Are the treatments costly?
This is not because the treatments are costly. A standard course of cognitive behavioural therapy involves up to 16 one-hour sessions, one-on-one - with the average number of sessions nearer to ten. The total cost is about £1,000 (or $2,000). With a 50% success rate for a serious condition, this is good value for money. And that is why it is recommended for almost all mental health conditions in the official guidelines for the British National Health Service.
But actually the economics is even better than that. There are some striking lessons here for those who finance the healthcare system. It turns out that mental health has a huge effect on physical health, and thus on healthcare costs. The effects on life expectancy are extraordinary: depression reduces your length of life as much as smoking does (and not mainly through suicide). And while you're alive, depression and anxiety conditions increase your visits to the family doctor and to specialists. Conversely, controlled trials show that, if you get psychological therapy, you go to the doctor for physical ailments much less often than those who remain untreated. The resulting savings are large enough to fully cover the cost of the psychological therapy. For the healthcare authorities, this is a win-win situation: pay for more psychological therapy and it will cost you nothing because of the savings on physical healthcare. The finances of healthcare actually improve through spending more on therapy.
So too do the finances of the welfare system, because many people with mental illness cannot work. When psychological therapy becomes more widely available, some of those who use it will be people who are on welfare or in danger of losing their job. As a result of the therapy, more of them will be at work and fewer on benefits. Robust calculations show that the resulting savings on benefits and lost taxes will exceed the cost of the psychological therapy. So there is a double pay-off - the cost of the therapy is repaid twice over, both in savings on physical healthcare, and in savings on benefits and lost taxes.
Despite this, those who finance healthcare are generally resistant to providing the extra resources needed. That is the main reason why so few people are in treatment: it is the funders above all who are to blame.
The case for more help becomes even stronger when we shift from adults to children. Here again good treatments exist but they are not widely available in most countries. The scale of under-treatment is as bad for youngsters as it is for adults: only one in four young people with mental health problems is in treatment.
The myopia here is quite extraordinary, since half of all mental illness in adult life began in childhood. Moreover child mental illness is a cause of so many of our social problems. Mentally ill children are much more likely than others to avoid school, to take drugs, and to self-harm. And when they become adults (if they had 'conduct disorder' in youth) they are much more likely to be arrested for a crime, to become teenage parents, to get divorced and to live off benefits. This brings us to our second, wider theme - the impact of mental illness on society at large.
A better society?
In the darkest days of World War II, Winston Churchill commissioned Sir William Beveridge to review the future of social policy. In his famous report, which determined the subsequent pattern of Britain's welfare state, Beveridge identified five giants that were responsible for the ills of society. They were Want, Idleness, Ignorance, Squalor, and Disease, or in modern parlance: poverty, unemployment, under-education, poor housing, and physical illness. Since then we have made huge progress against all five of these giants, except at times unemployment. Yet our society is no happier now than it was then. We have more broken families, more disturbed children, and more crime. One major reason is that the human factor inside each of us has remained much the same. We have tackled the external problems but not the one inside, the sixth giant: the evil of mental illness.
That is where the welfare state has gone wrong. It has assumed that all the problems are external. Many of them of course are, but not all. Problems of depression, anxiety, and dysfunctional personality are as old as the human race. What is new is that in the last fifty years we have developed major ways of addressing these problems.
We have therapies which people want and which are not expensive. And they have good success rates as measured by rigorous clinical trials. But they are simply not available to most people. Our claim is that if they were, we could have a truly better society.
This is not the only thing that needs doing - we also recommend preventive policies and major social changes. But in the meantime there are millions suffering. We know how they could be helped, and what the results would be. Getting them the treatment they need is the top priority, and the policy where we can be most sure of making a real difference. That is the main claim we want to establish in this book.
To do so, we ask a series of questions, chapter by chapter. In Part One we look at how mental illness affects people's lives, and the lives of those around them. We also ask what causes it. Then in Part Two we turn to what can be done about it. Excellent treatments exist, and these now need to be provided on a massive scale. England's Improving Access to Psychological Therapies programme is one example of what can be done. And there is also a whole raft of changes which can reduce the chances of mental illness in the first place.
The time is ripe for a radical rethink. Mental illness blights so many lives and causes so many problems. But there is great good news: it can be tackled, and it will not cost us an arm and a leg. Dealing with it, as one journalist has put it, is 'a no-brainer'.