On Tuesday of this week, I returned to the Duchess Theatre for the third of this series of four SANE/Ruby Wax and Judith Owen mental health forums. On this occasion Judith was unable to attend, but Ruby and the ever elegant Marjorie Wallace (SANE’s Chief Executive) were joined by Ruby’s own psychiatrist (and, she told us, mentor), Dr Mark Collins. As I described last week, the forums are part social support, part education for people experiencing mental health difficulties.
I won’t share the whole of Dr Collins’ talk, because you can watch it for yourself on the SANE website – and because a scientist I most certainly am not, and I don’t want to make some unintentionally hilarious neuroscientific gaffe. What I found very interesting about the talk was that it although it was presented as being on “brain chemistry and mental illness”, what was actually being discussed, right from the outset, was the problem of mental illness not being perceived as “real”. One of the drivers for researching what happens in the brain when people experience mental distress is, of course, to attempt to develop better treatments for service users; but without a doubt, another motivator is that if we can show through medical imaging that there are differences between the brains of mentally well people and those of people with mental health conditions, there will be less possibility for doubters to deny the existence of mental illness.
Why don’t people believe depression, for example, is a real illness? How can this be, asked Dr Collins, despite the fact that this year worldwide over one million people will take their own lives, most of whom will be suffering from depression, or a depressive phase of another mental health condition such as bipolar or schizophrenia? Why is the condition not taken seriously, although suicide accounts for more deaths in the UK than road accidents? There remains, among the general public and in the media, a suspicion that psychotropic drugs are being handed out needlessly and that those taking sick leave or claiming sickness benefits for mental health conditions are “malingerers” or “workshy”. The comments that people leave on this blog demonstrate that the belief that depressives are capable of “pulling themselves together” if they just put their minds to it is alive and well.
Stigma starts in the medical profession itself, Dr Collins pointed out, relating how when he moved from neurology to psychiatry, his colleagues reacted with puzzlement and horror, believing that he was committing “career suicide”. Although Dr Collins changed his specialty some time ago now, the Royal College of Psychiatrists recently expressed concern about the low numbers of young doctors opting to specialise in the field, with the outgoing President stating in June of this year that numbers choosing to work in mental health were “dangerously low”. Clearly many in medicine continue to hold the view that psychiatry is not “proper medicine” – the corollary of this being that mental illnesses are not “proper illnesses”.
Then, pointed out Dr Collins, if a doctor is faced with a patient who says that they are depressed, there is a semantic issue. “Depression” is a very broad term, and as I discussed in my post earlier this week, mental health terms can be used widely and generally in society, often with a quite different meaning to that employed in mental healthcare. A doctor cannot necessarily assume that when s/he and the patient discuss depression, they are talking about the same thing. Even when the term is being used in the clinical sense, for all we know currently, the set of symptoms which form the diagnostic criteria for “depression” may be the manifestations of several different disorders. Dr Collins likened it to a mediaeval apothecary who diagnoses “fever”, but lacks the knowledge to identify underlying causes and is therefore unable to offer specific treatments for malaria, flu or sepsis.
But this is beginning to change. Science is beginning to be able to use functional brain imaging to look at the changes occurring in people who experience depression and other forms of mental distress. Dr Collins hopes that eventually functional imaging might revolutionise our understanding of mental health conditions, in the same way that structural imaging revolutionised treatment of neurological conditions. It is for this reason that SANE funds the Prince of Wales International Centre for research into genetics, neuro-pathology and neuro-imaging in mental health; eventually we may be come to a point where we can demonstrate exactly what is going on in the brain with someone with mental health problems.
The brain is, of course, an amazingly intricate structure involving incredibly complex chemical and electrical messages. Our understanding of the system is at present somewhat simplistic. For example, suggested Dr Collins, there’s a well-known theory that low levels of the neurotransmitter serotonin “cause” people to feel depressed. But we don’t know that there’s a causative effect at all, just an association; the depletion in serotonin may be a response to an imbalance somewhere else in the system. I learned from Dr Collins that there are around 100 known neurotransmitters, and specialised subsets of receptors in the brain for each one. Trying to achieve mood change by targeting one specific neurotransmitter is therefore a rather blunt object approach, and can lead to significant side effects. At the moment, drugs are often prescribed knowing that they can be effective, but sometimes without knowing how/why.
So it’s going to be a long time before we can have anything like a working knowledge of how the brain operates in regard to mood, emotional trauma, and so forth. In the meantime, I keep coming back to something Professor Peter Fonagy said at last week’s forum: that one of the reasons that people don’t believe the depths of despair that others may be in, is that humans dissemble. We lie to each other about our inner worlds all the time. We say that we are “fine” when we’re not; we say “that’s okay” when actually something has hurt us very deeply. Maybe while science is working on pinning down our problems for all to see, we can increase the chances of people “believing in” mental illness by telling the truth. It’s scary. It’s going to require bravery. We have to do it without putting ourselves at emotional and physical risk. But sharing something real about our experiences is, for now, the only way I can see to demonstrate the truth of our illnesses.
The last of the current mental health forums is on Monday 26th September 2011 between 2-4 at the Duchess Theatre. The guest speaker will be Professor Mark Williams, Director of the Oxford Mindfulness Centre.