A note on an article in The Lancet Psychiatry

The latest edition of The Lancet Psychiatry features an intriguing, if odd, article. Entitled ‘Rethinking the biopsychosocial formulation‘, its main premise is that, “to split the psychological and social from the biological is no longer scientifically tenable.” This is something I vigorously agree with and have discussed in criticism of the trendy political term, ‘parity of esteem’. As the authors imply, over-attachment to mind-body dualism is a major threat to improving healthcare. And yet, the conclusion that they appear to draw out of this premise is quite baffling.

As a precursor, I should say that my institution only allows me to access the first page of the article, but, assuming the authors don’t make a significant u-turn later on, the claim can speak for itself:

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The authors seem to be concluding that problems with ‘splitting’ approaches to mental illness into three perspectives require us to discard of two of these perspectives – no surprises for which of the two the authors and psychiatrists wish to discard. It’s unclear how they expect to be able to favour a biological perspective without first ‘splitting’ it from the other two, an action they claim to oppose, or how this can possibly encourage the “integrative-approach” they apparently support.

Putting aside the contradictions, in suggesting a shift towards a more biological viewpoint they seem to be dismissing decades of scientific research and cultural progress that has moved us towards an integrated interpretation of mental illness that acknowledges the influence of social factors, environmental circumstances, and cognition. If nothing else, this is insulting to other mental health practitioners.

Thankfully another psychiatrist was quick to jump in and gently object to the point. After bringing the article to task for being “a little unfair” in its interpretation of the biopsychosocial model, Duncan Double, a ‘consultant psychiatrist and honorary senior lecturer’, discusses intellectual progress in psychiatry and the need for an integrated approach.

Dr. Double suggests that psychiatrists don’t need to be philosophers, but if they’re going to try and address the issue of dualism, they may do well to read up (here’s Stanford’s introduction). In contrast to their less labouring eastern counterparts, western philosophers have struggled with the mind-body problem since the time of Plato nearly 2500 years ago. Even in 400BC it was acknowledged that thoughts and feelings have a basis in the brain. But no sensible philosopher would go so far as to suggest that one should only view such things biologically – at least not until we can figure out consciousness and map out and biologically intervene in every thought and feeling. (That may take some time.)

Perhaps I’m being uncharitable towards the authors and the rest of the article is more nuanced; or perhaps they didn’t express themselves quite as intended? A quick search online and I see that the lead author of the article appears to have written a book on psychotherapy – which only adds to my puzzlement over the article. If those of us working towards joined-up approaches to mental health and healthcare can be a little sensitive about perceived threats to collaborative working, it’s only because we want to see the varying perspectives (biological, psychological and social) moving forward together. 

Are universities less healthy than they used to be?

This post was originally published to Huffington Post.

A journalist called me during a morning meeting recently to ask if I thought university was “unhealthy”. The question caught me off guard. It is not one those of us working in higher education tend to ask.

The existence of universities is such a given, and their place in society so highly valued, that to ask if they are ‘unhealthy’ can seem almost blasphemous. And anyhow, universities are just places of study, how can we generalise about whether they are healthy or not?

My initial response to the question was to point out that each institution is different, with differing support provisions and varied programs of study, so we can’t make sweeping claims. But the words coming out of my mouth left me uneasy. While I suggested that we can’t generalise the university experience, I realised that this is precisely what higher education lobbyists do.

Ministers and lobbyists speak of the value of a university education and of the higher salary one can expect. In doing so, they use what statisticians call an ecological fallacy– where the average in a group is used to wrongly infer the likelihood of something occurring for an individual. Lobbyists rarely make reference to individual differences – between institutions, between programs, between what’s right for particular people. Perhaps, then, we are reasonable in employing the same sort of sweeping judgments when considering the healthiness of a university education.

To answer a question like that on numerical data alone is problematic. We are relying on case-control studies, pitting those that went to university against those that did not. Such studies are inherently flawed measures of causality because healthy, wealthy parents are likely to send their healthy, well-supported children to university. Just as those attending university tend to have a head-start in terms of wealth over their non-graduating peers, so too do they in regards to health. Quite simply, there is no suitable control group.

Another issue with case-control studies is that they draw their conclusions over extended periods of time. For a stable and standardised intervention, like a pharmaceutical drug, that’s not an issue. But universities, economies and working environments are so changeable that a university education is anything but standardised. Graduating 10 or 20 years ago could be, and probably is, completely different to graduating in 2015.

If we wanted to use health related data from previous years to infer something about universities today, we might draw worrying conclusions based on rising suicide ratesand demand for counselling. But to avoid making claims based on historic data that doesn’t necessarily apply to institutions today, we can also break a university education down into its characteristics and constituents, and consider these against evidence-based determinants of health. When we do that, things don’t look much better.

One of the most studied social determinants of health is social support. In going to university, most students are moving away from their family homes and childhood communities, removing themselves from their most sustaining support units, which offered food and shelter, emotional support and the preventive healthcare that tends to be offered by one’s parents. In its place, they have access to informal support from university staff and peers, as well as formal student support services. These services consist of specific advice and guidance for students, as well as counselling services. While all universities have counselling services, waiting lists tend to be lengthy, and services have had their funds stretched since the recession – even in spite of rising tuition fees and rising demand.

In a recent publication, the Chief Executive of Universities UK, Nicola Dandridge, seemed to downplay the obligation of universities to provide adequate counselling and mental health services, saying, “institutions are academic, not therapeutic, communities”.

This is troublesome for a number of reasons. Firstly, it’s all very well to suggest that students ought to use community health services, as Dandridge seems to be implying, but most students are spending up to 9 months away from the communities they are familiar with. If students are expected to transition to community services in their university town, who else is going to support that transition and facilitate access to community services if not the university? To deny responsibility for that seems to show both a disregard for any adverse health events students may suffer, as well as discriminating against those students bringing existing health conditions. When we reflect on recent concerns raised by Stephen Hawking, universities hardly seem to be the progressive institutions that we like to think.

Secondly, while we might accept the claim that universities are places for growth and learning, rather than for correcting health issues, the attempt by Dandridge to disconnect academic and pastoral aspects of study suggests a worrying ignorance of what it means to be human.

As much as places of higher learning might wish to imagine humans only as ‘thinking beings’ without emotions or bodies, the reality is that pushing ourselves in our studies often also means pushing our mental and physical states to their limits. Extended periods of study often demand, or are at least conducive to, late nights, isolation, limited sunlight, limited exercise and poor diets, not to mention the stress of potentially having one’s entire career come down to a 2 hour examination.

Support goes beyond formal services. It includes the informal support offered by professors and staff. One of the promises of a university education is access to leading academics that can provide both intellectual and emotional guidance. But where once the student-staff ratio averaged approximately 1 to 12, it’s now around 1 to 22. And then there are the greater research burdens on lecturers that limit the time they can spend with students – and the quality of that time. While students being assigned a staff member as their ‘tutor’ on arrival would seem to be of value, the burden of obligations felt by staff elsewhere tends to make it a tokenistic arrangement consisting of minor administrative duties at best.

Then there is the informal support offered by peers. Peer networks are invaluable sources of information, emotional support, and belonging. But it’s not always a good thing, as the contagion of obesity has shown. Social networks lead to social norms, and if our networks are engaging in poor lifestyles, fuelled by alcohol and late-night kebabs, we’re probably more likely to do the same – particularly when struggling to make friends and settle into a new environment. And if we don’t manage to fit in, we have social isolation waiting for us, with all of its ill effects. The great range of study and living options, particularly outside of collegiate institutions, are such that we can find ourselves without any particular identifiable group aside from being a member of a 30,000 strong university. For those coming from a small town or school of a few hundred, it can be a bewildering experience.

Many student unions and societies are working to address the lack of support through health promotion, but these are not core structural functions of a university education. They are not standardised for students; they serve a complementary role as fringe additions to the formalities, set up in recognition of university limitations. And the increasing attention shift by student unions away from political issues towards welfare issues shows the true extent of these limitations. For the government, that’s probably quite convenient – students addressing health crises through peer-support means fewer students fighting abuses of power; although, as some students are beginning to recognise, the two are closely related.

No one would be brazen enough to say that universities are ever going to be ideal environments for one’s health. Few would be brazen enough to expect that. But if our hospitals are places to reduce poor health, is it too much of a stretch to suggest that our universities ought to be places that protect good health?

All mental health advocacy is political

This post was originally published at Huffington Post.

Equating mental health issues with physical illness is fashionable amongst health commentators. From analogies associating mental health issues with a broken leg or cancer, to calls for parity of esteem, the inference is that mental illness and physical illness ought to be considered in the same way. But while the message may have served a purpose in recent years, it’s also a simplistic and increasingly misleading interpretation of mental health, and we owe it to our society and to the millions struggling with mental health issues to do better.

In the aftermath of the general elections last month, New Statesman journalist Laurie Penny wrote an impassioned article that linked the election result with depression. Social media backlash quickly followed, accusing the author of being insensitive and naive about the seriousness of mental illness.

A political commentator lacking insight into mental health might have been inclined to admit error, even if only to avoid confrontation. But Penny is no stranger to the subject of mental health. Quite the opposite. One of her first roles in journalism was writing for One in Four, a magazine whose raison d’etre was to provide a voice for those with mental health issues.

What Penny knows, and what we perhaps all need to remind ourselves of, is that mental health and sociopolitical factors are deeply intertwined. Not least of which is the economy, with studies showing dramatic rises in suicide during periods of recession and high unemployment.

There is also a strong relationship between inequality and mental illness. And an underlying risk factor for poor mental health is a perceived lack of control over our lives – something that almost every political decision could be said to have an influence on. Interpreting mental health with a strictly medical model precludes all of this.

None of this is to say that mental illness doesn’t also have a biological basis. Of course it does. Medical interventions can help. And a medical interpretation of mental illness can reduce blame associated with those who are suffering. But a denial of social and environmental factors can also leave us feeling helpless and insensitive to what’s going on around us.

Studies have also indicated that a narrow, brain-based interpretation of mental illness may increase pessimism about recovery, reduce confidence in psychotherapies, and actually increase aspects of stigma.

The solution, needless to say, is with an integration of biological and sociopolitical factors. That may be difficult and uncomfortable to do in our dualist, western society with its love of clear definitions and boundaries, but only when it happens will we be on the right path. Not just for the benefit of those with mental illness but also for those with mental health. (Yes, I mean everyone.)

Mental health advocates have a tendency to lose sight of this. While some campaigners delighted in political parties putting mental health service funding in their 2015 election manifestos – others were skeptical in light of the government’s rhetoric-defying NHS cuts.

Irrespective, rises in mental illness and suicide should not only prompt an increase in medical service provision – which is a given – but also an examination and reversal of social and political contributors. Like the canary dying in the coal-mine, it should be seen as a sign that something is not right.

The onus to point this out shouldn’t only fall on the mental health community. It should fall on the political ‘left’. If the left is lacking direction, as some have claimed, it would do well to reflect on its attitude towards mental health, and its neglect of the social sciences. The Conservative government has mined the area, with its‘behavioural insights’ and ‘wellbeing index’. Why has the left not done the same, and used the the abundance of social sciences literature that inherently supports its position?

Were it to do so, it wouldn’t refer to the rise in mental health issues only in terms of health services, but in terms of a need for broad social and political reform. Reform that starts by recognising that the association between recession and suicide is a symptom of a society failing to do enough to protect its people from the downsides of misfortune, whether economic or otherwise.

There is no biological reason for why economic depression should lead to clinical depression. It’s entirely social and political. We’re all affected, and we need more public figures to be talking about it.