Mental health - again!

I know that this is a highly contentious subject but I just cannot understand why it is now proposed that Australian schools should be provided with “mental health and wellbeing counsellors”.

These are children growing up in a fractured world with raging hormones just trying to “fit in”! 

Now don’t get me wrong! I am fully aware of the indisputable fact that there are many mentally distressed people who are in desperate need of help and support. My “beef” is with how this distress is diagnosed, categorised and finally the efficacy of any treatment offered. 

Firstly, let it be known, and widely known, that there is no consensus or definition of “normal”. What is a “normal” human being? There are roughly 7.2 billion people alive today. That means there are roughly 7.2 billion different people going about their lives, doing different things and behaving in different ways. Does this mean there are roughly 7.2 billion different ways of being “normal”?

Please tell me!

Then we come to the diagnosis of “mental illness”. A popular “diagnostic tool” is the HONOS – Health Of Nations Outcome Scale (please check this on line if you doubt me). Now this scale, as with any others used to “diagnose” a patient’s mental health, and there are plenty of them, is purely subjective. It is a “tick a box” exercise. Using this HONOS each question – there are twelve of them – must be rated 0 to 4. More than a previously determined “score” and you are diagnosed as depressed, schizophrenic, psychotic – or whatever and in need of help. 

Ok. When that is done – what now?

The important question now arises - what is the cause of any distress?

The answer? Nobody knows. Simple. There are plenty of, “the inference is”, the assumptions are”, “there is hope that further research will determine”, etc, etc….!

Again let it be known, and widely known, that there are no objective tests, no biological cause – no blood tests, no fMRI tests (functional Magnetic Resonance Imaging), no genetic link, and particularly no causal link between an apparent “symptom” and the distress evident in the presenting patient. The symptoms enumerated in the DSM5 (Diagnostic and Statistical Manual version 5 of the American Psychiatric Association –APA), used world-wide, were agreed by a committee.

The simple fact is that the “etiology” - the cause – of most mental disorders (Huntingdon’s and Alzheimers disease are more or less determined) are not understood enough to accurately distinguish the “mentally ill” from the rest of us.

Now we enter the minefield of the treatment of “mental illness”. The fall back position of psychiatrists and clinical psychologists is to consider a “mental illness” as a biological condition and treat it as such with a perfect cornucopia of psycho-pharmaceutical drugs produced by “big pharma” to their enormous profit. There is limited evidence regarding the efficacy of these drugs compared to other treatments (“Big Pharma” are very reluctant to release any research that does not support their advertising). Furthermore the side effects – heightened risks of metabolic disorders, rapid weight gain, diabetes, sexual disfunction and heart disease for instance – are carefully sidelined.

That some people do derive benefit from these drugs cannot be denied. They do. But these drugs never “cure” – they are a stop-gap offered to often desperate patients by medicos “stumbling in the dark”.  Often a “suck it and see” approach is applied – “Try this one. If that doesn’t work, try this at double the dose”, kind of thing. But then again, many people get better on their own or feel better with a placebo (sugar pill).

So – to get back to my opening statement about treating school children - until we know the CAUSE of the obvious mental distress experienced by some patients, how can anyone determine, with any certainty, what treatment should be offered? 

Finally I will repeat a quote, from the Indian sage Jiddu Krishnamurti (1895-1986), who said, "It is no measure of health to be well adjusted to a profoundly sick society".

There we have it in a nutshell!

What is Schizophrenia?

What is schizophrenia? The short answer is that no one knows. The effects are well documented even though they are not necessarily unique to schizophrenia. Since the term was first used by Eugen Bleuler in 1911, intense research has so far failed to identify the condition’s causes though it is thought to be a combination, in varying degrees, of genetic, environmental and neurological factors. This debilitating mental disorder is believed to affect about 1% of the World’s population and is generally first diagnosed in late teenage and early adulthood. For reasons not yet established more males than females are affected.

Not only is schizophrenia difficult to define but is without any confirmed pathological, molecular or genetic origin – it has no confirmed biological basis. Diagnosis is made from observed behaviours meeting the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV Axis 1) criteria. These criteria relate principally to the determination of an afflicted individual’s mental state, from their speech patterns and perceptions which may indicate possible hallucinations and/or delusions. This is supported by observed unusual behaviour which may affect the afflicted person’s ability to function effectively in the broader community. Therefore any diagnosis cannot be objectively “scientifically” proven, it is subjective - someone’s opinion and interpretation of behaviour. Furthermore it is not an illness which prescription medication can cure. It is certainly an unfortunate and debilitating condition but it is not an illness – and to call it such is misleading and wrong.

There appear to be many factors involved in the causes of schizophrenia. Obstetric complications, such as foetal hypoxia (foetus deprived of oxygen); viral infections the mother may have experienced during pregnancy; even the season of the year when giving birth, (winter being statistically the least favourable); the patient’s social status; even where the patient resides - in an urban or rural locality (urban being the least favourable), all appear to have a bearing on the incidence of this condition.

While not one single factor has been identified as common to all patients with the condition researchers are working on some evidence that schizophrenia may be a polygenic disorder (influenced by many genes) which is further influenced by environmental factors and a person’s emotional vulnerability while developing in teenage years. Stress appears also to be a factor in the development of schizophrenia as it is recognised in playing a significant role in many medical conditions. It is now thought, with some individuals, that certain levels of stress experienced may exceed their adaptive capacity and thus compound the vulnerabilities of the person concerned. Comments critical of the patient’s demeanour and behaviour together with the alternative of an over-protective relationship have a significant bearing on the course of schizophrenia – this is called a high level of Expressed Emotion. Some patient’s may suffer a relapse from a relatively stable condition which allowed for their discharge from a treatment centre. There is, however, no agreement on the meaning of relapse.

It is now known that people suffering schizophrenia are more likely to recover and less likely to suffer a relapse if they live in a calm, non-critical, non-overprotective environment – a low level of Expressed Emotion. It is well documented that early intervention programmes are of vital importance in determining a favourable outcome for schizophrenia patients but there appears to be no agreement on what recovery actually means. Recovery varies considerably in effect from individual to individual – is it a “clinical” objective recovery (decided by using DSM IV criteria) or an individual’s subjective assessment of their quality of life? It was believed that, once diagnosed with schizophrenia, there was no chance of recovery. There is now, however, a body of evidence suggesting that the situation, for many sufferers, may not be quite so dire, particularly with those individuals not using street drugs and not drinking to excess. With a correct balance between antipsychotic drug treatments and other psychosocial and psychological interventions it is now known that between 20% to 30% recover sufficiently to lead relatively normal lives, with a further 20% to 30% manifesting continuing moderate symptoms. Other reports show that the recovery rate is actually quite high though generally under-reported and is actually somewhere between 50% and 60%. All this shows that the “experts” still don’t really know.

Given the astonishing lack of knowledge about what causes schizophrenia, expressed emotion, relapse and recovery together with the limited understanding of how they relate to one another, how scientists can claim statistical “evidence” and validity proves anything is really surprising. Research is consistent in reporting that high levels of expressed emotion are likely lead to a relapse by patients with schizophrenia. Why this should be, however, is not fully understood. The many factors involved may possibly be partly genetic but certainly involve subjective elements which are difficult to define and measure. No one knows what it really means to recover or relapse nor is it understood from “what” a recovery or relapse is occurring! Also no one knows why high levels of expressed emotion (an “un-calm” environment) may be a predictor of a patient’s relapse.

A mental condition as complex as schizophrenia cannot be artificially restricted to fit the requirements of the DSM-IV. Nature will not be governed by man-made conditions which attempt to force it to answer questions required for statistical analysis to satisfy the ideals of “scientific research”. Statistics are unable to adequately assess the nuances and subtleties of words, gestures, feelings, imaginings, desires and beliefs that, in varying degrees, are so tied to and characteristic of each individual and which are known to have an effect on the outcome of schizophrenia and any relapse or recovery.

To force a patient suffering from schizophrenia to take medication – without knowing what the medication actually does or how it works (and with significant side effects) – is ethically questionable and quite wrong in my opinion. The better way is to look at the physical and emotional environment and conditions which spawned the patient’s affliction. It is necessary to find out what all this means to the patient – their interpretation of the events and how it has affected his or her thinking.

Schizophrenia is as much a mysterious condition as it was 100 years ago, certainly the "experts" have no idea what it really is or how to "cure" the condition.