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Over 50% of the world population will develop a psychiatric disorder in their lifetime.1 In the realm of psychiatric treatment, two primary modalities have been established: pharmacotherapy and psychotherapy. Yet, pharmacological interventions often take precedence as the initial treatment choice despite their comparable outcomes, severe side effects and disputed evidence of their efficacy. This preference for medication foregrounds a vital re-examination of what it means to be invasive in medical treatments, namely in psychiatric care. De Marco et al challenge the standard account of invasiveness, presenting considerations that transcend the traditional criteria of physical intrusion.2 Through case studies centred on treatments for schizophrenia and depression, we aim to (1) reinforce De Marco et al’s challenge to the standard account of invasiveness and (2) extend the dialogue to the moral imperative of redefining mental invasiveness. Our aims are to broaden the definition of mental invasiveness, aligning with De Marco et al’s emphasis on context sensitivity, and to include the severity of side effects as a critical factor in this assessment.
Redefining what is considered invasive in psychiatric treatment has profound implications for patient care and medical decision-making. Labelling treatments, namely medications, as invasive encourages both patients and healthcare providers to approach these options with a heightened level of scrutiny and care. This is pertinent given that some medications carry severe side effects, such as increased risk of suicidality. In addition, there exists clear financial incentives behind the prescription of medication that influence the choice of pharmacological interventions.
A more nuanced definition of invasiveness, one that incorporates the severity of side effects and the contextual comparison of equally effective treatment, would better equip patients to understand the full spectrum of potential impacts of their treatment. For healthcare providers, this redefinition could prompt a more cautious approach in prescribing medications as first-line treatments, potentially leading to more individualised care and consideration of alternative therapies. Further, such a shift could drive the pharmaceutical industry to prioritise the reduction of serious side effects in drug development. To these ends, a reconsideration of mental invasiveness aims to enhance treatment outcomes and patient well-being by fostering a more comprehensive and patient-centric model of care in psychiatry, especially when considering the treatments provided for schizophrenia and depression.
Case study: schizophrenia, antipsychotics
Schizophrenia is a severe mental health disorder characterised by a range of psychological abnormalities, divided into positive (eg, hallucinations and delusions), negative (eg, emotional blunting and social withdrawal) and cognitive (eg, impaired memory and attention) symptoms.3 The exact cause of schizophrenia is not fully understood, but it is believed to result from a combination of genetic and environmental factors.3
Antipsychotic medications, often administered orally, are the primary treatment modality for schizophrenia, primarily aimed at managing positive symptoms. The medication works by modulating dopamine in the brain, a key neurotransmitter implicated in the pathophysiology of schizophrenia. Yet, the use of antipsychotics often yields severe side effects. Perhaps the most significant side effect is tardive dyskinesia, which often arises from use of antipsychotics. This condition, characterised by involuntary and repetitive body movements, is both distressing and socially stigmatising, contributing to a decline in mental and emotional well-being. Antipsychotics may also lead to weight gain, diabetes and increased risk of heart disease, further complicating the treatment landscape. Patients with schizophrenia frequently exhibit avoidance and estrangement behaviours, separating themselves from people, places or situations as a result of their side effects, resulting in further isolation from supportive environments. This detachment, coupled with feelings of guilt, shame or self-blame, further exacerbates the psychological burden of the disorder. As it stands, antipsychotics are considered non-invasive.
Case study: depression, SSRIs
Depression, formally known as major depressive disorder (MDD), is a pervasive mood disorder characterised by perpetual feelings of sadness, despair and loss of interest in routine activities.3 This disorder impacts the ability to perform day-to-day activities. MDD often manifests as episodic occurrences of longstanding feelings of sadness and hopelessness, poor concentration, disrupted sleep, low energy and thoughts of suicide.3
Antidepressants are the primary intervention for MDD. Selective serotonin reuptake inhibitors (SSRIs), the most commonly prescribed antidepressants, ease symptoms through blocking the reabsorption of serotonin in neurons, thereby increasing serotonin levels in the brain. Though these pill-based treatments are observed to improve symptoms, they are also characterised by side effects including drowsiness, insomnia, restlessness, appetite changes and low libido. Intensifying the related concerns, severe side effects may also arise, including movement issues, hallucinations and increased suicidality, especially in patients under the age of 25 years. Despite these severe side effects, SSRIs are deemed non-invasive.
Psychotherapy and the path forward
While pharmacotherapy remains the primary treatment modality for psychiatric disorders, there has been growing recognition of therapy-based alternatives. For instance, cognitive–behavioural therapy (CBT) demonstrates comparable, and at times superior, efficacy in treating mental health disorders, but without the severe side effects associated with pharmacological interventions. In schizophrenia, CBT is equally as effective as antipsychotics in the treatment of symptoms, but with significantly reduced side effects.4 In MDD, psychotherapies yield comparable outcomes as pharmacotherapies (eg, SSRIs), again with reduced side effects.5
These comparisons challenge the longstanding preference for pharmacotherapy as the first line of treatment, and the viability of these alternatives underscores the importance of De Marco et al’s consideration of context sensitivity. In doing so, it forces healthcare providers to morally reconsider the decision to prescribe medication when an equally effective yet less harmful intervention may exist. These case studies raise questions as to the true non-invasive nature of pharmacological interventions and the moral implications of accepting the rationale behind the preference.
In sum, comparable therapy-based treatments for neuropsychiatric disorders challenge both the standard use of pharmacotherapies in psychiatric care and the standard account of invasiveness. Moving forward, meaningful change lies in further moral dialogue centred on a more comprehensive definition of mental invasiveness—one that acknowledges context sensitivity, non-physical invasiveness and the well-being of the patient.
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Footnotes
Contributors CWM and JVG were directly involved in the creation of the article and each provided substantial contributions. CWM, as the lead author, was primarily responsible for conceptualising the main thesis, conducting the initial literature review and drafting the manuscript. JVG assisted in the editing of the article and expanding initial ideas, ensuring clarity and coherence in the ideas presented. Both authors agree to be accountable for all aspects of the work submitted.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
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