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The New and Growing Interest in Mental Health: Where Should it Be Directed?

Mental health provision and mental health research are undergoing something of a renaissance. The subject has been the priority of successive governments, more people are entering mental health professions, and mental health attracts a financial premium under the Research Evaluation Framework, through which universities receive care funding. The biological basis of many mental health diseases has recently been unravelled – see for instance past News Blogs on the molecular biology of schizophrenia, and Alzheimer’s disease.[1] [2] From a philosophical standpoint the mind is now seen as a function of the brain, just as circulating the blood is a function of the heart. The interaction between the brain and the rest of the body, first discovered by observations on Alexis St. Martin in 1822, and later seen in ‘Tom’ in 1947,[3] is now a major source of investigation (see another article in this News Blog on a part of the brain called the amygdala).

>Much of this renewed attention on mental illness carries the, often implicit, implication that mental health treatment should improve. This is undoubtedly the case for many diseases at the severe end of the psychiatric spectrum. One does, however, have to wonder whether the traditional medical model that serves us well in diseases such as schizophrenia and autism, is really the right way to go for other conditions such as depression and anxiety, especially in their milder forms. Depression, one often reads, affects 30% of the population. But 30% represents a choice of threshold, since the definition of ‘caseness’ turns on where the line is drawn. If set at roughly one-third of the population one has to wonder about the logistics of supplying sufficient treatment. And even if the logistics can be managed, it still seems wrong to make ‘cases’ of fully a third of the human race. To put this another way, common problems, such as depression and obesity are best tackled at the societal level. Therapeutic services can then deal with the most serious end of the spectrum – people who really should be given a diagnostic label. This would seem to be the way to go for (at least) two reasons. First, many people (especially at the milder end of the spectrum, where normality elides into diseases) do not present to health services. Their mental health is important. Second, the brain is a ‘learning machine’ and it is hard to reverse harmful behaviours, such as eating disorders, once they have been firmly encoded in neural circuits. Mental health practitioners therefore have a preventive / public health responsibility to intervene by encouraging a wider ‘psycho-prophylactic’ approach. And this topic needs research support every bit as much as therapy. A population level approach would seem to have two broad components – a supportive environment, and encouraging resilience in the population.

Let us consider a supportive environment. Reducing bullying in schools is an archetypal example of an intervention to create a psychotropic environment. There is clear and present evidence that the victim (but not the perpetrator) is harmed by bullying, and there is also good evidence that the problem can be prevented.[4] How a psycho-therapeutic environment may look in other respects is less clear-cut. Workplace culture is likely to be important. The Whitehall studies show that a feeling of powerlessness is associated with stress and illness,[5] but putting this right is not a simple manner. For example, it is widely believed that an optimistic, or so-called ‘positive’, outlook is helpful in the workplace, but the experimental evidence actually points the other way. Being realistic about difficulties ahead and (often low) chances of success, is more helpful than a culture of poorly titrated optimism.[6]

There are many specific groups that are at risk of mental suffering and where environmental modification may help. While the workplace is stressful and a source of anxiety and depression, it has its antithesis in the loneliness that often accompanies old age. There is a fashion to try to keep everyone living independently in their homes for as long as possible. However, such an environment is likely to lead to increasing isolation. I think that communal living should be encouraged in the declining years between retirement and death.[7]

What about resilience in the population? To a degree, the workplace will always be stressful since competing interests and time pressures are inevitable. How can we increase resilience? Taking part in guides and scouts is associated with better mental health outcomes in young people.[8] Exercise has positive benefits on mental health across the age spectrum,[9] and team sports seem particularly beneficial. It is possible that we can encourage ‘mental hygiene’ by talking about it and encouraging healthy mental behaviours. I have a tendency to self-pity and so practice a kind of cognitive behavioural therapy on myself – I think of role models and count my blessings. Others practice ‘mindfulness’. We need to learn more about how to build resilience through experience. Where lies the balance between a bland life devoid of competition, and a ruthless environment creating ingrained winners and losers? I hypothesise that an environment where people are encouraged to have a go, but where coercion is avoided and failure is seen as par for the course, will prepare children for life’s vicissitudes. However, I suspect we are in the foothills of discovery in this regard.

There is always a temptation to screen for illness when it cannot be fully prevented, but the screening can often do more harm than good, and this is true in mental health as well as a physical context. Certainly, routine debriefing after a major incident or difficult childbirth appears to be at best unhelpful. CLAHRC WM collaborator Swaran Singh and colleagues showed that screening for the prodromal symptoms of schizophrenia is also unhelpful as it produces an extremely high false positive rate.[10] Again, working out when screening is of net benefit is an important task for the future.

In conclusion, none of what I have written should be seen as a criticism of therapeutic research and practice. Rather, I argue for a broadening of scope, not only to find things that are predictive of poor mental health, but to find workable methods to improve mental health at a population level. Public mental health is an enduring topic in CLAHRC WM.

— Richard Lilford, CLAHRC WM Director

References:

  1. Lilford RJ. Psychiatry Comes of Age. NIHR CLAHRC West Midlands News Blog. 11 March 2016.
  2. Lilford RJ. A Fascinating Account of the Opening up of an Area of Scientific Enquiry. NIHR CLAHRC West Midlands News Blog. 11 November 2016.
  3. Wolf S. Stress and the Gut. Gastroenterol. 1967. 52(2):288-9.
  4. Menesini E & Salmivalli C. Bullying in schools: the state of knowledge and effective interventions. Psychol Health Med. 2017; 22(s1): 240-53.
  5. Bell R, Britton A, Brunner E, et al. Work Stress and Health: the Whitehall II study. London: Council of Civil Service Unions / Cabinet Office; 2004.
  6. Lilford RJ. Managing Staff: A Role for Tough Love? NIHR CLAHRC West Midlands News Blog. 2 September 2016.
  7. Lilford RJ. Encouraging Elderly People to Live Independent Lives: Bad Idea? NIHR CLAHRC West Midlands News Blog. 16 April 2014.
  8. Lilford RJ. Does Being a Guide or Scout as a Child Promote Mental Health in Adulthood?. NIHR CLAHRC West Midlands News Blog. 25 November 2016.
  9. Lilford RJ. On the High Prevalence of Mental Disorders. NIHR CLAHRC West Midlands News Blog. 7 March 2014.
  10. Perry BI, McIntosh G, Welch S, Singh S, Rees K. The association between first-episode psychosis and abnormal glycaemic control: systematic review and meta-analysis. Lancet Psychiatry. 2016; 3(11): 1049-58.
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