Mental illness can be a terrible affliction. It can drive those suffering from it to despair – even to suicide. I can also drive those affected by it, as loved ones of the afflicted person or as carers for yo, to despair – even to suicide. Because it can be such a terrible disease, it is important that it does not get trivialised by over-egging the problem. Because it can be such as terrible affliction, it is important that the treatment offered be the best one available, and that that such treatment be available regardless of ability to pay. The notion that a quick, cheap and easy fix is available is, well, madness.
Mental illness can be hidden or faked
Many varieties of mental illness, especially depression and manic-depressive illness are not easily diagnosed, even by professionals. This means that it is often possible for those truly ill to hide their condition, if it is advantageous to do so for professional, reputational or other reasons, such as being engaged in an adoption process. It is also possible for persons who are not mentally ill to fake it. There is enough information readily available on the web for anyone with an IQ in triple digits to put together an appropriate package of symptoms that will suitably impress a GP, psychiatrist, psychiatric social worker, psychologist, analyst or other therapist. Lower back pain is the only other medical condition that can be faked as easily.
Many people tell lies easily and effortlessly
Much of economics is based on the assumption, verified daily and universally, that almost everybody responds predictably to simple selfish material incentives. It also is clear that many (most?) people view honesty as a tactical option rather than something intrinsically valuable. They lie if it is to their advantage to do so. If you don’t lie it’s not because lying is wrong or sinful, but because the cost-benefit analysis of lying shows the costs (fear of detection and punishment, damage to reputation) to be higher than the benefits. The fact that so many people take a purely instrumental view of truth telling is consistent with the observation that lying and cheating are a regular and recurrent phenomenon both when it comes to reporting taxable income and when it comes to claiming benefits. This unfortunate moral state of affairs – people tell the truth only if it is in their interest to do so – is a standard assumption in most economic analyses in which truth telling plays a role.
Mental illness as a (self-) reported cause of disability
In May 2007 there were around 2.64million recipients of Incapacity Benefit or Severe Disablement Allowance (as against 2.66 million in August 1999). In addition there were around 335 thousand recipients of the Disability Living Allowance in May 2007 (figures are not available for 1999).
Thanks to the Department for Work and Pensions’ wonderful Accessible Tabulation Tool (every government department in every country should have one!) I was able to verify that in February 2005, of the 2,387 thousand IB claimants, 925.7 thousand, just under 39 percent, claimed because of Mental and Behavioural Disorders; of the 1,444.8 thousand IB beneficiaries, 460.9 thousand (around 32 percent), qualified because of Mental and Behavioural Disorders; of the 295 thousand Severe Disablement Allowance claimants, 117.6 thousand (almost 40 percent) claimed because of Mental and Behavioural Disorders.
About 504 thousand people below the age of 35 were claiming incapacity benefit or severe disablement allowance compared with 443 thousand claiming Job Seeker’s allowance in May of 2007. More than sixty percent of the claimants of IB under the age of 35 and more than fifty percent of the beneficiaries of IB, claimed IB for “Mental and Behavioural Disorders”, including depression and stress.
If you are Richard Layard and see these figures, you conclude that mental illness is rampant anno 2007 in neo-Liberal Britain, and that it is a major cause of incapacity and disability for all age groups and both genders, but especially for the young.
When I see these figures, my first reaction is: I just don’t believe it! Could these figures have anything to do with the fact that the typical weekly incapacity benefit is £81, while the corresponding jobseekers allowance is £20 less, and carries with it the obligation to actively seek a job? The Dutch experience, where the (high and rising) numbers of disabled working-age persons were suspiciously correlated over time with the generosity of the disability allowance and the severity of the effective eligibility criteria, makes me highly suspicious. This was reinforced by the markedly lower incidence of (reported) lower back pain, chronic fatigue syndrome and assorted mental illnesses in Belgium and other countries with demographic characteristics similar to the Netherlands.
Serious statistical study of the relationship between IB claims based on mental and behavioural disorders and possible non-medical drivers of such claims (such as the relative magnitudes of unemployment benefit/jobseekers allowance and IB, the degree of severity of the formal IB eligibility criteria and the effectiveness of their enforcement etc.) would be most helpful for achieving clarity on this matter. Even the best statistical study, however, will leave much room for debate, because of the complexity of the relationship between the number of IB claims/beneficiaries and the pecuniary incentives for lodging such claims. For instance, the political mechanism may well deliver higher IB benefits when the number of IB claimants increases. Sometimes the timing of policy reforms permits the identification conundrum to be overcome, but that is by no means always the case.
A more conclusive test of the proposition that some non-trivial share of the IB claims based on mental health problems represents bogus claims, would be provided by a comprehensive re-testing of the claimant population by qualified psychiatric experts. We may get some of that, but not, I fear, what we need. The government are proposing tougher disability tests for all IB claimants (not just those claiming on grounds of mental and behavioural disorders) to start in October 2008. The Tories are also proposing a comprehensive re-testing of all 2.64million UK incapacity benefit claimants. Those judged to be fit for work after an independent medical evaluation would lose their entitlement to incapacity benefit immediately and would be put on the £ 20 per week lower jobseekers allowance and its requirement to seek work.
I think neither the government nor the opposition know how complicated, costly and ultimately inconclusive would be a the creation of a high-quality process to verify a person’s inability to work because of mental health problems (or indeed lower back pain). It can only be done by experts with an appropriate medical degree. It may take multiple assessments over an extended period of time. And it will have to be repeated periodically.
I believe the Tories propose that the initial assessment would be done by non-MDs, who would refer to qualified MDs, those claimants they felt unable to assess. That would no doubt work with claimants whose claim is based on the absence of a limb. It will not work when it comes to any claim based on mental or behavioural disorders or indeed on medical claims based on anything other than the absence of some readily visible organ essential for employability. The cost of a serious ‘Personal Capability Assessment’ for 2.64 million IB claimants would be massive. The Conservative proposal would drown in Type 1 and Type 2 errors.
A similar denial of the obvious characterises Richard’s Layard’s proposal (which is, unfortunately, about to be funded and implemented by the government) for the training of an army of 10,000 cognitive behavioural therapists to stem and reverse the tide of anxiety and depression that he believes is threatening the fabric of society. As stated earlier, I don’t believe the figures on the incidence of mental illness in the UK that Richard Layard brandishes about. They are either self-reported by ‘patients’ many of whom have a pecuniary interest in the diagnosis, or reported by providers of mental health services who have an obvious conflict of interest in the matter.
The picture of 10,000 hastily trained cognitive-behavioural therapists let loose on the British public is a frightening one – like 10.000 semi-skilled plumbers taking charge of brain surgery in the UK. It’s a politically popular gimmick because (a) it is a lot cheaper than letting the mentally ill be treated by properly qualified professionals, and (b) it involves large numbers and motion – the illusion of decisive action. It is, at best, ineffective motion rather than action. At worst, it is inappropriate psychobabble that can do untold damage if these half-trained cbt operatives are left alone at any time with patients suffering from serious anxiety or depression.
Mental illness is a terrible thing. Effective treatments, that is, treatments that achieve a sustained improvement in the self-reported well-being of the patient (not just in any particular symptom) and in yo’s objectively verified ability to function effectively in the job market and other dimensions of yo’s life, are few and far between, except for some varieties of depression and manic-depressive illness. I have seen no convincing evidence that the true incidence of mental illness has increased significantly in the UK in the past forty years. Overstating its incidence, whether by fraudulent IB claimants, by self-interested sellers of mental health care services, or by deluded professors of economics, does not help the mentally ill.
P.S. For those who have noticed, I am indeed trying out ‘yo’ as a replacement for he/she/it, him, her, and ‘yo’s’ for his/her/its. It’s the only hope for George W. Bush to leave a positive legacy in any area of life.