By Maria Thomas, on 27 April 2020
This blog has been guest written by PhD Student Anne Gaule, UCL MRC Doctoral Training Programme in Neuroscience and Mental Health and research student in Department of Clinical, Education and Health Psychology, UCL Psychology and Language Sciences.
Much like most PhD students I imagine, I followed the news over the last weeks of February closely, wondering how I was going to be able to continue with my research if we entered a lockdown. I am in my third year of the four-year UCL MRC Doctoral Training Programme in Neuroscience and Mental Health. My PhD focuses on social information processing in adolescence, and how this may be affected in children with a history of conduct disorder. This means that a key part of my project is data collection in schools.
At this point I have nearly finished collecting data for one task. I have also been developing new tasks that are engaging and suitable for children whilst having the power required for my stats. Fortunately, (and surprisingly) everything was going according to plan and I was on track to start my piloting and data collection. Unfortunately, I’d planned to start this in March 2020.
For some background, the three new tasks that I have developed need to be run individually with each child at their school and with experimenters present. I have also developed a child version of an adult questionnaire to complement these tasks that needs validation before it can be used. For the new behavioural tasks, I need at least 90 children to take part – on top of piloting. For the questionnaire, 600 children must take part in order to run full analyses. To submit my thesis by the summer of 2021, I was hoping to have finished collecting data by October 2020 (the optimistic scenario), Christmas at the absolute latest. With around 250 questionnaires completed so far and my new tasks only at the piloting stage, I still have some way to go and the disruption from COVID-19 is putting serious brakes on this process.
My PhD project is a collaboration between our research team and the schools we work with and, as such, it requires time and organisation on both sides. When working with schools, whether mainstream or alternative provision, I am primarily working with teachers who are under an incredible workload. Despite already being overwhelmingly busy, they are generously offering to give up their time in order to help us to carry out this research – which we are all hoping may, in the long run, benefit the children they teach. I am hugely grateful to these teachers and I try my hardest to work around their schedule when setting up recruitment and data collection.
Practically, this translates to a huge number of phone-calls and emails – not to mention keeping track of who you’ve been in contact with and when. We also need consent from parents, which involves the school sending forms and leaving a two-week response period (and getting in touch with busy parents can be as tricky as getting in touch with busy teachers). Once we begin working with a school we need a quiet space on school grounds where we can work with the children relatively undisturbed – not necessarily easy during a busy school day. Finally, testing sessions themselves can also be challenging. We try our hardest to accommodate the children we work with, who are participating entirely voluntarily even if they have parent consent. If a child is having a bad day, we will come back on a different day, or break down the session into smaller sessions. The challenging behaviour of some of the children means the sessions sometimes won’t run smoothly or may take longer than planned. Consequently, an extended period of time has to be factored in for data collection on a project such as this. You can imagine how it felt when, after months of work to set up the data collection operation and with several schools having agreed dates in March for us to work with the children, I then had to cancel all of them. Naturally my anxieties about data collection are not comparable to the impact of this crisis on the schools that we work with – many of whom have vulnerable students whom they continue to support during this crisis. However, it’s hard to see how and when the face-to-face testing can move forward until there is more clarity on when we will emerge from this crisis.
Despite these anxieties, I want to reflect on the fact that I have also been incredibly lucky. I have received a huge amount of support since UCL has closed. For starters, my programme was very quick to notify us that, no matter what stage we are at in our PhD projects, we are all guaranteed an extension of some kind. This has been a huge load off my mind. My supervisor has provided guidance on how to adapt those aspects of my projects that can be conducted online (the questionnaire, for example, is easily transferable) and we have also discussed working on the literature review aspects of my thesis. As all the work I do involves children under the age of 18, whether vulnerable or not, I have had to submit amendments to my ethics in order to adapt various aspects of my data collection – such as taking parental consent online, and recruitment via social media instead of contacting schools directly. Here again I was happy to find that UCL has provided clear guidelines on which projects needed to submit ethics amendments for minor adaptations to protocol for online testing, and the best way to go about doing so. My department has been sending me updates about the UCL’s news and response to the crisis – including specific updates for doctoral students – and also immediately sent us guidance on how to set up to be able to work remotely, so I’ve had continued access to all of my files. My lab has set up regular meetings so that we feel less isolated now that we are no longer to leave our homes.
The immediate support from my programme, department, and supervisor has been a huge relief. I have actually started to enjoy the time I now have to read and to begin writing my thesis. I also believe that as the lockdown conditions ease, I may be able to collect data with the help of other team members, and complete my PhD on time.
National Hospital for Neurology and Neurosurgery: response to the COVID-19 emergency by Jennifer Foley, Edgar Chan, Natasja Van Harskamp & Lisa Cipolotti, UCL Queen Square, London.
By tonydavid, on 17 April 2020
The Department of Neuropsychology of the National Hospital for Neurology and Neurosurgery: response to the COVID-19 emergency
Jennifer A. Foley, Edgar Chan, Natasja Van Harskamp & Lisa Cipolotti
Department of Neuropsychology, National Hospital for Neurology and Neurosurgery, Queen Square, London.
At the time of writing, over 137,000 people worldwide have died with COVID-19 coronavirus. Since the first UK death less than one month ago, almost 13,000 people have now died, with numbers continuing to rise. The UK is in lockdown: ‘non-essential’ businesses and places of worship are closed. Similarly, schools are closed, except for children of key workers. People are only permitted to leave their houses for food, health reasons, one hour of exercise or essential work.
The COVID-19 emergency has required us all to rethink how we work. In the NHS we have had to restructure our clinical services. At the National Hospital for Neurology and Neurosurgery (NHNN), a leading tertiary referral neuroscience specialist centre in the UK and part of University College London Hospitals NHS Foundation Trust (UCLH), two inpatient wards have been dedicated to COVID-19 patients. In response to the rising bed pressure at UCLH, the Hyper-Acute Stroke Unit has been transferred to the NHNN and a new ‘Emergency Stroke Unit’ created. As a consequence, the discharge of inpatients has been greatly expedited. To prevent the spread of COVID-19, the NHNN has been placed in lockdown; all visitors are prohibited, even for patients who are very sick and dying. Non-urgent outpatient clinics have been cancelled, with those remaining mostly provided by telephone. Outpatients deemed to be ‘extremely vulnerable’ by Public Health England have been advised to shield for 12 weeks and instructed not to leave their houses, even for shopping or medication.
Clinical staff has to work at a quicker pace, in longer shifts and in smaller teams because of increased staff sickness. They must provide more general medicine and have to learn how to use personal protective equipment (PPE). Academic staff has been redeployed clinically and some staff members have been redeployed to the new London NHS Nightingale Hospital. All staff have to work knowing that they might contract COVID-19, potentially placing themselves and their own household at risk.
In response to the COVID-19 emergency and the changes in clinical care at NHNN the Department of Neuropsychology reconsidered its priorities and how best to quickly respond to the new needs. We developed brand new services to support our staff, patients, and families and carers and took urgent action to provide top-class neuropsychological care. Here, we provide a description of how we have achieved this over the past two weeks.
The Department of Neuropsychology at NHNN
Neuropsychology is a highly specialised branch of clinical psychology, whose main focus is on addressing fundamental questions about the relationship between brain and mind. We investigate how changes in brain functioning caused by neurological disorder affect how we think and how we behave. Neuropsychologists are not only trained in general mental health, but also have additional qualifications and substantial specialist knowledge in the neurosciences.
The Department is one of the most renowned and prestigious in the world. Each year we treat approximately 6,700 patients. Our main clinical role is in the assessment, management and treatment of patients with complex neurological, neuropsychiatric and neurosurgical conditions. To meet this need, we have developed a flexible, adaptive and rapid neuropsychological assessment protocol, designed for speed of administration, reliability/validity, as well as detecting change from baseline. Our assessment comprises a brief clinical interview and formal evaluation of thinking skills, including general intelligence, memory, language, perception, frontal ‘executive’ functions and speed of information processing, in addition to assessment of mental health. These thinking skills are assessed with tests developed to be reliable, valid and graded in difficulty, and suitable for people of diverse backgrounds and abilities.
We have also developed a wide range of specialised treatment programmes. These mainly focus on group interventions to help patients cope with the neuropsychological sequelae of neurological conditions. We provide strategies to help reduce the impact of deficits of memory, planning, attention and other cognitive impairments on daily living. We also provide one-to-one support to mitigate anxiety and depression, and to support adjustment to the life changes precipitated by a variety of neurological conditions.
The Department plays a role in generating world-class clinical research, publishing approximately 40 peer-reviewed research papers each year. Our research strategy aims to improve diagnostic assessment and further the understanding of brain disorders and cognitive functioning. Recent focus has been on acquiring knowledge to help improve NHS neuropsychological service provision through: development of new tests to allow better identification of frontal executive and nonverbal memory impairments; development of new brief cognitive screening tools; and improved characterisation of the reliability and stability of neuropsychological tests over time, to allow objective monitoring of patients’ thinking skills. We also undertake research addressing questions regarding the neural architecture of cognitive domains, such as frontal executive functions, memory and language, and the characterisation of specific neurological conditions.
Support services for staff
The perceived availability of direct psychological support for staff is crucial for psychological wellbeing in times of crisis (e.g. Khalid et al., 2016). Hence, we have established a psychological support service for all staff. We have developed twice-weekly, face-to-face, walk-in clinics and daily telephone clinics. Our experience, so far, indicates that staff members greatly appreciate our support services. Despite the fact that our services started very recently, we have good intake that continues to increase.
Recent studies emerging from China specifically focusing on the COVID-19 emergency reported that overall there was little uptake of formalised psychological support (Chen et al., 2020; Zhu et al., 2020). It remains unclear what type of support is most effective. Some studies have suggested that it is more helpful to focus on enabling staff members to meet their basic needs: health (adequate PPE), shelter (especially if having to isolate from family members), food and sleep (Chen et al., 2020; Khalid et al., 2016; Khee et al., 2004). Some of these studies have relatively little data (Chen et al., 2020), include few or closed questions (Dai et al., 2020), and/or non-anonymised data collection (Lee et al., 2005; Khee et al., 2004). These factors may somewhat limit the generalizability of their findings. Notably, no formal study has assessed staff members’ psychological needs during crisis in the UK. Therefore, we have developed an online survey to assess staff members’ distress and psychological needs, including access to basic provisions and usual coping strategies, as well as desire for informal or formal psychological support. The data will help us refine our support service response and inform future practice.
Neuropsychological services for inpatients
The Department has developed a highly specialised service to meet the demands of the increased number of acute stroke and neurosurgical inpatients within the time constraints of a very fast medical environment. We continue to provide comprehensive cognitive assessment where necessary, while also adopting a briefer specialist assessment model that draws upon previous work (e.g. Chan et al., 2019). In addition, we have developed a fast-turnaround reporting system to support early discharge and strengthened our work with multi-disciplinary teams to provide support for complex cognitive and behavioural difficulties. The quick discharge of patients with significant cognitive impairment has resulted in patients receiving only minimal rehabilitation in hospital. To support rehabilitation planning, we have focussed on building stronger links and outreaching to community services and relevant charity organizations such as Stroke Association.
Neuropsychological services for outpatients
Outpatient diagnostic services have been significantly delayed resulting in reduced care for patients with chronic and life-limiting neurological conditions. However, acknowledging that some assessments remain essential even during these times, we are continuing to provide face-to-face outpatient cognitive assessments for all urgent cases, with both clinicians and patients wearing PPE. We have deemed this to be necessary given the limited empirical evidence for either the validity or utility of diagnostic tele-neuropsychology (e.g. Bunnage et al., 2020).
For outpatients who have little social contact, isolation and delayed clinical care threatens to create a pandemic of loneliness (Armitage & Nellums, 2020; Van Bavel et al., In Press). The impact of this, exacerbated by increased exposure to negative framing within the media, will heighten stress responses. This may have a potential catastrophic impact upon mental health outcomes (Garfin et al., 2020). As far as we are aware, there are no evidence-based guidelines on how to manage patients’ distress at this time. Nonetheless, it is clear that patients need to be supported. Hence, we are offering all patients offered a rescheduled neuropsychological outpatient appointment a telephone consultation for interim psychological support. To relieve the burden upon already stretched clinical nurse specialists, GPs, community teams and voluntary sector helplines, we have also extended this service to all of the NHNN outpatients and stroke patients within North Central London.
Furthermore, those who had psychological difficulties before the current COVID-19 crisis are most vulnerable to exacerbated distress (Duan & Zhu, 2020). Therefore, we have not stopped any ongoing neuropsychological therapies and continue to accept all new routine referrals for ongoing psychological support. These appointments have now been converted to telephone clinics.
Support services for patients’ families and carers
For family members of inpatients with neurological conditions and/or COVID-19, we have started providing telephone consultations. For families and carers of stroke and neurosurgical patients, we have developed telephone psychoeducation about cognitive and emotional sequelae, and signposting for any ongoing needs.
In sum, we hope that our new support services not only contain and mitigate psychological distress, but also will allow us to research the psychological needs of staff, patients, their families and carers. By redesigning our existing neuropsychological services, we do not delay, but instead respond rapidly to the significant changes and increased demands caused by the COVID-19 emergency. These new services may be helpful in providing empirical evidence to determine which interventions are most useful. This will in turn inform future guidelines, should we have to face a resurgence of COVID-19 or another pandemic.
Armitage, R. & Nellums, L.B. (2020). COVID-19 and the consequences of isolating the elderly. The Lancet. Public Health; Mar 20.
Bunnage, M., Evans, J., Wright, I., Thomas, S., Vargha-Khadem, F., Poz, R., Wilson, C & Moore, P (2020). Division of Neuropsychology Professional Standards Unit Guidelines to colleagues on the use of Tele-neuropsychology. Division of Neuropsychology, British Psychological Society; Apr 20.
Chan, E., Garritsen, E., Altendorff, S., Turner, D., Simister, R., Werring, D. J., & Cipolotti, L. (2019). Additional Queen Square (QS) screening items improve the test accuracy of the Montreal Cognitive Assessment (MoCA) after acute stroke. Journal of the Neurological Sciences, 407, 116442.
Chen, Q., Liang, M., Li, Y., Guo, J., Fei, D., Wang, L., He, L., Sheng, C., Cai, Y., Li, X. & Wang, J.(2020). Mental health care for medical staff in China during the COVID-19 outbreak. The Lancet Psychiatry, 7, e15-e16.
Dai, Y., Hu, G., Xiong, H., Qiu, H. & Yuan, X. (2020). Psychological impact of the coronavirus disease 2019 (COVID-19) outbreak on healthcare workers in China. medRxiv.
Duan, L. & Zhu, G. (2020). Psychological interventions for people affected by the COVID-19 epidemic. The Lancet Psychiatry, 7, 300-302.
Garfin, D. R., Silver, R. C., & Holman, E. A. (2020). The novel coronavirus (COVID-2019) outbreak: Amplification of public health consequences by media exposure. Health Psychology; Mar 23.
Khalid, I., Khalid, T. J., Qabajah, M. R., Barnard, A. G. & Qushmaq, I. A. (2016). Healthcare workers emotions, perceived stressors and coping strategies during a MERS-CoV outbreak. Clinical Medicine & Research, 14, 7-14.
Khee, K. S., Lee, L. B., Chai, O. T., Loong, C. K., Ming, C. W., & Kheng, T. H. (2004). The psychological impact of SARS on health care providers. Critical Care and Shock, 100-106.
Lee, S. H., Juang, Y. Y., Su, Y. J., Lee, H. L., Lin, Y. H., & Chao, C. C. (2005). Facing SARS: psychological impacts on SARS team nurses and psychiatric services in a Taiwan general hospital. General Hospital Psychiatry, 27, 352-358.
Van Bavel, J. J., Boggio, P., Capraro, V., Cichocka, A., Cikara, M., Crockett, M., Crum, A., Douglas, K., Druckman, J., Drury, J. & Ellemers, N. (In Press). Using social and behavioural science to support COVID-19 pandemic response. Nature Human Behavior.
Zhu, Z., Xu, S., Wang, H., Liu, Z., Wu, J., Li, G., Miao, J., Zhang, C., Yang, Y., Sun, W. & Zhu, S. (2020). COVID-19 in Wuhan: Immediate Psychological Impact on 5062 Health Workers. medRxiv.
By tonydavid, on 15 April 2020
Call the psychiatrists?
Stereotypes abound regarding different medical specialists and their personalities. From aggressive, macho surgeons, nice-but-dim GPs to the mad-as-their-patients psychiatrists. The coronavirus outbreak has thrown other specialists into the spotlight. Critical care doctors are a new breed. Not selected for their bedside manner – their patients are usually anaesthetised. They are particularly skilled applied physiologists who understand oxygen saturation. In other words, a bit nerdy. Who knew they were brave too? The academic discipline of epidemiology – tired of explaining that theirs is the study of diseases in populations not ‘epidemics’, this is their moment to prove they have the statistical smarts to interpret the data, discern the trends and test the advice. Ironically, until COVID-19, public health specialists were perhaps the most beleaguered of all the non-coal face doctors practicing in the UK with large cuts to their budgets in recent years. Now they are effectively in charge with politicians supposedly following their advice to the letter. Even within that group’s medical specialism, the tide had long since turned away from infectious diseases – which normally account for a fraction of deaths in high income countries – towards ‘non-communicable diseases’: neurodegenerative conditions like Alzheimer’s, diabetes, heart disease, stroke, cancer, which are fast becoming the scourge of lower and middle income countries too.
Redeployment of ‘rear-guard’ staff to the frontlines followed by recall of retired healthcare workers to help with NHS cope with COVID-19 led to some amusing memes. The first was the blue woolly bespectacled face of Dr Grover being drafted in from Sesame Street to the ITU with the caption ‘stay home unless you want to be intubated by a psychiatrist’ and then Dad’s Army characters – ‘Don’t worry chaps, backup is coming’ with their pompous but insecure leader Capt. Mainwaring representing psychiatry.
We have all been asked to consider our mental health and offered myriad ways to preserve it during lockdown and social isolation. Much of the advice from the NHS has been reassuringly commonsensical and has pointed toward self-help and online resources. Do psychiatrists have particular role to play?
The biological effects of SARS-CoV-2 on the nervous system are not well understood. Experience from China does not suggest that we should anticipate cases of encephalitis and its inevitable neuropsychiatric manifestations as a result of direct infection of the brain in cases of COVID-19 but vigilance is required. The virus has been detected in the central nervous system in people with severe multi-organ disease. Common symptoms such as dizziness and headache and loss of smell and taste are best not seen as brain-based but rather general indicators of systemic unwellness and upper respiratory tract inflammation. The Association of British Neurologists is setting up a system to collate cases of suspected neurological COVID-19 and clinical neuropsychiatry colleagues from Edinburgh to Exeter have offered to help.
Experts interpret the life-threatening pneumonitis of the disease as a consequence of an all-out immunological response to the infection rather than the infection alone – it seems Boris Johnson dodged that particular bullet – and neurology textbooks have whole chapters on immune-mediated ‘post-infectious’ syndromes. But the contrast with a truly neurotropic virus such as polio which preferentially attacks motor nerve cell bodies could not be more stark. Some will remember the paralysing fear of paralysis which gripped families in the 1950’s and the dreaded spectre of the clumsy ventilators of the time – iron lungs.
The likely legacy of SARS, MERS and now COVID-19 includes psychiatric fall out. In those earlier epidemics, there were high rates of anxiety, depression and PTSD in the short term – although such outcomes never affected the majority. We know about them because people who recovered from infections serious enough to require hospitalisation were asked to fill out questionnaires on their experiences as part of simple research surveys. Few of the studies had controls groups which would allow us to conclude whether such rates were particularly high or not. PTSD is a strange one in this context. Not that being rushed to hospital and seeing the person in the next bed gasping for air and perhaps eventually succumbing, isn’t horrific and likely to etch itself on your memory. And the scene may come back to haunt you as intrusive memories and invade your sleep. But is it really best considered a direct consequence – part and parcel – of your own illness given that your sole allowable visitor, uninfected by the virus, might have been similarly traumatised?
If there are any lessons from psychiatry at times like this is it is to hang on to a kind of natural and shared immunity which we may find deeply embedded within. Natural in the sense of non-technical. Several studies on ‘psychological debriefing’ after traumatic events, have shown that, not only does this not help it makes the situation worse. Perhaps it derails the natural processes – biological, psychological and social – that have evolved to deal with major adverse events. By ‘medicalising’ the process, however unwittingly, it seems that we expose people to more harm rather than inoculating them against it. Hence the UK wide Royal College of Psychiatrists’ sensible advice to resist the temptation to offer such services to colleagues in the frontline. We don’t need the argot of traumatisation and therapy to speak to each other of loss, or bereavement and the yearning for physical contact. Those in the frontline don’t need someone to encourage them to emote in a certain way, to list the pain and guilt, the numbness or indeed the quiet victories. They do need a good night’s sleep, personal protection, reassurance that their efforts are appreciated and the above all the chance to share and fashion stories with each other.
The urge to ‘do something’ is strong and many of my senior colleagues feel at best side-lined and at worst, guilty for not practicing physical medicine. But there is plenty for us to do. Accident and emergency departments still attract a steady stream of people whose repertoire of coping with distress is limited to stereotyped and concrete demonstrations through the medium of physical self-harm. It is expecting too much of them that they will find more adaptive ways of dealing with it at the moment. It’s difficult enough for professionals to find the right words for them, or indeed any words but we are best placed to try. Suicide – since it was first studied by Emil Durkheim in the 1890s – tends to fall at times of national crisis like war perhaps because of an enhanced sense of collective solidarity. Let’s hope that applies to this pandemic. Then there are those with serious and enduring mental illnesses – such as schizophrenia. Perhaps half a million of them in the UK, living in sheltered accommodation, hostels and bedsits, if they’re lucky. People for whom companionship and intimacy are seldom seen as unalloyed good but often as harbouring threat. Social isolation for them is the default. If you live in a world where, at the best of times, religion, TV, and the internet rather than a comfort or distraction, seem arranged to undermine your sense of self, imagine what it’s like to be in the midst of a pandemic caused by invisible lethal particles invading your body – and your mind – where everyone is a bit paranoid. When AIDS was much more of a pre-occupation than it is today, one of my patients described how her longstanding nemesis, the persecutory voice that followed her every thought, announced that he was suffering from the virus ‘himself’. Eventually the voice, that personification of threat, succumbed to the disease and fell silent. My patient enjoyed a few days of blissful respite until the virus in a final posthumous category-defying leap, infected her too, at least that was her conviction. Such people are our responsibility and they need our arm’s length support not to mention maintenance medication.
For those feeling under pressure to play a more active role, the Hippocratic dictum: ‘first do no harm’ is worth remembering. I was required to take a version of the hippocractic oath when I qualified, and it always seemed to me to be a low bar and dead-weight to idealism and ambition. But now it seems aspirational. Colleagues in behavioural science struggled to come up with a useful ploy to get people to stop touching their faces; it’s not as easy as you think. ‘Sit on your hands’ was what they settled upon. Good advice all round.
14th April 2020, London.
Professor Anthony David, is Director of the UCL Institute of Mental Health and author of “Into the Abyss: a neuropsychiatrist’s notes on troubled minds.” Oneworld Publications.
The mental health impact of COVID-19: looking forward. Why we need high-quality longitudinal studies.
By Maria 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 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 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 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 firstname.lastname@example.org
By tonydavid, 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 tonydavid, 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 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!