‘A healthy mind in a healthy society’ by Dinyar Godrej

rsz_imagesHere’s a wonderful blog on the mental health scene from the New Internationalist magazine.

Sitting in the waiting room of a busy psychologists’ practice in Rotterdam, I’m intrigued by the furtive nature of the experience. People waiting for their 50 minutes of focused talk avoid each other’s eyes, acknowledging each other with embarrassment, if at all. I could be in the waiting room of a sexually transmitted diseases clinic.

I’m a bit puzzled. With the increased familiarity of stress-related problems nowadays, shouldn’t this kind of guilt (no other word quite captures it) be a thing of the past?

Depression is so common that at times it has felt as if I had more friends who were battling it than weren’t. Various compulsive behaviours are constantly pored over by the media, often in an attempt to demystify them.

With the advent of the internet there has been an explosion of mental health issues advocacy. Sound, down-to-earth information is now easily available, perhaps excessively so. Surely we are better equipped than ever to view mental distress and illness as part of a continuum of our life experience, rather than as a site of stigma and taboo?

The lived experience is, however, quite different. People with mental health problems still run up against a wall of unhelpful attitudes, ranging from ‘normalization’, which basically denies the problem, to an overly diagnostic attitude which sets the sufferer as a creature apart.

Disbelief is in there, too, aided no doubt by a US-led tendency to classify an increasing range of common human behaviours and emotions – such as shyness or grief – as pathological disorders. The last things you want when confronting mental illness in yourself is to either let others define you by it or for them to deny it outright. Little wonder that people often feel that they find true understanding only among a community of peers.

The lack of empathy for mental illness can, of course, come from a fear of it; we have all had ‘dark tunnel’ experiences where we feel our grip on our lives is slipping. But there can be a more fundamental lack – the inability to come to terms with the infinite flexibility of the human mind and what it can experience.

These words by Victorian poet Gerard Manley Hopkins haunt me with their truth: ‘O the mind, mind has mountains; cliffs of fall Frightful, sheer, no-man-fathomed.’

Bad chemistry
Were the vistas of the mind easier to map, our imaginations a little less creative, would we be better at fixing things that go wrong? All the evidence of mental health ‘treatment’ suggests, however, that this is perhaps the most misguided question one could ask.

For it is often when we take fixed hypotheses as the point of departure that mental healthcare goes seriously wrong. Take the increasing belief that mental problems are due to chemical imbalances in the brain.

A friend undergoing a major depressive episode was told by his general practitioner, after some cursory questions, that the cause was probably said chemical imbalance. An antidepressant drug was duly prescribed and day-to-day life became somewhat more bearable, but possible psychosocial triggers were left unexamined. A trajectory that will be familiar to many was set in motion.

Ten years along the line, the drug dependency is complete, while the effectiveness has diminished. As a result, a psychologist’s help has become an important support to this so-called ‘chemical’ problem.

The drug has not prevented further depressive episodes (many people experience problems of increased gravity some years into medication), and no-one has any idea what the lifetime effects of the drug will be, because it is still too recent a discovery. Yet the doctor is convinced that it must be taken life long – as is my friend. Current estimates are that 1 in 10 US and Belgian adults are on antidepressants

There is no doubt that medication does help many people who don’t have recourse to the other kinds of support needed to tackle depression. But drugs are as much a symptom of mental healthcare today as they are a proposed cure. And the question of whether there are better options (which, incidentally, may also include some degree of medication) tends to get silenced when the convenient pill is to hand.

Expanding the market
There is a growing stream of medications aimed at mental health ‘conditions’, and they are being marketed aggressively by Big Pharma. And why not, when the mental health system, even in wealthy countries, is in such a shambles that pills are seen as quick fixes and getting the right kind of help either involves running from pillar to post or a miracle.

Insurers increasingly refuse to pay for talk therapies. In the US, psychiatrists (who are seeing an influx of victims of the Wall Street meltdown) are dispensing with dealing with patients’ inner lives and going for short consultations geared towards ‘management’ with medication.

Yet for decades, this increasing medicalization has been resisted by a vocal psychiatric survivors’ movement, who decry unfeeling ‘care’ by professionals, the chemical cosh of ill-considered medication, and the assumption that their lives must be reduced to and arranged around a series of problems or ‘symptoms’. They are in search of more caring therapies, appropriate medication (when it is needed) and more meaningful ways of interpreting their experiences.

But the tide in the other direction is advancing at an astonishing pace. One area is in the irresponsible peddling of powerful antipsychotic drugs, now widely prescribed for children (often to control their ‘unruliness’), adults with bipolar diagnoses and elderly people with dementia.

These drugs were never designed for such ‘conditions’ and many of the studies advancing them are first conceived in marketing departments, with the outcomes preplanned. Data is then gathered and interpreted selectively, written up by ghost-writers and signed off by prominent physicians.[1]

Unethical promotion is rife: in the US, Pfizer paid more than 250 child psychiatrists to promote its antipsychotic, Geodon, at a time when it was only approved for adults. Serious side-effects can be talked down or just lied about, with sales reps trained to rebut such concerns. Eli Lilly created a video called the ‘The Myth of Diabetes’ to promote Zyprexa, which has been shown to cause… diabetes (and other metabolic problems).[1]

The long-term use of antipsychotics (studied among people with schizophrenia for whom the drugs were originally designed) was recently shown to shrink brain volume.

Previously, this shrinkage was assumed to be associated with the disorder itself and was correlated with worsening symptoms and impaired functioning. Now that it looks like the medication causes such shrinkage, it is no longer being paired with the negative effects.[2] At the very least, a vigorous risk-benefit debate of such medication is needed.

A universe of disorders
The online publication of the draft of the fifth edition of the US psychiatrist’s bible Diagnostic and Statistical Manual of Mental Disorders (DSM-5, due to appear in print in May 2013) has caused uproar with its proposed huge expansion of what is considered mental illness – to include teenage rebelliousness. With a widened range of human behaviours pathologized, the door is open to further overprescription of psychiatric drugs.

Opposition, even from within the mental health services community, is fierce, with groups as far afield as the Society of Indian Psychologists calling for radical changes. DSM-5 will further the tendency of reducing the mind, as one writer put it, ‘to a batter of chemicals we carry around in the mixing bowl of our skulls’.[3] Its global influence will be enormous.

US research tends to dominate the mental health field through its sheer volume and published output. An unfortunate result has been a universalizing view of mental distress and illness which is actually an American view.

Common sense suggests this must be nonsense; different cultures can have different ways of expressing and enacting emotion and mental illness. More dangerously, Western treatment models become accepted as ‘standard’ even when they may not be as effective, or are underresourced.

Over 30 years, beginning in the early 1970s, the World Health Organization (WHO) carried out three large international studies which delivered a startling finding: people with schizophrenia in the Majority World had better long-term prospects than in the US and Europe, with much lower relapse rates.

So did all the specialist care available in the rich world make no helpful difference? One possible explanation offered was that even unscientific beliefs about the cause of illness, such as spirit possession, had the benefit of keeping the affected individual within their social group and allowed a contained view of their problem that was distinct from their identity.[3]

We are back at stigma. One cannot suggest that mentally ill people are always better treated in the Majority World; instances of cruelty abound. But research suggests that biological explanations of mental illness that have gained currency in the West actually strengthen stigma rather than reducing it – the popular perception is of the person with the problem belonging to ‘a breed apart’.[3]

Another big society
It has long been recognized that the roots of mental illness lie in three areas: biological factors (including genetic predispositions), life events of the individual concerned, and the social sphere. The first two have hogged the attention, whereas the third is possibly the most important.

Even mental health problems at the more extreme end of the scale, such as schizophrenia, can be triggered by experiences of social deprivation and exclusion. The social matrix becomes crucial when one considers that anxiety is the underlying thread of most mental illness. A British lecturer in mental health nursing went as far as to say, ‘Good mental health is rooted in social cohesion, not the individual.’[4]

Both the promotion of mental health and the recovery from mental illness need to happen at a social level. Many mental health workers will tell you that being able to work and reconnect with society can be of greater benefit for an individual than other, more specialized, interventions.

In the West we are caught in the bind of fragmented, unequal societies that often lack any resemblance to community, and where individualism and the desire for privacy has led to alienation and loneliness. The material security we count on is getting increasingly wobbly for many as the financial crisis keeps racheting up.

When in trouble, there is often no social safety net. In addition, there is the onslaught of consumer culture, the constant corrosive influence of advertising, and a hitherto unforeseen state of perpetual distractedness brought about by the multiplicity of digital media channels. Having forgotten how to live in the moment, it would appear we are being forced to live in the instant.

A survey of depression published last year showed that rates are higher in wealthy countries (with France and US heading the list) than in poorer ones, with the poorest respondents in the wealthy countries being doubly at risk.[5] This led to much speculation about income inequality within rich countries actually being a cause of depression. (The gender imbalance where depression is concerned was global – women are twice as likely to be affected as men.)

Social erosion is also increasing in the Majority World, where modern psychiatric provision is usually sorely lacking. I was surprised to read that, in India, the break-up of extended families as a result of urbanization and industrialization is being blamed for higher rates of psychiatric problems in nuclear families.[6] Having grown up in an Indian nuclear family, I had always taken a dimmer view of extended families as repositories of coiling intrigues.

There is no doubt that people with mental health problems benefit from being in the community. The question is: does the community exist?

Here is one view from the US: ‘[In the 1970s] large numbers of patients were discharged from psychiatric hospitals only to find themselves adrift in uncaring communities: isolated, lonely, and lacking meaningful relationships. Limited financial resources restricted their social activity.

The media’s frequent portrayals of persons with mental illnesses as dangerous validated community rejection… Community and mental health professional stereotyping altered the quality and spontaneity of interpersonal relationships as negative attitudes were internalized.’

How, then, to create a real community? Obviously we need to go deeper than the greet-your-neighbour ‘wellbeing initiatives’ beloved of government departments. Radical equality-based restructuring of our societies would fit the bill, and now seems as good a time as any, but the world still holds its breath on that one.

In 2010, the WHO published a checklist of specific ways to promote mental health – and they are all social approaches. They include: supporting children through skills-building programmes and child-friendly schools, improving women’s access to education and credit, befriending initiatives for the elderly, stress prevention at work, improving housing, and community responses to prevent violence.[7]

The goal of developing a healthy society has been termed ‘recovery on a collective scale’. This view recognizes that such a collective journey requires not just building social supports but fighting discrimination and being politically active.[8]

This, in short, is about being human – and humane – again. It’s a dimension that needs to become much more visible in the way we work for better mental health.

[1] Duff Wilson, ‘Side Effects May Include Lawsuits’, The New York Times, 2 October 2010.
[2] Robert Whitaker, ‘Andreasen drops a bombshell: Antipsychotics shrink the brain’, Psychology Today, 8 February 2011.
[3] Ethan Watters, ‘The Americanization of Mental Illness’, The New York Times, 10 January 2010.
[4] Andy Young on NursingTimes.net, 18 January 2010: nin.tl/Hk8IPD
[5] Stephanie Pappas, ‘US and France more depressed than poor countries’, LiveScience, 25 July 2011: nin.tl/GXTnrF
[6] WHO Regional Office for South-East Asia, Conquering Depression, 2011
[7] WHO, ‘Mental health: strengthening our response’, September 2010: nin.tl/H1b9r1
[8] Weisser et al, A Critical Exploration of Social Inequities in the Mental Health Recovery Literature, CGSM, Vancouver, 2011.