For some time I have been confused by the use and misuse of the term “mental health”.
Most recently the Black Dog Institute has claimed that “almost 4 in 5 participants (of a survey of 5000 people) reported that since the (Covid 19) outbreak their mental health had worsened with over half (55%) saying it had worsened a little, and almost a quarter (23%) saying it had worsened a lot”… “Many people are experiencing high levels of uncertainty about the future (80%), and half reported moderate to extreme loneliness and worry about their financial situation. Given loneliness, social isolation, and financial stress or significant risk factors for mental and physical health, and risk factors for suicidal ideation, these findings are concerning.”
For years we have been told that 20% of the population have serious mental health issues. The notion being more resources should be spent on mental health. My concern is more about the 3% of people with a serious mental illness. This is the group that is severely disadvantaged, this is the group that has difficulty accessing treatment, this is the group that is stigmatised, this is the group that have major problems with quality-of-life. Too often mental health issues are conflated with serious mental illness both overstating the problems and resources required for those with mental health issues and understating the resources required for people with serious mental illness.
Andrew Fleming, the creator of Financial Mindfulness (a private start-up), has produced an app that is said to support the mental health of those in financial stress. He is quoted as saying that as the health threat of Covid 19 dissipates, anxiety over finances will remain potentially worsen. “Now the curve has flattened on new infections, another set of indicators are already in a dangerous upswing that seems certain to cause damaging financial stress long after the viruses sustained spikes in unemployment, mortgage stress, rent arrears, credit card and other debts,” he said…. “Financial stress, from uncertainty and reducing income could be the most serious enduring impacts of the global crisis”. This should be good for his bottom line.
Ian Hickie, Patrick McGorry and the AMA President have issued a joint statement that mental health problems triggered by Covid 19 would claim more lives than the virus itself. “Modelling suggests the pandemic may give rise to 25% more suicides, with up to 30% of those aged 15-25 years.”
Accordingly they call for:
I have been unable to access the modelling discussed in this release.
Interesting studies with regard to suicide include:
Suicide Life Threat Behav. 1992 Summer;22(2):240-54.
The impact of epidemic, war, prohibition and media on suicide: United States, 1910-1920. Wasserman IM1.
The paper utilizes a natural experiment approach to estimate the impact of exogenous social and political events on suicide behavior in the United States between 1910 and 1920. The study is concerned with determining the impact of World War I, the great Influenza Epidemic, and the prohibition experiment on suicide. Estimating the monthly population in the United States registration area from 1910 to 1920, monthly suicide and mortality rates are computed. A time-series model is postulated, and second-order autoregressive estimates are used to determine the impact of the independent variables in the model. It is concluded that World War I did not influence suicide; the Great Influenza Epidemic caused it to increase; and the continuing decline in alcohol consumption between 1910 and 1920 depressed national suicide rates.
Life and death during the Great Depression José A. Tapia Granados and Ana V. Diez Roux
Proceedings of the National Academy of Sciences PNAS October 13, 2009 106 (41) 17290-17295; https://doi.org/10.1073/pnas.0904491106
Recent events highlight the importance of examining the impact of economic downturns on population health. The Great Depression of the 1930s was the most important economic downturn in the U.S. in the twentieth century. We used historical life expectancy and mortality data to examine associations of economic growth with population health for the period 1920–1940. We conducted descriptive analyses of trends and examined associations between annual changes in health indicators and annual changes in economic activity using correlations and regression models. Population health did not decline and indeed generally improved during the 4 years of the Great Depression, 1930–1933, with mortality decreasing for almost all ages, and life expectancy increasing by several years in males, females, whites, and nonwhites. For most age groups, mortality tended to peak during years of strong economic expansion (such as 1923, 1926, 1929, and 1936–1937). In contrast, the recessions of 1921, 1930–1933, and 1938 coincided with declines in mortality and gains in life expectancy. The only exception was suicide mortality which increased during the Great Depression, but accounted for less than 2% of deaths. Correlation and regression analyses confirmed a significant negative effect of economic expansions on health gains. The evolution of population health during the years 1920–1940 confirms the counterintuitive hypothesis that, as in other historical periods and market economies, population health tends to evolve better during recessions than in expansions.(my emphasis)
Ian Hickie is reported as saying that “the most conservative estimate is that at least 10% of lost productivity is due to mental ill-health and suicide. It is likely that the real cost is twice that amount. Not only does the economic downturn because mental ill-health, but that ill-health feedback into long-term loss of productivity”.
It is unclear why he has conflated “mental ill health and suicide”. We know that the suicide rate is between 11-13 people per 100, 000, 3,046 in 2018. As far as productivity is concerned this is a qualitative analysis and I believe it to be dubious.
This seems to be significant over-reach.
The Black Dog Institute report appears to be a blinding glimpse of the obvious. Of course people are worried about their future in this current situation. Of course people are lonely because of the social distancing and isolation, however people have always had concerns about uncertain employment, debt, physical health issues, relationship problems etc.
My concern is our tendency to pathologise normal behaviour with the implication that such behaviour requires intervention, this is not to deny that at times we all need support, advice.
When I worked with kids I found that they fell into 3 groups, those who were made of rubber and coped with adversity, those who are made of putty and were dented but remained intact and those who are made of glass who shattered. This rough demarcation holds true with adults. Most people cope with adversity without needing to see their GP or using mental health services.
My concern is also that mental health researchers tend to be catastrophists, and with the best intentions, use these widespread disruptions as a reason to boost their influence, and not least, their funding.
An example is the push for increased funding for domestic violence services by “researchers” with the expectation that isolation and social distancing will lead to an increase in domestic violence. According to report in the Australian (11 May 2020) “Fewer people in New South Wales are being murdered or reporting assault partner or family members despite strict social distancing measures that experts feared would fuel violence at home. New South Wales Police Force Data shows 2194 domestic violence -related assault recorded in April, compared to 2408 in the same month last year. the number of people killed by intimate partners or a family member plunged by more than 60% in New South Wales to 4 in the year to May 4 compared to 11 over the same period last year.
The same researchers respond by saying “it is possible domestic violence figures had remained stable because isolation and effective her willingness or ability of victim to seek assistance from police. Peak body Women’s Safety NSW said the Covid 19 lock down had contributed to a 10% increase in the number of domestic and family violence victims seeking assistance since March. So there has been a 10% increase in those seeking assistance but a decline of 9.1% in those contacting the Police?
To go back to my concern about the use and misuse of the term “Mental Health”, some clarity came from a paper in the Journal of the World Psychiatric Association entitled:
Toward a New Definition of Mental Health (World Psychiatry. 2015 Jun; 14(2): 231–233)
According to the World Health Organization (WHO), mental health is “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”.
This definition, while representing a substantial progress with respect to moving away from the conceptualization of mental health as a state of absence of mental illness, raises several concerns and lends itself to potential misunderstandings when it identifies positive feelings and positive functioning as key factors for mental health.
In fact, regarding well-being as a key aspect of mental health is difficult to reconcile with the many challenging life situations in which well-being may even be unhealthy: most people would consider as mentally unhealthy an individual experiencing a state of well-being while killing several persons during a war action, and would regard as healthy a person feeling desperate after being fired from his/her job in a situation in which occupational opportunities are scarce.
People in good mental health are often sad, unwell, angry or unhappy, and this is part of a fully lived life for a human being. (my emphasis).
In spite of this, mental health has been often conceptualized as a purely positive affect, marked by feelings of happiness and sense of mastery over the environment.
Concepts used in several papers on mental health include both key aspects of the WHO definition, i.e. positive emotions and positive functioning. Keyes identifies three components of mental health: emotional well-being, psychological well-being and social well-being. Emotional well-being includes happiness, interest in life, and satisfaction; psychological well-being includes liking most parts of one’s own personality, being good at managing the responsibilities of daily life, having good relationships with others, and being satisfied with one’s own life; social well-being refers to positive functioning and involves having something to contribute to society (social contribution), feeling part of a community (social integration), believing that society is becoming a better place for all people (social actualization), and that the way society works makes sense to them (social coherence).
However, such a perspective of mental health, influenced by hedonic and eudaimonic (Eudaimonia, sometimes anglicized as eudaemonia or eudemonia, is a Greek word commonly translated as happiness or welfare; however, “human flourishing or prosperity” and “blessedness” have been proposed as more accurate translations.)
Traditions, which champion positive emotions and excellence in functioning, respectively, risks excluding most adolescents, many of whom are somewhat shy, those who fight against perceived injustice and inequalities or are discouraged from doing so after years of useless efforts, as well as migrants and minorities experiencing rejection and discrimination.
My point being that both the misuse of of the term ‘mental health’ and the catastrophising of well-meaning ‘experts’ with ‘skin in the game’” so to speak. I suspect their modelling vastly overstates the problem and ignores most people’s ability to cope. I am always dubious when mental health services claim to be the solution for social ills such as poverty, poor housing, unmployment and so forth. However, i may be wrong.