The mental health impact of COVID-19: looking forward. Why we need high-quality longitudinal studies.
By Maria A Thomas, on 3 April 2020
This blog has been guest written by Dr Daisy Fancourt, Associate Professor of Psychobiology & Epidemiology at the UCL Institute of Epidemiology & Health Care and leads the COVID-19 Social Study.
Researchers have been aware for years of the adverse effects of social isolation on mental health, incidence of physical illnesses such as coronary heart disease and stroke, and mortality risk 1,2. But COVID-19 has triggered the largest enforced isolation in living human history. So predicting how this will affect mental health is extremely challenging.
A handful of studies on previous periods of quarantine have already been published. A rapid review published in the Lancet last month identified 24 studies conducted during outbreaks such as Ebola, the H1N1 influenza and severe acute respiratory syndrome (SARS). These have found that it isn’t just social isolation itself that is a challenge. Factors such as boredom, inadequate supplies and information, financial loss, and stigma can have negative psychological effects including post-traumatic stress symptoms, confusion, guilt, and anger 3, with some effects lasting as long as 3 years following the end of quarantine. People from disadvantaged backgrounds (who may face greater financial burdens), young people (for whom there may be significant disruption to their planned education and career pathways), and people with lower educational qualifications appear to be especially vulnerable 3. Even once quarantine measures are lifted, studies have found the persistence of problems including long-lasting changes in health behaviours (e.g. insomnia and lasting increases in alcohol abuse), fragmentation of social engagement (e.g. avoidance of public spaces and contact with others), and adverse effects on work (e.g. reduced work performance, reluctance to work, and increased consideration of resignation) 3.
These effects are all especially concerning as they occurred after just 7-30 days of isolation. Our isolation is anticipated to last significantly longer than this and is happening not just in certain towns and regions but across the globe. Consequently, there could be major immediate and lasting implications for the NHS and mental health services. So it is imperative that we dynamically capture the experiences of individuals and identify potentially protective activities during this period of isolation so that more specific guidance can be given to mitigate against adverse effects. It’s also key that we track what the emerging mental health problems are to enable the development of evidence-based social policies and services that can support individuals beyond the end of this epidemic.
In light of this, UCL has launched a large-scale UK study into the effects of COVID-19 on mental health. The study aims:
- To understand the psychological and social impact of Covid-19
- To map how the psychosocial impact evolves over time as social isolation measures get stricter and once measures are relaxed
- To ascertain which groups are at greatest risk of adverse effects
- To explore the interaction between psychosocial impact and adherence to healthy and protective behaviours
- To identify activities during isolation that could buffer against adverse effects
Already, 50,000 people in the UK have taken part and are completing weekly online surveys. We’re producing weekly reports on findings and working with government, public health bodies and the NHS to help shape the support and advice that people are receiving. We’re also starting telephone interviews exploring the experiences of vulnerable groups in more detail.
We’re not alone in this endeavour. UCL is co-leading a new network of international longitudinal studies focused on mental health, working with teams internationally to harmonise measures and undertake collaborative analyses.
Mental health research right now is critical. Finding ways to support people whilst they stay at home will help reduce the pressure on NHS services both for mental health and other health conditions, and could increase adherence to government guidelines. Further, the findings from research will support us in understanding the adverse effects of isolation in more detail and in preparing for future epidemics.
Also, the findings from this research may not all be negative. Lessons following previous epidemics such as SARS include the amazing ability of people to bounce back and even find some positives amidst even the most adverse experiences. What’s more, Covid-19 has focused attention on which jobs really are the most important within society, giving prominence and status to individuals in roles now designated as ‘key workers’ that have previously not been so well acknowledged or valued. Whether this translates to changes in subjective wellbeing amongst these groups will be interesting to discover.
To take part in the study, visit www.covid19study.org or click on this link: https://redcap.idhs.ucl.ac.uk/surveys/?s=TTXKND8JMK. To find out more about the study and see reports, visit www.marchnetwork.org/research. If you are running a longitudinal mental health study of COVID-19, register details of it with the COVID-Mind International Network here: https://www.surveymonkey.com/r/covid-mind-network
- Valtorta, N. K., Kanaan, M., Gilbody, S., Ronzi, S. & Hanratty, B. Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies. Heart 102, 1009–1016 (2016).
- Holt-Lunstad, J., Smith, T. B., Baker, M., Harris, T. & Stephenson, D. Loneliness and Social Isolation as Risk Factors for Mortality: A Meta-Analytic Review. Perspect. Psychol. Sci. 10, 227–237 (2015).
- Brooks, S. K. et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet 395, 912–920 (2020).
The impact of COVID-19 on people with severe and complex mental health problems. Concerted action needed urgently.
By Maria A Thomas, on 30 March 2020
While we are all adjusting ourselves mentally to the viral pandemic, spare a thought for those with the most severe mental disorders and people caring for them. Helen Killapsy, Professor of Rehabilitation Psychiatry, Division of Psychiatry, UCL writes about people living in supported accommodation often staffed by people who are neither NHS or local authority care staff.
The COVID-19 emergency presents an unprecedented challenge to us all, but people with particularly complex mental health problems need special consideration. Around 20% of those who develop a major psychotic illness such as schizophrenia or schizoaffective disorder have ongoing symptoms that don’t respond well to the usual medications or treatments. For this group, there are often accompanying cognitive and functional impairments that impact negatively on the person’s interpersonal skills and ability to manage basic everyday tasks such as self-care, cleaning, shopping and cooking. Mental health rehabilitation services work with people with problems such as these. Due to the severe nature of their symptoms, more complex medication regimes are commonly needed, including clozapine, long acting injectable antipsychotic medications and mood stabilisers, that require regular administration and monitoring through routine blood tests. Many will also have long term physical health conditions as well, including pulmonary and cardiovascular illness which put them at greater risk of more severe infection and, potentially, death from COVID-19.
There are about 5000 inpatient mental health rehabilitation beds in England provided by the NHS and independent sector. In the community, around 30,000 people with complex mental health problems live in supported housing services provided by the non-statutory and voluntary sector, where non-clinical support staff are available up to 24 hours a day to help people manage their activities of daily living, supervise their medication and enable their engagement in community based activities that promote recovery, such as leisure, education and supported employment. Community mental health rehabilitation teams operate in about half of NHS mental health Trusts across England to provide specialist clinical input to people with complex mental health problems living in supported accommodation. In areas where there is no community rehabilitation team, this function is provided by a standard community mental health team.
Over the last few days, it has become clear that staff working in inpatient and community based rehabilitation settings are really struggling to help service users follow Public Health England (PHE) guidance on handwashing, social distancing and self-isolation to reduce the spread of COVID-19. Due to their mental health problems, many service users find it difficult to concentrate and take on board instructions. Many cannot understand the importance of following the advice and staff cannot enforce it. As the number of cases rise and staff fall sick or have to self-isolate, the system’s ability to provide the essential treatment and support that this group need will come under immense pressure. The situation is further exacerbated by a lack of clear guidance about the use of, and access to, Personal Protective Equipment (PPE), particularly for staff working in mental health supported accommodation, some of whom are questioning whether they should come to work unless PPE is available. The British Medical Journal has just published a stark warning about the risks of a lack of PPE in care homes (1) but supported housing services also need to be included in planning and guidance.
Most staff working in supported housing have no previous experience of working within a clinical environment and urgently need training to know how and when to use PPE. Furthermore, supported housing services vary widely in configuration, with some provided in communal settings and others providing on-site staff support to people living in individual or shared apartments. Generic guidance for supported accommodation services about managing COVID-19 needs to be interpreted locally for each individual service. Local Authority and NHS mental health rehabilitation leaders need to work together urgently to provide tailored advice to enable these services to keep operating and to provide support as safely as possible. Arranging additional cleaning services seems an obvious priority, alongside staff trying to restrict the number of service users using communal areas at any one time, through advice and notices. Stopping group activities and closing off communal areas has been suggested but could make the situation worse in buildings with limited space if it leads to people crowding together in corridors. Further discussions will be needed about the ethics of applying PHE’s legal powers to contain individuals with severe mental health problems who are unable to follow Government guidance on social distancing and self-isolation.
In this national emergency, it seems clear that those with the most severe and complex mental health needs are going to be at significantly higher risk of negative outcomes. The situation is similarly bleak for others with high support needs, such as people with dementia or more severe intellectual disabilities. At present the COVID-19 case reporting processes do not include the level of detail that would inform the relative prevalence of suspected and confirmed cases and deaths amongst groups of people with different types of mental health problem. Initial guidance published by the Royal College of Psychiatrists for mental health clinicians on managing COVID-19 has, understandably, not yet been formulated to include the specific needs of all sub-groups (2). The appalling example of the abandoned residential care home in Spain provides a worst case scenario of what a collapse of the supported housing system could mean (3).
We need to act now to prevent a catastrophic failure in care for those in our society with the highest vulnerability. We are therefore working at pace with colleagues from NHSE and the Royal College of Psychiatrists to use existing systems for gathering facts and figures as well as more open-ended feedback from mental health rehabilitation clinicians to monitor the situation for people with complex mental health problems and to share examples of good practice and creative problem solving. This kind of activity may not win accolades as ground-breaking research, but it is an essential, concerted and constructive response that will inform practical guidance needed right now for those working in one of the many COVID-19 ‘front lines’.
London, 30th March 2020
- Gareth Iacobucci. COVID-19: Lack of PPE in care homes is risking spread of virus, leaders warn BMJ 2020; 368.m1280 (Published 27 March 2020)
- Royal College of Psychiatrists. Responding to COVID-19. Guidance for Clinicians. RCPsych, 2020. Accessed 29.3.2020
BBC News. Coronavirus: Spanish army finds care home residents ‘dead and abandoned’. (Published
By Maria A Thomas, on 24 February 2020
This blog has been guest written by Rochelle Burgess from UCL Institute for Global Health – prompted by our previous blogs from Prof Tony David (Insight and Psychosis: the next 30 years and What is mental health?)
Earlier this month, the New York Times published an obituary for Dr. Bonnie Burstow, feminist therapist, professor and anti-psychiatrist. Once discovered, I promptly fell through a rabbit hole of Twitter feeds and debates reflecting on her career, most notably her critiques of a psychiatric care system that situates women’s (and everyone’s) mental health problems in the brain, instead of the problematic worlds where these brains and bodies live. This critique has always resonated deeply with me on many levels – as a mental health service user but also more systematically in my research, studying the mental health needs and treatment experiences of marginalised groups exposed to poverty, oppression and various forms of violence, in high-income and low-income settings. That day’s rabbit hole was full of people confirming the ongoing relevance of her work, viewing mental health sciences as disciplines still grappling with some pretty old problems and a rage that is as robust today as it was in the early days of Burstow’s work.
There are probably many reasons to explain this persistence. But they all converge around a long standing critique of the psy-disciplines, well-articulated by Foucault, R.D.Laing, and more recently, Thomas and Bracken’s Post-psychiatry framework, and some critical spaces of the global mental health world. Essentially, patients don’t feel seen. Not fully. Service users are seen in a partial sense – a way that prioritises diagnosis, biological and neurological mechanisms, over what it means to be in the world with a condition, and to the full range of needs of a person.
This is not for a lack of trying. Social and community psychiatry have embraced recovery paradigms and more recently, responding to calls for social interventions. Each in their own way complicates our approach to supporting a process of being ‘in’ the world and experiencing mental distress. But even in this, mental health feels a little stuck in the idea that a person is primarily their diagnosis (see – recovery in the bin movement), and what counts as treatment remains fairly narrow. We still forget the world where bodies live – in spite of the wealth of evidence we have that highlights the structural drivers of mental illness, the impacts of those drivers on treatment outcomes. But we just can’t seem to shift things, probably because the way we define the problem still doesn’t give enough space to the complex needs of people.
We need a new way. Anti-psychiatry doesn’t feel right, as that in its own way removes complexity – ignoring that there are places, spaces and people who will benefit tremendously from access to diagnostics and medications.
This is where wellbeing paradigms have something to offer. Though seen as a hot new topic popularised (and arguably distilled) by ‘happiness’ studies and indexes, wellbeing paradigms are rooted in classical philosophical concepts of Eudaimonia and hedonia – and reflect our earliest attempts to understand the roots of happiness wellbeing. For me, Hedonic perspectives, focused largely on pleasure, are less helpful here. But Eudaimonic perspectives, which looks at meaning, self-actualisation and the ‘full functioning’ of a person, provide the foundations for more holistic, meaningful and potentially radical mental health spaces – where all kinds of care are on the table.
Sociologist Corey Keys, and psychologist Carol Ryff have made considerable contributions to our understandings of how wellbeing principles relate to mental health and mental illness. Importantly, their analyses place mental health and mental illness as two separate but related spectrums, rather than the opposite ends of a single spectrum. Using a framework of ‘complete mental health’ they suggest that the absence of mental illness doesn’t automatically lead to mental health (though they are often co-related), and for this to occur, we need the presence of social, psychological and emotional wellbeing – defined as the ability to flourish. Most importantly for marginalised groups, flourishing encapsulates social wellbeing concerns beyond our relationships, demanding attention be paid to socio-political structures and the world where we live. It’s a model of person-centred care where addressing social-structural realities is as important as psychological and relational ones.
Imagine a field where this is our dominant framing? Where minds, bodies and the places they live are treated as one? Lately, I feel like we’re getting there. Daisy Fancourt is doing amazing things to push forward an evidence base for the importance of social prescribing and community networks to positive mental health, and for the biological dimensions of wellbeing. In communities where I work in the global south, a wellbeing perspective has driven the exploration and testing of intervention models that combine, within treatment programmes, psychological and community development support. Early findings from my recent pilot study of collective narrative therapy for women with complex trauma in South Africa suggests there is a positive booster effect when a focus on how to tackle problematic social environments is included in the intervention.
Burstow wanted a psychiatry/psychology that was as much about the brain, as it was about the world. This is entirely possible – all we need is a healthy dose of wellbeing.
Photo credit: MARCH network – Groups
By Maria A Thomas, on 16 December 2019
On the 21st and 22nd October 2019, Dr Georgia Pavlopoulou and other experts in the field of autism delivered a two day course on ‘Improving Access to Psychological Services (IAPT) for Autistic Children and Young People’ at the Anna Freud Centre. This short IAPT course was funded by Health Education England to help practitioners to understand the barriers experienced by autistic CYP in accessing IAPT services and share examples of good practice and to develop innovative approaches of working with, rather than on or for, autistic CYP.
A key aim of the training is to support practitioners in their role to improve the effectiveness of psychological services for autistic children and young people with, and without, a learning disability by embedding the necessary changes required into service culture. The key outcomes of the two days were to challenge the stereotypes practitioners may hold about autism, promote a better understanding of the communication differences between autistic and non-autistic people and what works, as well as understand autistic burnout, meltdown/shutdown and masking in relation to mental health. The course is beneficial to mental health professionals, social workers and nurses working in child and adolescent mental health services (CAMHS), voluntary support/peer groups/third sectors, and charity sectors.
The plan for the two days was co-produced by Dr Georgia Pavlopoulou who leads the IAPT Autism/ Learning Disabilities stream with Ann Memmott, Autistic Autism Trainer, Director at AT-AUTISM and three young people with a diagnosis of autism/learning disability/ADHD who have been service users at CAMHS, and presented talks and group exercises run by national experts including clinical tutors, academics and autistic people and their family members to collaborate on key issues such as trauma, anxiety and depression, and autism.
Georgia Pavlopoulou (Academic co-Lead):
For me it all started with a question that has motivated my work for the past 17 years: how do we move from ‘fixing’ autistic people to shared power and a more democratic approach to mental health support? Autistic people, their parents, carers and clinicians agree that children and young autistic people often do not receive the psychological help they deserve because those trained in delivering evidence based therapies feel inadequately trained in adaptations for those with a diagnosis of Autism and/or Learning Disability diagnoses and those with significant experience of working with these groups are insufficiently trained in evidence-based methods of therapy.
The above has been a dominant theme in my professional and research career and I am delighted that I now have the chance to work with Dr Peter Fuggle, Dr Russell Russ, our Young Champions and other wonderful academic and clinical colleagues across UCL and Anna Freud Centre in order to explore further issues of co-production and co-delivery in mental health when working with neurodivergent populations. The Psychological Therapies for Children and Young People with a diagnosis of Autism and/or Learning Disability curriculum has been developed as part of the Child and Young People Improving Access to Psychological Therapies programme (CYP IAPT). IAPT aims to improve people’s access to psychological therapies and evidence based practice through the NHS and associated agencies.
During the two days of the short course we co-run activities with delegates, our IAPT clinical tutors and autistic experts and shared celebrations and struggles. Through these exercises we hope that practitioners can identify more ways in which their service might improve autistic participation from an IAPT value viewpoint.
Julia Avnon (Clinical Tutor at Anna Freud Centre):
Over the two days we invited autistic people and their families to help us understand that there is still a lot of room for improvement with the intention of stimulating discussion around how we might improve the way we work in the therapy room with neurodivergent population. It’s so important that autistic people’s mental health experiences are told to our trainees if we aim to improve local mental health services so they are aware of stressors, autistic burnout, alexithymia, what makes autistic people happy and how to work with, rather than on or for autistic people to adapt therapy.
Working together, we maximise the chances to find ways to improve the mental health of autistic people working with autistic people, focusing on aspects that matters to them in their preferred ways. That is a key message of this two day course.
Ann Memmott, PGC (Autistic Autism Trainer Co Lead of the Short Course, AT-AUTISM Director):
With a substantial number of autistic children and young people experiencing mental health conditions, the need for up-to-date, authentic training for professionals has never been greater. This short course, with funding from Health Education England, was very well received. Those present were enabled to collaborate, explore key new materials, and listen to first-hand accounts of what helps and hinders in therapeutic practice around mental health and autism. Unique in its field, this format has given an excellent grounding in the differences and approaches that need to be taken into account for successful outcomes. With a sizeable waiting list for future courses, it is clear that there is a strong need for further provision of the training. A delight to have collaborated on this, and looking forward to further work with all involved.
Quotes from participants:
“There is a need to encourage understanding of non-autistic people and culture rather than teaching how to poorly mimic what one is not – is key strategy to reduce stress in autistic people.” Damian Milton, autistic academic, guest speaker at the event.
“I have witnessed some great interaction with delegates moving around into new groups in bringing new ideas from autistic adult, autistic parent, parent, professional, clinicians and researchers perspective. I was here to today to discuss how we can do things better from a BAME perspective.” Vanessa Bobb, CEO A2Voice, mother of child with autism.
“So grateful for two enriching days. Made me think where is the Autistic person’s voice in the Autism narrative? Mutuality & collaboration not modification. Celebrating difference not focusing on deficit. Now time for reflection and sharing.” R.E, Art therapist.
For more info on the PG IAPT course in Mental Health for Autistic CYP or upcoming short courses, please contact Module Leader: Dr Georgia Pavlopoulou at email@example.com
By Anthony S David, on 25 October 2019
I published my first paper on the topic of insight in relation to psychosis about 30 years ago in the British Journal of Psychiatry. An anonymous Lancet editorialist commented at the time that studying insight was, “academically nourishing but clinically sterile”. Torn between feeling flattered by the attention and insulted by the judgement, I persisted. Now seems a good time to take stock and look forward to the next 30 years. We can now say that we have some ‘facts’ about insight in psychosis: first that it is possible to measure in ways that are at least as valid and reliable as any other psychopathological phenomenon. Next, that there are some very well replicated associations: poorer insight, worse psychopathology; lower IQ, lower insight; and lower mood, better insight. Finally there is the obvious and clinically relevant relationship between insight and treatment adherence and hence outcome.
The relation between insight and adherence, or rather poor insight and coercive treatment is, naturally, where critics of the insight concept converge. ‘Insight’ they say is mere agreeing with the doctor. But where a patient’s self-appraisal as not being unwell or needing help is at odds with their peers and family, might this not be regarded as a lack of insight? The interface between insight and capacity to decide upon treatment is where current ethical debate is concentrated and is seen most vividly in the ability to a ‘use and weigh’ information, a key criterion for mental capacity used in the Mental Capacity Act (2005) definition. It is hard to see how the benefits and harms of a proposed treatment can be weighed in the balance if you don’t believe you are ill in the first place.
Metacognition is a relatively new area of psychology examining people’s ability to reflect upon their own cognition and appears to be related to insight as used in psychiatry. The cognitive neuroscience of metacognition is beginning to make important contributions to psychopathology. Lack of metacognitive awareness – not reflecting on whether a decision is correct – underpins much thinking in say, depression, while excessive metacognition can inhibit decision making as in obsessive compulsive disorder. The lack of ability to change one’s mind in the light of new evidence is a core feature of delusions. Paradigms that build on advances in metacognitive research and make use of computational modelling also promise much in this regard.
For insight in psychiatry, the metacognitive challenge posed is to reflect on one’s own mental and interpersonal functioning. It involves an attempt to see one’s thinking and behaviour ‘objectively’ as if through another person’s eyes and then comparing it to some representation of mental health. There is just one fundamental question asked in relation to clinical insight (after Aubrey Lewis): do I have an illness and is the Illness mental? It includes the moment-to-moment evaluation of mental activity (e.g., was someone speaking to me or was it my imagination?) as well as more enduring ‘semantic’ evaluations such as whether my beliefs are true and shared by others. Note that while that representation of mental health will be the amalgam of received opinion and experience, there is no judging doctor, as it were, in sight.
Cognitive insight is a new construct put forward by pioneer of cognitive therapy, Aaron (Tim) Beck. It refers to a cognitive style or propensity to question one’s ideas, beliefs and behaviour. One advantage it affords research is that it enables insight to be studied in healthy individuals without confounders such as stigma and the effects of treatment, and thus linked to normal psychological processes. An early area of interest is the relationship between cognitive and clinical insight – which surprisingly, turns about to be rather weak. We still do not know if poor cognitive insight in a vulnerable individual may be a risk factor for later psychosis per se.
Can insight be fostered?
Restoring or improving insight is a worthwhile psychotherapeutic aim. It should be in the form of acknowledging difficulties as a first step in gaining mastery over them. Then, encouraging openness to taking up an effective treatment for those symptoms that cause distress at least as a start, and not at all the forced acceptance of some abstract illness model. This was the aim of the now retro-sounding ‘Compliance Therapy’ trials back in the 1990s. Talking therapies designed to improve metacognition (Metacognitive Therapy and Metacognitive Training) across a range of mental disorders have been developed and tested in small clinical trials and subjected to meta-analysis – and the results are promising. To some extent the success of all these therapies depends on the closeness of the link between metacognition and insight which, as discussed is itself a topic of ongoing enquiry.
Apart from medication, which if effective at relieving symptoms is correspondingly effective at improving insight – a new area of therapeutic research is neuromodulation. Transcranial direct current stimulation (tDCS) is a simple, safe and non-invasive method for selectively modulating cortical excitability. Of interest, tDCS over the dorso-lateral prefrontal cortex has been reported to significantly increase awareness of errors on attention tasks in the elderly. Also, a pilot study showed that tDCS to same region increased insight in patients with schizophrenia – replication with a control condition is obviously required.
In conclusion, the study of insight has proved to be both academically simulating and clinically fertile. It is a biopsychosocial construct par excellence. I am looking forward to what new insights the next 30 years will bring.
A fuller version of this blog will be published soon as a comment piece in the British Journal of Psychiatry. *The full comment can be found at https://doi.org/10.1192/bjp.2019.217
A.S.David, Director, UCL Institute of Mental Health
October 17th 2019
- David AS. Insight and psychosis. Br J Psychiatry 1990; 156: 798-808. https://doi.org/10.1192/bjp.156.6.798
- Amador XF, David AS. (Eds). Insight and psychosis: awareness of illness in schizophrenia and related disorders. 2nd edn. Oxford: Oxford University Press, 2004.
- Beck AT, Baruch E, Balter JM, Steer RA, Warman DM. A new instrument for measuring insight: the Beck Cognitive Insight Scale. Schizophr Res 2004; 68: 319-329.
- Philipp R, Kriston L, Lanio J, Kühne F, Härter M, Moritz S, Meistert R. Effectiveness of metacognitive interventions for mental disorders in adults—A systematic review and meta‐analysis (METACOG). Clin Psychol Psychother 2019; 26: 227– 240. https://doi.org/10.1002/cpp.2345
- De Jong S, van Donkersgoed R, Timmerman M, Aan het Rot M, Wunderink L, Arends J, Pijnenborg G. Metacognitive reflection and insight therapy (MERIT) for patients with schizophrenia. Psychological Medicine 2019; 49: 303-313
- Harty S, Robertson IH, Miniussi C, Sheehy OC, Devine CA, McCreery S, O’Connell RG. Transcranial direct current stimulation over right dorsolateral prefrontal cortex enhances error awareness in older age. J Neurosci 2010; 34:3646 –3652.
Bose A, Shivakumar V, Narayanaswamy JC, Nawani H, Subramaniam A, Agarwal SM, Chhabra H, Kalmady SV, Venkatasubramanian G. Insight facilitation with add-on tDCS in schizophrenia. Schizophr Res 2014; 156:63-65.
By Anthony S David, on 13 August 2019
All of a sudden, everyone is talking about mental health. But what does it mean? First of all, is it just a euphemism for mental illness which avoids (yet perpetuates) stigma? Are mental health and mental illness poles on a continuum? And if so, how do you decide when good health passes into ill health?
If we look at general health – physical health – we might learn some useful lessons. In 1948, the World Health Organisation (WHO) defined Health as: “A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This was regarded at the time as bold and progressive, perhaps part of the spirit of post war optimism. Now at best, it seems utopian. At worst it implies medicalisation of all aspects of life. A group of international but mostly Dutch public health physicians, researchers, policy makers and educationalists [Huber et al, 2011] have recently proposed that a new definition of health based on “the ability to adapt and to self manage” be considered. Their initiative is driven by the fact that the health challenges of the 21st Century are dominated by chronic conditions and ageing which are inescapable for the majority so should encourage adaptation rather than eradication. Indeed it is a truism that for most people, ageing may not be great but at least it is better than the alternative. Huber and colleagues also suggest that physical, mental and social domains be separated when definitions of health are contemplated.
Another problem with definitions of health which include notions of function is that it depends so much on what resources are available to the individual, in order to for example, overcome or manage disability or adapt to change.
In reviewing definitions of mental health I am struck by how they tend towards the mystical. Returning to the WHO, their 2014 definition of mental health is: “A state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” Terms like ‘a sense of coherence’; ‘self actualization’ and ‘mastery’ crop up in other proposed definitions [see Maxwell et al, 2015 for approaches to this issue]. I am minded to call these states ‘bliss’ rather than mere ‘health’. This again merits concern about over-medicalisation. If health (mental or physical) approaches a state of perfection it dooms the rest of us to the status of ill health. Feeling pain – from time to time if predictable and not extreme – is surely healthy. Same for fatigue. Same for anxiety and depression.
As for well-being – another term often bracketed with health and just as slippery – definitions are elusive. It is economists like Richard Layard, rather than mental health professionals, who are most comfortable with ‘well-being’ sometimes simplifying it further to ‘happiness’. Their work has shown that basic needs – food, shelter, safety – are a prerequisite but above that threshold it is a highly subjective phenomenon and moreover, it is highly relative. Our sense of well-being is strongly associated with our social status and wealth relative to others rather than in absolute terms. While we would be foolish to ignore this window into human nature, it provides a problematic basis for a definition of health (or illness) which, as I see it, at least ideally should be somewhat ‘objective’.
My preferred stance is to expand the range of what is regarded as healthy, whether it be physical or mental and restrict what is regarded as unhealthy. It means that the former no longer feels like an unattainable goal but something broader, more recognisable, imperfect, ‘good enough’. This holds back the encroachment of pathology into everyday life thus avoiding iatrogenic illness, expensive unnecessary treatments and fear. However, even if it is agreed that the transition between health and illness occurs way up toward the ill end of the spectrum it still leaves the thorny issue of whether a line should be drawn – creating a category of illness or ill people – and if so, where exactly should it be drawn.
I have argued [David, 2010] that there are dangers in not drawing a line somewhere, while acknowledging that, in the mental health field, this is unlikely to be carving nature at its joints. The main one being that diagnosis becomes not just arbitrary but up for grabs – by Big Pharma, politicians and anyone else. This in turn is likely to lead again to over-medicalization and sometimes discrimination. From a practical point of view, planning health services and doing research are hampered unless the health problem – the diagnosis – is clearly and reliably defined and communicable.
Finally should we be separating mental and physical health? Some would argue that this is hopelessly dualist. Most people agree that our minds arise out of and are entirely dependent on our bodies. There are biological as well as psychological and social elements within all psychiatric disorders and indeed all diseases. The biopsychosocial model is an important guide and underpinning philosophy here [see Bolton and Gillett, 2019]. Let’s stay with dualism and instead of conceiving of a single health-illness dimension, we consider two orthogonal dimensions, like the points on a compass with mental health-to-ill health running from west to east and physical health-to-ill health running north to south. A person is unlikely to feel in good mental health if they are in poor physical health and vice versa. I would imagine most patients would aggregate in the south east quadrant of the graph while I would hope that most of us spend most of our time in the ‘north west’.
Just as ‘Peace’ may be defined as “the absence of war”, so ‘Health’ – contrary to the WHO – may be usefully and simply ascribed to “the absence of disease”. It’s actually not a bad place to start.
Tony David, Director, UCL Institute of Mental Health. August 2019
Huber M, Knottnerus JA, Green L, Horst H, Jadad AR, Kromhout D, et al. How should we define health? BMJ 2011; 343 :d4163
Manwell LA, Barbic SP, Roberts K, et al. What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey BMJ Open 2015;5:e007079. doi: 10.1136/bmjopen-2014-007079
David AS. Why we need more debate on whether psychotic symptoms lie on a continuum with normality. Psychol Med 2010, 40: 1935-42.
Bolton D, Gillett G. The Biopsychosocial Model of Health and Disease. Palgrave Pivot, Cham, 2019, 1-145.
By Maria A Thomas, on 9 July 2019
Welcome to UCL Institute of Mental Health (IoMH) blog.
Here we will invite guests and IoMH team to contribute their thoughts and research in current mental health topics.
You can find out more about the Institute on our website: https://www.ucl.ac.uk/mental-health/
Watch this space!