Bleeding inside: why mental health is too important to get wrong

16th June 2016 at 11:20

Tom Bennett tries to get behind the headlines on claims of a rising tide of mental illness

Mental illnesses across the population, but particularly concentrated in younger groups, are getting worse and more common. Exam stress is now leading to more and more children suffering from mental health problems. This is all obvious, right?

But nothing to do with mental health is obvious. Despite this, there is a rising tide of commentators who believe that everything in the first paragraph is true. More worryingly, many seem to be unconcerned with substantiating those claims. And if you ask for supporting evidence, discussion quickly degenerates to accusations of "not caring" about mental health in children, or "not listening to people on the front line".

That wouldn’t be funny even if it were true. None of us should have to prove ourselves in the High Court of All The Feels, as if whoever emotes the most, wins. I shouldn’t have to count off friends I’ve lost to suicide, or seen buried in their own misery, to participate in this discussion. Virtue signalling appals me. It’s charitable to assume that everyone cares about this topic, and deal with the facts as best we find them. I just assume that we would all prefer a world where everyone enjoyed optimal physical and mental health. But how to get close to that? 

There are two claims, it seems to me, within the scare quotes: 

  1. There is a current and new crisis
  2. It has been measurably increased or instigated by current educational policies

Is there a crisis?

Our definitions are vital. If you believe that any level of poor mental health constitutes a crisis then yes, there is, but that would be a banal, pointless conclusion. We reserve terms like crisis to refer to specific events, just as the words endemic, pandemic, epidemic refer to specific levels of public health disorder. This has a concomitant effect on funds and resources made available, differences in response and so on. Doctors describe pain as acute or chronic, anaesthetics as local and general. Words matter. A crisis is "an emergency, or an unstable, dangerous situation". It entails, for example, a sudden worsening of mental health. 

This is important. Understanding the true extent (and cause) of a problem is essential in how we respond to it. If a doctor finds a patient choking in a restaurant, knowing the difference between a cardiac arrest and a cayenne pepper allergy makes the difference between CPR and tracheotomy with a steak knife and a Bic pen. Understanding who is ill, when, how often and why, is a crucial part of dealing with the problem. Anxious responses that "Everyone is sick!" leads us nowhere. Crucially, it can lead to people who do need help not getting it. I’ve had pupils say they wanted to end it all; a hasty referral to the CPO revealed they just needed to talk through, for example, their parents' divorce. Symptoms can indicate multiple causes, just as headaches can present in both hangovers and brain tumours. Diagnoses are best left to diagnostic professionals, which is why self-reported (or even school-reported) data needs to be analysed very carefully before we accept it as rigorous. A recent lump on my eyelid had me reaching for my last Will and Testament; turned out to be a stye. And a sore throat can be followed by a funeral. 

Dr Stan Kutcher, one of Canada’s leading experts in young people’s mental health, agrees that misdiagnosis is a problem

We have the same proportion of mental illness in our society now that we had 40, 50, 60 years ago. There is no epidemic of illness, there is better recognition of illness, which is good but what we’re seeing now is an epidemic of ‘I think I have a mental disorder when I’m just really feeling unhappy,’ and that is a direct reflection of poor mental health literacy…Now depression happens in adolescents and depression is a serious disease and if you have depression you need the proper treatment for depression, but feeling unhappy, that’s not depression…So I think a lot of people have become confused with all the talk about mental health and mental illness without the literacy to understand what they’re talking about.

Kutcher takes mental health very seriously, and where it exists he is adamant that provision needs to be made. But there is an important lesson here: only mental health professionals are qualified to diagnose mental illness, not well-meaning armchair bloggers or columnists…or even teachers. 

Are exams driving our children mad?

Sadly, a lot of rhetoric I’ve heard has already focused on one possible cause: exams. Throughout social media and cross-stitched through headlines we see an extraordinary attribution to current school systems as the Petri dish of many mental health problems. But there really isn’t any data to serve this theory. Which isn’t to say it isn’t true, but that the data we have can’t support that conclusion. However if you suggest that this is the case, (and suggest the claimants write cheques the data can’t cash), those already wedded to the anti-exam cause often cleave to their cherished beliefs at the expense of reason or evidence.

God knows, there’s a lot I would change about the way that we assess children. But we abuse their trust in us when we falsely ascribe symptoms and syndromes to them as a group that might not be true. It’s as if we become complicit in an enormous Munchausens-by-proxy, (where the sufferer pretends their children are sick so that they can enjoy the status of carer, victim and martyr). This is why I find recent speculation often unhelpful. Is mental health a serious public health problem? God, yes. Is enough being done about it? It probably never could. Do we all care? Redundantly, unsurprisingly enough, yes, I think lots of people do care. Do we have a problem as a society talking about it? Without a doubt. Is there a crisis? It’s incredibly hard to say. Are people more or less well than 10 years ago, or 100? We have almost no idea. Some indicators (admissions for self harm at A&E) are up. Others (suicide rates per 1000) are down. Do the former indicate a real rise, or a rise in our ability to talk about these things, to seek help? Maybe. We don’t know. People who want to show boat on alarmist claims are free to do so, while simultaneously unicycling on the moral high ground. But surely the truly moral thing is to seek the truth?

Big claims, small evidence

One thing certainly has increased: newspaper stories referring to a mental health crisis. This should surprise no one: crisis, conflict and alarm are prime engines of attracting interest. But recently they have frequently referred to one of two pieces of data: a 2004 study of mental health (which is interesting, but clearly can’t tell us if there is a current crisis or not) and a parliamentary answer about the dramatic rise of A&E admissions for mental health problem in young people, which could be as easily explained by the reduction in community mental health services as any other factor. That’s the point; we just can’t tell. I’m deeply distressed by the lack of provision for people with mental health problems. But this doesn’t justify creating narratives that serve our project.  

I’ve read a lot of data indicating that more people are, for example, accessing mental health services, or attempting to – waiting lists are another rich data seam. But is this a genuine rise in  unwellness, or a rise in expectations of availability and accessibility? To put it another way, why would we be more unwell now than before? Are we claiming that society was more or less stressed during the Blitz, the Winter of Discontent, the recession of the 80s? We just don’t know. We’ve certainly improved both our attitudes towards and our capacity to treat mental health. And we’ve got, I’m sure a long way to go. 

First, do no harm

I recently came across an interesting, unsettling word: "iatrogenic". It means: "caused by the diagnosis, manner or treatment of a physician." This syndrome is particularly acute in mental health; because a component of our mental health is built from our self-perception, psychiatry recognises that some mental health problems can be exacerbated through misdiagnosis: bipolar disorder in paediatric patients, chronic fatigue syndrome, post-traumatic stress disorder, for example. Just as we can be convinced of itching sensations or headaches, we can be talked more deeply into sub-optimal mental health in some forms, like Itchy Leg Syndrome. Or look up delusional parasitises (in fact don’t, because you’ll catch it). Copycat suicides are also well known, which us why there are oft-ignored guidelines for how the press reports it. This spike in suicides after a well-publicised suicide is called the Werther effect, when clusters of suicides emerge in schools or communities, and seems particularly pronounced when a cherished celebrity like Robin Williams takes their life.  

None of this ameliorates the challenge of poor mental health; what it does is remind us how important it is to diagnose sincerely, carefully, and accurately. And when we discuss it in public, we take the utmost care not to sensationalise, or worse, use it to promote a political or personal/commercial agenda.  

Mental health is a problem too important to discuss in terms of anecdotes, strongly held opinions or insta-hot-takes. In 2010, 14 employees at Foxconn City (an industrial park in Shenzhen, China) committed suicide. People (mostly reporters, then readers) were scandalised; and many believed it indicated that Apple and Hewlett Packard (among other major customers at Foxconn) had driven them to suicide…until it was pointed out that the suicide rate of the employees was still below the national average (above 20 per 100,000; by contrast, Foxconn employed around 350,000 people). In fact, it would probably be easier to make a case that they were doing something right there, not wrong. Numbers matter. To people like me, who aren’t used to dealing with them at this level of nuance, it’s easy to bulldoze and bully figures to mean what we want, especially when simple conclusions help our personal crusades. 

But is that a good enough attitude when people’s lives and wellbeing are at stake? 

Obviously, that’s rhetorical.

Care Wars

One option is simply to suggest that if you don’t believe there to be a crisis then it implies some kind of compassion deficit; that you’re unwilling to do anything because you’re (in the words of one person to me) "downplaying the problem" (or worse, "Trivialising children's distress in order to seem intellectually superior"). This is a powerful rhetorical device but a terrible way to understand a problem. If one person succumbed tragically to scurvy, would we be guilty of downplaying the tragedy if we hesitated to call something a crisis? If flu infection had held steady for 100 years, should we be castigated for suggesting that the pattern was stable rather than alarming? 

"You don’t care enough" is an unworthy response, and somewhat of an insult to the cool-headed stalwarts of medicine who prefer to deal with facts, not fiction. Let us observe the principle of charity and accept that everyone in this conversation cares about the mental wellbeing of children. And then let’s move on, because in a world where everyone cares, caring by itself loses currency. Broken legs don’t heal because we care; they heal because we stitch and set and sanitise them. And broken hearts and minds need more than good wishes; they need clinical, professional diagnoses and support. 

Society has only just started to have public conversations about private mental health as a public issue. That’s good. Let’s not derail that awakening with pseudoscience and intemperance. Too much is at stake.