Should Psychiatry be working to prevent Mental Illness in the first place?
Mental health stigma and discrimination is slowly decreasing, as shown in the report ‘Time to Change’ in 2015. Given the current effects of the COVID-19 pandemic and associated social distancing/quarantining, the incidence of mental health problems is anticipated to rise.
As a final year medical student on a placement in GP at the moment, I have witnessed first-hand the mental distress induced by the pandemic. Many people fear of contracting the virus while others have had their support structures break down to maintain social. The support that is available is predominantly virtual which doesn’t suit everyone (see the blog from my fellow Psych Star Anushka on a balanced review of the future of telepsychiatry). It is a difficult time to be living in, but I remain hopeful that mental health services will continue to do their best to serve those who most need it.
As we pass world mental health day, now is a good time to reflect and take the opportunity to think about how our efforts might be best focused to help peoples’ mental health in future.
Mental health is slowly becoming recognised as something we all struggle with to varying degrees at some time in our lives, just as we do with our physical health. As a young British Pakistani man, I myself am very grateful for the way prominent men have spoken about their struggle with mental illness; most recently Freddie Flintoff discussing his struggle with Bulimia comes to mind.
More broadly I am very happy to see that more culturally tailored mental health services exist, such as the Muslim Youth Helpline, who have been doing great work at supporting young people with mental health problems in a culturally sensitive way.
Even within healthcare itself, the taboo of being a healthcare provider with mental health issues is being broken down, and individuals such as Dr Ahmed Hankir, a psychiatrist with lived experience of mental distress (who has also written a blog on InSPIre the Mind), are being rightfully celebrated.
All this progress even within my relatively short life-span is astonishing; it has made me feel so much more comfortable and open discussing my own mental health with family, friends and colleagues.
The perception of Psychiatry has come a long way and people have been getting better at recognising common and serious mental health problems, from depression to psychosis. Although stigma still remains and needs to be tackled, the discussion shifts towards what other responsibilities psychiatry has.
My fellow Psych stars have already done a great job at discussing various aspects about the future of Psychiatry. As we reach a point where we are advocating for equal care for both mental health and physical health, the question that arises for me is: shouldn’t we have pathways in place to prevent mental health problems, as well as we do for physical health?
A helpful example in general medicine is the QRISK-3 score, a well-established algorithm which predicts the risk of heart attack or stroke over the next ten years, putting together a range of risk factors such as age, gender, ethnicity, blood pressure, cholesterol and family history. The risk can’t tell us with guarantee whether an individual will have a heart attack in the future but, regardless, it is used widely by doctors Using the tool. A 45-year-old Indian man who has a diagnosis of diabetes and high blood pressure but with no family history, would have greater than a 10% chance of a heart attack and stroke in the next 10 years. Based on this calculation, this man would be started on statins (a medication to reduce cholesterol) to prevent them from getting a heart attack, even though it may never have happened anyway.
In the same way, why are prediction tools for various mental health problems not being more widely used to prevent mental illness?
In doing so we could help reduce the pressure on an overstretched mental health service, reduce complications, and overall improve patients’ lives by reducing the potentially devastating effect of mental illness.
The exact algorithms/tools to use to predict mental illness are being developed by continuing research. The question for Psychiatry remains how to implement the use of these tools in a meaningful way.
A particularly pertinent issue within mental health is the issue of “over-medicalising”. We all have mental health and mental wellbeing, yes, but that doesn’t mean we all have mental illness (see figure below).
Classically, a mental health problem is diagnosed as a disorder once it fulfils specific clinical crieria and is causing “clinically significant distress or impairment in social, occupational, or other important areas of functioning”. However, as we move into primary prevention of mental illness, where do we draw the line? By intervening too early we risk over pathologizing and medicalising normal human phenomenon.
One area that has illustrated the blurry line between mental illness and benign human experience is in the realm of psychosis.
Psychosis is the experience of either having hallucinations (experiencing a sensation in the absence of anything causing it, such as hearing voices) or having delusions (fixed beliefs that are not in keeping with reality).
Over the last few decades, there has been a shift to recognising that treating psychosis earlier is linked to improved outcomes and this has led to the integration of core “early intervention services” to assess, investigate and treat individuals with first episode psychosis (the first time someone experiences psychosis symptoms). This takes a whole-person approach (both medical and psychological) to treat individuals with psychosis before a formal diagnosis (e.g., schizophrenia, schizoaffective disorder) is given.
Research has taken this even further with the identification of those in an “At-Risk Mental State” (ARMS) — individuals with a 20–30% chance of developing psychosis in the next 2–3 years. However, an even earlier stage of the “psychosis spectrum” (see figure ) are Psychotic-like experiences (PLEs).
The majority of people will have psychotic-like experiences at some point in their lives, such as feeling like people around you are saying things with double meaning or thinking you are destined to be someone who is very important. For the majority of people though, these experiences don’t last and are ultimately harmless, never developing into mental health problems.
However, a small group of people with distressing and persistent experiences have a greater likelihood of future mental health illness, especially psychotic disorders. Even with this increased risk, many will never transition to psychosis. Therefore, if we are hoping to implement interventions to prevent transition to psychosis, we have to ensure that the risk of interventions doesn’t out-weigh the relatively low risk of psychosis, and that the interventions are cost-effective.
One such answer is the “Clinical staging model” which originates and is already widely used to stage cancers; it’s a simple way to classify how severe someone’s disease is, and treatment is targeted to their stage. It helps provide a universal language, giving both patients and doctors information about severity, chance of complications and how to measure progression.
Similarly, in mental health it might be useful to move away from whether a particular mental health disorder is present or not, but towards a staging model on which to target care. By having such a framework, it also allows for less severe conditions between normal behaviour and mental illness to be targeted, allowing individuals to be caught before they develop a mental disorder and be given appropriately targeted treatments.
This could in the long run reduce mental healthcare costs and maximise the resources available to those who need it the most.
The question does arise: what is the role of a psychiatrist in all of this? Should psychiatrists simply stick to treating mental illness once it arises?
Although that will always stay a significant part of clinical duties as a psychiatrist — and is an important use of their skill set — I think there is scope and opportunity for psychiatrists to get involved more broadly and larger scale using their training.
We need greater Psychiatrist representation: within public health, to promote mental wellbeing; to implement targeted interventions for those at risk of mental illness, and conduct the studies to assess them in at risk individuals; and finally, to run and oversee clinical services targeted towards high-risk groups, such as Oasis. Working in collaboration with the multi-disciplinary team and GP’s may help to treat common mental health problems at an earlier stage.
Special note from the editors: This is the tenth blog of our series, The future of mental health as seen by the future leaders in mental health, written by the 2020 ‘Psych Stars.’ Selected by The Royal College of Psychiatrists, Psych Star ambassadors are a group of final year medical students awarded for their particular interest and commitment to psychiatry. During the year-long scheme as Psych Stars, students are nurtured in their interest in psychiatry through the assignment of mentors, by gaining access to learning resources and events, and by becoming part of a network of like-minded students. More information on the Psych Stars scheme can be read here. We have decided to invite each of the Psych Stars to write a blog on how they envision the future of mental health by choosing an area in which they are passionate. We have decided to run the series as a celebration of these student’s success and to provide an outlook for each of the awardees to share their passion. With a new blog published each Friday, the series will run over the next few months.
If you enjoyed today’s blog by Danish, be sure to head over to InSPIre the Mind and check out the previous blogs in our Psych Star series covering topics such as compassion, the mind-body interaction, the future of child & adolescent psychiatry, gender inequality, global health, male mental health, neuropsychiatry, telepsychiatry, and psychedelics.