Thursday, 12 December 2013

How useful are comparisons in mental health?

Everywhere you look in life there are comparisons to be made, comparisons being made, it's part of how we learn and assess the world around us. We make decisions based on comparing the options and judge ourselves based on comparisons with others or conceptual versions of ourselves.

Enter the weird and wonderful world of mental health and you have a while new realm of possible comparisons. From the resentful indignation of 'well I'm more I'll than her why does she get so much help?' to the opposite, suffering quietly in a corner believing everyone else is so much sicker than you.
Scale it up and it's not just sufferers who compare either, there's a constant assessment from above; who is most at risk, who may warrants funding, who to focus limited resources on. Medications and other treatments are based on studies stating in what percentage of cases they work better than placebo. Everything is judged and analysed and put in boxes with other comparable cases.

Scale up once more and you find yourself in the place I really want to consider in this post. The place where you're comparing mental illness with physical illness. It happens a lot of course, both positively and negatively. On an individual level someone may be seen as less deserving of help or sympathy if they have a mental rather than physical condition, they may find it harder to get benefits, treatment, social support. On a societal level mental health departments and charities may get supported and funded differently, mental health may be portrayed differently in the media.
Which leads nicely into the 'positive' comparisons. Often mental health awareness images, such as the one featured, will draw comparisons to physical illness as a way to shock and make people think. Comparisons of funding amounts, levels of research, mortality rates can also be seen. All of this can only be a good thing, it raises awareness, gets people talking and presents a new viewpoint. But does it go far enough?

Are we shooting ourselves in the foot by comparing mental and physical illnesses, does it just help to cement the public perception of them as two entirely separate entities? Should we stop talking about mental and physical health and instead just talk about health?

The more you compare the more you highlight the differences as well as the similarities and the more pronounced segregation you create. Of course, no-one is suggesting schizophrenia and lung cancer are similar in any but the most basic ways. But the same could be said for lung cancer and crohn's disease. We take physical illness and split it down in hundreds of different ways: congenial disease, vascular disease, cardiac disease. There are hospital departments for oncology, radiology, endocrinology. And yet we take all mental health lump it together and treat it as something entirely different.

A holistic approach has long been established in other cultures, Chinese medicine is probably the one most famed for its all round approach. Mind body spirit. Here in the West we refer to it as a biopsychosocial approach and we're a little more wary of it.
However there have been links drawn between mental and psychical illness stretching back to Frued and his (admittedly somewhat dubious) case studies of 'hysterical illness'. Whilst the cases themselves don't always stand up to scrutiny the idea is important, that psychological illness can cause physical illness.
More modern studies show similar links, I'm thinking particularly of research into stress as that's what I know but I'm sure there are other examples. The 'executive monkeys' who appeared to develop stomach ulcers simply from the stress of being responsible for whether or not they and other monkeys were shocked (Brady 1958). The drop in immune activity in medical students during exam time compared to the same students in less stressful times (kiecolt-glaser et al. 1884). The puncture biopsies that took, on average, 24% longer to heal in those in the stressful situation of caring for a loved one than they did in matched controls (kiecolt-glaser et al. 1995). You get the picture.
And then you have the same flipped on its head. Low levels of serotonin identified in depression. Twin studies that show a genetic link in anorexia nervosa and bulimia. Possible structural changes in the anorexic brain.
Then what of diseases such as alzheimer's? Widely accepted as a medical condition, we can pin point a wide range of neurological changes and it has some physical symptoms. It also has significantly more psychological symptoms. It's also affected hugely by the mood of the sufferer and by their social situation. If floats somewhere in the middle. Yet similar things can be said about illnesses we consider as purely psychological.

Intuitively we know that our mood suffers if we're physically ill, we're more likely to catch that big that's going around if we're stressed out. As for the social aspect of biopsychosocial, everything is just a little bit better when you've got someone who cares, right?
Bearing all this in mind it seems hugely reductionist to think merely in terms of black and white, mental and physical. There's a huge spectrum of wonderful grey out there that doesn't want to stay in the boxes it's been forced into.
Illness is illness no matter what part of the body it affects and no matter how well or poorly we understand it.

End lecture! Night. X