AN OVERVIEW OF THE MENTAL HEALTH SERVICES IN ENGLAND AND THE ROLE OF THE PSYCHOTHERAPIST IN THIS CONTEXT

The article discusses the increasing prevalence of antidepressant use in the UK and concerns surrounding the reliance on psychotropic medication. The impact of the COVID-19 pandemic on mental health is also mentioned, along with the increasing rates of probable mental disorders in children and young people. The author highlights the role of psychotherapists in discussing medication-related topics with clients and advocating for collaboration with Family Doctors (GPs) and psychiatrists. It suggests that a combination of pharmacotherapy and psychotherapy may be more effective than medication alone, but long waiting times for therapy services pose a challenge. Staff shortages in mental health services are identified as barriers to adequate care and patient involvement in decision-making processes. The Balance Model is proposed as a framework for planning interventions, focusing on the four areas of life (physical, mental, emotional and spiritual) to support clients in managing the side effects of starting or stopping medication. Overall, the article calls for a comprehensive approach to mental health treatment that considers both medication and psychotherapy, addresses the challenges associated with medication use, and advocates for improved training and collaboration among healthcare professionals.


Introduction
In my practice, I often hear patients say, "I have been taking antidepressants for the past six years, I don't feel any better, but I'm worried that my condition may worsen if I stop taking them." In response, I typically suggest that they consult with their General Practitioner/ Family Doctor (GP). It has become increasingly common for patients to be on antidepressants, and I have noticed that unmedicated patients are rare in my practice. To gain a better understanding of this phenomenon, I looked for more information on the topic.
According to my findings, in England, prescribing the 10 most popular antidepressants (Citalopram, Amitriptyline, Sertraline, Mirtazapine, Fluoxetine, Venlafaxine, Duloxetine, Paroxetine, Trazodone, and Escitalopram) has increased by 25% from 58 million in 2015 to 72 million in 2019. These 10 antidepressants make up 96% of all antidepressant prescriptions. Citalopram, an SSRI, was the most frequently prescribed antidepressant, and between 2015-2019, it was among the top 20 most commonly prescribed medications in England across all prescription items. (Lalji et. al., 2021) Since 1998, there has been a significant increase of over 3 million prescriptions for antipsychotics. Additionally, in the UK, there are currently 296,929 individuals who are long-term users of benzodiazepines. Interestingly, data ISSN 2710-1460 WAPP indicates that as many as 119,165 of these individuals may be willing to accept prescribed drug dependency withdrawal services, however, this service is not offered. According to the current British National Formulary (BNF) guidelines, benzodiazepines and Z-drugs, including Zolpidem, Zopiclone, and Zaleplon, should only be prescribed for up to 4 weeks. However, anecdotal evidence suggests that many patients are being prescribed these drugs for much longer periods. This presents a serious public health concern, as there is evidence that prolonged use of these drugs can lead to adverse physiological and neurological effects, as well as complications associated with protracted withdrawal (Davies et. al., 2017), The Royal College of Psychiatrists suggests that the increase in the number of people being given psychotropic medicines is due to more individuals with mental illness seeking medical advice. However, others believe that the rise in prescriptions is a result of overstretched mental health services and doctors feeling that they have no other options for patients. A study by the Mental Health Foundation found that 78% of GPs had prescribed an antidepressant when they believed that an alternative approach might be more appropriate. It is estimated that one-third of individuals taking antidepressants long-term in the UK have no clinical reason to continue treatment and could potentially try stopping (Cruickshank et all., 2008).
Data collected by the Office for National Statistics (ONS) revealed a rise in the prevalence of moderate or severe mental disorder following the onset of the pandemic. Between July 2019 and March 2020, the prevalence was recorded at 10%. However, by June 2020, it had increased to 19%, and further rose to 21% from January to March 2021, indicating a significant impact of the pandemic on mental health.
In a 2022 survey focusing on children and young people's mental health, it was found that 18.0% of children aged 7-16 were deemed to have a probable mental disorder in 2022, a significant increase from the 12.1% reported in 2017. Among individuals aged 17-19, the percentage with a probable mental disorder rose from 10.1% in 2017 to 25.7% in 2022 (Baker & Wade, 2023).
It is not uncommon for clients to ask whether they should consider taking antidepressants, but providing a straightforward answer can be challenging. There is a range of perspectives regarding the efficacy of antidepressants in alleviating depression symptoms. Some mental health professionals harbor doubts about their effectiveness, while others deem them indispensable. However, similar to other treatments, these medications may be beneficial in certain scenarios but not others. They exhibit effectiveness in cases of moderate, severe, and chronic depression, but are likely less effective in mild instances. Additionally, they can give rise to side effects. Engaging in a thorough discussion with your doctor regarding the advantages and disadvantages of antidepressants is crucial. Typically, antidepressants are prescribed for daily use. Initially, the objective during the first weeks and months is to alleviate symptoms and, if feasible, achieve remission from depression. Once this goal is attained, the treatment is sustained for a minimum of four to six months. This continuation therapy is essential to prevent the recurrence of symptoms. In certain cases, the medication may be taken for an extended period to prevent relapses. The duration of treatment is also contingent upon the progression of symptoms over time and the likelihood of depression resurfacing. (Overview -Antidepressants -NHS, 2023) Mental Health services in the UK are split into two main categories: primary services such as GP practices or talking therapies services such as IAPT (Improving Access to Psychological Therapies -CBT based 6-12 sessions talking therapy service) and secondary services such as inpatient/ outpatient services, specialized services (eating disorders, personality disorders, etc.), or Community Mental Health Teams.
A report by the CQC (Care Quality Commission) raises concerns about staff shortages and the impact this has on patient care. The mental health sector continues to grapple with challenges surrounding workforce retention and staffing shortages, which have been further exacerbated by the COVID-19 pandemic and the departure of staff due to retirement or seeking alternative employment.
Insufficient staffing levels can have a detrimental impact on both patient and staff safety. Moreover, chronic staffing shortages have impeded the ability of staff to respond effectively to incidents, often resulting in untrained personnel being assigned responsibilities beyond their capacity to safely carry them out. These factors contribute to the ISSN 2710-1460 WAPP development of closed cultures, further escalating risks. Patients have also experienced difficulties accessing therapeutic care due to staffing shortages, resulting in reduced patient involvement in decision-making processes (Monitoring the Mental Health Act in 2021 to 2022; Staff shortages and the impact on patients, 2022).
"Not having the right levels and skill mix of staff can affect the services' ability to provide safe and effective care and treatment that is in line with the guiding principles of the Mental Health Act Code of Practice." This means that patients who should be assessed and reviewed by a psychiatrist are often only seeing their GP (Monitoring the Mental Health Act in 2021 to 2022; Staff shortages and the impact on patients, 2022).
Despite over 40% of all GP appointments involving mental health issues, and with demand rising, there is currently no mandatory practicebased mental health training for GPs in the UK. Less than half of GPs who completed their training in 2017 opted to take a psychiatry placement, exacerbating the issue. According to MIND's 2017 Big Mental Health Survey, this lack of training can leave patients in the dark about the potential side effects of psychotropic medication. Around one-third of patients prescribed medication for their mental health would have liked more information from their GPs about the possible side effects. (Mind, 2018). This is supported by similar findings in the research done in 2022 by Mind on the lived experience of mental health (Gunstone et. al., 2022). Additionally, GPs face multiple pressures from stress, overwork, and the demands of Clinical Commissioning Groups (CCGs) and patients. Limited prescribing pathways may also contribute to the over-reliance on medication as opposed to talking therapies, especially in mild depression. Encouraging a cultural shift towards a preference for talking therapies over medication will require addressing the lack of mandatory mental health training for GPs.
Numerous studies indicate that a combination of pharmacotherapy and psychotherapy yields greater effectiveness compared to treatment solely relying on antidepressant medication. However, in primary care settings, the prevailing practice often involves offering either pharmacotherapy or CBT, with limited instances of both being provided concurrently. A possible reason for this could be the long waiting times. According to a recent assessment of Mental Health Services, the average waiting time for primary care talking therapy services, known as IAPT, is approximately 21 days from referral to assessment, however, certain regions in England have reported waiting times as long as 299 days. Furthermore, the average waiting time between the first and second treatments is around 50 days, but in certain areas, it can extend to 291 days. (Baker & Wade, 2023).

The potential risks of relying on repeat prescriptions
The increasing number of individuals who take antidepressants but don't find them helpful is raising concerns about our society's reliance on prescription drugs. Dr James Davies, a psychotherapist and reader in Social Anthropology and Mental Health at the University of Roehampton UK, warns that we may be in the midst of a psychiatric drug epidemic, with prescribed drug dependency being a particular concern. Currently, over 15% of the adult population in the UK is on psychiatric medication, and this number continues to rise. Studies in the UK indicate that about half of the individuals on antidepressants have been taking them for two years or more, which is consistent with similar findings in the USA. However, as patients take antidepressants for a longer period, the frequency of mental health reviews tends to decrease, reducing the chances of reevaluating the appropriateness of the treatment and potentially leading to unnecessary continuation. As a result, patients may receive repeat prescriptions, be reviewed infrequently, and assume that they are expected to continue treatment indefinitely (Davies ed., 2017).
The situation is similar with benzodiazepines, which are frequently prescribed for anxietyrelated conditions, resulting in patients taking drugs that were only meant for short-term use. It is like being given antibiotics for a chest infection and taking them for two decades simply because nobody reviewed the case. For instance, one of my clients was prescribed Lorazepam after failing an exam as a teenager, and 34 years later, when she came to me for help, she was still taking it.
Research also indicates that the use of antidepressants can increase the likelihood of depression developing into bipolar disorder, impair patients and lead to government disability claims. Science writer, Robert Whitaker, highlights that disability claims due to depression and anxiety increased from 721,000 to 1,081,000 in the UK between 1998 and 2010. This corresponds with the increased use of antidepressants, which could worsen long-term outcomes (Davies ed., 2017).

Side Effects & Withdrawal
The difficulty of discontinuing benzodiazepine treatment is widely recognized, and even street users are aware that quitting "cold turkey" can be more painful and difficult than quitting heroin. Many of my patients and some of my family members who have been prescribed Xanax (Alprazolam) have expressed the need for reassurance that their symptoms during withdrawal are not a sign of mental illness and that the process of withdrawal takes time and support. It is important for them to know that they are not alone in this journey.
What is less known is that with any SSRI, 50% of the patients will experience some form of side effects and withdrawal. If there is a plan to put someone on antidepressants, there also needs to be a plan of taking the person off the medication.
One of my clients who had been on antidepressants for two years after being diagnosed with Postpartum OCD (by the GP), decided to discontinue the medication. I recommended that she see her doctor to come up with a plan to gradually stop taking Fluoxetine (Prozac). The GP's proposed plan, involved taking half a tablet per day for the first week, followed by half a tablet every other day for the second week. However, my client immediately experienced a range of withdrawal symptoms, including insomnia, digestive issues, headaches, nausea, dizziness, and passive suicidal ideation. Despite these symptoms, the GP failed to recognize the withdrawal and instead increased the dosage of Fluoxetine. After several discussions between myself, the patient, the GP, and the charity Bridge Project, (https://thebridgeproject.org.uk), it was decided that the patient should be put on a liquid form of the medication so that she could gradually reduce the dosage and avoid more severe withdrawal symptoms.
It is important to underline that withdrawal can last months, not just weeks, and our clients need support to understand and rebalance their nervous systems. (Nice Guideline NG222, 2022).

The way forward for psychotherapists?
As psychotherapists, we often have conversations with our clients about medication, including its potential side effects and withdrawal symptoms. However, I have noticed gaps in understanding and knowledge in myself and among some professionals during supervision sessions. Some therapists may feel that it is not their place to discuss medicationrelated topics because they are not medical doctors. But if we do not talk about it, who will?
Due to the current state of affairs in Mental Health services in England, we often find ourselves therapeutically holding patients who need specialized medical interventions.
We have a place in the patient's journey, whether it involves initiating psychotropic medication or supporting them towards a medication-free approach. However, it is imperative that any decision to start or stop medication is made under the supervision of a doctor. Our collaboration with the patient's general practitioner (GP) and preferably, when available, a psychiatrist is vital for successfully implementing this process.
In my experience, when they come to see a therapist, clients do not seek medical expertise on withdrawal or side effects but value psychological support, curiosity, and a safe space to explore their experiences. Therapy can provide a support system that patients do not typically receive from doctors. Together with our clients, we can create a plan that is not fixed and rigid, but that considers what actions can be taken when things are challenging.
As Positive Psychotherapists, we can use the Balance Model as a framework to plan this intervention. The Balance Model takes into consideration the four areas of life: Body, Achievement, Relationships and Future/Fantasy. Together with the client we structure and plan their journey of managing the side effects of starting/stopping medication and rebalancing the client's nervous system. The unique feature of the Balance Model is that it covers the four most critical dimensions of well-being: physical, mental, emotional and spiritual. For example, the intervention might include: recognizing body changes, improving diet, increasing exercise, learning or practicing a new skill, celebrating small achievements, maintaining social contacts, ISSN 2710-1460 WAPP engaging in a conversation with a trusted individual can provide a sense of relief, journaling, encourage creativity in expressing sensations, emotions and thoughts, practicing mindfulness, yoga, guided meditation or trying reflexology. These small changes and steps can make a significant difference in someone's life because struggling with withdrawal or side effects can be easily misconstrued and lead to feelings of isolation for our clients.

Conclusions
As therapists, does our ethical responsibility change, when we learn about the potential harm that long-term use of psychotropic medication can have on our clients?
Many therapists have likely encountered clients who are taking or stopping psychotropic medications, and specialized training is not always necessary or available for them to assist clients with problems related to medication side effects or withdrawal during therapy.
In my opinion, it is important to educate ourselves to consider this issue and take informed steps within the framework and scope of therapy.