Do we really “have” mental illnesses?

Should we see our mental illnesses as parts of our genuine selves or as unwelcome, alien entities? I’d be very interested to hear your thoughts on this. Personally I’m open to persuasion.

The current norm is to say “I have depression” or “I have OCD”, as if something foreign has invaded from the outside, like a bacteria.

There are obvious reasons why this is a helpful way of phrasing things. By externalising the problem, stating that the illness is not a part of their real self, the person is absolved from any blame. Their character is instead seen as having been attacked by something they had no control over. This relieves stigma, lessens feeling of self doubt and in so many cases, is a vital part of recovery.

But is it always a good thing?

To be honest, it actually doesn’t make sense to me in the context of some physical health problems. To say you “have” heart failure, for instance, sounds strange. It’s the same heart you’ve always had, except now it isn’t working as well – what exactly have you acquired, except the symptoms of the failing organ?

The same query can be applied to mental illnesses. In some cases, might it make more sense to state the problem in the personal sense, for example, “I am depressed” or “I am someone who becomes psychotic”? After all, it’s the same brain in your head, just working differently. No virus has crept in, no tumour has appeared.

Does externalising the problem prevent some people getting better? Does believing the problem is an outside agent, over which we may have little control, make changing things harder sometimes? Perhaps for some people, recognising that their diagnoses are the result of complex interactions between the outside world and their own personal reactions to it would be more appropriate. Concluding that the illness forms a part of themselves that is as authentic as any other may be a more constructive step.

In the extreme form, if a mental illness is severe and unresponsive to all treatment, could externalising the problem lead to a feeling of being tortured by something foreign that cannot be expelled? Would coming to terms with the cause of suffering as part of oneself bring a relative sense of peace?

This, of course, is a very different stance to arguing that diagnoses themselves should be done away with. As in the heart failure example, the diagnosis can still be solid despite the fact that saying someone “has” it sounds inaccurate. It’s also very different to stating that people with mental illnesses are in some way to blame for them.

So, are mental illnesses things that people partially are, rather than things they get?

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Antidepressants are not ‘happy pills’

 

I am sick and tired of the way the press portrays depression as unhappiness and antidepressants as ‘happy pills’.

Over and over and over and over and over again they tell us that we’re medicalising our normal emotions and that resorting to tablets simply encourages our own helplessness.

The professional equivalent of cutting and pasting, the same article seems to keep coming back like a bad penny. For problems in other areas of health we’d only trust the experts to comment, but when it comes to mental health it seems like anyone can cast judgement. Every author seems to think they’ve discovered something amazing, when all they’re actually doing is repeatedly insulting a huge group of people with their ignorance.

‘Normal Unhappiness’

Depression is not normal unhappiness, it is not something everyone goes through at some point. Only someone who has not been depressed would say that. It is not a bad day at the office or a row with your partner. Depression feels like someone has reached inside your chest and torn out your soul with a rusty spoon. And is laughing at you about it.

You can’t just choose to instantly recover from depression. It is not a case of willpower or a lifestyle choice. Why would anyone choose to be depressed? Unsurprisingly, ‘snapping out of it’ or ‘pulling yourself together’ have already occurred to people who are depressed, because they aren’t stupid.

I agree, the causes and biological markers of depression are still murky to us. We don’t have a blood test or a scan for it and we realised that the ‘serotonin hypothesis’ was too simplistic decades ago. But this does not make depression any less of an illness, because the symptoms are still there. Just like migraines, we know very little, but we shouldn’t bizarrely stop calling it an illness just because of that.

‘Happy Pills’

Antidepressants are not ‘happy pills’. They do not make you happy. If you’re lucky they take the edge off the searing, crushingly hopelessness and allow you to focus your thoughts in reality just long enough to find a solid foundation for recovery. Taking them is not an admission of defeat or weakness, it is accepting help for a problem which can lead to devastating consequences.

Nor is taking antidepressants an admission that you have a brain disease instead of a complicated illness with psychological and social factors. Antidepressants can be the crutch people use to make it to talking therapy, just like pain killers can be the crutch people use to do physiotherapy. If they help it should be lauded, not chastised on ideological grounds (‘I know you feel better on tablets but I don’t think it’s right for you to be taking them’).

However complex the cause of depression is, we know that antidepressants can help. Even staunch antidepressant-hater Joanna Moncrieff has done a meta-analysis which suggests it, and the largest critical meta-analysis suggests they still work in severe depression.

They don’t work for everyone, but no drug does. In fact, antidepressants work at least as well, if not better, than drugs from the rest of medicine. They have side effects, but every drug does. Some say ‘they only numb you’, as if being numb sounds like a bad thing to someone who feels so gut-wrenchingly low.

The real issues

The real issues are that so many people feel so low that a doctor thinks they might benefit from antidepressants, and that there isn’t enough provision of alternatives in these situations. The first choice treatment for mild to moderate depression, as every reasonable GP knows, is actually talking therapy. But the waiting lists are horrendous and GPs feel they need to do something.

The press desperately need to take a more nuanced view of these genuine issues or they’ll continue to trample over the thousands of people who genuinely need antidepressants to continue living their lives.

For the final time:

Depression is not normal unhappiness and antidepressants are not ‘happy pills’.

First Do No Harm

Sometimes people tell me that treatments like antipsychotic medication and ECT are unethical because they can have side effects. The Hippocratic adage “First Do No Harm” gets quoted as proof that no treatment that could harm someone should ever be prescribed.

And that would be fine, except that’s not what the old saying really means. Doctors would be in a tricky spot if it were. Every single treatment ever given to a patient has held the potential to cause harm – chemotherapy is a horrendous assault on a person; any operation could be terminal. Even taking a blood sample can cause bruising.

In reality, “First Do No Harm” (or “Primum Non Nocere”) is more complicated, and in fact, Hippocrates never even said it. The earliest known attribution is to medieval doctor Thomas Sydenham (1624-89) in an 1860 book by Thomas Inman.

In modern times we associate the famous saying with the two ethical principles of non-maleficence (avoiding harm) and beneficence (doing good). The two principles constantly hang in a delicate balance as we try to decide just how much to treat someone, knowing that every treatment we give has inherent risks. Sometimes it might even turn out that doing nothing is best, if all the available treatments are known to be ineffective or the condition is known to be self-limiting.

So a more authentic interpretation of the phrase might actually be “make sure you consciously try to do more good than harm”, though that wouldn’t look so good in Latin.

This balance between trying to do good and risking harm is no less important in psychiatry than anywhere else. It’s also where the real ethical criticism of some of our treatments can be found – we sometimes get the balance wrong, giving too little thought to risks when we chase improvements. Antipsychotics can be prescribed for too long and in high doses; admissions under the Mental Health Act can drag on long past the point of overall benefit. Thousands of people are given antidepressants for sadness that will pass naturally.

I can understand how this happens. The future is hard to predict; we can never really be sure how well a treatment will work or which side effects will show up. Turning incomplete information into good decisions is not something the permanently biased human brain does well, so we often do something rather than nothing simply because it feels like we’re helping.

But another medical ethical principle could help us out – autonomy. The right of the patient to make decisions for themselves if at all possible is, I think, the most overriding right in medicine. If we involved patients more often in making decisions about their care, by explaining the potential risks and rewards of each option, the best course of action might become obvious. Some would be immediately keen on taking the risk, for others they might have strong personal reasons against it. We could share in the success when things go well and share the responsibility when things go badly.

So “First Do No Harm” doesn’t mean what many people think it does, but perhaps we could still improve on it.

How about “First, Discuss The Harms”?

Maudsley Debate #50: “CBT for psychosis has been oversold”

I live-tweeted from the 50th Maudsley debate, “CBT for psychosis has been oversold”, earlier tonight. You can read my storify of the event here.

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