As always I should probably start with a caveat on the use of language. My use of language can be complicated. I consider there is precision in the meaning of the words but I consider the concepts the most important thing. I can be guilt of using the word madness or using the word mental health problems to describe the same concept but make differentiations between mental health problems and mental illness. I probably have a split personality or something. ; ) Its just a laziness of communication.
The conversation in the pub yesterday evening started with the misquoted 1 in 4 statistic. Its actually a reasonably high quality statistic though as all statistics in social science it is a ball park figure. Its 1 in 4 in a year but its often misquote as 1 in 4 in a lifetime by most of the people who use it.
The figure comes from the work of Huxley and Goldberg from a book they published in the 1980s. They established a period prevalence of 180/1000 people with a very high expectation of a clinical mental health problem sampled (if I remember right) in a one month period and using some complicated science estimated a multiplying factor to calculate the incidence (yearly prevalence) which came to exactly 250/1000, hence 1 in 4 in a year. In their later book in the 1990s they admitted that multiplying factor may have been miscalculated and underestimated. That's good scientists for you.
The figure is also backed up by the Adult Psychiatric Morbidity Survey using British Housepanels Survey data (if I remember right) uses a 2 week sampling period to establish a 1 in 6 figure at any one time. That sampling period is around half that used in the Huxley and Goldberg 180 in 1000 figure and 1 in 6 is approximately 167 in 1000. Using the same multiplying factor the 1 in 6 figure comes in slightly lower than 1 in 4 a year which is expected with the shorter sampling period. They're both in the same ball park. There's also no evidence I've ever found for a 1 in 4 in a lifetime measure of people with mental health problems.
Both those high quality examples produce a 1 in 4 figure but its important to know what that means and that's what's often contented by mental health scientists and statisticians when discussing 1 in 4. Does it mean mental illness (psychiatric illness), mental health problems (a broader definition) or experience of mental distress (as is used by one of the major UK charities in a lot of its marketing)?
Lets get rid of the last one first. In any sense of real use of language 1 in 4 is not to do with people who experience mental distress. Everyone in their lifetime experiences mental distress, or 99.95% do because there are always exceptions and different experiences of life. That may even be true for the incidence as well.
The second two options are where the debate gets interesting though takes something of a tangent. The idea of psychiatric mental illness is a concept based dogmatically on the strict fitting of symptoms to the cluster of systems defined in the accepted diagnostic criteria (usually DSM). High scores on the screening tool used in the APMS do not mean the same as a clinical interview or a diagnosis given by a psychiatrist, though it would indicate a high probability that the individual may be suffer from mental illness. "mental health problems" are often misconstrued as a euphimisation of mental illness whereas those who are precise with the language consider them to be lesser conditions or conditions based around distress specifically rather than the spectrum of psychiatric illness.
The conversation last night moved onto the point about homosexuality. After it was demedicalised first in America there was a debate about a diagnosis about homosexuality that was to remain in. I can't remember the name of the diagnosis but it covered the period of adjustment and the associated distress where a person goes from considering themselves hetereosexual (or 'normal') to accepting the homosexual feelings and desires. This diagnosis was not kept in DSM-III and future revisions. If I remember right the diagnosis was not included because the distress was thought to be a normal part of the process and therefore not to be medicalised.
(need to find the reference for this)
The conversation also moved onto grief as another example where 'normal' distress is not considered part of the mental health system. An often underused diagnosis in primary care is the adjustment disorder which relates to a life stressor creating symptoms defined as mental illness, however it carefully excludes anything related to grief. Bereavement and its consequences though they may be distressful and may induce social or psychological dsyfunction seems not to be part of the mental health systems compassion. (This has to be balanced by the fact that practice and academia are two very different worlds and it is likely that a GP may consider a referral for psychological therapies even if they suspect symptoms may be caused by a death and may consider medication).
Another digression moved into alternate mental health systems, specifically religion, and their consideration of grief. First of all this particular "alternate mental health systems" is a concept that needs further explaining is a separate post but for the moment its necessary to accept that the psychiatric system is not the only system that has ever controlled and helped people with emotional, behavioural or other forms of expressions of unusualness or distress. The example of a system of grief management was taken from the Islamic system (though in fact this may be a cultural system rather than specific to the religion). It is culturally accepted and it is even encouraged to wail and cry and 'freak out' and externalise as much as possible after a death. These behaviours are possibly considered "a bit much" in repressed societies but in other societies the holding in of grief and showing a bit of stuff upper lip is conisdered a poor way to deal with the aftermath of death. In the same system though there is a time limit on this grief. After one month the mourning period is over and it becomes time to get on with things.
Its surprising that there's nothing on grief in DSM-IV-TR. In fact there is. On page 756 of the 1323 page manual there's a short paragraph on the section about depressive disorders. It sets 2 months as the length of time before a diagnosis of major depressive disorder can be given and an individual offered short-term psychotherapy to deal with unresolved grief issues and pharmacotherapy. It also mentions that normal grief 'symptoms' usually happen within 2-3 weeks and resolve spontaneously over 6-8 weeks. That's it.
So the psychiatric system is clearly different from what most people would expect based on the ideal of a formalised system of human compassion. Its careful to select which forms of distress are normal and which aren't. It carefully attempts to tread that line between what is thought to be normal and what it considers an illness and abnormal, even though 1 in 4 people in a year are likely to receive a psychiatric diagnosis. The diagnostic criteria seems to leave certain types of distress out, specifically grief, lumping it in haphazardly into a paragraph in the length section on depressive disorders. And it used to 'treat' normal ways of being such as homosexuality.
Its a bloody interesting thing eh?!
No comments:
Post a Comment