Thrive: How Better Mental Health Care Transforms Lives and Saves Money
392
Thrive: How Better Mental Health Care Transforms Lives and Saves Money
392eBook
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Overview
A compelling argument for improving society's mental health through increased services and better policy
Mental illness is a leading cause of suffering in the modern world. In sheer numbers, it afflicts at least 20 percent of people in developed countries. It reduces life expectancy as much as smoking does, accounts for nearly half of all disability claims, is behind half of all worker sick days, and affects educational achievement and income. There are effective tools for alleviating mental illness, but most sufferers remain untreated or undertreated. What should be done to change this? In Thrive, Richard Layard and David Clark argue for fresh policy approaches to how we think about and deal with mental illness, and they explore effective solutions to its miseries and injustices.
Layard and Clark show that modern psychological therapies are highly effective and could potentially turn around the lives of millions of people at little or no cost. This is because treating psychological problems generates huge savings on physical health care, as well as massive economic savings through more people working. So psychological therapies would effectively pay for themselves, generating potential savings for nations the world over. Layard and Clark describe how various successful psychological treatments have been developed and explain what works best for whom. They also discuss how mental illness can be prevented through better schools and a better society, and the urgency of doing so.
Illustrating why we cannot afford to ignore the issue of mental illness, Thrive opens the door to new options and possibilities for one of the most serious problems facing us today.
Product Details
| ISBN-13: | 9781400873333 |
|---|---|
| Publisher: | Princeton University Press |
| Publication date: | 09/15/2015 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 392 |
| File size: | 12 MB |
| Note: | This product may take a few minutes to download. |
About the Author
Read an Excerpt
Thrive
How Better Mental Health Care Transforms Lives and Saves Money
By Richard Layard, David M. Clark
PRINCETON UNIVERSITY PRESS
Copyright © 2014 Richard Layard and David M. ClarkAll rights reserved.
ISBN: 978-1-4008-7333-3
CHAPTER 1
What's the Problem?
I was much too far out all my life
And not waving but drowning
Stevie Smith, "Not Waving but Drowning"
Dennis Stevenson is a well-known businessman, and has occasional bouts of depression. This is how he describes them. "I once broke my leg in ten places. As I was taken to hospital, someone shut the door on my leg. You can imagine the pain. But I can tell you the pain of depression is many times worse: it is excruciating."
Mental pain is as real as physical pain. It is experienced in the same areas of the brain as physical pain and is often more disabling. Yet these two types of pain are not treated equally. While nearly everyone who is physically ill gets treatment, two in three of those who are mentally ill do not. If your bone is broken you are treated automatically, but if your spirit is broken you are not.
This is a shocking form of discrimination, which occurs in every health care system in the world. It is particularly shocking because we have very good treatments for the most common mental health problems, which are depression and crippling anxiety disorders. The treatments — modern psychological therapy and drugs when appropriate — are not expensive. And the economics are striking.
Treating mental health problems produces extraordinary savings — fewer people on welfare benefits, and fewer people being treated for physical illnesses made worse by mental illness. So on any reasonable estimates the treatments pay for themselves. They cost society nothing. And yet they are provided to under a third of those who need them. That is a great injustice and a gross inefficiency. And it is the main reason we have written this book — the pain of untreated mental health problems, and the fact that they can be treated at little or no cost.
There is also a wider issue. The last fifty years have seen enormous progress in advanced societies — less absolute poverty, better physical health, more education, and better housing. And yet in the United States, Britain, and many other countries, there is almost as much misery as there was fifty years ago — at least as many social problems and more family conflict, more crime, and more antisocial behavior. Dealing with the externals of income, education, physical illness, and housing has not been enough to produce happier or more orderly lives. We have left something out — the inner person. Mental health is something that requires deliberate cultivation and expert help when it goes wrong. If our society had better mental health, we should all gain. That is the second reason we have written this book: the huge social cost of mental illness.
The facts we lay out are in many cases quite remarkable — indeed, after many years in the field some of them still amaze even us. Here are the main questions we investigate.
How Many Suffer?
Mental illness is the great hidden problem in our societies, so most people are amazed when they hear the scale of it. In the Western world today one in six of all adults suffers from depression or a crippling anxiety disorder. Roughly a third of households currently include someone who is mentally ill.
When people ask us what we work on and we say mental health, the reply is almost always, "Oh, my son ...," or "my mother ...," or sometimes, "I have to admit that I ...," but then usually, "and please don't tell anyone." (This is particularly true when it's a politician.) In America, more people commit suicide than are killed in road accidents.
Mental illness is not only common, but it can also be truly disabling through its impact on people's ability to care for themselves, to function socially, to get around, and to avoid physical and mental pain. In that sense, depression is on average 50% more disabling than angina, asthma, arthritis, or diabetes.
So here is an extraordinary fact. When in 2008 the World Health Organization measured the scale of illness and allowed for its severity, they found that in rich countries mental illness accounted for nearly 40% of all illness. By contrast, stroke, cancer, heart disease, lung disease, and diabetes accounted for less than 20%. Figure 1.1 says it all.
Mental illness is extremely difficult to adapt to — much more so than most physical illness except for unremitting pain. It is terrible for those who experience it. But it is also bad for business, since it gives rise to nearly half of all days off sick. And it is bad for taxpayers, since mental illness accounts for nearly half of all the people who live on disability benefits. And it is bad for insurers since mental health problems add 50% to a person's bill for physical health care.
Given all this, you would think that mental illness would be high on the priorities of every insurer and every government's department of health. But not so. In 2007 we met with Britain's new secretary of state for health after he had been in his job for three weeks. At the end of our meeting he said, "Something has struck me. I've been in post for three weeks and gone to about forty meetings, but I have not so far heard the phrase 'mental health.'"
The situation is similar with employers. In January 2012 the World Economic Forum was having its usual snowbound conference in Davos. This included a meeting of the Workplace Wellness Alliance — a group of sixty of the world's most enlightened employers. The meeting was about the health challenges facing employers, and there were detailed presentations on cardiovascular disease, diabetes, lung problems, cancer, and musculoskeletal issues — but there was nothing on mental illness, even though it causes so much sickness absence. People just don't want to talk about it.
Do They Get Help?
Given this, it is not surprising that most mental illness goes untreated. While most people with physical illness are in treatment, this is true for fewer than one in three people with mental illness. This figure applies throughout the advanced world, and even for major depressions the figure is under a half in the United States, Britain, and continental Europe. If your pancreas is not working you automatically get treatment, but if your mind has been disordered for decades you do not.
What could account for this shocking failure? Stigma is one reason. People are ashamed of being mentally ill. They feel that, while physical illness is an act of the gods, mental illness is in some way their own fault. Relatives are also full of guilt. In most countries no effective lobby exists on behalf of people with mental illness, as it does for heart disease, cancer, and the like.
But another important reason is simply technological lag. Many people don't know that we have new treatments for mental illness that are just as effective as the treatments for many physical illnesses.
Can They Be Treated Effectively?
This is a new situation. Until the 1950s there were no scientifically validated treatments for mental illness. But in that decade there were major discoveries of drugs that could help to control psychotic symptoms (the antipsychotics) and depression (the antidepressants). Even so, many sufferers are averse to drugs, often because of their side effects, and that partly explains the low numbers in treatment. But then in the 1960s and 1970s came major breakthroughs in psychological therapy. The most important of these was what is now called cognitive behavioral therapy (CBT), which relies on the fact that thoughts affect feelings, and that good mental habits can be systematically built up step by step. CBT is certainly not the only therapy that works, and it does not always work. But it has been evaluated so much more often than any other therapy that we can speak with certainty about its average overall effects. These have now been established in hundreds of randomized clinical trials of exactly the same kind as those used in testing any medical treatment.
The general finding is that around 50% of people treated with CBT for depression or anxiety conditions recover during treatment, and many others improve significantly. For depression, CBT is as effective as drugs in the short run, and more effective in preventing the recurrence of depression down the road. For anxiety, CBT is even more impressive. Many people with conditions like social phobia, panic disorder, or obsessive-compulsive disorder have had their condition for decades, but if successfully treated they are mostly cured for life.
A leading hero of this "psychological revolution" is the psychiatrist Aaron Beck of the University of Pennsylvania. He began as a psychoanalyst and wanted to make psychoanalysis scientific. So he designed a study to confirm one of its central tenets — that depression is due to unconscious hostility that has been repressed and directed against yourself. With a team of colleagues, he compared the dreams of depressed and nondepressed patients. Contrary to his expectations, it turned out that the depressed patients had less hostility in their dreams than the other patients did. However, their dreams did seem to be quite similar to how they were actually thinking when awake. They saw themselves as victims; people or circumstances were against them; they felt thwarted, rejected, or deserted.
Beck focused all his efforts on what his patients were actually thinking — getting them to observe the automatic thoughts that were part of their thinking style. He sat facing them to try and detect their unspoken thoughts. When a cloud passed over a face, he would say, "What was going through your mind just then?" It turned out that the thinking style of depressed people included catastrophizing (thinking the worst), black-and-white judgments, and overgeneralizing from a single bad experience. To help his patients, Beck trained them to examine their thoughts and how they might be biased or distorted. To his surprise, they often stopped coming to see him within twelve sessions, saying they had had all they needed.
Another hero of the "psychological revolution" was Joseph Wolpe, a South African doctor who moved to Philadelphia. He also trained in psychoanalysis but was frustrated at the slow pace of treatment. He read the work of the Russian physiologist Ivan Pavlov, which showed that fears in animals could be extinguished by exposing the animal to the object of its fears in a gradual way. Wolpe applied this form of behavior therapy to his clients and, like Beck, found they recovered quickly. Beck and Wolpe had essential insights that became combined in the development of cognitive behavioral therapies. To ensure that their new treatments could have reliable results, they developed manuals of good practice that any well-trained practitioner with enough empathy could apply. And to measure effectiveness they developed rigorous scales of measurement and used these in scientific randomized trials to find out what proportion of patients recovered. The resulting recovery rates of 50% or more now offer hope to millions of people worldwide.
There are certainly other therapies that can also be extremely effective. They need to be systematically developed and tested. So when the history is written we shall hopefully see how CBT paved the way for other, perhaps more powerful, therapies. But for the moment, what CBT has done is to bring psychological therapy to a point where it can claim scientifically to be able to transform lives. It will be seen to have changed our culture forever.
One striking fact about modern treatments (be they drugs or therapy) is the rigor with which outcomes are measured. This is far from the vague, less structured and more prolonged therapy that many doctors tend to despise. It is science of a high order, based on randomized controlled trials and capable of replication, with success rates as high as in the majority of treatments available for physical illnesses. But not enough people know this, and evidence-based psychological therapy is hard to access in almost every country.
Are the Treatments Costly?
This is not because the treatments are costly. A standard course of cognitive behavioral therapy involves up to sixteen one-hour sessions, one-on-one — with the average number of sessions nearer to ten. The total cost is about $2,000. With a 50% success rate for a serious condition, this is good value for money. And that is why it is recommended for almost all mental health conditions in the official guidelines for the British National Health Service.
But actually the economics is even better than that. There are some striking lessons here for those who finance the health care system. It turns out that mental health has a huge effect on physical health, and thus on health care costs. The effects on life expectancy are extraordinary: depression reduces your length of life as much as smoking does (and not mainly through suicide). And while you're alive, depression and anxiety conditions increase your visits to the family doctor and to specialists. Conversely, controlled trials show that if you get psychological therapy, you go to the doctor for physical ailments much less often than those who remain untreated. The resulting savings are large enough to fully cover the cost of the psychological therapy. For the health care authorities and insurers, this is a win-win situation: pay for more psychological therapy and it will cost you nothing because of the savings on physical health care. The finances of health care actually improve through spending more on therapy.
So too do the finances of the welfare system, because many people with mental illness cannot work. When psychological therapy becomes more widely available, some of those who use it will be people who are on welfare or in danger of losing their job. As a result of the therapy, more of them will be at work and fewer on welfare benefits. Robust calculations show that the resulting savings on benefits and lost taxes will exceed the cost of the psychological therapy. There is a double payoff — the cost of the therapy is repaid twice over, both in savings on physical health care and in savings on benefits and lost taxes.
Despite all this, those who finance health care are generally resistant to providing the extra resources needed. That is the main reason why so few people are in treatment: it is the funders above all who are to blame.
Early Intervention?
The case for more help becomes even stronger when we shift from adults to children. Here again good treatments exist, but they are not widely available in most countries. The scale of undertreatment is as bad for youngsters as it is for adults: only one in four young people with mental health problems is in treatment.
The myopia here is quite extraordinary, since half of all mental illness in adult life began in childhood. Moreover, child mental illness is a cause of so many of our social problems. Mentally ill children are much more likely than others to avoid school, to take drugs, and to self-harm. And when they become adults (if they had "conduct disorder" in youth) they are much more likely to be arrested for a crime, to become teenage parents, to get divorced, and to live off benefits. This brings us to our second, wider theme — the impact of mental illness on society at large.
A Better Society?
In the darkest days of World War II, Winston Churchill commissioned Sir William Beveridge to review the future of social policy in Britain. In his famous report, which determined postwar policy, Beveridge identified five giants that were responsible for the ills of society. They were Want, Idleness, Ignorance, Squalor, and Disease, or in modern parlance: poverty, unemployment, undereducation, poor housing, and physical illness. Since then we have made huge progress against all five of these giants, except at times unemployment. Yet our society is no happier now than it was then. We have more broken families, more disturbed children, and more crime. One major reason is that the human factor inside each of us has remained much the same. We have tackled the external problems but not the one inside, the sixth giant: the evil of mental illness.
(Continues...)
Excerpted from Thrive by Richard Layard, David M. Clark. Copyright © 2014 Richard Layard and David M. Clark. Excerpted by permission of PRINCETON UNIVERSITY PRESS.
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Table of Contents
Foreword by Daniel Kahneman ixPreface xv
Part One: The Problem 1
1. What’s the Problem? 3
2. What Is Mental Illness? 17
3. How Many Suffer? 39
4. Do They Get Help? 53
5. How Does It Affect People’s Lives? 65
6. The Economic Cost 83
7. What Causes Mental Illness? 93
Part Two: What Can Be Done? 115
8. Does Therapy Work? 117
9. How Therapies Are Developed 133
10. What Works for Whom? 153
11. Can We Aff ord More Therapy? 181
12. Improving Access to Psychological Therapies 193
13. What Works for Young People? 219
14. Can We Prevent Mental Illness? 229
15. Would a Better Culture Help? 245
16. Stop This Pain 259
Our Thanks 267
Sources of Tables and Diagrams 271
List of Annexes 275
Notes 277
References 319
Index 367
What People are Saying About This
"Drawing together disparate material, this important book addresses an issue that is not widely known. Psychologists who teach and offer mental health interventions will find the book interesting, and those who are arguing for more mental health services will find it invaluable."—Edward Diener, coauthor of Happiness: Unlocking the Mysteries of Psychological Wealth"This clearly written and accessible book explores an incredibly important issue."—Angus Deaton, author of The Great Escape: Health, Wealth, and the Origins of Inequality"This book is an inspiring success story and a stirring call to further action. Its message is as compelling as it is important: the social costs of mental illness are terribly high and the costs of effective treatments are surprisingly low."—Daniel Kahneman, author of Thinking, Fast and Slow"Extremely easy and pleasurable to read. It's the most comprehensive, humane and generous study of mental illness that I've come across." —Melvyn Bragg, author of The Adventure of English: The Biography of a Language"Remarkable . . . presents the issues in a style that is easy for the professional, the general public, and policymakers to understand."—Aaron T. Beck, emeritus professor, University of Pennsylvania"Layard and Clark (the Dream Team of British Social Science) make a compelling case for a massive injection of resources into the treatment and prevention of mental illness. This is simply the best book on public policy and mental health ever written."—Martin Seligman, author of Flourish: A Visionary New Understanding of Happiness and Well-being