Sickness and disability benefits are a hot topic in the United Kingdom at the moment. The government’s new system means that everyone’s benefit entitlement is being reviewed, and this is causing huge stress and anxiety for many people, including my patients. Some people have suggested that for this reason, I should not have published the recent paper on trends in sickness and disability benefits that I published with a colleague, Sebastiao Viola (1, http://bjpo.rcpsych.org/content/2/1/18.) It was unethical and should not have been allowed, apparently (2, http://www.philipfthomas.com/index.php/blogs/28-un-critical-psychiatry), even though almost all the data is already in the public domain – on the Department for Work and Pensions’s website – in the name of transparency.
But we cannot simply ignore or suppress such a seismic shift in social trends. When I looked at benefit statistics in the 1990s, musculo-skeletal disorders (principally back pain) were overwhelmingly the biggest and fastest growing cause of receiving what were then called incapacity benefits, and cardiovascular disorders were the second most common cause in men. In 1994-1995, mental disorders accounted for just 20% of days on which benefits were claimed (3, http://jpubhealth.oxfordjournals.org/content/22/1/59.long).
Since that time, mental disorders have far outstripped all other types of medical conditions and become the leading cause of claiming sickness and disability benefits. While the number of people claiming benefits for other medical conditions fell by 35% between 1995 and 2014, the number of people claiming benefits for mental disorders more than doubled. In 2014, 47% of all claims for disability benefits – almost half- were made by people whose primary condition is a mental disorder. 1.1 million people in the UK, or 2.7% of the working age population, claim disability benefits due to a mental disorder (4). The costs to the individuals who are unable to support themselves, and to the society as a whole, are huge.
These figures are important for what they tell us about the success or otherwise of current approaches to helping people with common mental health problems, and for what they say about the economy, and the nature of modern work.
I started looking at disability benefits back in the 1990s in order to find some objective measure of the performance of people diagnosed with depression Depression and anxiety disorders account for the majority of disability claims by people with mental disorders. In 2014, almost half (44.2%) of disability benefits awarded to people with a mental disorder were for depression and two thirds were for depression or anxiety (66.8%) (1). These proportions have not changed much since the 1990s.
In the early 1990s, campaigns like the Defeat Depression Campaign publicised the message that large numbers of people were depressed without knowing it, and that they should go and get the new and wonderful antidepressants that had just come onto the market (the SSRIs of course!). Since that time, the use of antidepressants has increased four times! In England, prescriptions have risen over 10% a year since 1998 (4, http://bjp.rcpsych.org/content/200/5/393.long).
If antidepressants are effective, and people with depression are more likely to be prescribed them, then you would expect the consequences of depression to start to lessen. One of those consequences, according to government statistics, is being out of work. But what we see is quite the opposite: Increasing use of antidepressants correlates with increased numbers of people with depression who are out of work and claiming benefits, and increasingly on a long-term basis. And this is at a time when disability due to other medical conditions has fallen.
The idea that conditions like depression and anxiety can be quickly and effectively treated with medication or short courses of therapy that re-adjust your thinking is not borne out by the evidence. Rather than helping people improve their lives and get on their feet again, this approach seems to create ever rising numbers of people who are viewed, and may come to themselves, as chronically sick. Far from helping people towards a meaningful recovery, taking an antidepressant may simply be a daily reminder of the idea that you are permanenelty flawed.
One of the ways our current approach is wrong is that we are looking for the problem in the individual- inside the brain. Instead we need to ask what it is about our society that means that so many people feel too unhappy, worried or mentally frail to work. Having a ‘decent’ job is an incredibly important part of people’s lives, and most people want one. Research shows that even people with severe mental disorders would like to be in work, if they could (5,6). A good job is a source of satisfaction, purpose and camaraderie. People without work easily lose confidence and become socially isolated.
Fewer and fewer ‘decent’ jobs exist, however, especially at the unskilled end of the jobs market. Most jobs, even fairly menial ones, have become increasingly competitive and demanding, with performance targets and micro-management. I heard one radio journalist describe how he had attempted to apply for a job as a local petrol station attendant. He had to complete complex questionnaires designed to assess his levels of motivation and dedication, as if the application were for a high flying executive position. Despite his University education, he failed miserably to qualify, and wondered how anyone without a degree in management consultancy was able to get shortlisted.
Unskilled jobs have either gone altogether, or have become increasingly casualised. With the increase in agency work and zero-hours contracts, there are fewer jobs with paid sick leave and holidays. For these reasons, some analysts have referred to the problem of ‘disguised unemployment,’ indicating that many disability claimants are willing and able to work if suitable employment opportunities existed (7). But they need jobs that will accommodate the fact that they might not always be performing at 100% efficiency (like everyone, of course), and they might need to take time off occasionally. They need understanding employers, who respect and value their contribution, not agencies which can simply hire someone else.
Working in a highly pressured, insecure and competitive situation is bad for everyone. Rising disability benefits are a sign that we need to do something about modern employment conditions. We need to provide more opportunities to work in a supportive and accommodating environment. This is especially important for people with mental health problems, but it would benefit us all.
(1) Viola S, Moncrieff J. Claims for sickness and disability benefits owing to mental disorders in the UK: trends from 1995 to 2014. BJPsych Open 2016;2:18-24. http://bjpo.rcpsych.org/content/2/1/18
(2) http://www.philipfthomas.com/index.php/blogs/28-un-critical-psychiatry
(3) Moncrieff J, Pomerleau J. Trends in sickness benefits in Great Britain and the contribution of mental disorders. J Public Health Med 2000 Mar;22(1):59-67. http://jpubhealth.oxfordjournals.org/content/22/1/59.long
(4) Calculated using figures from ONS: http://www.ons.gov.uk/ons/rel/pop-estimate/population-estimates-for-uk–england-and-wales–scotland-and-northern-ireland/mid-2014/sty—overview-of-the-uk-population.html, deducting population of Northern Ireland (since disability benefits data do not cover Northern Ireland), and assuming working age pop is 64% of population, as given by ONS data
(5) Ilyas S, Moncrieff J. Trends in prescriptions and costs of drugs for mental disorders in England, 1998-2010. Br J Psychiatry 2012 May;200(5):393-8. http://bjp.rcpsych.org/content/200/5/393.long
(6) Boycott N, Akhtar A, Schneider J. “Work is good for me”: views of mental health service users seeking work during the UK recession, a qualitative analysis. J Ment Health 2015 Apr;24(2):93-7. http://www.ncbi.nlm.nih.gov/pubmed/?term=boycott+and+akhtar
(7) Marwaha S, Johnson S. Views and experiences of employment among people with psychosis: a qualitative descriptive study. Int J Soc Psychiatry 2005 Dec;51(4):302-16. http://www.ncbi.nlm.nih.gov/pubmed/16400906
(8) Beatty C, Fothergill S, Macmillan R. A theory of employment, unemployment and sickness. Regional Studies 2000;34:617-30. http://www.tandfonline.com/doi/abs/10.1080/00343400050178429
Joanna Moncrieff 
Reblogged this on Chrys Muirhead .
Thank you so much for this essential education.
Currently facing this at the moment. Brilliant insight, thank you. I suffer from Anorexia and depression; and recently my antidepressants were simply doubled when I told the DRs my depression was getting worse. Ironically, this has led to my mental state deteriorate significantly. Now I am unable to get out of bed most days, so work is out of the question. I saw in the news yesterday that the Conservatives were trying to reduce ESA by around £30 a week. I’m unaware of the details, but imagine living on approx £20 a week? It is a cycle. It is difficult as it is at the moment. You need to buy a lot of food (more than your average person) when trying to recover from an eating disorder. And it is even worse when you go through binging episodes too. I just wish the current government would show some insight, and perhaps review how the NHS responds to the display of mental health conditions.
I very much welcome this article. I was treated for depression for 40 years with all the different types of antidepressants that came on the market. They had little positive effect and some of the side effects were awful – aggression, severe insomnia, dangerously low blood pressure, for example. For 40 years I wondered what was wrong with me, why did I feel the way I did. Was it my genes, my biochemistry or worse my personality. It was a terrible burden. Now at age 61 I am finally free from that burden. I had been prescribed nitrazepam in 1975 for myoclonic epilepsy. Soon after I tried to commit suicide and so my “psychiatric career” began. I have had to endure a terrible ordeal to get off nitrazepam and have been bedridden for over two years, physically disabled. However, I am free for the first time in 40 years. I am emotionally and psychologically well. I was fortunate to work most of my life but it was a daily struggle to function cognitively and physically. I worked well below my capabilities. I have cost the economy a great deal of money – in patient stays, day patient care, drugs, welfare benefits, sick leave from work, GP visits, psychiatry consultations and not once did any doctor suggest that the drugs I was consuming might be the problem. I am now free from depression and epilepsy and do not require any prescription medication. My story is not unique. Others have suffered in a similar way. But the tendency is to assume the “fault” lies with the patient. This is not good medicine. I am campaigning to raise awareness of this issue. http://www.actionpddwordpress.org
The reason you were rightly criticised by service users, activists and a former psychiatrist is because your original article failed to place the data within a political context of ideological austerity and social injustice which is harming and even directly killing people. We have ministers stating ‘work is the solution’ whilst removing all social supports and social housing. So your original article failed to place the data within context. Context is everything. Your work is rightly highly respected, anyone can misjudge a piece, you did, so take it on the chin Joanna.
Thank you Ethel. The original article was an academic paper published in a psychiatric journal, so it was not possible to discuss political and economic factors at length. However, I did put the data in the context of the important debate about ‘disguised unemployment,’ so there was some context in the paper. I think the meaning of these figures is an important debate to have, and I welcome yours and others critical (and non critical) comments.
The thing is Joanna, within psychiatric journals is exactly where economic and political explanations should be
You said there is less stigma and I don’t understand that because disability hate crime has risen dramatically over the last 5 yrs and politically it’s been especially aimed at mental ‘illness’ via policies evidenced by high court judgements. It could be said that the greater discrimination and stigma is now attached to being a benefit recipient rather than possessing a diagnosis, even in work. Drugs disable yes, no doubt about that, but take those away and there would still be no infrastructure to support people with inconsistent working ability. It’s not all down to employers, it requires a robust welfare state as well. The attack on people’s lives are on all fronts right now, and according to ministers ‘work is the solution’. The unspeakable truth is that not all people can work or all the time. Some people have fared better doing voluntary work as their ‘outcome’, which has been happily used by psychiatry, psychology, nursing, social work, charities, universities.