Mental illness is not a state of mind

The author’s view that the ‘pathological’ state of mental illness must be distinguished from the ‘normal’ one of existential hardship is highly problematic. I’m concerned that this article serves only to exacerbate several misunderstandings about mental illness which prevail amongst healthcare professionals and members of the public.

From a practical point of view, the fact that antidepressant medication, antipsychotic medication, and cognitive/behavioural interventions all have the same effects in mentally ‘healthy’ individuals as in those who have been assigned a psychiatric diagnostic label1,2,3,4 shows that trying to divide the mentally well from the mentally unwell is at the very least a therapeutically useless exercise, whether or not it is a scientifically valid one. All of our currently available treatments for mental illness ameliorate symptoms; they do not cure disease.

The author suggests that the mentally unwell can be identified as those who demonstrate an inability to “adapt correspondingly to their surroundings and circumstances” and whose “objective reality is not distorted by their perceptions”. Even if it were useful or valid to make such a distinction, who should determine whether a distressed person’s response is appropriate or their perception is non-distorted? It should be noted that the Oxford English Dictionary defines ‘objective’ as “not dependent on the mind for existence”5, meaning that no human being can ever pronounce ‘objectively’ on such matters.

In addition, the author’s statements that “Someone with major depressive disorder or psychosis is not going to get better simply by meditating or going for a brisk walk” and “I do not think that bipolar depression or psychosis can be substantially alleviated by words or behavioural advice” are also problematic, because the former is incorrect and the latter appears to be an opinion which is at odds with the available evidence. There is insufficient evidence to make definitive statements on the effect of exercise on major depressive disorder or the effect of cognitive/behavioural interventions on bipolar depression (although it would appear that psychological therapy is likely to reduce the probability of relapse in bipolar disorder by 40%6). However, there is ample meta-analytic evidence that mindfulness meditation produces symptom reduction in major depressive disorder and psychosis7,8,9,10, as well as that cognitive/behavioural interventions produce symptom reduction in psychosis11,12,13. Of note, the effect sizes for these interventions are similar to or greater than those of antidepressant14 and antipsychotic15 medication. Whether or not one considers these benefits to constitute ‘getting better’ or ‘substantial alleviation’ is, of course, a matter of opinion.

The author’s overarching concern – that suffering due to psychological experiences is often minimised by people in our society – is one that I share and am bothered by on an almost daily basis. However, there is accumulating evidence that labelling sufferers as ‘diseased’ and therefore ‘abnormal’ is not only unhelpful but is in fact harmful – it causes distress to sufferers16 and increases negative attitudes towards them17.

Given the current state of scientific evidence pertaining to the mechanisms of mental illness, I think a more nuanced view is required. When we suffer from mental illness we are neither ‘overreacting’ nor ‘diseased’ – due to associations learned during previous experiences and influenced by our genotype, our brains often react to thoughts and events in ways which might ultimately lead to distress and functional impairment.

1 Seretti, A., et al., 2010. Antidepressants in healthy subjects: what are the psychotropic/psychological effects? European Neuropsychopharmacology, 20, pp.433-453.
2 Healy, D. & Farquhar, G., 1998. The immediate effects of droperidol. Human Psychopharmacology, 13, pp.113-120.
3 Malouff, J.M., et al., 2007. The efficacy of problem solving therapy in reducing mental and physical health problems: a meta-analysis. Clinical Psychology Review, 27, pp.46-57.
4 Mazzucchelli, T.G., et al., 2010. Behavioural activation interventions for well-being: a meta-analysis. The Journal of Positive Psychology, 5(2), pp.105-121.
5 Oxford University Press, 2016. Oxford Dictionary of English [online] Available at: https://en.oxforddictionaries.com/definition/objective
6 Scott, J., et al., 2007. A meta-analysis of relapse rates with adjunctive psychological therapies compared to usual psychiatric treatment for bipolar disorders. The International Journal of Neuropsychopharmacology, 10(1), pp.123-129.
7 Khoury, B., et al., 2013. Mindfulness interventions for psychosis: a meta-analysis. Schizophrenia Research, 150, pp.176-184.
8 Chiesa, A. & Seretti, A., 2011. Mindfulness based cognitive therapy for psychiatric disorders: a systematic review and meta-analysis. Psychiatry Research, 187(3), pp.441-453.
9 Klainin-Yobas, P., et al., 2012. Efficacy of mindfulness-based interventions on depressive symptoms among people with mental disorders: a meta-analysis. International Journal of Nursing Studies, 49(1), pp.109-121.
10 Piet, J. & Hougaard, E., 2011. The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: A systematic review a meta-analysis. Clinical Psychology Review, 31, pp.1032-1040.
11 Zimmerman, G., et al., 2005. The effect of cognitive behavioural treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. Schizophrenia Research, 77(1), pp.1-9.
12 Pfammatter, M., et al., 2006. Efficacy of psychological therapy in schizophrenia: conclusions from meta-analyses. Schizophrenia Bulletin, 32(1), pp.S64-S80.
13 Wykes, T., et al., 2008. Cognitive behaviour therapy for schizophrenia: effect sizes, clinical models, and methodological rigour. Schizophrenia Bulletin, 34(3), pp.523-527.
14 Hieronymous, F., et al., 2016. Consistent superiority of selective serotonin reuptake inhibitors over placebo in reducing depressed mood in patients with major depression. Molecular Psychiatry, 21(4), pp.523-530.
15 Leucht, S., et al., 2013. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet, 382, pp.951-962.
16 Beresford, P., et al., 2016. From mental illness to a social model of madness and distress. London: Shaping Our Lives.
17 Angermeyer, M.C., et al., 2011. Biogenetic explanations and public acceptance of mental illness: a systematic review of population studies. The British Journal of Psychiatry, 199(5), pp.367-372.