I've just spent a very stimulating and enlightening couple of weeks, first at the Rome Workshop in Experimental Psychopathology, and then at the University of Exeter - both times talking about experimental psychopathology. But these talks were not just about how to do experimental psychopathology, they were also about how many other researchers were simply not equipped to do experimental psychopathology, or simply had no idea about what this scientific paradigm was. And that has some very dramatic consequences for mental health funding, as well as our broader understanding of the mechanisms that contribute to mental health funding.

Let’s be quite clear about the main issue here. Most funding for mental health research goes to high profile, expensive, medically oriented research on the biological substrates of mental health problems. Why is that? Well, while psychologists learn about both biological mechanisms and psychological mechanisms, medics simply don’t learn about psychological mechanisms - in fact they tend to have no knowledge whatsoever of the inferential methodologies that allow psychologists to develop models of psychological processes - but rather sadly, there is a majority of those medics on the panels of most funding bodies for mental health research.

Is this important? Yes it is, because, I'm quite happy to assert that most common mental health problems are acquired through perfectly normal psychological mechanisms that involve attention, decision-making, learning, memory and other general cognitive processes - so the mechanisms are not in any way abnormal - only the outcomes of the process are abnormal - so why do we waste research time and taxpayers money trying to look for abnormal neurological mechanisms or medically aberrant signatures of psychopathology when they probably do not exist?

As an experimental psychologist studying learning in nonhuman animals I learnt a lot about inferential experimental methodologies that allowed us to infer cognitive processes in any organism – human or nonhuman. These are the same types of methodologies that are used to understand most human cognitive processes - such as memory, attention, decision-making and learning. What many researchers from a medical background do not grasp is that scientific method allows us to infer the nature and structure of psychological mechanisms without having to know anything about the biological underpinnings of these mechanisms. In fact, whatever medical or biological research does subsequently to psychologists elaborating these mechanisms will merely be to substantiate the infrastructure of these mechanisms – and indeed, as radical as it may seem, it will be very little more than that.

Experimental psychopathologists should have the lead on all research questions to do with the aetiology of mental health problems. Their research is cognitive, experimental, inferential, provides evidence for the causal relationships that underlie the acquisition of mental health problems, and allows the development of testable models of mental health problems – and it’s a hell of a lot cheaper than most other medically driven approaches!

I have recently been heard to say that experimental psychopathology needs a manifesto to enable it to compete with other explanatory approaches to mental health problems such as neuroscience and genetics – well, it does. We need this manifesto to prevent other disciplinary lobbies from monopolizing funding and – most importantly – from hijacking the way we explain mental health problems. Most mental health problems develop out of perfectly natural psychological processes – not medical problems. Understanding those processes in the normal, inferential way that psychologists do research will provide the basis for good mental health research.

As promised, here is another piece from the forthcoming second edition of Psychopathology. This time, here is a new section discussing mental health stigma, its causes, why it matters, and how we can eliminate it.

There are still attitudes within most societies that view symptoms of psychopathology as threatening and uncomfortable, and these attitudes frequently foster stigma and discrimination towards people with mental health problems. Such reactions are common when people are brave enough to admit they have a mental health problem, and they can often lead on to various forms of exclusion or discrimination – either within social circles or within the workplace. In the following sections we will look at (1) what mental health stigma is, (2) Who holds stigmatizing beliefs and attitudes?, (3) What causes stigma? (4) Why does stigma matter? And (5) How can we eliminate stigma?

What is mental health stigma?: Mental health stigma can be divided into two distinct types: social stigma is characterized by prejudicial attitudes and discriminating behaviour directed towards individuals with mental health problems as a result of the psychiatric label they have been given. In contrast, perceived stigma or self-stigma is the internalizing by the mental health sufferer of their perceptions of discrimination (Link, Cullen, Struening & Shrout, 1989), and perceived stigma can significantly affect feelings of shame and lead to poorer treatment outcomes (Perlick, Rosenheck, Clarkin, Sirey et al., 2001).

In relation to social stigma, studies have suggested that stigmatising attitudes towards people with mental health problems are widespread and commonly held (Crisp, Gelder, Rix, Meltzer et al., 2000; Bryne, 1997; Heginbotham, 1998). In a survey of over 1700 adults in the UK, Crisp et al. (2000) found that (1) the most commonly held belief was that people with mental health problems were dangerous – especially those with schizophrenia, alcoholism and drug dependence, (2) people believed that some mental health problems such as eating disorders and substance abuse were self inflicted, and (3) respondents believed that people with mental health problems were generally hard to talk to. People tended to hold these negative beliefs regardless of their age, regardless of what knowledge they had of mental health problems, and regardless of whether they knew someone who had a mental health problem. More recent studies of attitudes to individuals with a diagnosis of schizophrenia or major depression convey similar findings. In both cases, a significant proportion of members of the public considered that people with mental health problems such as depression or schizophrenia were unpredictable, dangerous and they would be less likely to employ someone with a mental health problem (Wang & Lai, 2008; Reavley & Jorm, 2011).

Who holds stigmatizing beliefs about mental health problems?: Perhaps surprisingly,  stigmatizing beliefs about individuals with mental health problems are held by a broad range of individuals within society, regardless of whether they know someone with a mental health problem, have a family member with a mental health problem, or have a good knowledge and experience of mental health problems (Crisp et al., 2000; Moses, 2010; Wallace, 2010). For example, Moses (2010) found that stigma directed at adolescents with mental health problems came from family members, peers, and teachers. 46% of these adolescents described experiencing stigmatization by family members in the form of unwarranted assumptions (e.g. the sufferer was being manipulative), distrust, avoidance, pity and gossip, 62% experienced stigma from peers which often led to friendship losses and social rejection (Connolly, Geller, Marton & Kutcher (1992), and 35% reported stigma perpetrated by teachers and school staff, who expressed fear, dislike, avoidance, and under-estimation of abilities. Mental health stigma is even widespread in the medical profession, at least in part because it is given a low priority during the training of physicians and GPs (Wallace, 2010).

What factors cause stigma?: The social stigma associated with mental health problems almost certainly has multiple causes. We’ve seen in the section on historical perspectives that throughout history people with mental health problems have been treated differently, excluded and even brutalized. This treatment may come from the misguided views that people with mental health problems may be more violent or unpredictable than people without such problems, or somehow just “different”, but none of these beliefs has any basis in fact (e.g. Swanson, Holzer, Ganju & Jono, 1990). Similarly, early beliefs about the causes of mental health problems, such as demonic or spirit possession, were ‘explanations’ that would almost certainly give rise to reactions of caution, fear and discrimination. Even the medical model of mental health problems is itself an unwitting source of stigmatizing beliefs. First, the medical model implies that mental health problems are on a par with physical illnesses and may result from medical or physical dysfunction in some way (when many may not be simply reducible to biological or medical causes). This itself implies that people with mental health problems are in some way ‘different’ from ‘normally’ functioning individuals. Secondly, the medical model implies diagnosis, and diagnosis implies a label that is applied to a ‘patient’. That label may well be associated with undesirable attributes (e.g. ‘mad’ people cannot function properly in society, or can sometimes be violent), and this again will perpetuate the view that people with mental health problems are different and should be treated with caution.

            We will discuss ways in which stigma can be addressed below, but it must also be acknowledged here that the media regularly play a role in perpetuating stigmatizing stereotypes of people with mental health problems. The popular press is a branch of the media that is frequently criticized for perpetuating these stereotypes. Blame can also be levelled at the entertainment media. For example, cinematic depictions of schizophrenia are often stereotypic and characterized by misinformation about symptoms, causes and treatment. In an analysis of English-language movies released between 1990-2010 that depicted at least one character with schizophrenia, Owen (2012) found that most schizophrenic characters displayed violent behaviour, one-third of these violent characters engaged in homicidal behaviour, and a quarter committed suicide. This suggests that negative portrayals of schizophrenia in contemporary movies are common and are sure to reinforce biased beliefs and stigmatizing attitudes towards people with mental health problems. While the media may be getting better at increasing their portrayal of anti-stigmatising material over recent years, studies suggest that there has been no proportional decrease in the news media’s publication of stigmatising articles, suggesting that the media is still a significant source of stigma-relevant misinformation (Thornicroft, Goulden, Shefer, Rhydderch et al., 2013).

Why does stigma matter?: Stigma embraces both prejudicial attitudes and discriminating behaviour towards individuals with mental health problems, and the social effects of this include exclusion, poor social support, poorer subjective quality of life, and low self-esteem (Livingston & Boyd, 2010). As well as it’s affect on the quality of daily living, stigma also has a detrimental affect on treatment outcomes, and so hinders efficient and effective recovery from mental health problems (Perlick, Rosenheck, Clarkin, Sirey et al., 2001). In particular, self-stigma is correlated with poorer vocational outcomes (employment success) and increased social isolation (Yanos, Roe & Lysaker, 2010). These factors alone represent significant reasons for attempting to eradicate mental health stigma and ensure that social inclusion is facilitated and recovery can be efficiently achieved.

How can we eliminate stigma?: We now have a good knowledge of what mental health stigma is and how it affects sufferers, both in terms of their role in society and their route to recovery. It is not surprising, then, that attention has most recently turned to developing ways in which stigma and discrimination can be reduced. As we have already described, people tend to hold these negative beliefs about mental health problems regardless of their age, regardless of what knowledge they have of mental health problems, and regardless of whether they know someone who has a mental health problem. The fact that such negative attitudes appear to be so entrenched suggests that campaigns to change these beliefs will have to be multifaceted, will have to do more than just impart knowledge about mental health problems, and will need to challenge existing negative stereotypes especially as they are portrayed in the general media (Pinfold, Toulmin, Thornicroft, Huxley et al., 2003). In the UK, the “Time to Change” campaign is one of the biggest programmes attempting to address mental health stigma and is supported by both charities and mental health service providers (http://www.time-to-change.org.uk). This programme provides blogs, videos, TV advertisments, and promotional events to help raise awareness of mental health stigma and the detrimental affect this has on mental health sufferers. However, raising awareness of mental health problems simply by providing information about these problems may not be a simple solution – especially since individuals who are most knowledgeable about mental health problems (e.g. psychiatrists, mental health nurses) regularly hold strong stigmatizing beliefs about mental health themselves! (Schlosberg, 1993; Caldwell & Jorm, 2001). As a consequence, attention has turned towards some methods identified in the social psychology literature for improving inter-group relations and reducing prejudice (Brown, 2010). These methods aim to promote events encouraging mass participation social contact between individuals with and without mental health problems and to facilitate positive intergroup contact and disclosure of mental health problems (one example is the “Time to Change” Roadshow, which sets up events in prominent town centre locations with high footfall). Analysis of these kinds of inter-group events suggests that they (1) improve attitudes towards people with mental health problems, (2) increase future willingness to disclose mental health problems, and (3) promote behaviours associated with anti-stigma engagement (Evans-Lacko, London, Japhet, Rusch et al., 2012; Thornicroft, Brohan, Kassam & Lewis-Holmes, 2008). A fuller evidence-based evaluation of the Time to Change initiative can be found in a special issue dedicated to this topic in the British Journal of Psychiatry (British Journal of Psychiatry, Vol. 202, Issue s55, April 2013).

For those of you that would like to test your own knowledge of mental health problems, Time to Change provides you with a quiz to assess your own awareness of mental health problems.

Summary: Hopefully, this section has introduced you to the complex nature of mental health stigma and the effects it has on both the daily lives and recovery of individuals suffering from mental health problems. We have discussed how mental health stigma manifests itself, the effect it has on social inclusion, self-esteem, quality of life and recovery. We ended by describing the development of multifaceted programmes to combat mental health stigma and discrimination.

DSM-5 is at the binders and being prepared for release in May, but I can report that a new Task Force has already begun its preliminary work on its successor, DSM-6.

While the most recent changes to the DSM have been extensively discussed and researched, many of the revisions have been received critically, and the APA has moved rapidly to stymy criticism of DSM-5 by convening a new Task Force that has already reported on some further significant changes to mental health diagnostic criteria that will refine and elaborate on the changes in DSM-5.

The APA has recently confirmed that "Many of the revisions in DSM-5 will help psychiatry better resemble the rest of medicine", but now the aim of DSM-6 is to align psychiatric diagnosis with car maintenance. This will move diagnosis and treatment away from airy-fairy, psychological concepts such as ‘recovery’ to the more practical notion of fixing something that is clearly broken. Pursuing the ‘car maintenance’ analogy, DSM-6 will recommend that everyone should have an annual “road test” to ensure that their mental health is fit for purpose. Failing the test (e.g. by reporting the experience of at least one negative emotion in the previous 12 months) will require compulsory medication for a period to be determined by a panel of experts recruited from salesmen within the pharmaceutical industry.

Other new changes within DSM-6 include:

1.         An increased number and range of prodromal risk factors for mental health problems. These include dementia compulsio – forgetting whether you’ve locked the door and returning to check; risum cacoethes – uncontrollable inappropriate giggling fits – a known risk factor for a number of diagnosable disorders such as delirium, mania and bipolar disorder; anxietatem dentalis - feeling anxious when reading magazines you’ve previously encountered in your dentist’s waiting room, a precursor for a range of irrational fears.

2.         Nose-picking disorder is recognized as a new independent disorder category, along with Gluttony (formerly known as Binge Eating Disorder), and Jealousy (a former sub-type of Borderline Personality Disorder).

3.         The ‘scorn exclusion’ has been removed from the diagnosis of Antisocial Personality Disorder. This allows scorn (or contempt) to be included as a contributor to a diagnosis of Antisocial Personality Disorder.

4.         All criteria for major Depression have been removed and replaced by the single cardinal feature of ‘low mood’. This will allow GPs and physicians to prescribe antidepressants on the basis of an immediate diagnosis rather than – as before – a financial inducement from a pharmaceutical industry rep.

5.         DSM Criticism syndrome is a new psychosis sub-type characterized by delusional beliefs that DSM is not a necessary requirement for helping people to recover from mental health problems and merely provides labels that stigmatize sufferers. People diagnosed with this disorder should not be approached directly because of their revisionist and anti-establishment views. The APA has set a target date of 2020 for the total eradication of this particularly virulent illness.

You can find a much fuller summary of the recommendations for DSM-6 here. When published, DSM-6 is expected to cost in the region of $45,000 a copy.

First published 21/02/2013 at http://grahamdavey.blogspot.co.uk

Another short piece written as a Focus Point for the second edition of my Psychopathology textbook (due to be published late 2013).


DSM regularly undergoes an intensive revision process to take account of new research on mental health problems and to refine the diagnostic categories from earlier versions of the system. One would assume that this would be a deliberate and objective process that could only further our understanding of psychopathology, and that is certainly the intention of the majority of those involved. However, at least some people argue that the process of developing a classification system such as DSM can never be entirely objective, free from bias, or free from corporate or political interests. Allen Frances and Thomas Widiger were two individuals who were prominent in the development of the fourth edition of the DSM, and they have written a fascinating account of the lessons they believe should be learned from previous attempts to revised and develop mental health classification systems (Frances & Widiger, 2012). They make the following points:

1.         Just as the number of mental health clinicians grows, so too will the number of life conditions that work their way into becoming disorders. This is because the proliferation of diagnostic categories tends to follow practice rather than guide it.

2.         Because we know very little about the true causes of mental health problems, it is easier and simpler to proliferate multiple categories of disorder based on relatively small differences in descriptions of symptoms.

3.         Most experts involved in developing DSM are primarily worried about false negatives (i.e. the missed diagnosis or patient who doesn’t fit neatly into the existing categorizations), and this leads to either more inclusive diagnostic criteria or even more diagnostic categories. Unfortunately, experts are relatively indifferent to false positives – patients who receive unnecessary diagnosis, treatment, and stigma – and so are less likely to be concerned about over-diagnosis.

4.         Political and economic factors have also shaped the ‘medical model’ view of psychopathology on which DSM is based, and also contributed to the establishment and proliferation of diagnostic categories. For example, the pharmaceutical industry benefits significantly from the sale of medications for mental health problems, and its profits will be dependent on both (1) conceptions of mental health based on a medical model that implies a medical solution, and (2) a diagnostic system that will err towards over-diagnosis rather than under-diagnosis (see Pilecki, Clegg & McKay, 2011).

First published 13/02/2013 at http://grahamdavey.blogspot.co.uk

As promised, it's my intention to post some new pieces written for the second edition of my Psychopathology textbook (due to be published late 2013). This post begins that process with a new section written to introduce and evaluate DSM-5 from the Chapter on Classification & Assessment in Clinical Psychology.

"Published in 2013, DSM-5 arguably represents the most comprehensive revision of the DSM so far, and it has involved many years of deliberation and field trials to determine what changes to mental health classification and diagnosis are essential and empirically justifiable (Main chapter headings for DSM-5 are provided in Table 1).

The main changes between DSM-5 and its predecessor (DSM-IV-TR) are listed in Table 2.

First, previous versions of DSM placed mental health problems on a number of different axes representing clinical disorders (Axis I), developmental and personality disorders (Axis II), or general medical conditions (Axes III). This multiaxial system has been scrapped – largely because there was not enough evidence to justify the differences between them. Instead, in DSM-5 clinicians will be encouraged to rate severity of symptoms along continuums developed for each disorder. Secondly, the importance of some disorder categories has been recognised either by allocating them to their own chapter or by recognising them as new individual diagnostic categories. For example, Obsessive-Compulsive Disorder (OCD) is recognized as a significant mental health problem by being allocated it’s own chapter in DSM-5, and new diagnostic categories within this chapter include Hoarding Disorder (see Chapter 6) and Excoriation Disorder (skin-picking disorder). Similarly, DSM-5 has a new chapter on Trauma & Stress-Related Disorders that now includes Post-Traumatic Stress Disorder (PTSD). DSM-5 focuses more on the behavioural symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of the previous three. Thirdly, major changes have been made to the criteria for diagnosing Autism Spectrum Disorder (ASD), Personality Disorders, Specific Learning Disorders, and Substance Use Disorders. Autistic Spectrum Disorder has become a diagnostic label that will incorporate many previous separate labels (e.g. Asperger’s disorder, childhood disintegrative disorder, pervasive developmental disorder) in an attempt to provide more consistent and accurate diagnosis for children with autism (see Chapter 16). DSM-5 will retain the categorical model for Personality Disorders outlined in DSM-IV-TR, but rating scales are provided to assess how well an individual’s symptoms fit within these different types (Chapter 12). The new Specific Learning Disorder category is broadened to represent distinct disorders which interfere with the acquisition and use of one or more of a number of academic skills, including oral language, reading, written language or mathematics (Chapter 15), and the new Substance Use Disorder category will combine the previous DSM-IV-TR categories of substance abuse and substance dependence into one overarching disorder. Some other important changes include (1) the elevation of Binge Eating Disorder from an appendix to a recognized diagnostic category, (2) Disruptive Mood Regulation Disorder as a new category for diagnosing children who exhibit persistent irritability and behavioural outbursts, and (3) the removal of the “bereavement exclusion” from the diagnosis of Major Depression; this means that depressive symptoms lasting less than two months following the death of a loved one can be included amongst the criteria for diagnosing Major Depression, and reflects the recognition that bereavement is a severe psychological stressor that can precipitate major depression.

Criticisms of Changes in DSM-5:  While these most recent changes to the DSM have been extensively discussed and researched, many of the revisions have been received critically, and it is worth discussing some of these criticisms because they provide an insight into the difficulties of developing a mental disorders classification system that is fair and objective.

First, many of the diagnostic changes will reduce the number of criteria necessary to establish a diagnosis. This is the case with Attenuated Psychosis Syndrome, Major Depression, and Generalized Anxiety Disorder, and this runs the risk of increasing the number of people that are likely to be diagnosed with common mental health problems such as anxiety and depression. It is a debatable point whether increases in the number of diagnosed cases is a good or a bad thing, but it is likely to have the effects of “medicalizing” many everyday emotional experiences (such as ‘grief’ following a bereavement, or worry following a stress life event), and creating “false-positive” epidemics (Frances, 2010).

Secondly, DSM-5 has introduced disorder categories that are designed to identify populations that are at risk for future mental health problems, and these include Mild Neurocognitive Disorder (which would diagnose cognitive decline in the elderly) and Attenuated Psychosis Syndrome (seen as a potential precursor to psychotic episodes). Once again, these initiatives run the risk of medicalizing states that are not yet full-blown disorders, and could facilitate the diagnosis of normal developmental processes as psychological disorders.

Thirdly, there are concerns that changes in diagnostic criteria will result in lowered rates of diagnosis for some particularly vulnerable populations. For example, applying the DSM-5 criteria for Autism Spectrum Disorder to samples of children with DSM-IV-TR diagnoses that would no longer be available in DSM-5 suggested that 9% of this latter group would lose their autism diagnosis with the introduction of the new DSM-5 criteria (Huerta, Bishop, Duncan, Hus & Lord, 2012). Similar concerns have been voiced about changes to Specific Learning Disorder diagnostic criteria in DSM-5, and the possibility that deletion of the term dyslexia as a diagnostic label will disadvantage individual with specific phonologically-based, developmental reading disabilities (http://www.disabilityrightsohio.org/news/dsm5-dyslexia-june-2012).

Finally, two enduring criticisms of DSM generally that have continued to be fired specifically at DSM-5 have been that (1) DSM-5 has continued the process of attempting to align it’s diagnostic criteria with developments and knowledge from neuroscience (Regier, Narrow, Kuhl & Kupfer, 2011), when there is in fact very little new evidence from neuroscience that helps define specific mental health problems, and (2) most mental health problems (and psychological distress generally) are now viewed as dimensional, so any criteria defining a diagnostic cut-off point will be entirely arbitrary. DSM-5 has attempted to recognise the importance of the dimensionality of symptoms by introducing dimensional severity rating scales for individual disorders. But as we have seen from the discussion above, each iteration change in DSM diagnostic criteria changes the number and range of people who will receive a diagnosis, and this makes it increasingly hard to accept diagnostic categories as valid constructs (e.g. Kendler, Kupfer, Narrow, Phillips & Fawcett, 2009).

Despite its conceptual difficulties and its many critics, DSM is still the most widely adopted classification and diagnostic system for mental health problems. Such a system is needed for a number of reasons, including determining the allocation of resources and support for mental health problems, for circumstances that require a legal definition of mental health problems, and to provide a common language that allows the world to share and compare data on mental health problems. Having said this, there are still many significant problems associated with DSM, and diagnosing and labelling people with specific psychological disorders raises other issues to do with stigma and discrimination. Indeed, we should be clear that diagnostic systems are not a necessary requirement for helping people with mental health problems to recover, and many clinical psychologists prefer not to use diagnostic systems such as DSM-5, but instead prefer to treat each client as someone with a unique mental health problem that can best be described and treated using other means such as case formulation (see Section 2.3 for a fuller description and examples of case formulation)."

First published 02/11/2012 at http://www.psychologytoday.com/blog/why-we-worry

I’ve agonized for some time about how best to write this post. I want to try and be objective and sober about our achievements in developing successful interventions for mental health problems, yet at the same time I don’t want to diminish hope for recovery in those people who rely on mental health services to help them overcome their distress.

The place to start is a meta-analysis of cognitive therapy for worry in generalized anxiety disorder (GAD) just published by my colleagues and myself. For those of you that are unfamiliar with GAD, it is one of the most common mental health problems, is characterized by anxiety symptoms and by pathological uncontrollable worrying, and it has a lifetime prevalence rate of between 5-8% in the general adult population. That means that in a UK population of around 62 million, between 3 and 5 million people will experience diagnosable symptoms of GAD in their lifetime. In a US population of 311 million these figures increase to between 15 to 25 million sufferers within their lifetime. Our meta-analysis found that cognitive therapy was indeed significantly more effective at treating pathological worrying in GAD than non-therapy controls, and we also found evidence that cognitive therapy was superior to other treatments that were not cognitive therapy based.

So, all well and good! This evidence suggests that we’ve developed therapeutic interventions that are significantly better than doing nothing and that are marginally better than some other treatments. Our results also suggest that the magnitude of these effects are slightly larger than had been previously found, possibly indicating that newer forms of cognitive therapy were increasingly more effective.

But what can the service user with mental health problems make of these conclusions? On the face it they seem warmly reassuring – we do have treatments that are more effective than doing nothing, and the efficacy of these treatments is increasing over time. But arguably, what the service user wants to know is not “Is treatment X better than treatment Y?”, but “Will I be cured?” The answer to that is not so reassuring. Our study was one of the first to look at recovery data as well as relative efficacy of treatments. Across all of the studies for which we had data on levels of pathological worrying, the primary recovery data revealed that only 57% of sufferers were classed as recovered at 12 months following cognitive therapy – and, remember, cognitive therapy was found to be more effective than other forms of treatment. To put it another way, 43% of people who underwent cognitive therapy for pathological worrying in GAD were still not classed as recovered one year later. Presumably, they were still experiencing distressing symptoms of GAD that were adversely affecting their quality of life. I think these findings raise two important but relatively unrelated issues.

First, is a recovery rate of 57% enough to justify 50 years of developing psychotherapeutic treatments for mental health disorders such as GAD? To be sure, GAD is a very stubborn disorder. Long-term studies of GAD indicate that around 60% of people diagnosed with GAD were still exhibiting significant symptoms of the disorder 12 years later (regardless or not of whether they’d had treatments for these symptoms during this period). Let’s apply this to the prevalence figures I quoted earlier in this piece. This means that the number of people in the UK and the USA suffering long-term symptoms of GAD during their lifetime might be as high as 3 million and 15 million respectively. In 50-years of developing evidence-based talking therapies, have we been too obsessed with relative efficacy and not enough with recovery? Has too much time been spent just ‘tweaking’ existing interventions to make them competitive with other existing interventions? Perhaps as our starting point we should be taking a more universal view of what is required for recovery from disabling mental health problems? That overview will not just include psychological factors it will inevitably include social, environmental and economic factors as well.

Second, what do we tell the service user? Mental health problems such as GAD are distressing and disabling. Hope of recovery is the belief that most service users will take into treatment, but on the basis of the figures presented in this piece, it can only be a 57% hope!  This level of hope is not just reserved for cognitive therapy for GAD or psychotherapies in general, it is a figure that pretty much covers pharmaceutical treatments for GAD as well, with the best remission/recovery rates for drug treatments being around 60% (fluoxetine) and some as low as 26%.

I have spent this post discussing recovery from GAD in detail, but I suspect similar recovery levels and similar arguments are relevant to other forms of intervention (such as exposure therapies) and other common mental health problems (such as depression and anxiety disorders generally). It may be time to start looking at the bigger picture required for recovery from mental health problems so that hope can also be extended to the 40-45% of service users for whom we have yet to openly admit that we cannot provide a ‘cure’.