The fantastic aim of preventing ‘mental health problems’

The Mental Health Foundation(MHF) believesthat mental health problems are preventable.¹

What is a mental health problem? In a summary of ‘fundamental facts’, the MHF adopts the discourse of symptoms, disorders, and diseases.² In an earlier MHF document³, an inquiry into the long-term future of mental health services, one would have expected to find a more considered answer to this question but it is not there. Based on a psychiatric epidemiological approach, it seems that almost 20% of the population are suffering from ‘common mental disorders’.^2,4However, a ‘mental health problem’ is often understood in a looser sense than this, and the term could perhaps be applied to around half the population. Many ‘mental health professionals’ are also apparently sufferers.⁵ On these grounds, there is no clear divide between the mentally healthy and the unhealthy.

The means by which the authors of the inquiry into future services sought clarity (when it suited them) was to fall back on the more restrictive concept of ‘mental illness’. Although they had reservations about ‘medicalisation’, they assumed that there will still be people who are diagnosed as having a mental illness in 20-30 years time. These are people who will require care and treatment. They may be right about the needs of a relatively small group of people often described as having ‘severe mental illness’ but this group cannot be equated with everyone who is thought to have a ‘mental health problem’.

According to an attitude survey conducted on a random sample of the UK population in 2010,⁶ the general public agree that there are different classes of mental health problem. The authors of this survey sought respondents’ opinions about possible candidates for a ‘mental illness’. It turned out that 68% ‘agreed strongly’ that ‘schizophrenia’ was a mental illness whereas the proportion that regarded ‘stress’, ‘grief’, and ‘drug addiction’ as mental illnesses was around 20%. Stress and grief are presumably seen as ‘mental health problems’ (or simply as life’s hardships) rather than illnesses. The authors of the survey did not seek an opinion on typical ‘mental health problems’ but were content to define the latter as conditions for which an individual would be seen by healthcare staff. On these grounds, it follows that the prevalence of mental health problems will increase as a more and more service providers find employment.

I suggest that concepts of mental illness and psychiatric disorder should be abandoned.⁷ It is not of course possible to define away peoples’ problems but there exists a variety of non-medical approaches for their resolution. There is no need for the great majority of them to come within the remit of a ‘health service’.

At present, people commonly consult health care professionals, especially general practitioners (GPs), when they experience some form of distress. Eighty three per cent of the sample in the attitude survey said they would consult a GP about a mental health problem. For instance, it is quite common for someone experiencing stress at work (sufficient to impair performance) to get ‘signed off’ for weeks or even months. With this system, an employer can feel reasonably confident that a gatekeeper is applying control over potential malingering without necessarily knowing what the health problem is or how it is diagnosed. The blurry, somewhat meaningless, terminology of mental health performs a euphemistic function, somewhat similar to other circumstances or motives that are best left un-explicated (such as ‘waste matter’, ‘dodgy’, or ‘the departed’). The GP simply writes ‘stress’ in the case notes.

It is probably just as well that most GPs have little or no training in psychiatry and are not inclined to assign a considered diagnosis. To name something as a problem or disorder implies a judgement (by self or an agent of society) that something is amiss. Most people want to be seen as problem-free and therefore would prefer not to publicly advertise the existence of a problem. There seems to be an advantage in ‘keeping up appearances’, hoping any problem will eventually be resolved, as often happens. This is not a sign of denial but indicates an acceptance and toleration of problems, an attitude of live-and-let-live. Life is not expected to proceed without a hitch and some people are not gifted with the temperament, abilities, or inclination to choose a path in life that avoids the kind of situation that creates problems.

The contrary point of view is to nail a problem down and eliminate it. I accept that this approach may at times be necessary whether or not a problem is medicalised. However, the path of regarding ‘mental health problems’ as serious and burdensome leads to unrealistic expectations that can never be met by ‘mental health services’. The MHF states that mental health problems cost the UK economy an estimated £70-100 billion each year. This figure is around six times the amount the UK government pays annually to the EU for membership and is therefore a very large sum. For comparison, total NHS annual spending on mental health is somewhat over 10 billion.

The medicalisation of life’s problems encourages a steady expansion in the number mental health professionals who are needed to deal with them. On current prevalence figures, society will soon approach a state in which a person is either a service provider or a service user. The latter are viewed as unfortunates who need to be cared for. The MHF report inquiring into the future remarks that: One-to-one human contact, a smile and kind words have a timeless benefit to people with mental health problems. How nice, thoughtful, and caring that is. The remark implies a ‘holier than thou’ attitude, a sense that anyone with a problem deserves our pity.

The future of mental health envisaged by this MHF report would require that all problems be clearly labelled. Services will build service user’s capacity to self-manage their conditions. They will know these conditions by the label they are given. Their self-management will be guided by research that points them in the right direction. Future mental health services can be based on proven and effective service delivery mechanisms. A key element . . . will be an effective computerised system for sharing patient information both within the NHS and across boundaries with other organisations.

A consequence of having this kind of information system in place would be the ability to identify who it is that belongs to the ‘blessed’ and who to the ‘blemished’. Those unfortunate enough to be in the latter group could be quickly identified and tracked across different settings.

Out of interest, I examined my own computerised medical records held by my general practice. It stated that 18 years ago I had had a ‘mild depressive episode’. Of what use is that information without a context to give it meaning? In years leading up to that period my partner and my mother had both died from long drawn out illnesses (cancer and dementia) and I myself had been misdiagnosed for a serious medical condition requiring surgery that everyone thought, including myself, was terminal. My state of mind was not ‘mild’, nor was it simply a ‘depressive episode’. How are we supposed to characterise complex life situations as ‘mental conditions’? Casual and de-contextualised labelling can be socially damaging, especially when a ‘condition’ has undesirable connotations such as a ‘personality disorder’. In view of the risks of labelling, I am often consulted (as a therapist) by individuals who wish to pay privately. They do not want to leave any official trace of having done so. This is not driven by the shame or stigma of ‘mental illness’ but by a common sense appreciation of the tendency to pigeonhole people, and the reality that a problem can affect a person’s social functioning in a way they might not wish to advertise publicly.

The authors of the MHF inquiry state that we take patient confidentiality seriously, not least because of the immense stigma that still surrounds a diagnosis of mental illness. However, this same stigma can also apply to a ‘mental health problem’. It is hard to credit assurances that digitally stored information is secure, especially as any individual can find their own record easily and share it, as I have done. Sharing ‘across settings’ enormously magnifies the likelihood of illegitimate access. It is also illusory to suppose that problems can be cleansed of any negative connotation by calling them ‘conditions’ or ‘illnesses’ from which anyone might happen to suffer. A problem is a problem because it implies a failing (by self or others) or a failure to meet a standard of some kind. There is no gain from having it medicalised, and the concept of ‘prevention’, in a medical sense, is inappropriate. The existence of problems is an inevitable feature of life. Problems are preferably resolved, not ‘treated’. This outcome can be achieved in a variety of non-medical ways and settings.⁷

1. Mental Health Foundation (2015). Prevention review: Landscape paper.www.mentalhealth.org.uk/publications/prevention-review
2. Mental Health Foundation (2013). Starting today: The future of mental health services. Final inquiry report.     www.mentalhealth.org.uk/sites/default/files/starting-today.pdf
3. Mental Health Foundation (2016). Fundamental facts about mental health.https://www.mentalhealth.org.uk/publications/fundamental-facts-about-mental-health-2016
4. Steel, Z., et al., (2014). The global prevalence of common mental disorders: A systematic review and meta-analysis 1980-3013. Int. J. Epidemiol. 43(2) 476-493.
5. Rao, A. S. et al. (2016). Psychological wellbeing and resilience: Resetting the balance.www.bps.org.uk/system/files/Public%20files/ar_v10_resetting_the_balance_160516.docx.pdf
6. Research Report JN 207028. (2010). Attitudes to mental illness. www.webarchive.nationalarchives.gov.uk
7. Hallam, R. (2018). Abolition of the concept of mental illness: Rethinking the nature of our woes. London: Routledge.