From the Editor

As stigma fades, as mental health problems are recognized and discussed, we have an opportunity to re-think old approaches.

This week, the Readings touch on two large issues: how to handle mental illness in our society, and what to do about addiction and the law. The first comes from a recent speech by the Prime Minister of Britain; the second, from an editorial in The Lancet Psychiatry.


Readings have drawn from many sources over these past few years – journals, books, and newspapers. This is the first time we’ve looked to 10 Downing Street for material. But perhaps it wouldn’t be the last time. More and more, people discuss these issues with thoughtful comments; the political class can be counted among them. #Progress


Helping Those with Mental Illness

“Life Chances”

David Cameron, 11 January 2016

This government is all about security. It’s that security that underpins our long-term economic plan: in a world of risks, we want to ensure the British economy, and British families, are secure. It’s security that drives our defence policy and strategy to combat extremism: in dangerous times, we know our first duty is to keep our country safe. And it’s our national and economic security that is front and centre of my mind as I renegotiate a better deal for Britain in Europe. Security is also what drives the social reform that I want this government to undertake in my second term.

Individuals and families who are in poverty crave security – for them, it’s the most important value of all. But those who are struggling often have no security and no real chance of security.

Prime Minister David Cameron

So opens a speech delivered by U.K. Prime Minister David Cameron. In it, he speaks directly to the link between poverty and mental illness, and the need to address the latter to tackle the former.

Historically, Cameron argues that two views have dominated the discussion of how to address poverty. On the left, there is the argument that more robust welfare payments will make a difference. On the right, there is the belief that free markets will lift people out of poverty.

Cameron goes on to reject both views:

Talk to a single mum on a poverty-stricken estate: someone who suffers from chronic depression, someone who perhaps drinks all day to numb the pain of the sexual abuse she suffered as a child. Tell her that because her benefits have risen by a couple of pounds a week, she and her children have been magically lifted out of poverty. Or on the other hand, if you told her about the great opportunities created by our market economy, I expect she’ll ask you what planet you’re actually on.

It’s a bold statement. He continues, discussing the impact of mental illness on society:

Some people with mental health problems today are almost guaranteed to live a life in poverty. And the number of people who suffer from poor mental health is larger than you might think. One in 5 new mothers develop a mental health problem around the time of the birth of their child. Up to one in 4 of us will have a problem – perhaps a form of depression or anxiety – this year alone. There is the terrible fact that suicide has become the leading cause of death for men under 50.

He includes significant mention of addition.

Let’s be honest: when we hear the words ‘drug addict’ or ‘alcoholic’, there is still such a stigma that comes attached. Still a view that addiction is simply a question of will, a sense that it’s simply about self-control, a feeling that it’s somehow shameful if we admit to having a problem.

We see it as weakness. It isn’t. Seeking help is strength.

How to address this? Cameron outlines an ambitious plan to invest billions of pounds into mental health services. He also outlines specific proposals: money to target children and young people with mental illness, a greater focus on women before and after birth, crisis services in EDs that run “24/7,” and better addiction services.

A few thoughts:

1. What a comment on our times that so many politicians speak up about mental health problems. Around the time this speech was delivered, presidential candidates in the U.S. were discussing mental illness – including very personal comments by the former governor of Florida Jeb Bush who talked about his daughter’s struggle with opiates. And the newly elected Canadian federal government has been clear in its intention to do more for those with mental illness, in part because of the personal commitment of Prime Minister Justin Trudeau, who has spoken about his mother’s struggle with Bipolar.

2. Prime Minister Cameron’s thoughts are nuanced and interesting, tying education (or lack thereof) to poverty – yes – but also mental illness to poverty.

3. The British have already done much to enhance evidenced-based care, including better access to publicly-covered psychological interventions. That’s not an unfettered defence of the Cameron years (or the Blair-Brown years before them), but an observation that changes often touted in Canada have international precedence.


Better Drug Laws

“Drug policy: getting over the 20th century”

The Editors, The Lancet Psychiatry, March 2016


One night in 1916, on West Street in central London, two police sergeants spotted a man called Willy Johnson acting suspiciously. He fled when they approached, dropping a bag; it was full of cardboard boxes containing cocaine. Johnson, the subject of what has been called London’s first drug bust, was brought to trial but acquitted. Even if he had been found guilty of selling the substance, the maximum fine would have been £5. Cocaine was, after all, a drug legally available from chemists. But this was not the end of the matter. There was a backdrop of pre-war national and international concern about substance use. And 1916 had seen increasing public alarm over cocaine use in the UK’s capital city; it was feared that sex workers would introduce troops to the use of the drug. ‘It is driving hundreds of women mad’, warned the Daily Chronicle. ‘What is worse, it will drive, unless the traffic in it is checked, hundreds of soldiers mad.’ The Defence of the Realm Act authorised a swift crackdown on the cocaine trade. After World War I ended, the Dangerous Drugs Act of 1920 cemented the decisions made in the heat of international conflict. Substance use was no longer simply a vice, or even a disease: it was a crime.

Dr. Niall Boyce, Editor of The Lancet Psychiatry

So opens an editorial from The Lancet Psychiatry that argues that current drug laws have failed. The editorial is written for a British journal and focuses on British drug laws, but is equally relevant on this side of the Atlantic.

Drug use can cause profound harm, often to society’s most vulnerable people. True, a hard line makes it clear that the government recognises the dangers of substance use. But the role of the law should be to mitigate harm, not to exacerbate it. Blanket bans do not make a problem go away; they merely change its form.

The editors object to a recent UK law, yes, but also decades’ worth of law.

To revise drug policy such that it protects young people will require not just good science, but a profound historical reassessment of how we got where we are today, and how we might do things differently.

My thought: this is a far-reaching editorial – dramatic from the title on – but difficult not to consider. Speaking as a Canadian, it’s hard not to feel that our drug laws are often dated and ill-informed, built on old thinking and misconceptions. The current push? As we move to ban cigarettes, we are slowly embracing marijuana – yet do little to address addiction to harder drugs.

Back to the editorial: “the role of the law should be to mitigate harm, not to exacerbate it.” Well said.

Further Reading

The Lancet Psychiatry runs a series on “substance use in young people.” This includes an excellent paper on the global burden of substance, as well as a systematic review of interventions.

Closer to home, The Canadian Journal of Psychiatry looks at substance this month, including a solid paper on injection drug use and a thought-provoking paper on alcohol and stress.

Please note that there will be no Reading next week.

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.