Kirsten Patrick is Deputy Editor at CMAJ
A week ago, André Picard published a column in the Globe and Mail entitled “How many people actually suffer from mental illness?” and later he tweeted his thanks to readers for making that column the publication’s most-read story of the day. The column may have been well-read – it certainly sparked controversy on social media – but it wasn’t because Picard had anything very profound to say. In fact the piece was based on an epidemiological faux pas, which is why I called it a nothingburger.
Commenting on the findings of a poll commissioned by Sun Life Financial Canada, which found that 49% of Canadians have “experienced a mental health issue” at some point in their lives, Picard mistakenly drew a line between the findings of a national survey seeking to establish lifetime prevalence of self-reported symptoms of mental ill health and our health system’s present failure to meet treatment need for mental illness. Because he’s André Picard, some people nodded their heads in agreement as he joined dots that had no business being joined.
Picard wrote that numbers don’t speak for themselves and that they need some unpacking before jumping to conclusions. He then jumped straight to the conclusion that, as a society, we are “increasingly leaving people with the impression that having feelings and emotions is somehow problematic” and that “what the poll tells us, more than anything else, is that we are pathologizing normal emotions.”
Wow, that’s quite a leap. But let’s be clear: there’s no more scientific basis for drawing that conclusion than for drawing the conclusion that half of people in Canada currently have a mental illness, which would obviously be false.
Some physicians politely commented on Twitter that they “don’t see a lot of mental health resources being abused by the not sick enough’”, to which Picard replied that, “People with severe, life-threatening illness are not getting adequate attention or care. Those who are over-diagnosed (or ‘not sick enough’) are not wasting resources as much as they are distracting us from focusing on those most in need.”
Okay, so, which is it? Is it Let’s Talk about mental illness to reduce stigma? Or did I miss the memo that #letstalk is only a January hashtag because actually too much owning up to mental health issues really just ruins it for people who have proper mental illness?
One maternal mental health advocate asked Picard, “Why… would you write this just as we’re gaining ground in #mentalhealth awareness?” and continued, “Your article panders to those who wrongly believe mental illness is a crock. You’ve just set the clock back 50 years.”
I don’t agree that Picard’s column has the clock back 50 years. It would take a lot more than one column – even one from a veteran health journalist with close-to-godlike status who is deservedly renowned for his insight into the Canadian health system – to do that. But I do think that Picard was irresponsible to write it, given his national influence. Here’s why.
For one thing, careless spin like Picard’s column throws governments a free pass on mental health.“Don’t worry, [Government], it’s not your fault for designing and funding mental health services appallingly badly; it’s the fault of all those pesky not-sick-enoughs distracting service providers from the properly mentally ill who are much closer to death’s door and therefore worth treating.” Obviously I exaggerate for effect, but this is just the sort of poorly examined thinking that makes mental illness the Cinderella of diseases, underfunded and under-researched all over the world.
We know that, for most physical illness, funding treatment at an early stage of disease – or even pre-disease – is way more efficient than treating only the very sick. No one would even try to dispute that today. Yet it seems that many are still unable to grasp the logic when it applies to mental illness.
Furthermore, and perhaps more worryingly, suggesting that there is a threshold below which you should not presume to call your mental discomfort ‘an issue’, might silence people who really should be reaching out for help. Mental illness does not announce itself as illness, you see. It plays tricks on the mind and causes self-destruction by thought. Self-doubt, self-loathing, self-denial, self-abasement, feelings of unworthiness: these are its calling cards. People with mental illness often don’t feel sick as much as they feel like the wrong person in the wrong place at the wrong time, wearing the wrong skin. It can take time to put a name to the state of mind.
I had postnatal depression after the birth of my first child. It took me 7 months of feeling like the wrongest mother in the world before I understood that it was depression (and I was a physician working in psychiatric research at the time). Only once I had the insight did I see that it was by no means my first episode of depression; my first (of several that predated it) was probably when I was about fourteen or fifteen. Would that I had had the mental health literacy in my teens to be able to identify my condition; perhaps I might have saved myself decades of truly awful quality of life and disability. When my first child was a year old I was lucky enough to get to be a guinea pig in a pilot trial of mindfulness based behavioral therapy, which worked very well for me and helped me to taper my antidepressants. After the birth of my second child, however, I started getting depressed again. Having insight, I knew exactly what it was and I reached out right away for help, only to be met with a bit of skepticism on some fronts… as if having great insight into my condition and being high-functioning meant I couldn’t be all that unwell. I didn’t care. I knew what it was and I knew I needed care. Despite my poor mood I had enough self-knowledge to advocate for myself. This is the benefit of being able to articulate your state of mind.
So, did all those people surveyed by Sun Life who reported a ‘mental health issue’ (and, yes, that is a meaningless journalistic term, as Picard rightly pointed out) have a diagnosable mental illness?
Probably not. More accurate estimates put lifetime prevalence of diagnosable mental illness in Canada closer to 20%.
But does it matter? If they didn’t tick all the DSM-5 boxes does it mean that those who reported a mental health issue weren’t distressed by it or that their quality of life was not diminished by their discomfort?
Let’s remember that psychiatric diagnoses are constructs devised mainly for research purposes and to facilitate professional diagnostic agreement. These diagnostic criteria are not biomarkers; being able to tick boxes and categorize people as binary disorder/no-disorder does not make physicians experts on the subjective impact of symptoms on a person’s quality of life. And quality of life is a key indicator in mental illness. At the end of the day there must be a place for people to articulate their experience and for that experience to be acknowledged as being real.
Can we really say, of mental illness, that someone is ‘not sick enough’?
Are physicians being inundated by scores of patients reporting sort-of-mental-health-issues and demanding care?
Are physicians confused and overwhelmed because they can’t tell who’s really sick and who isn’t?
Er, no, I don’t think this is our main problem.
Are there lots of people with debilitating mental illness who need treatment but can’t access it in Canada?
ABSOLUTELY! Let’s keep our eye on that ball and not get distracted by nothingburgers.
Is it a bad thing that people are in touch enough with their state of mind to be able to report feeling mentally-not-so-great even though they may never have sought professional help for it?
For goodness sake, NO! We should be celebrating that.
Just yesterday the mental health advocate and author, Matt Haig, tweeted, “Telling someone with anxiety they are wrapped up in themselves is like telling someone with their leg on fire they are a bit shouty. Worry heads inwards.”
Perhaps Matt’s analogy seems dramatic, but it really IS that dangerous to try to silence people on mental illness.
Here’s a thing. You know CBT and mindfulness, those non-drug therapies that have been shown to work about as well for conditions like moderate depression, anxiety disorder, OCD and even addiction, as drug treatments? Well, I’ll let you in on a secret: the way that those techniques work is first to help people become aware of what they are feeling. Taking steps to deal with how those feelings are messing up their life is only a follow-up step. Awareness of mental state is a prerequisite to recovery.
So if we are going to jump to far-fetched conclusions based on the very lowest quality of evidence researchers can drum up – as André Picard did in his column – let’s avoid producing irresponsible and possibly harmful clickbait. Heck, how about we jump to a radically positive conclusion? We could just as well observe that human beings, collectively, seem to be in a place where we are more comfortable than ever before with naming and expressing our difficult feelings and acknowledging our mental states. I, for one, think that’s great.
* Nothingburger, according to the Urban Dictionary, means “something lame, dead-end, a dud, insignificant; especially something with high expectations that turns out to be average, pathetic, or overhyped.”
Excellent rebuttal to Mr. Picard’s simplistic and hostile journalism on this issue. We need more resources and more care and less “snowflake”, “toughen up” attitudes. As a sociologist by training, my opinion is that we also need to address the ways in which our society makes us feel sad, isolated, inadequate etc every day through its social and economic systems, urban planning and city design, etc etc. This is one area I’d like to see health care practitioners get more active – swimming upstream as it were to identify and prevent the causes of much grief and hardship, rather than searching for more and better ways to treat them after the fact.
Thank you Kristen Patrick for this commentary and sharing your own history of depression. As a female GP I also share a history of recurrent depression. While working in a small town in BC from 1997-2003, I befriended the Chief of Medicine in the local hospital. He shared with me that 40% of the doctors who held privileges at that hospital were taking psychoactive medication for anxiety or depression. A few of them were on atypical anti-psychotic medications. We know that physicians are typically high functioning, they strive for excellence, have type A personalities, and perfectionistic expectations of themselves. Many have obsessive-compulsive traits. I begin to wonder if this estimation, that 50% of the population might have mental health issues, is actually true. I do think that the prevailing wisdom of a 20% prevalence of mental illness is an underestimate. Particularly since substance abuse/dependence, and dementia are now under the umbrella of psychiatric disorders.
I think his column can rightfully be taken another way. There has been a tremendous amount of energy going into stigma awareness. Presumably that has encouraged more people to step up and look for help. But the resources to actually deal with all those people haven’t substantially increased. Waiting lists are longer, etc.
More importantly, if we’re using those limited resources for people who are “having mental health issues” we’re not using them for people with mental illness.
Because doctors are spending less time with people, they’re also not doing as good a job as differentiating between mental health issues and mental illness. If someone mentions that they check the door a few times before leaving home, that’s not enough to diagnose them with OCD, but it happens. Combine this with the expansiveness of the DSM-5 (which Allen Frances has written about extensively) and you do see normal behaviour being pathologized.
Talking about that spectrum of severity (from ‘could be better’ to ‘having issues’ to ‘mental illness’ to ‘severe mental illness’) is important to how we use our limited resources.
Take the people who have been waiting for a year to get care, who don’t know where to turn, who keep getting the run around, or a brief 15min appointment which completely misses the point. Tell them stigma is the big problem in mental health, and they’ll laugh in your face.
I sometimes joke that the best way to improve mental health treatment is to promote stigma, which will leave more resources available… (if you don’t develop a dark sense of humour in mental health, there is something wrong..)
Jennifer Wilson MD FRCPC
Well said. The other aspect of care for mental illness across the spectrum of severity is to build community-level access/connectivity to a family physician, nurse practitioner or other provider able to provide continuity of care. We fall short there too.
Thank you, Kirsten. As someone who has struggled with chronic major depressive disorder for many years, mostly while maintaining a believable facade of got-it-togetherness, I can attest that mental illness can most certainly be an invisible disability with potentially life-threatening consequences when left untreated. Without an incredible amount of self-insight, which requires a lot of effort and support, a person could easily believe their symptoms are simply poor coping skills and feel they are not “sick enough” to seek the help they need when they need it, and they will likely not have their need for help readily recognized by others.
Harry Zeit MD, Certified in Sensorimotor Psychotherapy
Thank you for this article Kirsten Patrick. Recognizing the deficiencies in our mental health care system, as Andre Picard does in his article, does not and should not lead to the conclusion that too many people are utilizing the system, or that less people would benefit from psychotherapy.
You are so right about early intervention. Often it is heartbreaking to see patients with Complex PTSD struggling with their various symptoms and only seeking definitive care late in life, already isolated and robbed of the education and careers that might have placed their lives on a different trajectory.
Without access to a system that offers expertise and good treatment, it is very difficult to know who will and will not benefit from more intensive treatment – not much different than in the ER – not all fevers are the same and not all anxiety, or depression (or OCD or ADHD) are the same.
We all agree that our system is failing us. We are far too pathologizing, we lack an appropriate mind/body approach, we fail to study and offer treatments that address causality rather than symptom management … the list goes on, and way too many people are not helped (and even traumatized) in their interactions with a system which is clearly flooded and incapable of managing the increasing burden of human hurt and suffering.
I do note a shift in the CMAJ editorial policy, with more open-ness to what “mental” illness is and is not, and to increasing awareness of the need for models of care that are less “biologic” and more integrative, humanistic and holistic. I also appreciate your honesty and your advocacy for a world where we are more aware of what we are feeling, and more able to share our emotions, fears and vulnerabilities with others, whether mental health care providers or family & friends.
This can, as you state, only lead to a better world.