RANZCP Essay

Submitted as part of the RANZCP 2019 PIF Essay competition.
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Topic: 'The more we understand mental health, the more we diagnose mental illness'

Introduction and Background

In a World health report issued by the World Health Organization (WHO) almost two decades ago, then-Director General Dr Gro Harlem Brundtland issued a rallying call for global policy makers and members of the public to consider the urgency with which mental health issues needed to be addressed (World Health Organization [WHO] 2001). The report entitled Mental Health: New Understanding, New Hope contained within its missive a growing awareness of the biological, social, and psychological factors contributing to mental illness, as well as an understanding that mental wellbeing represented a fundamental public health priority (WHO 2001). It is now common knowledge that mental health disorders place a significant burden on communities from a variety of healthcare, social, and economic perspectives.

One in five Australians are estimated to experience a mental disorder each year; with forty-five percent of the population having a common mental disorder in their lifetime, equating to around 8.7 million people based on 2017 population statistics (Australian Institute of Health and Welfare [AIHW] 2019). The neglect, social stigma, discrimination and physical health consequences faced by those with mental illness may inevitably, and tragically, culminate in suicide (State of Victoria, 2019). Suicide constitutes the leading cause of death among people aged 15-44 years, and accounts for the highest number of years of potential life lost, with over 3000 Australians dying prematurely from intentional self-harm (Australian Bureau of Statistics 2018).

Where mental illness and (good) mental health have traditionally be diametrically opposed (State of Victoria 2019), an increase in the evidence-base surrounding identification and treatment of psychiatric illness, as well as a rise in popularity of certain buzzwords like “wellbeing” and “mindfulness” in the social media lexicon have simultaneously brought mental health and its interface with mental illness to the fore (Parker et al. 2018). The recent Royal Commission into Victoria’s Mental Health System recognised that mental health is not simply the absence of mental illness, but the circumstances in which individuals may be allowed to reach their fullest potential, and contribute meaningfully and productively to their community (State of Victoria 2019; Council of Australian Governments 2017). Indeed, individuals are no longer referred to as ‘suffering’ from mental illness, rather that they are ‘living’ with it. With this collectively burgeoning interest in mental health, there are concerns regarding the overdiagnosis of mental health problems and the medicalisation of normal human experiences as part of illness (Dowrick & Frances 2013; Parker et al. 2018). This essay aims to deliberate whether a greater understanding of mental health has brought with it increasing diagnoses of mental illness; as well as the harms and benefits in allowing these ends of a spectrum to coalesce.

The Social and Economic Implications of Mental Health Diagnoses

As Perkins et al. (2018) have pointed out, diagnosing a mental health condition may have unintended consequences and lead to increased individual and societal burden, feelings of hopelessness, frustration, as well as alienation and disengagement from services. Conversely, it may also engender a sense of relief; offering hope for recovery, improved relationships, and reduced uncertainty (Perkins et al. 2018). Where a diagnostic label may provide the same revelatory capacity as a cape to a superhero, the question becomes a matter of perceiving how individuals will use their newfound knowledge for better or for worse. From an economic perspective, it remains a question of whether the country’s mental health system is structurally-replete to handle the growing number of mental health diagnoses, as well as the expectations surrounding treatment.

In recent years, mental health services were estimated to comprise 7.4% of combined government recurrent health spending; which in 2016-17 amounted to $9.1 billion in economic expenditure (AIHW 2019). The Royal Commission conceded that mental health-related services had reached ‘crisis point’ (State of Victoria 2019). ‘Cracks’ in the system meant that many people living with mental illness were not receiving adequate support when and where it would be the greatest benefit (State of Victoria 2019). Meanwhile, increasingly commonplace diagnoses of major depressive disorder, combined with the arguably more liberal use of antidepressants, have raised concerns that health systems are medicalising unhappiness; and diverting resources away from those who need it most (Dowrick & Frances 2013).

The Harms of Overdiagnosis in Mental Health

Where false-positive results have been more frequently identified than missed cases in a meta-analysis of depressive disorders (Dowrick & Frances 2013), the likelihood of overdiagnosis seems more probable than underdiagnosis when applied to mental health conditions. As society has become more cognisant of the neurobiochemical imbalances implicated in the development of mood disorders, the solution has been distilled into a once-daily pill designed to supplement serotonergic stores and universally offer reprieve (Dowrick & Frances 2013). In 2017-18 alone, 4.2 million patients in Australia received mental health-related prescriptions (AIHW 2019). The danger in performing such prompt diagnosis and treatment is the propensity to neglect other important (social) contributors to emotional wellbeing, which may require longer-term adjustment but could prove to be more effectual in bringing about positive change (Parker et al. 2018; Hackmann et al. 2019).

It is also implied that there is room for misdiagnosis and mistreatment where diagnostic lines fall equivocally short (Perkins et al. 2018). An observational study of seven UK general practices, which measured discrepancies between GP ratings of depression severity and validated screening instruments (Kendrick et al. 2005), found that almost half of the patients prescribed antidepressants did not fall under the category of major depression (Aragones et al. 2005, Kendrick et al. 2005). Less than a third of patients in whom depression was suggested as a diagnosis were offered follow-up or counselling (Kendrick et al. 2005). Where there is a failure in initial response to treatment, decisions to increase or switch to second or third-line therapies pose additional risks of multiple drug combinations and deleterious side effects (Parker 2007). What ultimately results is an increase in unsolicited prescriptions to patients who might not warrant or benefit from medical treatment.

A further risk of overdiagnosis falls under the purview of mental health diagnoses acting as self-fulfilling prophecies (O’Connor et al. 2018). The possibility that diagnoses may influence expectations of a person’s behaviour, which in turn changes how they are received by peers, services, or in future employment – may ironically render these illnesses more likely. Such an argument favours the perspective that a greater understanding of mental health leads to more diagnoses of mental illness in the community. An alternative view is that mental health problems are likely to be incipient in predictably vulnerable groups; and by targeting interventions in the early stages of illness, there is a greater chance of mitigating secondary comorbidities (Hickie 2007; O’Connor et al. 2018).

The Benefits of Increased Mental Health Awareness

An expansion in public understanding of mental health, such as through the advent of mental health apps (Parker et al. 2018) and discernibly influential campaigns like ‘R U Ok? Day’ (Ross & Bassilios 2019) have allowed for an encouragingly positive discourse on mental illness. Where increased rates of diagnosis have necessarily led to treatment and prevention of suicide, the potential for saved lives may ostensibly outweigh any risks of overdiagnosis (Hickie 2007; Ross & Bassilios 2019). In insurance-based health schemes like the US where diagnostic labels carry even greater significance for covering the cost of treatment (Dowrick & Frances 2013), the incentives for seeking out mental health care are magnified, along with the benefits of removing societal stigma, reducing substance misuse, and encouraging active interventions towards improving quality of life (Hickie 2007). Fundamentally, ascribing a label to validate an individual’s emotional distress also appears to redress harmful self-medication (O’Connor et al. 2018); while exposure to others who have sought help for mental health disturbances is predictive of similar treatment success (Wright et al. 2007).

With due respect to the clinical shrewdness of primary care clinicians, psychiatrists, and purveyors of the mental health service, most doctors are reasonably well-versed in differentiating normal distress from severe psychiatric conditions (Hickie 2007). Contingency plans which facilitate ongoing collaborative diagnosis, communication, and shared-decision-making regarding treatment or therapy may inherently empower patients to seek help if symptoms worsen, fluctuate, or if functional capacity is impaired (Inder et al. 2010; O’Connor et al. 2018, Hackmann et al. 2019).

Where there is fear that the medicalisation of unhappiness places undue burden on individuals and health systems, the inverse suggests that an open discussion of mental health diagnoses favours greater self-understanding, self-enhancement, and individual agency in the use of healthcare services (O’Connor et al. 2018). An improved health literacy can likewise help to foster a shared identity with similarly-affected groups (Jetten et al. 2014). Insofar as group-identification may be regarded as an invaluable psychological resource, individuals with lived-experiences of mental illness also typically provide a rallying-point around which support and education can be mutually-exchanged (Jetten et al. 2014; State of Victoria 2019). Such processes might even lessen the load on higher-level services. A greater collective transparency around mental health therefore has the best chance of improving outcomes for all.

Conclusion

The dilemma that society’s enhanced awareness of mental health issues has shifted the focus towards conflating normal human experiences with mental illness is a concern that must be weighed against the benefits of providing care to those with actual psychological and psychiatric needs. The duty of the psychiatrist, and the healthcare professional alike, remains strongly enmeshed in the responsibility of benefiting a patient’s physical and mental wellbeing. By establishing the grounds for long-term therapeutic relationships, there is no real danger of overdiagnosis and instead, we are working to preclude the loss of human lives and the preservation of an essential vitality in our communities.

References

Aragones, E, Pinol, JL & Labad, A 2006, ‘The overdiagnosis of depression in non-depressed patients in primary care’, Family Practice, vol. 23, no. 3, pp. 363-368.

Australian Bureau of Statistics 2018, 3303.0 Causes of death, Australia 2018, viewed 12 December 2019, https://www.abs.gov.au/ausstats/abs@.nsf/mf/3303.0.

Australian Institute of Health and Welfare (AIHW) 2019, Mental health services: in brief 2019, Cat. no. HSE 228, Australian Institute of Health and Welfare, Canberra.

Council of Australian Governments Health Council 2017, The fifth national mental health and suicide prevention plan, Australian Government; Canberra.

Dowrick, C & Frances, A 2013, ‘Medicalising and medicating unhappiness’, British Medical Journal, vol. 347, no. 7937, pp. 20-23.

Hackmann, C, Wilson, J, Perkins, A & Zeilig, H 2019, ‘Collaborative diagnosis between clinician and patient: why to do it and what to consider’, BJPsych Advances, vol. 25, no. 4, pp. 214-222.

Hickie, I 2007, ‘Head to head: Is depression overdiagnosed? No’, British Medical Journal, , vol. 335, no. 7615, p. 328.

Inder ML, Crowe, MT, Joyce, PR, Moor, S, Carter, JD & Luty, SE 2010, ‘“I really don’t know whether it is still there”: ambivalent acceptance of a diagnosis of bipolar disorder’, Psychiatric Quarterly, vol. 81, no. 2, pp. 157-165.

Jetten, J, Haslam C, Haslam, SA, Dingle, G & Jones, JM 2014, How groups affect our health and well-being: the path from theory to policy, Social Issues and Policy Review, vol. 8, pp. 103-130.

Kendrick, T, King, F, Albertella, L & Smith, PWF 2005, ‘GP treatment decisions for patients with depression: an observational study’, British Journal of General Practice, vol 55, no. 513, pp. 280-286.

O’Connor, C, Kadianaki, I, Maunder, K & McNicholas, F 2018, ‘How does psychiatric diagnosis affect young people's self-concept and social identity? A systematic review and synthesis of the qualitative literature’, Social Science & Medicine, vol. 212, pp. 94-119.

Parker, G 2007, ‘Head to head: Is depression overdiagnosed? Yes’, British Medical Journal, vol. 335, no. 7615, p. 328. 

Parker, L, Bero, L, Gillies, D, Raven, M, Mintzes, B, Jureidini, J & Grundy, Q 2018, ‘Mental health messages in prominent mental health apps’, Annals of Family Medicine, vol. 16, no. 4, pp. 338-342.

Perkins, A, Ridler, J, Browes, D, Peryer, G, Notley, C & Hackmann, C 2018, ‘Experiencing mental health diagnosis: a systemic review of service user, clinician, and carer perspectives across clinical settings’, Lancet Psychiatry, vol. 5, no. 9, pp. 747-764.

Ross, AM & Bassilios, B 2019, ‘Australian R U OK? Day campaign: improving helping beliefs, intentions and behaviours’, International Journal of Mental Health Systems, vol. 13, pp. 1-12.

State of Victoria 2019, Royal Commission into Victoria’s mental health system, interim report, parl paper no. 87, Victorian Government Printer, Melbourne.

Wright, A, Jorm, AF, Harris, MG & McGorry, PD 2007, ‘What’s in a name? Is accurate recognition and labelling of mental disorders by young people associated with better help-seeking and treatment preferences?’, Social Psychiatry and Psychiatric Epidemiology, vol. 42, no. 3, pp. 244-250.

World Health Organization (WHO) 2001, World Health Report 2001: Mental Health: New Understanding, New Hope, World Health Organisation, e-book, ProQuest Ebook Central, Ann Arbor, MI, viewed 15 December 2019, https://ebookcentral.proquest.com/lib/unimelb/detail.action docID=284797.