(This post was first published on the Mental Health Foundation website).
We’ve come a long way in public mental health in recent years. Part of the ground that we have covered – towards making a difference in how mental health problems are perceived and how people with lived experience can be supported – is because of our concentrated efforts to tackle the stigma of ill-health. The language that we use is fundamental to that. We have managed, as a society, to move away from stigmatising and discriminatory terms like ‘mental’, ‘maniac’ and ‘madman’. But what about ‘murderer’?
Last night’s BBC Panorama programme A prescription for murder? has unhelpfully triggered the same discussion again. The programme went, at length, to investigate some cases of people who have committed homicides and attempted to explore a causal link with mental health problems and SSRI medication. Selective serotonin re-uptake inhibitors (SSRIs) are a type of widely prescribed drugs aiming to decrease symptoms of anxiety and depression through increasing the levels of serotonin in the brain (serotonin is a chemical messenger that transfers signals between neural cells and the brain). The programme provided case studies and interviews with families of victims and clinicians.
Unfortunately, those of us working in public health know that relying on individual case studies to draw generalised conclusions is poor practice. In fact, we dedicate our careers to building the evidence base that will help us make good – both clinical and non-clinical – decisions and recommendations.
So what does the evidence tell us? Most past observational studies or reviews of randomised controlled trials have been inconclusive. Some of these studies have reported outcomes such as hostility and aggression, but have not shown that this would translate into harder outcomes, like violence. In a 2015 Swedish study, the largest of its kind, researchers examined data from more than 850,000 individuals with linked data from prescriptions and crimes databases. They found that for about 80% of people who were prescribed SSRIs there was no clear association with violent crime. Their use, though, resulted in an increased risk for violent behaviours among young people aged 15 to 24 years. However, when attempting to interpret this finding, the researchers added that this is not a conclusion that should be taken out of context. Young people sometimes withdraw from medication and this leads to side effects. Also, in the study, a lot of young people received sub-therapeutic doses (i.e. not adequate), and hence may have developed symptoms due to that. In addition, when some younger people start taking this medication, they feel better and may start misusing alcohol, which we know can lead to aggressive behaviour. Thus, in essence, the best available evidence tells us to be very careful with the prescription and patterns of use of anti-depressants in adolescents. This is largely the case for any prescribed medication.
In countries like the UK and the US, almost 1 in 10 people receive an anti-depressant. In such large populations, patterns of adverse effects of that seriousness are almost always evident by the data that are routinely collected and analysed. To the best of our knowledge, psychosis is a very rare side effect of anti-depressive medication, and only an incredibly small sub-percentage of those developing such symptoms may become violent.
The problem with programmes like A prescription for murder? is that they contribute to sustaining a conversation that presents people experiencing mental health problems as violent and dangerous. And such portrayals in the media can be powerful in shaping the thinking of viewers. Over a third of the wider public think that people with a mental health problem are likely to be violent. Contrary to this popular belief, recent studies have shown that the rates of homicides committed by people diagnosed with mental health problems have remained reasonably stable since the 1990s. In fact, people with severe symptoms are much more likely to be the victims, rather than the perpetrators, of violent crimes, and the vast majority of violent crimes, including homicides, are not committed by people who have mental health problems.
While the programme attempted to use appropriate language where possible, encouraged open publication of pharmaceutical data, and included advice to viewers to not stop any medication, it overall begged the question: why do we need programmes themed and framed like this? Who would actually benefit from watching? Surely, topics only peripherally mentioned, like gun availability and violence in the United States, are more urgent public health concerns. With nearly two thirds of us having experienced a mental health problem in our lifetime, it’s time we shift all our focus and efforts to the real public mental health challenges of inequalities and prevention. Oh, and to ditch one more M-word.