tackled. The report proposes nine practical calls to action relevant to the mission of the Beyond Pills APPG - some of which can bring immediate benefits as well as others that will take a great deal of time and effort. Many clinicians recognise the need for these radical changes, but they will need the leadership and support of the NHS, government and the professional bodies. I congratulate the authors of this report and commend it wholeheartedly. These are timely and important recommendations. Lord Nigel Crisp Co-Chair of the Beyond Pills All-Party Parliamentary Group Chief Executive of the English NHS and Permanent Secretary of the Department of Health 2000-2006 May 2024 ### Executive summary This report calls for urgent reform of the mental health sector in the United Kingdom. It highlights the pressing need to address the current crisis in mental health outcomes, which is characterised by high rates of psychiatric drug prescriptions, lengthy waiting times for treatment, soaring societal and individual costs of worsening mental health, and persistently poor outcomes despite significant investments in services and research over the past four decades. Key findings of the report include: 1. Mental health outcomes have not improved despite substantial investments in services and research, with rates of poor mental health worsening in the general population and the mortality gap widening between individuals with severe mental health problems and the general population. 2. The dominant biomedical model of mental health care has led to over-reliance on psychiatric drugs and neglect of effective social, community and relational approaches. This approach fails to address the underlying social, economic and psychological determinants of mental distress and is contributing to worsening outcomes. 3. The United Nations and WHO have called for fundamental reforms in mental health care, emphasising the importance of psychological and social support alongside efforts to address the social causes of distress. 4. The report outlines six principles for mental health reform, including recognising the social and relational nature of mental health problems, addressing the social determinants of distress, challenging societal messages that contribute to emotional distress, promoting positive narratives and language to support recovery, using psychiatric drugs with caution, and prioritising research on psychosocial interventions. In conclusion, the report emphasises the need for a paradigm shift in mental health care towards a more holistic and person-centred approach that addresses the social, economic and psychological factors contributing to mental distress. Facilitating this shift is not the sole responsibility of government; it requires everyone involved in the UK mental health system to play an active part. The Beyond Pills APPG has identified nine specific recommendations relevant to its mission that it will be advocating for in the following arenas as its contribution to this shift: ### Services 1. Boost provision for social interventions including social prescribing 2. Fund community-based mental health hubs for all ages 3. Fund drug deprescribing services as well as a national withdrawal support helpline 4. Reverse rates of unnecessary antidepressant prescribing ### Regulation 5. Reform the MHRA, the regulator of medicines in the UK 6. Implement a UK Sunshine Act to improve transparency of conflicts of interest in medicine ### Education 7. Integrate Social and Emotional Learning programmes within the national curriculum 8. Improve the education and training of health professionals ### Public and professional awareness 9. De-medicalise mental health language By adopting the recommended principles and supporting the needed reforms government can improve mental health outcomes, reduce the rising economic burden of poor mental health and promote overall societal health and well-being. ### Why we need an overhaul of our mental health system We have reached a crisis point in the nation’s mental health. Nearly a quarter of the adult population is prescribed a psychiatric drug in any given year,¹ and a similar proportion of young people now meet the criteria for a mental health diagnosis.² Waiting lists for NHS treatment are up to three years,³ NHS provision for psychotherapy is patchy and often of low quality,⁴ and interventions directed at the social and psychological causes of distress have been under prioritised. According to the NHS Independent Mental Health Taskforce, mental health outcomes have worsened in recent years, coinciding with an increase in rates of suicide.⁵ Indeed, taking a longer view and looking at trends in mental health outcomes, they have at best flatlined over the past four decades and according to some measures have deteriorated.⁶ For instance, despite efforts to broaden access to mental health services, there has been no observable reduction in the prevalence of mental disorders since the 1980s,⁷ while mental health disability has almost trebled in recent decades.⁸ Moreover, despite decades of work and investment, current psychiatric drugs show no discernible superiority in overall efficacy compared to the initial agents introduced over 50 years ago.⁹ While society has witnessed remarkable gains in life expectancy over the last five decades, largely attributed to biomedical advances in general medicine, individuals diagnosed with severe mental health problems have not experienced commensurate improvements. Rather, the gap in life expectancy between individuals with severe mental health issues and the general population has doubled since the 1980s.¹⁰ Alarmingly, the mortality rate among individuals experiencing severe and sustained emotional distress is now 3.6 times higher than that of the general population, resulting in a significant reduction in life expectancy, with those people who have been diagnosed dying approximately 20 years earlier than the average person.¹¹ Such lack of progress in outcomes is a matter of significant concern given the substantial resources (we estimate nearly a quarter of a trillion pounds) allocated to mental health services, initiatives and research over the last four decades. The failure of the mental health sector to achieve meaningful improvements in outcomes has also resulted in an exacerbation of the economic burden of poor mental health on wider society. A recent study commissioned by the NHS Confederation’s Mental Health Network found that the total cost of poor mental health in England in 2022 alone was approximately £300 billion.¹² The three major costs comprised: 1. Losses to the economy due to absenteeism and presenteeism at work, staff turnover and unemployment among people with mental ill health: £110bn 2. The human costs of reduced quality of life and premature mortality: £130bn 3. The health and social care costs provided by public services and informal care provided by family and friends: £60bn For many within the mental health sector, the response to this crisis in outcomes, rising costs and worsening mental health has been to call for more funding of conventional, medicalised approaches as if ‘doing more of the same’ will lead to different results. The evidence, however, suggests that our mental health crisis is not only a resource problem, but a problem of having adopted the wrong approach: of having side-lined effective social, community and relational approaches. We need to move from a system that has significantly over-medicalised and mis-treated real mental distress (one that essentially focuses on ‘symptom management’) to one that identifies and challenges the psycho-social causes to which so much distress is a rational and understandable response. We need a radical new vision of how best to frame and manage poor mental health in order to improve clinical outcomes and reduce the escalating economic, societal and human burden of rising levels of mental distress. ### The WHO/UN call for mental health reform In 2017, two reports were published by the United Nations calling for greater attention to be paid to the psychosocial drivers of mental distress in order to address the failure of our mental health sectors to improve clinical outcomes.¹³ These reports built on a growing consensus that, in most cases, mental health problems are understandable responses to life circumstances - social, relational and psychological adversities that result in emotional harms - and are not essentially medical problems to be solved by strictly medical interventions.¹⁴ In other words, outcomes are failing due to the over-reliance of services on the biomedical model¹⁵ - a model which misrepresents the nature and causes of much mental distress and which systematically downplays the importance of psychosocial and economic causes and solutions. The World Health Organisation, in a recent report, broadly supported the UN’s critical observations, urging us to pay greater attention to the social determinants of mental distress, which it defines as “the conditions in which people are born, grow, live, work, and age, and the wider set of forces and systems shaping the conditions of daily life…forces and systems [that] include economic policies and systems, development agendas, social norms, social policies, and political systems.” These forces and systems, as the WHO also indicates, “are [in turn] shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices.”¹⁶ Research into the situational and social determinants of poor mental health supports this growing consensus (among the UN, WHO and beyond) about the importance of challenging the social determinants of distress and has produced a vast body of evidence demonstrating that poor mental health is inextricably linked to the contexts in which people live, work and develop. For example, there is now substantial evidence that the social conditions driving and sustaining poor mental health are rooted in factors such as inequality,¹⁷ socioeconomic disadvantage,¹⁸ unemployment,¹⁹ low socioeconomic status,²⁰ poor education,²¹ food security,²² poor housing,²³ financial stress,²⁴ discrimination,²⁵ childhood adversity,²⁶ substance abuse,²⁷ family dysfunction and breakdown²⁸ as well as the breakdown of community support and the inability to access effective and affordable mental health care.²⁹ Substantial evidence also shows that various forms of relational deprivation, such as early trauma,³⁰ abusive family and other environments,³¹ neglect,³² loneliness,³³ bullying,³⁴ and social media use³⁵ are key drivers of poor mental health.³⁶ Aside from such social and relational drivers, poor mental health is also exacerbated by ineffective treatments,³⁷ iatrogenic or treatment harms,³⁸ as well as systematic underinvestment in psycho-social and relational interventions.³⁹ The UN and WHO’s call to respond to the social determinants of distress, was further supported in April 2024 by The BMJ Commission on the Future of the NHS, which launched a report demanding urgent government action to tackle the social determinants of health in order to reverse the deteriorating health and rising inequalities in the UK population.⁴⁰ It called for leaders of all political parties to act on the evidence, starting by setting up a cross- party task force accountable for public health in tandem with re-establishing Public Health England. Priorities should include: implementing policies to tackle poverty so that people can lead healthier lives; investing in sustainable housing compatible with good health; and giving every child the best start in life. The report acknowledges that as adverse life circumstances significantly affect mental health, a higher burden of population‐level mental distress is disproportionately experienced by those closer to the margins of our societies.⁴¹ Levels of poor mental health, in other words, are not evenly distributed across the population but fall heaviest upon those more likely to be subject to past and/or present circumstantial harms. Many of these harms can be further compounded by limited access to good treatments, poor efficacy of many existing treatments, and the burden of suffering unrecognised iatrogenic harms. The two reports published by the United Nations in 2017 also called for two fundamental reforms to mental health sectors internationally to address the current crisis caused by over-reliance on biomedical ideas and interventions. These are: 1) Wider implementation of psychological and social support for people with mental health difficulties (relational, community-based and group/peer support) 2) Greater attention should be paid to tackling the social causes of distress: inequality, poverty, abuse, discrimination, over-work and social exclusion. Both UN reports asserted that these vital reforms were being neglected due to three common obstacles that have held back reform over recent decades. The first obstacle is dominance of the biomedical model in mental health care - an approach that frames most mental distress as medical illness, and which favours biomedical explanations and interventions like psychiatric drugs. The UN reports explain that the dominance of this approach has led to an overreliance on unnecessary prescribing, the neglect of effective psychological, community and social alternatives, and the misrepresentation of the nature and causes of mental distress as primarily medical rather than social, relational or psychological. It has also largely led professionals to overlook the complex social and psychological determinants of distress, to the detriment of individual and public health. The second obstacle has been the mutually beneficial financial links between psychiatry and the pharmaceutical industry, including the biased use of evidence to shore up the dominant biomedical approach. During the psychiatric drug boom of the 1980s, 1990s and 2000s, the pharmaceutical industry allocated substantial financial resources towards promoting psychopharmaceuticals in the media and throughout public, professional and political communities. This concerted effort involved direct financial targeting of academic and medical professionals, alongside funding patient advocacy groups, charities and other mental health organisations. The influence of these financial resources have extended across other facets of the mental health sector, including policy-making, education, clinical practice and research activities. Psychiatric professionals have been the primary beneficiaries of research funding, consultancy fees, speakers’ fees, sponsorship, donations and other contributions from industry entities.⁴² Research indicates that such forms of remuneration bias recipients in favour of industry products, thereby skewing educational, research and clinical practices in pro-industry directions. In essence, this systemic entanglement of psychiatry with the pharmaceutical industry has undermined the objectivity and independence of mental health professionals and information and has, according to one UN report, corrupted research and the dissemination of information to the extent that ‘our collective knowledge about mental health had become tainted’.⁴³ An example of this bias ‘is the use of evidence to inform people with mild and moderate forms of depression that they should receive psychotropic medications (antidepressants), despite the clear evidence that they should not. This is even more shocking when we know that other non-biomedical interventions are more effective, such as the ones targeting relationships and the social and underlying determinants of mental health, rather than the brain.’⁴⁴ The excessive use and misuse of psychiatric medications has ultimately created a serious human rights issue, by denying us the right of access to safer and more effective forms of mental health care. The third obstacle identified in the report is power asymmetries in policy making, medical education, research and care relationships. In short, the dominance of biomedical thinking, leadership and practice has side-lined the voices and concerns of harmed patients as well as those advocating for wider systemic reform of our mental health services. These power asymmetries have been further entrenched by the industry’s financial sponsorship of drug regulatory agencies, and by the absence of any regulation which would require all UK medical professionals to publicly report their annual industry payments, as they must now do in the United States under the Sunshine Act. Currently, the power that industry is still able to exert though undeclared financial conflicts of interest goes largely unrecognised and unchallenged due to a lack of financial transparency rules. ### Six principles for mental health reform In order for the Government to address these obstacles and reform the mental health sector along the lines consistent with the evidence base, the following six principles must be adopted: 1. Mental health problems are mostly about our circumstances and relationships Research has demonstrated that traumatic interpersonal events such as violence, abuse, neglect, bullying and discrimination, especially in childhood, are key causal factors in most mental health difficulties. This includes both specific events and constant low-level background stressors. The damaging effects can be mitigated by trusting and secure relationships within families, schools and communities. Relationships, both formal and informal, are central to healing, and must be the core focus of all service provision. Services should therefore aim to offer relational support to everyone, with specific trauma-informed therapies where appropriate. Staff themselves must be appropriately trained and well- supported in order to carry out this demanding work. 2. Mental health problems arise within our social environments Economic insecurity and inequality cause emotional distress in their own right, while increasing the likelihood of traumatic events and relational conflict. They also reduce access to restorative and supportive resources, compounding an already significant health inequality. Poverty is a major underlying cause of mental distress (sometimes said to be the cause of the causes), as it results in debt, poor housing, inadequate nutrition and many other adversities, which place people under extreme pressure. Poverty erodes family and community life and blights children’s early lives, making poor mental health almost inevitable. Ensuring financial, social and material support for families, schools and communities will significantly reduce distress and hence the need for referrals. 3. Mental health problems are exacerbated by societal messages We must challenge widespread cultural norms, pressures and messages that lead to emotional distress in the general population. We know that an over-emphasis on appearance, lifestyle, competition and consumerism adversely affects wellbeing. Perceived failure to live up to societal expectations results in feelings of inadequacy, shame and worthlessness for both children and adults. Rather than framing this as an individual illness or disorder, we must tackle the unrealistic social expectations that generate distress. We must also beware of framing difficult yet understandable experiences as mental health problems that only trained experts can ‘treat’. While well-intended, this message can be disempowering to all, including parents and teachers, make us afraid of our emotions and undermine our natural resilience. 4. Positive narratives and language are needed for recovery Describing people’s problems as individual deficits or disorders is not only contrary to most of the evidence, but has been shown to increase shame, stigma, pessimism, despair and disempowerment. This in turn contributes to ever-increasing referrals for interventions that may not be addressing root causes. Instead, we need to build on existing approaches, which support people to create positive narratives about surviving difficult circumstances and finding new ways forward. There are many examples of successful, non-medical community and peer-led projects which draw on shared experiences, strengths and resources. 5. Psychiatric drugs should be used with caution and over-prescribing must be reduced Nearly a quarter of the adult population is prescribed a psychiatric drug each year, with evidence showing widespread over-prescribing, leading to adverse effects and economic costs. Such over-prescribing needs to be reversed and provision for non-medical alternatives significantly increased. While psychiatric drugs have a limited role for some more serious mental health problems, they cannot resolve relational or social adversities and when widely prescribed may do more harm than good. People should be enabled to give fully informed consent, based on awareness of the whole range of harms and benefits associated with drug treatment. Offering ‘a pill for every social ill’ does not work and in some cases exacerbates the original problems. Furthermore, long-term use of psychiatric medication is associated with many adverse effects, including weight gain, neurological effects, negative sexual effects, severe withdrawal effects and higher all-cause mortality. 6. Research should focus on better psychosocial provision Much current and proposed future research is based on the hope that individualised solutions - both medical and psychological - will help people whose problems are rooted in relational and social issues. Decades of investigation has shown this approach is failing. We need to secure funding for the many successful psychosocial projects and encourage all services to move in these new socially informed directions. We need to identify barriers to change in our system and how to overcome them. In applying these principles, we will be moving in the direction recommended by the World Health Organisation and the United Nations, which now call for us to move away from the biomedical model and privilege a de-medicalised, psychosocial, person-centred and human rights-based approach. “Mental health and wellbeing are strongly associated with social, economic and physical environments, as well as poverty, violence and discrimination. However, most mental health systems focus on diagnosis, medication and symptom reduction, neglecting the social determinants that affect people’s mental health.”⁴⁵ As the UN Special Rapporteur continued: “The urgent need (is) to…..target social determinants and abandon the predominant medical model that seeks to cure individuals by targeting ‘disorders’”.⁴⁶If we can do all this, we will be improving not just people’s emotional wellbeing but every aspect of their lives, while contributing to the betterment of mental and emotional health across society. ### Calls for action Adopting the principles described above to achieve the desired shift in balance will require many reforms. Facilitating this shift is not the sole responsibility of the government; it requires everyone involved in the UK mental health system to actively play a part. The Beyond Pills APPG will advocate for nine calls to action under the headings of Services, Regulation, Education and Public & Professional Awareness in order to help achieve the desired change. This is not an exhaustive list but rather areas of focus that are within the scope of the mission of the APPG. ### Services 1. Boost provision for social interventions, including social prescribing and community-based resources As the WHO states, “mental health and well-being are strongly associated with social, economic and physical environments, as well as poverty, violence, and discrimination. However, most mental health systems focus on diagnosis, medication and symptom reduction, neglecting the social determinants that affect people’s mental health.”⁴⁷ We call upon the Government to upscale social and community interventions, in particular social prescribing services for people with mild to moderate mental health issues. Evidence shows that social prescribing can have a positive impact on a very wide range of outcomes, including decreases in loneliness, improvements in mental health, in increased social connections and in overall wellbeing.⁴⁸ Social prescribing seeks to reduce health inequalities. Vast differences in the social impacts on health, individual health behaviours, illness, disability, availability of services and activities, quality and experience of care, proximity to accessible natural spaces, geography and wealth mean that health outcomes are not the same for everyone, with marginalised and vulnerable people often experiencing the worst outcomes. Social prescribing may address both the circumstances that make an individual unhealthy and their symptoms by supporting individuals to address their unmet social needs. Social prescribing can lead to reduced health service usage within both primary and secondary care. For example, an evaluation of the social prescribing service in Shropshire showed a 40% reduction in GP appointments for people who had accessed social prescribing after three months. Evaluations consistently show a favourable social return on investment, with a large study by the University of Sheffield showing a social return of £3.42 for every £1 invested.⁴⁹ By reducing the number of GP appointments and prescriptions, social prescribing can also help the NHS to reduce its carbon footprint. It can also promote connection with nature, which has been shown to encourage pro-environmental behaviours. 2. Fund and deliver community-based mental health hubs for people of all ages Labour has announced that it will tackle the crisis in children’s and young people’s mental health by measures including an open access mental health hub for every community for up to 25s. It is essential that such hubs do not simply increase the number of children diagnosed and prescribed medication through a ‘more-of-the-same’ biomedical approach. We therefore call upon the Government to offer de-medicalised mental health hubs for children - and adults - based on an approach that integrates social prescribing (to help with the social determinants of mental health concerns), lifestyle support and psychosocial interventions. These local mental health and wellbeing hubs would adapt to the needs of the local community through direct involvement, aiming to support people through emotional difficulties and prevent them escalating, as well as providing targeted resources for those who need it. There are examples where this kind of service is already offering vulnerable people support of different kinds. In North Cornwall, for instance, communities are setting up their own walk-in hubs, supported by local NHS primary care teams and by volunteers. Across Cornwall, pain cafes run by social enterprises in tandem with NHS personalised care help patients suffering chronic pain to learn self-management techniques.⁵⁰ 3. Fund and deliver a national 24-hour prescribed drug withdrawal helpline and website The World Health Organisation states: “Support should be provided to help people safely withdraw from treatment with drugs.”⁵¹ Thousands of patients are currently suffering debilitating and sometimes life-changing withdrawal effects from psychiatric medicines which they have taken as prescribed, and for which there is currently almost no NHS support. They are experiencing harm as a direct result of NHS treatment, and there is therefore a moral imperative for the health service to provide support for this cohort. Public Health England’s 2019 Prescribed Medicines Review⁵² stated that 1 in 4 of the adult population in England had been prescribed drugs associated with dependence and withdrawal in 2017-18. It also identified there is currently very limited support available to patients seeking to withdraw from such drugs. Recent research also reveals that 5.4 million people in England are being unnecessarily prescribed dependence forming psychiatric and painkilling drugs, costing the NHS more than £560M per year.⁵³ In addition to the reduction of the harms of unnecessary dependence, there are substantial savings to be made that justify investment in dedicated services to help patients come off these drugs safely. Unlike illicit drugs, there is currently almost no funded provision of these services. One of the key recommendations of the PHE review is the creation of a UK-wide 24-hour helpline and associated website to provide expert advice and support (including tapering and drug information) for patients, their families and doctors, linked to local in-person withdrawal support services. The Government must fund and deliver this helpline as soon as possible to support the many thousands of patients who have been harmed by the drugs they were prescribed, and who currently have little or no withdrawal support at all. 4. Reverse the rate of unnecessary antidepressant prescribing In December 2023, Beyond Pills APPG members and experts as well as politicians and patient representatives called for the Government to reverse the rate of antidepressant prescribing. As we collectively wrote in the British Medical Journal, over the past decade antidepressant prescriptions have almost doubled in England, rising from 47.3 million in 2011 to 85.6 million in 2022-23. Over 8.6 million adults in England are now prescribed them annually (nearly 20% of adults),⁵⁴ with prescriptions set to rise over the next decade. In addition, the average duration of time for which a person takes an antidepressant has doubled between the mid-2000s and 2017, with around half of patients now classed as long- term users.⁵⁵ While rising long term use is associated with many adverse effects, including withdrawal effects,⁵⁶ it is not associated with an improvement in mental health outcomes at the population level, which, according to some measures, have worsened as antidepressant prescribing has risen.⁵⁷ Questions remain about the extent to which poor outcomes are fuelled by such adverse effects together with the poor efficacy of antidepressants for many groups. Multiple meta-analyses have shown antidepressants to have no clinically meaningful benefit beyond placebo for all patients except those with the most severe depression,⁵⁸ which is why guidance from the National Institute for Health and Care Excellence states that they should not be routinely prescribed as first line treatment for less severe depression, while still respecting the importance of shared decision-making. Despite this, rates of prescribing to patients with mild and moderate depression remain unacceptably high.⁵⁹ Furthermore, there are now evidence-based objections to prescribing antidepressants for people with chronic pain, where efficacy is very low,⁶⁰ alongside evidence of disproportionate prescribing to women, older people and those living in deprived areas.⁶¹ This raises questions about the extent to which we are wrongly medicalising and medicating the effects of disadvantage and deprivation. As well as the human costs of unnecessary antidepressant prescribing, there is evidence of substantial unnecessary economic costs being incurred by the NHS in England of up to £58m annually⁶² - money that could be better spent boosting non-pharmacological provision. A reversal in the rate of antidepressant prescribing can be achieved by following through with various public health recommendations, in line with the NHS National Medicines Optimisation Opportunities 2023-24,⁶³ which include: - Stopping the prescribing of antidepressants for mild conditions for new patients - Adhering to the 2022 NICE guidance on safe prescribing and withdrawal management, including properly informed consent and regular review of harms and benefits - Including the reduction of antidepressant prescribing as an indicator in the NHS Quality and Outcomes Framework - Funding and delivering local withdrawal services integrated with social prescribing, lifestyle medicine and psychosocial interventions, in line with the NHS framework for action ‘Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms’ - Funding and delivering a national 24-hour prescribed drug withdrawal helpline and website (see above). ### Regulation 5. Reform the MHRA, the regulator of medicines in the UK In 2005, the Health Select Committee issued a report highlighting concerns regarding the Medicines and Healthcare Products Regulatory Agency (MHRA); this emphasised its proximity to the pharmaceutical industry, compromising its ability to safeguard public health.⁶⁴ The report noted many instances of regulatory capture where industry funding of the MHRA and former industry professionals in leadership roles at the MHRA have both significantly undermined its impartiality and regulatory standards, leading to systemic favouring of industry interests over patient safety. Despite recommendations for systemic reforms to ensure regulatory effectiveness in the public interest, subsequent investigations, including a recent BMJ inquiry in 2022, reveal persistent issues of conflicts of interest and overly lenient regulation at the MHRA.⁶⁵ The All- Party Parliamentary Group (APPG) on Pandemic Response and Recovery has echoed these problems, citing "serious patient safety concerns" about the MHRA, "owing to the state of regulatory capture”.⁶⁶ Experts have emphasised the need for rigorous, independent regulation to restore public trust and ensure patient safety in the approval and monitoring of medicines. 6. Implement a UK Sunshine Act to improve transparency of financial conflicts of interest In addition to the problems emerging from conflicts of interests and regulatory capture at the MHRA, there remains a lack of transparency regarding financial conflicts of interest in medicine overall.⁶⁷ Extensive research highlights the influence of industry financial ties on psychiatric practices, favouring pharmaceuticals. Poor transparency has permitted conflicts of interest to thrive, unrestrained by any threat of reputational reprisals.⁶⁸ Despite clear evidence of bias, there is no legislation obliging doctors in the UK to report potential financial conflicts. In contrast, the Sunshine Act in the US has, since 2010, legally mandated that doctors publicly disclose industry payments on an annual basis. We urge the Government to enact a similar Sunshine Act to enhance transparency, while simultaneously addressing regulatory capture at the Medicines and Healthcare products Regulatory Agency (MHRA). Structural reforms, including establishing independent evaluation bodies like Germany's Institute for Quality and Efficiency in Health Care and making the MHRA free of industry funding, are necessary to ensure unbiased decision- making and safeguard patient safety. Additionally, a drug and vaccine safety board independent of the regulator is proposed to investigate incidents of patient harm. ### Education and training 7. Integrate Social Emotional Learning (SEL) into the national curriculum Ever-increasing numbers of children are diagnosed with anxiety, depression and other mental health conditions. In 2023, 20% of children and young people aged 5 to 16 were identified as having probable mental health conditions, a considerable increase from one in nine in 2017.⁶⁹ This surge in poor mental health has adverse impacts on educational engagement, personal relationships, and long-term prospects. Secondary schools particularly struggle to adequately support students with mental health issues, exacerbating the problem (e.g. a survey of 1271 secondary school children, conducted by Mind in 2021, found that 78% of the children reported that school made their mental health worse).⁷⁰ The implications extend beyond the educational sphere, affecting employment opportunities, health outcomes and societal wellbeing. To help tackle this, Social and Emotional Learning (SEL) should become an essential component of education within our society and be incorporated into the national curriculum. SEL is an educational approach that focuses on developing social and emotional skills in young people. It enables them to acquire the knowledge, skills and attitudes necessary for effectively managing emotions, achieving personal and collective goals, fostering empathy, nurturing supportive relationships and the capacity to make responsible and compassionate decisions. SEL strategies should be incorporated within the broader framework of a Whole Systems Approach in schools. The Whole Systems Approach emphasises collaboration among teachers, administrators, students, parents and the community to create a cohesive environment supportive of good mental health.⁷¹ This approach goes beyond traditional academic instruction to address the social, emotional and behavioural needs of students, by way of personalised learning initiatives, multi-tiered support systems and partnerships with community organisations that can help address social and economic adversity. By focusing on the interconnectedness of all elements within the school ecosystem, the Whole Systems Approach aims to improve student outcomes, mental health and overall school performance. The five core competencies of SEL (self-awareness, self-management, social awareness, relationship skills and responsible decision-making) form the foundation of SEL programmes. These competencies are developed through various school learning experiences and interactions, promoting holistic development among students. Extensive research demonstrates the positive impact of SEL on student well-being, academic 72 73 74 achievement, and future life outcomes. SEL interventions have been associated with reduced emotional distress, improved academic performance⁷⁵ and enhanced social and emotional skills among participants.⁷⁶ Moreover, SEL initiatives yield substantial benefits that outweigh their costs, offering a high return on investment in terms of societal outcomes.⁷⁷ We urge the Government to integrate SEL into the national curriculum and within the existing Whole Systems Approach operating in many schools, as it offers a promising response to the growing mental health challenges facing children and young people. 8. Improve the education and training of health professionals Reforming the UK’s mental health care system requires a critical reappraisal of the training and education of health professionals. This training, which is crucial at both undergraduate and postgraduate levels, must align with the emerging socio-psycho-bio, whole person approach to health and care. At the undergraduate level, university curricula for health professionals should integrate comprehensive modules and assessments focusing on: - appropriate and necessary prescribing versus overprescribing - safe deprescribing - holistic mental health approaches such as social prescribing, lifestyle medicine and psychosocial interventions - emphasising the understanding of mental health within social, economic, and environmental contexts. Similarly, for postgraduate training, continued professional development (CPD) programmes should concentrate on safe prescribing and deprescribing, social prescribing, and community engagement. To implement these educational reforms, collaboration between government, the NHS, educational institutions and professional bodies is essential. Dedicated funding should be allocated by the Government for the development and updating of curricula, and robust mechanisms set up to evaluate the effectiveness of new training modules. Government support is crucial to mandate the inclusion of socio-psycho- bio approaches in medical and healthcare training. The Beyond Pills APPG is currently establishing a special interest group for trainees and medical students with the aim of developing educational materials that can be used for both undergraduates and postgraduates. Through partnership and collaboration with key educational bodies, the APPG intends to embed key principles of safe deprescribing and non-medical interventions at the core of the essential curricula for current and emerging health professionals. Our aim is to ensure that today's and tomorrow's healthcare professionals are equipped to deliver comprehensive, personalised care for those affected by mental health problems of all kinds. We call for the reform of the training of health professionals, aligning undergraduate and postgraduate education with a socio-psycho-bio approach. This entails integrating modules on appropriate prescribing, safe deprescribing, holistic mental health approaches and understanding mental health in its broader social/cultural contexts. To implement and fund such reforms requires a concerted collaboration between government, the NHS, educational institutions and professional bodies. ### Public and professional awareness 9. De-medicalise mental health language in both public and professional spaces In 2015 the British Psychological Society (BPS) published Guidelines on Language in Relation to Functional Psychiatric Diagnosis.⁷⁸ These guidelines presented a different set of mental health terms that avoid labelling, pathologising and depoliticising emotional distress. They offer more neutral terminology in order to prevent the negative effects associated with using medicalised language, while promoting relational and contextual understandings and responses to distress. The movement towards using more formulation-based and non-medical mental health meanings and terms is rooted in evidence demonstrating the often adverse emotional and psychological effects of embracing medical terminology. While some individuals may feel validated by interpreting their distress in medical or pathologising terms, and while framing distress medically is currently a prerequisite, in most cases, for receiving support, research nevertheless shows that framing distress as mental ‘disorder’, ‘illness’ or ‘dysfunction’ can also hinder recovery and increase stigma, especially if individuals erroneously believe their problems to stem from biological abnormalities.⁷⁹ Being medicalised should therefore not be a precondition for receiving mental health care and support. For example, people who come to believe their problems are due to chemical imbalances experience worse pessimism about their recovery, increased self-stigma, more negative expectations and self-blame⁸⁰ as well as more depressive symptoms after the close of their treatment⁸¹, compared to people who reject this hypothesis. Similar results have also been found for those who embrace biogenetic explanations for their distress,⁸² which regularly increase stigmatising attitudes among patients and mental health professionals⁸³ as well as hopelessness in those believing their conditions to be chronic.⁸⁴ Furthermore, medicalising distress (even when severe) may make it challenging for individuals to eventually perceive themselves as healthy participants in normal life or in control of their fate. It can foster dependency on psychiatric authority and prompt individuals to downgrade their prospects and ambitions for the future. Framing emotional problems in terms of an illness or disorder is also more likely to kindle fear, suspicion and hostility in others than if we articulate those very same problems in non-medical, psychological terms.⁸⁵⁸⁶ Even seemingly benign labels like depression can lead to negative perceptions, with those diagnosed being more likely to be viewed as having frail wills or character flaws, as being afflicted by personal weakness, or as being lazy and unpredictable.⁸⁷ More serious diagnoses like schizophrenia can exacerbate stigma and perceptions of being dangerous, which can compound a person’s sense of isolation through social rejection.⁸⁸ As the largest meta-study into how medicalisation impacts outcomes concluded: ‘Medicalisation is no cure for stigma and may create barriers to recovery.’⁸⁹ We call upon the Government to cease making being medicalised a precondition for receiving any care and support. Removing this precondition will enable us to move away from describing real everyday struggles in terms of illness and disorder, towards accepting that such problems often have clear roots in social, relational and psychological adversities that need to be acknowledged and addressed. We need to move towards narrative-based formulations that use more neutral terms in how we discuss and manage emotional distress in both public and professional contexts. This shift, while still recognising that such problems are real and require support and care, will also help reduce the stigma associated with mental health challenges and likely improve outcomes. ### Conclusion It is evident that the current state of mental health care in the United Kingdom requires urgent and comprehensive reform. The challenges outlined in this report underscore the need for a paradigm shift away from the traditional biomedical model that fuels the over- medicalisation and medicating of distress, towards a more holistic, person-centred approach that more fully recognises and addresses the social, economic and psychological determinants of mental health. Over the past four decades, significant investments have been made in mental health services and research yet outcomes have not improved and, according to some measures, they have worsened. Rates of poor mental health have continued to grow while the mortality gap between those with severe mental health issues and the general population has widened. Despite nearly a quarter of the adult UK population being prescribed psychiatric drugs each year, their efficacy in improving functional outcomes remains questionable and concerns about overprescribing, serious long-term harms and adverse/withdrawal effects persist. The UN and the WHO have now issued calls for fundamental reforms in mental health care, emphasising the importance of psychological and social support alongside efforts to address the underlying social determinants of mental distress. These calls have been echoed by numerous experts and organisations, highlighting the need to move away from the dominance of the biomedical model and prioritise interventions that address the root causes of mental health issues. Six key principles for mental health reform have been proposed, emphasising the importance of understanding mental health problems within the context of individuals' circumstances and relationships, as well as their broader social and economic environments. These principles advocate for a reduction in the overprescribing of psychiatric drugs, increased funding for psychosocial interventions, and a shift towards a de-medicalised understanding of mental health issues. The Beyond Pills APPG has identified nine specific recommendations for policy changes relevant to its mission that would contribute to the needed shift, including reversing unnecessary antidepressant prescribing, establishing a national withdrawal support helpline, investing in community-based mental health hubs and social prescribing, implementing regulatory reform and a UK Sunshine Act, integrating social and emotional learning programmes within the national curriculum, demedicalising mental health language, as well as improving the education and training of health professionals. These recommendations broadly align with the World Health Organisation's guidelines for promoting mental health and well-being, emphasising the importance of social interventions and community support networks. By adopting these principles and supporting these reforms, the Government can help improve individual mental health outcomes, address broader social inequalities and promote overall societal wellbeing. By prioritising holistic, person-centred approaches to mental health care and addressing the social determinants of mental distress, we can build a healthier society for all. Authors: Dr James Davies (lead author) Dr Anne Guy Luke Montagu Sarah Stacey Dr Bogdan Chiva Giurca Dr Lucy Johnstone NHS Business Authority 2023) NHS releases mental health medicines statistics for 2022/2023 in England. Website: https://media.nhsbsa.nhs.uk/news/nhs-releases-mental-health-medicines-statistics-for-20222023-in-england 2 NHS England (2023) Mental Health of Children and Young People Surveys. Website: https://www.england.nhs.uk/2023/11/one-in-five-children-and-young-people-had-a-probable-mental-disorder-in-2023/ 3 Children’s Commissioner (2024) Over a quarter of a million children still waiting for mental health support. Website: https://www.childrenscommissioner.gov.uk/blog/over-a-quarter-of-a-million-children-still-waiting-for-mental-health-support/ 4 MIND (2013) We Still Need to Talk: a report on access to talking therapies. Website: https://www.mind.org.uk/media-a/4248/we-still-need-to-talk_report.pdf 5 NHS Mental Health Taskforce Strategy. The Five Year Forward View for Mental Health. (website), 2020 https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf (accessed Sep 2020) 6 Davies, J (2022) Sedated: how capitalism caused our mental health crisis. 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