The pendulum may have swung too far in mental illness
December 3, 2014
It’s time to stop saying almost half of all Australians suffer from a mental illness at some time in their lives. Although this is the official view, it depends on floppy definitions and figures.
Drawing on figures from 2007, the Australian Bureau of Statistics tells us “almost half (45 per cent) of Australians aged 16 to 85 reported they would have met the criteria for a diagnosis of a mental disorder at some point in their life”.
This is quite different to glibly saying, as many mental health campaigners do, that half of us suffer a mental illness at some time.
On the numbers, Jon Jureidini, professor of psychiatry at the University of Adelaide, believes the touted 50 per cent results from the conflation of two populations.
He says 1 to 2 per cent of the population suffers from severe mental illness that requires psychiatric help.
Community surveys show that in a given year, 15 to 20 per cent suffer a level of distress that meets the criteria for a mental disorder. However, there is little evidence they need more psychiatric help than seeing their GP or a counsellor, or doing nothing.
“The problem is that people translate the 15 to 20 per cent in any given year as 15 to 20 per cent at any given time. But a lot of these episodes are self-limiting and resolve within the year, so the number of people suffering at any given time is significantly lower.
“The assumption is also made that the 15 to 20 per cent have the same sorts of needs and will benefit from the same sorts of interventions as the 1 to 2 per cent.”
Jureidini says the 50 per cent is absurd, and can easily slide to 100 per cent.
“If you want to define every episode of significant distress that someone experiences as an illness, then we all suffer from self-limiting mental illness at some time in our lives.
“Taking distress seriously doesn’t amount to giving it a medical label and giving medication for it,” he says.
The number of Australians who may be mentally ill has grown as the definitions of mental illness have expanded.
The ABS describes mental illness as “a number of diagnosable disorders that can significantly interfere with a person’s cognitive, emotional or social abilities”.
Naming or shaming?
The definitions of mental illness are global, but their floppiness is evidenced by the fact that in Britain, officially only 25 per cent of people suffer a mental illness in their lifetime.
Or is it that we have double the trouble?
But there is a positive side to broad definitions. They help destigmatise the illness and the suffering.
The fact that mental illness is so common makes it easier for people to volunteer that they have an issue and easier to seek help.
Some are greatly relieved to receive a diagnosis. “Thank goodness you’ve got a name for this, and a treatment,” is a sentiment that is often heard.
This helps people understand their condition and perhaps find some community support. But then, on receiving a diagnosis, some feel they have a label that will dog them for life.
For others, a label can be a useful excuse. Jureidini says when a boy is labelled with ADHD, the parents feel less blamed and the boy feels he has an explanation. “But then you hear him saying ‘Oh, I couldn’t control that. That was my ADHD’. ”
Labelling often brings a loss of autonomy. A key word in mental health, autonomy is about a person’s ability to be self-governing and make decisions that are informed, rational and in accordance with their values.
“The difference between good psychiatry and bad psychiatry is whether I increase or decrease my patients’ autonomy,” Jureidini says.
“Feeling worse but being more autonomous is a superior state to feeling better and being less autonomous.”
Jureidini also points to a paradox in the push to medicate more people.
“Take a man in his 50s who becomes depressed out of the blue. He’s invited to think of it as biological and adds antidepressants to the booze he is already drinking to excess, which everyone, including his doctor, is turning a blind eye to.
“The alternative is to reflect and think back regretfully about how he gave so much priority to work, and look at the effect on his relationship with his kids and say ‘I am really disappointed at how my life turned out’.
“It could be good for him to live with this distress for a few months and maybe begin to build meaningful relationships with his grandchildren rather than taking a few pills and getting on with being a dead-shit father.”
The paradox lies in the stigma. Jureidini says people take a dimmer view of mental illness caused by brain chemistry than by social and environmental factors.
The broadening definitions bring negatives, particularly for those with milder forms of mental illness.
Paul Biegler, winner of the Eureka prize for his book The Ethical Treatment of Depression: Autonomy through Psychotherapy, says many people are unnecessarily put on medication when they are going through variations of normal experience, such as loss in the form of grief, relationship breakdown or financial failure.
“We trivialise these experiences and treat them as a derangement in brain chemistry that can be normalised with a pill. Perhaps a better approach might be to look for the meaning in what has happened and address it more functionally,” he says.
When people are given anti-depressants for such conditions, they are encouraged to take a biological view of their illness, which can rob them of autonomy. Rather than working out a way to resolve or accept the circumstances, they take a pill.
Biegler, a physician and an adjunct research fellow at the Centre for Human Bioethics at Monash University, says people treated with psychological therapy, such as cognitive behavioural therapy, are less likely to accept a biological model of their illness.
Rather, they tend to see their condition as a response to stressors in their environment and are more motivated to target them. “They are more autonomous in getting through their current and their future episodes of depression,” he says.
A primitive science
Despite questions about their efficacy for mild to moderate depression, antidepressants are often the first line of treatment for these conditions.
And Australia is a very high user. Last year, an Organisation for Economic Co-operation and Development survey showed that out of 33 countries, Australia was the second-biggest user per head of antidepressants. Iceland was first.
The survey showed almost 9 per cent of Australians were prescribed some form of daily antidepressant. A decade earlier it was half that.
“I think 9 per cent is an excessive amount of prescribing,” scientia professor and head of the school of psychiatry at the University of NSW, Philip Mitchell, says.
“In any 12 months, some 5 per cent of Australians experience depression and some of it is mild and does not require medication.”
Much prescribing is done in the general practitioner setting, often under pressure from patients. Mitchell points to the structural difficulty of remuneration and time in general practice.
“The system is antithetical to coming to grips with the patients’ experience and distinguishing clinical depression from a difficulty adjusting to difficult circumstances.”
Mitchell, also a professorial fellow at the Black Dog Institute, is concerned about the 50 per cent.
“Any condition where you start to talk about that level of prevalence in the community starts to worry me.”
It has not been well communicated that the figures include mild, moderate and severe disease. Formal diagnostic criteria are used because a degree of impairment or dysfunction exists, but some of it is mild illness, which requires watching and waiting without active intervention.
So what does the 50 per cent mean? “It means that a trained interviewer in the community would say at some stage in their life, these people have had some symptoms that fulfil the diagnostic criteria.”
It does not mean that half of all Australians have needed to go through the mental health system.
Our definitions and criteria are largely drawn from The Diagnostic and Statistical Manual of Mental Disorders. Known as the DSM, it is American and serves as an almost universal authority for psychiatric diagnosis. With each new edition, new diagnostic categories emerge.
The benefit is that it allows people to know what they are talking about in different countries. In this regard, Mitchell says it has improved the reliability of diagnosis. But he says the big issue is about its validity – its ability to validate reality to the diagnosis.
“I see these things as evolutionary. Today, for most of the disorders we don’t have a biological test. We are dependent on pattern recognition in dealing with these complex and subtle disorders and this can be a problem.
“We look for signs and symptoms that cohere, that make a syndrome. This is where medicine was in the mid-19th century. It had syndromes but few biological tests.
“Psychiatry will evolve. I believe we will look back in 50 years and say this was very primitive. But we can only do the best we can with existing knowledge.”
Too much goodwill
At the moment, however, our prescription rate is rising fast. Last year a study in the Australian and New Zealand Journal of Psychiatry showed that in the decade to 2011, there was a 58 per cent rise in dispensing psychotropic drugs.
Ray Moynihan, senior research fellow at Bond University’s Centre for Research in Evidence-Based Practice, believes the pendulum has swung too far in mental illness.
“There have been extremely valuable campaigns in Australia to destigmatise mental illness, but some zealous advocates have created the appearance of a giant epidemic.
“When you label every second person as having had a mental illness, you run the risk of undermining the debilitating and severe nature of genuine psychiatric illness.”
In our attempt to help, we are pushing the boundaries too wide and labelling too often. Rather than a conspiracy, Moynihan says it’s an accident of too much goodwill – a road paved with the best of intentions!
This page reproduces an article on the Australian Financial Review’s website.