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. 

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.

‘Student mental health not our responsibility’, says British government

In response to a letter enquiring into how the government is ensuring that students receive adequate support, the Department for Business, Innovation & Skills advised that the responsibility for determining student support rests with educational institutions.

The department’s response, received by email on July 18th, stated: “HEIs are autonomous bodies, independent from the Government.  They have legal responsibilities under the Equality Act 2010 to support disabled students in higher education, including those with mental health conditions but it is for the HEIs themselves to determine what welfare and counselling services they need to provide to their students to offer that support.”

The letter had been sent to David Willetts, minister for universities and science, and called on the government to provide funding for a national body to monitor student support and advise institutions, in light of the recent increase in student suicides, and an NUS survey earlier this year. The department replied, “Whilst we have noted and appreciate your suggestion, this is not something we can consider at the present time.”

The response also noted that, despite the independence of HEI’s, the government was providing a “comprehensive package of financial support to ensure that Higher Education (HE) students with disabilities, including those with mental health problems, receive the best possible support”. According to the department, this amounted to £109.2m being allocated to English students claiming Disabled Students Allowance in (2010/2011), and £13m to HEIs (2011/2012).

The total amount allocated in 2011/2012 by HEFCE to FE & HE institutions was £6507m.

In Praise Of Student Support Staff

At a Student Welfare event I was speaking at yesterday, I tried to catch a student support advisor after one of the sessions. She had left the room swiftly, and was on the phone in the corridor outside. There was a look of concern on her face, and at first I wondered if it was a logistics issue – perhaps a son or daughter that needed picking up from school, or some other personal matter. But it wasn’t anything like that. She was phoning to check on a student at her university that was having a particularly tough time.

I don’t often meet someone who shows this level of compassion and concern for others, but when I do, it’s invariably a member of student support staff. There has been an increase in the number of articles examining student mental health and questioning whether universities are doing enough, but very few of these have recognised the extraordinary work done by existing support staff.

One of the things I’m most proud of from my time at NUS-USI earlier this year was the groundwork we laid for an Open Your Mind awards programme. We wanted to recognise not just things done by students to promote mental health, but also the tireless work done by support staff to help thousands upon thousands of students every year. It wasn’t that we thought staff would want the recognition (they are too selfless for that) but we hoped maybe it would help others to see why student support is so valuable.

I don’t know why support staff don’t get more recognition. Maybe because they don’t make a fuss about things. Maybe because others think they are only ‘doing their job’. Anyone who has spent time with support staff will know that this is not the case, and that they give a huge amount to others. Nobody gets involved in student support for their own interests – they do it because they care, deeply.

Campaigners urge government to act on children’s wellbeing

A new UK mental health charity has called for more to be done to support children’s mental health after a YouGov poll indicated that one in five children show symptoms of depression, the BBC reports. The story follows increasing concerns (which we reported here) about young people’s mental health in the UK and internationally.

Mindfull, an online mentoring and counselling service for 11-17 year olds launched today by the BeatBullying Group, has urged that mental health needs to be added to school curriculums, but there are question marks about where the expertise to deliver such classes could come from. Since 2000, schools in the UK have been expected to teach children about mental health through PSHE, but the program has been criticised for neglecting mental health, and an Ofsted report in May noted that PSHE teachers were lacking “subject-specific training and support.”

There are a number of British schools – notably, Wellington College – that deliver emotional wellbeing classes, and in 2007, 90 teachers in schools across three regions were trained to deliver classes in emotional resilience as part of a pilot programme backed by the Department for Education – although it was not rolled out beyond the pilot. The government is yet to make further commitments to funding mental health training in schools.

The YouGov poll, which, according to reports, also indicates that a third of young people have considered suicide, raises questions about the causes of children’s mental health problems. Earlier this year, Peter Tait, head of Sherborne Preparatory School in Dorset, suggested that students’ wellbeing was being damaged by excessive emphasis on grades. It’s an issue that’s being recognised in other countries. Last week it was reported that educational reforms in China are set to shift emphasis away from testing over concerns about the impact that narrow methods of evaluation were having on students’ mental health.

In 2005 the UK’s Department for Education introduced SEAL in primary schools, which encourages a “whole school approach to promoting social and emotional skills”, but a 2010 report from the Department of Education showed mixed results, and concerns have been raised recently that the government’s emphasis on exam results has been pressuring schools to give up SEAL.

Note: Free resources for teachers wanting to deliver mental health classes are available through Young Minds, here. Children and parents concerned about mental health can also access information and helpline details through Young Minds. Further resources and information about mental health, and helplines, are available through Mind

University students to undergo psychological evaluation

According to the online news website Colombo Page, new students in Sri Lanka may soon be subjected to psychological evaluation. Sri Lanka has one of the highest suicide rates in the world, and the measure is thought to be being considered as a way of addressing mental health issues fuelled by increasing academic pressures.

Earlier today, Australian newspaper, The Age, reported on plans to introduce compulsive psychological testing at Australian university, RMIT. According to the report, the tests would form part of a ‘Fitness for Study Panel’ that would evaluate the health of students, and identify whether any students with health conditions were likely to display “behaviour of ‘serious risk’ to the student or others”.

Compulsory psychological evaluations are controversial. Proponents claim that it would help distressed students to receive proper treatment, but there are concerns that such tests undermines civil liberties, and could be used to discriminate unfairly.

 

USA students donate $50,000 to wellbeing services

Graduating students at the University of Washington have pledged $50,000 to their university’s mental health services in recognition of the pressures affecting students. The donation is part of a tradition in the United States in which leaving students offer their university a ‘senior class gift’.

The donation is the university’s largest ever senior gift, according to The Seattle Times. The money will go to the Student Counseling Center, and be used to develop mental health awareness campaigns and educational materials to help students look after themselves.

In a USA survey of more than 28,000 university students, half reported “overwhelming anxiety” and almost a third reported having experienced depression. Earlier this year, USA Today reported that roughly 2.2 million students had accessed counselling services during 2012, and that services have become increasingly stretched.

Referring Back To CR166 (And A Note For Journalists)

Blind Men And The Elephant
During the past few months, there have been articles about the mental health of students in the Guardian (here, here, here, here, and here), the Independent (here and here), Times Higher Education (here, here, and here), and now the BBC (here). It’s great to see the issue being covered, even if it’s because of tragic statistics and stories.

If there’s one issue with the coverage it’s that it tends to focus a lot on problems and not much on solutions. It’s important that those covering the subject don’t ignore the work that’s already been done to provide us with answers.

The Royal College of Psychiatrists’ report doesn’t have all the answers. It doesn’t even have all the questions. (It makes it clear that more research and data is needed – some of which has since become available thanks to the work of organisations such as NUS and the Equality Challenge Unit). But the report does give us a few clear guidelines and recommendations that can be acted on immediately. More than that, it’s the most comprehensive report on student mental health we have, with input from organisations across the higher education and mental health sectors. It gets us on the same page. We should all be referring to it.

When I get phone calls from journalists looking to cover student mental health, it’s usually immediately apparent that they are full of compassion and sensitivity for the subject. I enjoy talking with them. But I don’t think I’ve had a single journalist start by asking me what needs to be done. The focus has always been on what’s wrong, and why. I suppose that’s the nature of journalism, but hopefully it can begin to shift a little.

I wrote a review of the Royal College of Psychiatrists’ report after it’s publication, summarising key points and adding a few things that were omitted. I’ve now updated this paper, adding data and developments from the past 18 months. If you’re a journalist or policymaker looking to do something around the mental health of students, take a look.

Student suicide data, and what needs to be done

(Note: The issues discussed in this article may be distressing for those affected by suicide. You can find out more information about suicide at the Mental Health Foundation’s website, here. If anyone has been affected by the issues discussed in this post and needs to talk to someone immediately, you can call the Samaritans helpline and speak to someone confidentially, 24 hours a day, on this number: 08457 90 90 90.)

A report published by the Royal College of Psychiatrists last year warned that there was a “pressing need” to do more around student mental health. New figures released last week show what’s at stake. In 2011, 112 students in England and Wales took their own lives. Every suicide is tragic. But what makes this figure particularly concerning is that it is almost a 50% increase on 2007.

I was sent the data on Wednesday by the Office of National Statistics whilst researching for an article to mark the one year anniversary of the Royal College of Psychiatrists’ report (which I reviewed here). Having failed to find any up to date statistics, I contacted the ONS with a freedom of information request on Monday. The figures have been published to the ONS website here*, and are discussed in a Guardian article here.

Although the ONS officer I worked with urged caution about drawing conclusions due to the numbers involved, the increase corresponds with a BMJ study of the wider population that suggests the financial crisis may have caused a significant rise in suicides. It also corresponds with concerns raised in the Royal College of Psychiatrists’ report about the current pressures facing students: “Social changes such as the withdrawal of financial support, higher rates of family breakdown and, more recently, economic recession are all having an impact on the well-being of students and other young people.”

When I received the figures, I was writing an article about the lack of urgency around student mental health. These figures raise further questions about the higher education sector and about what institutions are doing to ensure their students have adequate support. It’s time for the sector to respond.

The Royal College of Psychiatrists’ report provides clear recommendations for institutions and policy-makers. Currently, it is difficult to know which institutions, if any, are making serious efforts to meet these recommendations. This needs to change;

  1. Institutions should guarantee a certain level of support for their students.
  2. Institutions should put in place an institution-wide mental health policy and make it publicly available through their website; the policy should be reviewed and updated regularly by an institution-wide mental health & wellbeing committee that meets several times a year.
  3. The sector should fund a national committee to recognise and promote good practice in student mental health.

It’s up to students, staff, parents, and all those with an interest in the welfare of young people, to demand that institutions and policy-makers prioritise student support.

*The figures are for students aged 18+. ONS data was only available for England and Wales. The number of students in full-time education has increased by 15% during the same period.
Resources:  Universities UK produced a guidance paper on Reducing the Risk of Student Suicide in 2002, available here.

The cause of low mental health disclosure rates: "Fear of appearing weak" or poor publicity?

Yesterday, The Times Higher Education (THE) published an article suggesting that the low number of students and staff disclosing mental health problems could be explained by “a fear of appearing weak”. I’m not sure that’s a good explanation.

Firstly, the context — The article refers to a report from the Equality Challenge Unit (a charity that, according to its website, “works to further and support equality and diversity for staff and students in higher education”) highlighting that just 0.7% of students and 0.2% of staff are reporting a mental health problem. Even using conservative estimates about the prevalence of mental health problems, there is clearly a very significant number of students and staff that are not disclosing their condition.

The consensus is that stigma prevents disclosure, and that if people feel less stigmatised then the number reporting their conditions will grow. That may be true. But there’s a question in this discussion that needs more attention: Why should they disclose?

If the sector believes that students and staff will benefit from disclosing a mental health problem to their institution then they need to explain how. And it would follow that if the numbers still aren’t increasing then it’s because students and staff don’t think the advantages are significant enough. Or they still know nothing about them.

The ECU’s report states that students with a disability who access Disability Support Allowance don’t only benefit financially, but are also more likely to receive a first class or upper-second class degree. If institutions want more DSA uptake then they need to publicise this, and use it as a way of communicating the benefits of disclosure. They can start by addressing the issue of most students and staff not knowing that they would be entitled to DSA due to confusion around the use of the word ‘disability’. Or by developing, and making available to all staff and students, a university-wide mental health policy – as recommended in the Royal College of Psychiatrists’ report into student mental health.

Stigma is a part of this. But stigma should not be used by policy-makers as a way of shifting responsibility away from their role. If institutions want more of their members to disclose a mental health problem then it’s up to them to give good reasons for doing so. Gary Loke doesn’t seem to understand this:

Gary Loke, head of policy at the Equality Challenge Unit, said the survey showed that many people in the academy with mental illness were suffering in silence.

“If you do not disclose you have a problem, universities cannot help you,” he said. “Institutions are generally very supportive to disabled staff, but people need to feel they can come forward and talk about their mental health problems.”

You may mean well, Gary, but the bigger question to answer is this: how will universities help those that talk about their mental health problems? And what exactly do you mean when you say that institutions are “generally” very supportive? The burden of responsibility for low disclosure rates does not end with those that are not disclosing;  institutions must work on creating settings in which people feel inclined to disclose.