Chapter 8 Health Professionals

Happiness is the highest form of health.

–– Dalai Lama

In 1999 Britain established a remarkable institution, with the attractive name of NICE.1 For every illness, NICE analyses which health care treatments work best – and how much they cost. A good treatment is one which either extends your life or improves its quality or both. To get a single measure of benefit, they add these two effects together into an overall effect on years of life, adjusted for quality. This they call the number of QALYs: Quality-Adjusted Life-Years.

This revolutionary concept was first developed by American academics but, when it was adopted by NICE, it was the first time a government had attempted to measure outcomes in terms of the quality of life as people experience it. Remarkably, QALYs were accepted with little opposition. So NICE was able to assess treatments by the benefit they provided (in terms of QALYs) relative to their cost.2

The National Health Service now has the duty of providing – to all who need them – those therapies that NICE recommends. And, broadly speaking, the service does just that for most physical illnesses. But for most problems of mental illness it does not. This is typical of health care worldwide: the shocking failure to give people with mental disorders the well-established treatments that exist.

Ill-health and misery

The failure would not matter so much if mental-health problems were marginal causes of misery. But they are not. In fact, the evidence is that mental illness causes as much misery in the world as is caused by physical illness.

In three advanced countries we can measure mental illness in surveys which ask, ‘Have you been diagnosed with depression or an anxiety disorder?’ Likewise, we can measure physical illness by the number of illnesses from which people suffer. So how important are mental and physical illness as causes of misery, when compared with each other or with family income (per head) or with unemployment?

To answer this, we first measure misery by looking at a person’s life-satisfaction and seeing whether this puts them in the lowest 10 per cent or so in their country. And then we estimate simultaneously the effect of all the four possible causes of why that person is in misery.3 As Figure 8.1 shows, mental illness is a greater cause of misery than poverty is. And mental illness is also at least as important a source of misery as physical illness is.

In fact, even if we include the poorest countries, mental illness causes at least as much misery as physical illness does.4 This is because mental illness is not only so devastating when it occurs, but it is also so common. In the typical country about 16 per cent of adults are currently suffering from either depression or from an anxiety disorder such as PTSD (post-traumatic stress disorder) obsessive compulsive disorder, social phobia, panic attacks or generalized anxiety. In this overall percentage, depression and anxiety are about equally common, but they often overlap. Strikingly, rates of mental illness are similar in rich and poor countries – these problems are not just products of modern civilization.5 In addition, some 3 per cent of people suffer from severe mental disorders like schizophrenia, bipolar disorder, personality disorders or severe substance abuse.6

Figure 8.1 How much misery is explained by each factor?
Figure 8.1
How much misery is explained by each factor?

Britain

Australia

USA

Mental illness can kill. One way is through suicide – and some 90 per cent of those who will kill themselves are mentally ill.7 Nearly half of those who commit suicide have suffered from unipolar depression and the rest had even more serious mental illness. In 2013, 840,000 people in the world took their own lives. This was double the number of people who were murdered. And it represented over 1 per cent of all deaths worldwide. By contrast, in the whole of the twentieth century, only 0.7 per cent of all deaths were in battle.8 Thus in the last century, more people probably died from suicide than in battle.

So mental illness can be deadly serious. Moreover, on top of suicide, mental illness can kill through the effect of the mind on the body. Some of these effects are direct: psychological stress triggers the production of cortisol, increases inflammation and weakens the immune system. Other ways are indirect – via increased smoking, drinking and drug addiction. In consequence, mentally ill people are much more likely to die than others, as Figure 8.2 shows. These deaths are mainly from physical causes, but they also include intentional suicide and accidental suicide through drug overdose, which is now reaching epidemic proportions in the USA.9

So is mental illness becoming more common? In Britain and the US it is rising gradually for adults over twenty-five, but more significantly for younger adults, and even more rapidly for adolescents.10 But, whether mental illness is rising or not, it is one of the worst experiences a person can have. So what can be done about it?

Figure 8.2 Mental illness makes death more likely
Figure 8.2
Mental illness makes death more likely

Treating most mental illness costs nothing

The good news is that we now have treatments that can make a real difference.11 These include many psychological treatments, as we saw in Chapter 3, and also medication. In Britain, NICE recommend medication for all forms of serious mental illness as well as for severe depression and for some forms of anxiety. They also recommend that psychological treatments should be offered for all forms of mental illness. Using psychological therapy the recovery rates for depression and anxiety are at least 50 per cent after an average of about seven sessions, and higher if more sessions are provided. Moreover, such treatments not only reduce people’s symptoms but increase their energy and their social connections, which are so crucial to a happy life.

Given the horrible effects of mental illness, one would think that such effective treatments would be at least as available as treatments for most physical conditions. But this is not the case anywhere in the world. In most high-income countries only a quarter of people with depression or anxiety disorders are in any form of treatment,12 and, more often than not, the only treatment is medication.13 In the poorest countries the position is even worse, with only one in twenty people being treated.14

Common humanity demands that this change. But, sadly, materialism runs so deep in our culture that what is not immediately visible counts for little compared with suffering which can be seen and touched.15 So mental health advocates have to deploy another argument – that of economic cost.

Mental illness is mainly a disease of working age, while in rich countries most physical illness afflicts people in retirement. So the economics is quite different for mental illness. One half of all disability in rich countries is due to mental illness, and the same is true of time off work (absenteeism, in the jargon). If we also allow for reduced productivity at work, mental illness reduces the nation’s output by about 4 per cent.16 It also adds to the bill for physical illness, because a person with a given physical illness consumes 50 per cent more physical health care if they are also mentally ill.

For these reasons, there will be massive savings if we can reduce mental illness. The evidence is clear. A programme that provides psychological therapy for depression and anxiety can pay for itself through savings on lost output and on physical health care. And it can help people to a new life.

Improving access to psychological therapy

In 2005 the clinical psychologist David M. Clark and I put precisely these arguments to the British Prime Minister, Tony Blair. At that time, if you had depression or anxiety disorders and sought specialist psychological help from the National Health Service, you would normally be turned down – unless you were a suicide risk or close to that. You might be offered a few sessions of counselling, but not usually of the type recommended by NICE.

And that was the shocking point. NICE were recommending that people should be offered therapy, and it was simply not happening. Moreover, what most of them wanted was therapy – two thirds of people in need say they prefer psychological therapy to drugs.17 So the National Health Service was not doing its job. Fortunately, the government listened to our argument and in 2008 they launched a new public service known as Improving Access to Psychological Therapies.18

To make this succeed, there were three main challenges. The first was to train up a whole new workforce in the therapies that NICE recommended. From 2008 onwards, roughly 1,000 therapists were trained each year. The second challenge was to develop the services within which they should be trained, employed and supervised. By around 2012 there was a service in every area and by 2018 over 600,000 people were being treated annually.

But did they recover? We can only know the answer to that if people’s progress is monitored. And it must be done session by session because some people just stop turning up. So the third key feature of the programme was session-by-session monitoring. And from it we learned that, yes, 70 per cent of the people who were treated improved significantly and 50 per cent recovered fully. They had received on average seven sessions. Knowing the outcomes was crucial for the continued political support for the programme.

Of course some local services achieve worse recovery rates than others, and we know a lot about what causes this: too few sessions, less-well-trained therapists, and so on. But one finding is clear: the services that do well are those which use proper diagnostic approaches and provide the right therapy for each patient.19

The leading science journal Nature has said the service is ‘world-beating’, and by now a similar approach has been considered – or actually introduced – in at least six other countries.20 The existing service in England is of course far from perfect. It only treats 10 per cent of all those who are suffering from depression and anxiety. So it needs to become much larger and to offer more sessions. It is only now addressing the huge challenge of helping – in a new way – people who have both a physical illness (like diabetes, angina, lung disease or cancer) and a mental-health problem.

One huge new development is going to be the use of online psychological therapies. These have now been tested successfully in hundreds of trials.21 They generally work best if linked to some telephone contact with a therapist and should only be used if they are what the patient actually prefers.

One thing is clear. We are dealing here with one of the oldest and largest sources of unhappiness afflicting humankind. Every country will have to tackle the problem in its own way. But in every system there has to be a radical rethinking of priorities. This should not exclude people with severe mental illness. People with schizophrenia or bipolar disorder definitely need medication, but NICE also recommends that they too should get psychological treatment. They ought to get it, and the progress of their mental state should also be routinely monitored.

In rich countries, all the therapy should be provided by specialists – it is the least we can do for people who are in real need. In poorer countries, however, that may not be feasible for some years. The main way forward will be for general health-workers to be given short courses in the recognition and treatment of common mental-health problems. Trials show this can yield quite good results.22

Figure 8.3 Foreign aid discriminates against mental illness
Figure 8.3
Foreign aid discriminates against mental illness

But the scale will have to change everywhere and especially in poor countries, many of which have virtually no mental-health services, even though the problem is as great as in the West. There should also be much more foreign aid allocated to deal with mental health. The worldwide burden of disease (measured by Disability-Adjusted Life Years lost) is twice as great from mental illness as from HIV/AIDs. Yet HIV/AIDs gets roughly sixty-eight times more foreign aid than mental illness does (see Figure 8.3). The attack on HIV/AIDS is vital, but health budgets everywhere need to grow much faster for mental illness than for physical illness. And that is especially so when it comes to children.

Help for children

If a person has a mental-health problem, they need help as early as possible – often in childhood. Over half of the children who have experienced mental-health problems by the age of fifteen will again have mental problems as adults.23 So why leave treatment until people are adults? By that time, they have felt bad for years. Quite often their education has suffered, and in many cases they have fallen foul of the law – setting them off on a life of constant turmoil.

At any one time, about 10 per cent of children would be diagnosed as mentally ill. Around 5 per cent suffer from some form of anxiety disorder or (less common) depression. And another 5 per cent have serious behavioural problems, sometimes accompanied by ADHD (attention deficit hyperactivity disorder).24

But good treatments exist for children as well as adults, though they have been much less well researched. For anxiety and depression, the standard NICE-recommended treatment for children (as for adults) is CBT. For anorexia, it is family therapy. And for behavioural problems, except for the most serious, it is (as we explain in the next chapter) group training of the parent or parents. If the child has ADHD, medication generally helps.

In most countries, most children are not getting the help they need. As with adults, only about a quarter of the children with mental-health problems get specialist help in rich countries, and even fewer elsewhere.25 In most publicly funded systems, children are only treated if they are incredibly aggressive, or self-hating, or self-destructive. This is a disgrace, and it can only be dealt with in the same way as for adults. A new workforce has to be created, trained in evidence-based therapies, and services have to be created which are easy to access in a non-threatening, informal context. This generally means that they need to be physically based in schools, while being firmly led by health care professionals.26

The length of life and the quality of life

I have concentrated heavily on mental health because it is so neglected and has such a major effect on our happiness. But physical health is also vital for our quality of life – and for life itself. This book is mainly about the quality of life. But a good society provides not only happy lives but long ones. As Thomas Jefferson said, the only things that ultimately matter are ‘life and happiness’.27

So the success of a country depends not only on the quality of life (and how it varies across people) but also on the length of life (and how that varies across people).28 In Britain the average length of life is now eighty-two – up from fifty-seven a century ago. That is an amazing improvement. As Figure 8.4 shows, deaths under the age of sixty have largely been eliminated. So there is much less variation than before in how long people live. The variation in the length of life (measured by its standard deviation) is now only fourteen years, compared with twenty-nine years a century ago – an even more incredible improvement and a triumph of modern medicine.29 Today, we die at much more similar ages than in the past. What a real blessing to couples who love each other.

This change represents a fundamental reduction in health inequality. For the fundamental inequality in our society is the inequality across people and not across social classes. Just as income inequality is across people, so is health inequality.30 And it is deeply unequal if some people die much younger than others. Fortunately that inequality has been significantly reduced and in fact the length of life is now more equal across people than the distribution of life-satisfaction.31

But why has life expectancy risen so much? There are many reasons: higher income, better social conditions, a less polluted environment, and of course modern medicine.32 Each year medical science becomes better at keeping people alive. But it is much less clever at providing a good quality of life during those extra years. For many patients, the extra years can be horribly painful and humiliating. So there is now a huge debate within medicine about the right balance of effort between improving the quality of life and extending its length.33 In England, 15 per cent of all health expenditure goes on the last year of life – which accounts for barely 1 per cent of our total experience of life.34 In the meantime, there is severe rationing of key expenditures on the quality of life, such as child and adult mental health.

Figure 8.4 Age at which people died in the UK – 1910 compared to 2016.
Figure 8.4
Age at which people died in the UK – 1910 compared to 2016.

In most cases, sick people really want to go on living as long as possible. But for some people the suffering becomes unbearable and they want to die. If they are terminally ill and want to end it now, we should surely let them do so if they are mentally competent. As autonomous human beings, it should be their right to choose. There should not have to be some grubby underhand arrangement where you have to persuade your doctor to break the law; or, if the docter refuses, you have to starve yourself to death or stop your medication – both of which may have horrible consequences. If people are terminally ill, they should be allowed to die with dignity at a time of their choosing, with their loved ones around them.35 The US State of Oregon (and now Washington, Vermont and California) allow just that, with strong legal safeguards against unloving relatives applying pressure on vulnerable patients. In twenty years there have been very few problems with this law in Oregon, and it is therefore a model that could be copied worldwide.36 In Oregon, palliative care has thrived, and the law has brought more openness about dying, and peace of mind to many dying people.37 The hospice movement, which originally opposed the law, now wholeheartedly supports it.

That said, most of us want to live longer and in better health. Many of us want more health care than we can get. So there is a problem with the existing scale of health care and, as I show in Chapter 11, wellbeing research suggests it should be greater than it is.38 This is obviously true in poor countries, but it is also true in rich ones. There is also an important and different point about growth over time. It is a universal truth that as people become richer they want more of their money spent on health care. This is because, as incomes increase, the gain in happiness from increased household consumption falls sharply, while the gain from better health care is reduced much less. So in a world where policy is targeted at wellbeing, we ought to see rapidly rising spending on health care.

We should also be doing more to prevent illness before it occurs. Healthy living can be promoted by schools, managers and public health professionals, but it is ultimately a matter for each of us. Like the ancient Romans, we should aspire to ‘a healthy mind in a healthy body’. We should sleep properly (preferably eight hours a night), eat well (five portions of fruit and vegetables a day), not smoke, exercise throughout our life, drink responsibly, and take few narcotic drugs.

Narcotic drugs are a health problem

Throughout history, people have sought comfort and joy from mind-altering substances. And, for some people, small doses are not dangerous. The problem is that, for many others, these substances are highly addictive and the results of taking them can be terrible. By far the worst drug is alcohol – about 1 per cent of the population in rich countries become serious alcoholics and of these about one in seven take their own lives.39 By comparison, natural cannabis is relatively safe, though strong variants can be addictive.40 Opioids and cocaine, however, are highly addictive.41

So should narcotic drugs be banned? The UN’s 1961 Single Convention on Narcotic Drugs said just that: it banned all production, sale and use throughout the world. And a few years later US President Richard Nixon declared the ‘War on Drugs’.

But this war has been lost. In any Western city today you can find a seller of cannabis, heroin or cocaine within a matter of minutes. But, at the same time, the war has created the biggest criminal industry in human history. The annual turnover is hundreds of billions of dollars.42 Some of this money has gone to finance terrorism. But, worse than that, the fight for the spoils has generated unparalleled peacetime violence between rival drug gangs, and between the gangs and national security forces. In the rich countries this has filled our prisons to bursting point. And in Latin America more people have died in drug-related violence than in all the violence in Iraq since 2003.43 It is a total disgrace, for which the rich countries must bear the blame, since they declared the war in the first place and they now generate the profits for the criminals.

So what should be done? Let’s begin with the use of drugs, as opposed to their sale. Does it help to make the use of drugs a criminal offence, as the war on drugs requires?44 Obviously not. People suffering from drug addiction need treatment and they are much less likely to seek it if their addiction constitutes a crime.45 Instead, they will continue to suffer. They may become thieves to pay for their drugs. Eventually they are likely to get caught anyway, and then receive a criminal record, which makes it even harder for them to earn an honest living. So they keep paying the drug barons, whose profits depend entirely on the illegal nature of the market. It is a totally vicious circle.

So we should decriminalize the use of drugs, making it at most an administrative offence. This is what has been done in Portugal. If you are caught there using drugs, you are sent to a special tribunal which diagnoses your problem. If you are not considered to be addicted, you receive a warning from the tribunal. If you are addicted, you must accept a contract to attend a clinic and, if you do not attend, you get an administrative fine or community service. Most do attend.46

Has this more lenient approach increased the problem use of drugs? Not at all. The number of problem users fell when the new system was introduced in Portugal.47 The Western countries with large numbers of problem users include two of those with the harshest laws: the USA and the UK.48 Fortunately, however, opinion is changing in both countries – often led by police who are unwilling to waste their time and money on those millions of drug users who cause little trouble.

So, second, what about the sale of drugs? Many drugs such as natural cannabis (not skunk) or ecstasy (MDMA) are less dangerous than alcohol. It is highly preferable that people consume these drugs rather than opiates, cocaine or powerful synthetics. But, if it is illegal to sell any drugs at all, the same gangs will be selling cannabis and hard drugs, and they will push buyers on to the more profitable hard drugs. So we ought to establish a regulated market for relatively safe drugs – as we have done for tobacco and alcohol.

There is another good reason to do this. Most drug deaths occur because people do not know what they are taking. It may be too strong (as ecstasy can be) or it may be adulterated. When the only market for drugs is black, you can never be sure what you are buying. So there is a huge argument for developing a market for the safer drugs that operates in the open, with proper labelling and proper regulation. If such a market were allowed, initially for cannabis and ecstasy, it would displace much of the black market – not only for cannabis but also for the new psychoactive substances and the harder drugs. People would choose the drug that they knew about and that was legal.

But what about the sale of hard drugs? The unregulated supply must remain illegal. But for dangerous substances like heroin, there are demonstrable advantages in the Swiss system of supplying them to addicts for legal consumption in a clinic under supervised conditions.49 Rational approaches like this will be of huge benefit to people who are addicted and who consume 90 per cent of all heroin. Communities will also benefit. Heroin users who attend clinics reduce their levels of burglary and other property theft by 80 per cent.50 Fortunately the United Nations, which used to oppose all recreational use of drugs, now accepts a public health approach to drug policy, and countries have been freed to reform their own policies.51

There is one other point. Cannabis products have great potential as medicines and as painkillers. For many conditions they are safer and more effective than existing treatments. They provide huge benefits for many patients with epilepsy, multiple sclerosis, chronic neuropathic pain, and nausea/insomnia after chemotherapy.52 There is an overwhelming case for licensing cannabis products for these conditions. In fact what could be more absurd than allowing opioids to be treated as medicines and refusing to license cannabis products, which are much less dangerous and addictive, have fewer side-effects, and are often as effective? If this were done, millions would benefit.

If we decriminalize drugs and treat addiction as a mental-health problem, we will eventually undermine the giant criminal industry which wreaks havoc on so many continents and fills so many prisons. Cracking the drugs problem is certainly a key element in creating a happier world.

Conclusions

Health is central to wellbeing and, as we become richer, we should give it ever more priority. And this applies in particular to mental health.

All health care – physical and mental – attracts idealists. But if you want to fight for a neglected cause, the barricades of today are the barricades of the mind. There can be nothing more challenging or more satisfying than the work of a psychological therapist – to change the course of a person’s life.

But shouldn’t our parents have made that unnecessary? It is time to examine the role of families.

“If I told you where the happy place in my mind is, you’d start showing up there and ruin it.”