tag:theconversation.com,2011:/global/topics/mental-illness-2084/articlesMental illness – The Conversation2024-03-26T17:02:22Ztag:theconversation.com,2011:article/2258272024-03-26T17:02:22Z2024-03-26T17:02:22ZFor people with mental illness, drugs and alcohol can be a key survival strategy. I’ve learned they shouldn’t have to ‘get clean’ to get treatment<figure><img src="https://images.theconversation.com/files/582279/original/file-20240315-20-k4w6kp.jpg?ixlib=rb-1.1.0&rect=43%2C60%2C5708%2C3768&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-on-bottles-blurred-person-drinking-1200866920">Ground Picture/Shutterstock</a></span></figcaption></figure><p>A decade ago, while working in a women’s prison, I met a young woman whose story would leave an indelible mark on me. She had endured severe abuse at the hands of men, and I was initially concerned that, as a male social worker, my presence might rekindle her trauma. Yet, through careful and considered engagement, we were able to forge a relationship of trust.</p>
<p>Jenny* confided in me that heroin had become her refuge – the only respite that quieted the relentless storm of her thoughts. But her dependency had brought dire consequences: the removal of her children and her subsequent imprisonment for possession with intent to supply. Even so, Jenny told me that before she was imprisoned: “Heroin was the only thing that helped me to cope.”</p>
<p>While inside, she experienced regular flashbacks and profound anxiety. Her treatment regime included antipsychotic medication Seroquel and heroin replacement Subutex – but Jenny didn’t use them conventionally. “The only way they help is if I grind them together and snort them,” she explained. This method provided her a fleeting, euphoric respite from her psychological torment.</p>
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<p><em>Across the world, we’re seeing unprecedented levels of mental illness at all ages, from children to the very old – with huge costs to families, communities and economies. <a href="https://theconversation.com/uk/topics/tackling-the-mental-health-crisis-147216?utm_source=TCUK&utm_medium=ArticleTop&utm_campaign=MentalHealthSeries">In this series</a>, we investigate what’s causing this crisis, and report on the latest research to improve people’s mental health at all stages of life.</em></p>
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<p>It wasn’t Jenny’s drug revelation that struck me most profoundly, but the reaction of some of my prison colleagues. Her unconventional use of the medication was labelled substance abuse, leading to her being ostracised by the prison’s mental health service, which refused to work with her until she “sorted out” her drug issues.</p>
<p>Even though I had known Jenny for a year, it was only when she was about to be released from prison that I really understood how serious her situation was. I was shocked to see her breaking the prison’s rules on purpose because she didn’t want to leave. She started smoking in places she shouldn’t, damaged her own cell and areas everyone used, attacked another prisoner, which was not like her at all, and started using spice and hooch.</p>
<p>Jenny preferred staying in jail over facing life outside, but she was let out all the same. A week after her release, I received news that she had died from a heroin overdose.</p>
<h2>My search for answers</h2>
<blockquote>
<p>Mental health problems are experienced by the majority of drug and alcohol users in community substance use treatment. Death by suicide is also common, with a history of alcohol or drug use being recorded in 54% of all suicides in people experiencing mental health problems. (<a href="https://assets.publishing.service.gov.uk/media/5a75b781ed915d6faf2b5276/Co-occurring_mental_health_and_alcohol_drug_use_conditions.pdf">Public Health England guide</a>, 2017.)</p>
</blockquote>
<p>Jenny’s tragic story left me with many questions – what were the underlying causes of mental illness? What spurred the spiral into addiction? Why did individuals turn to substance use? – that, even after six years as a mental health social worker working in prisons and psychiatric hospitals, I had neither the knowledge nor experience to answer. Talking to colleagues did not resolve them, so I sought answers by returning to academia alongside my day job.</p>
<p>A postgraduate diploma helped me better understand the theories of mental health from neuroscientific, psychiatric and pharmacological perspectives. But above all, I realised that many of the people I was now encountering in my new role, working in a crisis home treatment team (a community-based team set up to support people experiencing severe mental health issues), would never get better. Rather, they would just keep coming back with a new crisis.</p>
<p>And for a large majority of them (around four in five), substances ranging from highly addictive narcotics to potent, mind-altering chemicals would be a key part of their daily lives in addition to, or as an alternative for, their prescribed psychiatric medication.</p>
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<img alt="" src="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><strong><em>This article is part of Conversation Insights</em></strong>
<br><em>The Insights team generates <a href="https://theconversation.com/uk/topics/insights-series-71218">long-form journalism</a> derived from interdisciplinary research. The team is working with academics from different backgrounds who have been engaged in projects aimed at tackling societal and scientific challenges.</em></p>
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<p>Roger was one of many people I met who relied on <a href="https://theconversation.com/what-is-spice-and-why-is-the-drug-so-dangerous-60600">Spice</a>, a synthetic cannabinoid designed to mimic the effects of naturally occurring <a href="https://www.ncbi.nlm.nih.gov/books/NBK563174/#:%7E:text=Delta%2D9%2Dtetrahydrocannabinol%20(also,the%20class%20of%20cannabinoid%20medications.),%20the%20psychoactive%20ingredient%20in%20marijuana.%20Regular%20Spice%20users%20face%20severe%20health%20risks,%20in%20particular%20to%20their%20cognitive%20function,%20and%20an%20increased%20risk%20of%20%5Bpsychotic%20outcomes%5D(https://onlinelibrary.wiley.com/doi/full/10.1002/wps.20341">THC</a>. (In addition to consumption by smoking, there are increasing reports of synthetic cannabinoids being used in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5398321/">e-cigarettes or vapes</a>.)</p>
<p>Nonetheless, Roger told me Spice was the “only thing that would help sort my head out”. And, after listening to a lecture from me about the dangers of these substances, he responded:</p>
<blockquote>
<p>I know how much to take – I know when I’ve taken too much or not enough. I use it in doses now. Why would I stop if it’s the only thing that works?</p>
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<p>It was clear that Roger knew much more about the effects of Spice than I did. Interactions like this ignited a desire in me for deeper knowledge – not from books or universities, but directly from people with co-existing mental health and addiction problems.</p>
<p>Perhaps surprisingly, in the UK we don’t know how many people are living in this combined state. Estimates have tended to focus only on people with severe mental health problems and problematic substance use. For example, a <a href="https://www.drugsandalcohol.ie/17764/">2002 Department of Health guide</a> suggested that 8-15% of its patients had a dual diagnosis – while acknowledging that it is difficult to assess exact levels of substance use, both in the general population and among those with mental health problems.</p>
<p>A decade earlier, US research had identified that for <a href="https://psycnet.apa.org/record/2005-09774-007">people with schizophrenia</a>, substance use (non-prescribed drugs) was a significant problem relative to the general population. More recently, a 2023 global review of evidence identified that the prevalence of co-existing mental health and substance use among <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9955022/">children and adolescents treated for psychiatric conditions</a> ranged between 18.3% and 54%.</p>
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<a href="https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Painting of Thomas De Quincey" src="https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=644&fit=crop&dpr=1 600w, https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=644&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=644&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=810&fit=crop&dpr=1 754w, https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=810&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=810&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Thomas De Quincey, author of Lessons From an English Opium Eater.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Thomas_de_Quincey_by_Sir_John_Watson-Gordon.jpg">National Portrait Gallery via Wikimedia</a></span>
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<p>But what I found particularly interesting was an analysis of the writings of Thomas De Quincey from more than 200 years ago. In his 2009 article <a href="https://www.tandfonline.com/doi/abs/10.3109/10826089009056230">Lessons From an English Opium Eater: Thomas De Quincey Reconsidered</a>, leading clinical academic, John Strang, highlighted that issues raised by De Quincey in 1821 remain causes for concern some two centuries later.</p>
<p>De Quincey was arguably the first person to document his own use of substances, in particular opium. His writing shows that he self-medicated to manage pain, including “excruciating rheumatic pains of the head and face”:</p>
<blockquote>
<p>It was not for the purpose of creating pleasure, but of mitigating pain in the severest degree, that I first began to use opium as an article of daily diet … In an hour, oh Heavens! What an upheaving, from its lowest depths, of the inner spirit! </p>
</blockquote>
<p>De Quincey’s use of non-prescribed drugs mirrors that of John, Jenny, Roger and so many other people I have met as a social worker. Clearly, we’ve known about the close relationship between mental illness and substance abuse for hundreds of years, yet are still wrestling with how best to respond.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/guide-to-the-classics-confessions-of-an-english-opium-eater-by-thomas-de-quincey-a-dense-strange-journey-through-addiction-190435">Guide to the classics: Confessions of an English Opium Eater by Thomas De Quincey – a dense, strange journey through addiction</a>
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<p>Official guidance almost always advocates for a <a href="https://www.nhsconfed.org/system/files/2022-12/NHS%20Confederation%20parliamentary%20briefing%20-%20No%20wrong%20door%20-%20a%20ten-year%20vision%20for%20mental%20health%20learning%20disability%20and%20autism%20services.pdf">“no wrong door” policy</a>, meaning that those with dual addiction and mental health issues will get help whichever service encounters them first. But from what people with lived experience were telling me, this was not the case.</p>
<p>I sent freedom of information requests to 54 mental health trusts across England, to try to discern any patterns of variation in the way their patients were being measured and treated. Some 90% of the trusts responded, of which a majority (58%) recognised the dual occurrence of mental illness and substance use. However, the estimated prevalence of this dual diagnosis varied widely – from only nine to around 1,200 patients per trust.</p>
<p>What I found most alarming was that less than 30% of the mental health trusts said they have a specialised service for addiction which accepts referrals for dual diagnosis patients. In other words, throughout England, a lot of these patients are not being appropriately supported.</p>
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<a href="https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Out-of-focus man holding a syringe in the foreground" src="https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drug-addict-young-man-syringe-action-599693732">271 Eak Moto/Shutterstock</a></span>
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<h2>‘When I say I use heroin, people change’</h2>
<blockquote>
<p>I started using when I was around 18. Things weren’t good in my life at the time, and I got in with a crowd who offered me heroin. It was the most amazing experience; all my worries disappeared better than the antidepressants I had been taking. But the more I used, the more I needed it. Now I use it in stages, just before I go to work and at night.</p>
</blockquote>
<p>Carl had been using heroin for more than ten years when I interviewed him. When I asked if he wanted to stop, he shrugged and said no, explaining:</p>
<blockquote>
<p>I’ve tried so many times – I’ve been on methadone but that was worse, especially coming off it. I know how much to take, and no one knows I use gear – so, no. But, as soon as you tell a professional you take heroin, their whole attitude changes. I’ve seen it many times. I dress quite well and I have a job, but as soon as I say I use heroin, they change. It’s almost as if they don’t see the same person any more.</p>
</blockquote>
<p>Talking to Carl underlined that many users know far more than me about the substances they take and why they take them. Yet as soon as a professional (typically a nurse, social worker or doctor) hears they are taking an illegal substance, or are misusing a legal substance such as alcohol, they are stigmatised and often ostracised from service provision.</p>
<p>Suzanne was homeless and also using heroin, but for different reasons to Carl. I asked why she started using it:</p>
<blockquote>
<p>I’ve had a shit life – it numbs all of that. Now being homeless, it helps me to sleep and keeps me warm, but I only use it in the winter because I need to sleep.</p>
</blockquote>
<p>In summer, Suzanne explained, she would switch to taking “phet” – amphetamines. I asked her why:</p>
<blockquote>
<p>You need to be awake – there are lots of dickheads around. I’ve been beaten and raped in the summer when I was asleep, so you need to be awake more.</p>
</blockquote>
<p>Hearing the stories of people fighting their personal battles with mental health and substance use issues was at once haunting and cathartic for me. It was deeply moving to hear them, time and again, struggling with the most difficult aspect of their condition: the simple decision to ask for help. And sadly, far too often, when they did summon the courage, their requests would go unheard, unheeded, or they would be engulfed by a sprawling system that seemed unable to help.</p>
<p>Dave had been using alcohol for many years and had asked for support on several occasions – only to be passed from service to service:</p>
<blockquote>
<p>I was made redundant and, at 50, was finding it hard to get another job. I wasn’t drinking all of the time then. But as I started to get into more debt and the bailiffs were knocking on the door, I needed a drink to get me through it. It was not until I was charged with drunk driving that I knew I had a problem.</p>
</blockquote>
<p>Dave said he wasn’t shy about asking for help – at least, for a while. But he found himself caught in a downward spiral that led to more drinking, more suffering, and less support:</p>
<blockquote>
<p>So many times I’d stop drinking, but I couldn’t deal with the voices in my head. I’d ask for support, but the waiting lists were so long. The medication the doctor gave me did nothing, so I’d start drinking again, and because I’d start to drink again, mental health services wouldn’t touch me. All they kept saying was: ‘You should stop drinking first.’</p>
</blockquote>
<h2>The biggest barrier to getting support</h2>
<p>To expand my understanding, I also sought the perspectives of a dozen people working on the frontline of mental healthcare – from professionals in NHS mental health and substance use teams, to people working for charitable support groups. Their insights revealed a <a href="https://www.miragenews.com/northern-england-life-ups-death-risk-from-1195801/">frayed and fragmented network of services</a>, with the holes and inefficiencies obvious and crying out for attention and repair. As one nurse explained:</p>
<blockquote>
<p>The stress of trying to get services to help is unbelievable. You’ve got pressure from the person’s family because they are afraid they’ll end up dead. You’ve got pressure from managers to discharge the person. All I’d get is criticism which far outweighed encouragement or support. The stress made me so anxious that I almost gave it all up – and even considered suicide myself.</p>
</blockquote>
<p>Over 80% of the professionals I spoke to called for an integration of mental health and substance use teams, in part because of the huge cuts nationwide in funding to substance use services. One social worker in a substance use service explained the current situation:</p>
<blockquote>
<p>If you get someone with an alcohol addiction, it becomes quite apparent that they use drink as a way of coping with their mental health. But, because of massive waiting lists within mental health services or because they are told they need to stop drinking before [they can be treated], mental health support can’t be offered. So, the person just keeps drinking and eventually disengages from our services as there is no hope for them. We shouldn’t expect someone to stop using a substance that they perceive is helping without offering an alternative treatment.</p>
</blockquote>
<p>For all the professionals I interviewed, the most significant barrier to getting support for someone’s mental health issues was that they used substances and would not receive any treatment until they addressed this. As one mental health nurse told me:</p>
<blockquote>
<p>I had one chap who was using cocaine, mainly due to social anxiety. Initially, he’d use it when socialising with friends. But because it gave him confidence and he could talk to people, he started to use it all the time and got himself in debt. I wanted to address the root cause, the social anxiety, so I referred him to our Improving Access to Psychological Therapy service. But I was told he needed to be abstinent from cocaine for three months before they’d accept him. He eventually disengaged, and I haven’t seen him since.</p>
</blockquote>
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<a href="https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="The word HELP spelled out in white powder" src="https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=363&fit=crop&dpr=1 600w, https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=363&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=363&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=456&fit=crop&dpr=1 754w, https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=456&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=456&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/word-help-spelled-out-by-cocaine-2289738709">Runawayphill/Shutterstock</a></span>
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<h2>A seismic shift is needed</h2>
<p>In the shadows of our society, hidden behind the walls of our prisons and in the dark corners of our streets, the experiences of Jenny and countless others bear witness to the profound failings of our healthcare system to address co-existing mental health and substance use issues. For those caught in the merciless cycle of addiction and illness, these systemic inefficiencies and administrative blockades do much to intensify their torment.</p>
<p>Their often brutally honest accounts (and the insights of those who try to support them) draw a portrait of a split and underfunded service, collapsing under the weight of its contradictions. The loud calls for integrated mental health and substance addiction treatment become muffled amid the bureaucratic din of funding cuts, lengthy waiting lists and policy neglect.</p>
<p>The evidence overwhelmingly confirms the need for a model of care that is <a href="https://theconversation.com/how-to-solve-our-mental-health-crisis-214776">holistic and integrated</a> – one that shifts the narrative from stigma and isolation to awareness and support.</p>
<p>The economic case for reshaping investment in our mental health and substance misuse services is powerful. The annual cost of mental health problems to the UK economy is a staggering £117.9 billion – equivalent to <a href="https://www.england.nhs.uk/aac/wp-content/uploads/sites/50/2022/09/B1482_research-demand-signalling-national-mental-health-programme_september-2022.pdf">5% of its annual GDP</a> – with substance misuse adding a <a href="https://www.gov.uk/government/publications/review-of-drugs-phase-two-report/review-of-drugs-part-two-prevention-treatment-and-recovery#:%7E:text=There's%20a%20strong%20'invest%20to,was%20spent%20on%20drug%20treatment.">further £20 billion</a>.</p>
<p>However, these figures tell only part of the tale. While we know that <a href="https://assets.publishing.service.gov.uk/media/5a75b781ed915d6faf2b5276/Co-occurring_mental_health_and_alcohol_drug_use_conditions.pdf">70% of people in treatment for drug misuse and 86%</a> of people in treatment for alcohol misuse have a mental health diagnosis, the full financial impact of people with these co-occurring disorders is probably far greater.</p>
<p>This also includes people who often plough through a <a href="https://www.emerald.com/insight/content/doi/10.1108/ADD-11-2017-0021/full/html">punitive and bewildering series of services</a> as they navigate their intersecting problems, encountering barriers at every turn that fail to address their <a href="https://assets.publishing.service.gov.uk/media/5a75b781ed915d6faf2b5276/Co-occurring_mental_health_and_alcohol_drug_use_conditions.pdf">acute health</a> and social care needs. As their distress is amplified, the costs to <a href="https://www.emerald.com/insight/content/doi/10.1108/17570971111197175/full/html">wider society</a> escalate too – as one social worker explained to me:</p>
<blockquote>
<p>I am currently supporting a woman who is struggling with alcohol dependency, a condition that began after she endured significant domestic abuse. The cycle is devastating: her trauma cannot be effectively addressed because of her dependency on alcohol, and she cannot abandon alcohol because it’s the only solace she finds from her emotional torment. Despite several attempts at rehabilitation, none of the programmes have sufficiently tackled the mental health aspects of her trauma. Now, with cirrhosis of the liver, her health is in critical decline. It’s a heart-wrenching situation – a stark reminder of the desperate need for integrated treatment approaches that address both substance dependency and the underlying psychological trauma.</p>
</blockquote>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Out-of-focus woman with a glass of alcohol on the table in front of her" src="https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<h2>‘I might as well be dead’</h2>
<p>In the quiet confines of a West Midlands mental health crisis centre, I’m preparing to meet someone whose story I know only from the clinical notes on my screen. The phrase “is alcohol dependent” is highlighted in bold. Behind those words is another person whose life is unravelling in the silence of a battle fought alone.</p>
<p>John walks into the room, a man living in the grip of two relentless forces – addiction and mental illness. “It was just to stop the noises,” he says of the whisky he uses as medication for his inner turmoil. His hands are trembling. This is the moment of truth – his story is no longer trapped within the clinical pages of a case file. </p>
<p>“I’ve lost everything,” he tells me. “I might as well be dead.” </p>
<p>Then John explains why he’s given up hope:</p>
<blockquote>
<p>I’ve asked for help so many times, but all I get told is that I need to stop drinking before my mental health can be treated. However, alcohol is the only thing that works for me. I’ve gone through detox, but then I had to wait months for counselling. I just can’t cope that long without any support – antidepressants don’t do anything for me. What’s the point?</p>
</blockquote>
<p>Over the past 15 years, I have met countless “Johns”, both during my day job as a mental health social worker and, latterly, in my academic research. This has led me to conclude that the health and social care system in which I work falls catastrophically short. </p>
<p>This is no mere professional critique. It is an impassioned plea for society to rediscover its collective heart; to explore the human stories that lie hidden in statistics such as that, between 2009 and 2019, <a href="https://documents.manchester.ac.uk/display.aspx?DocID=60521">53% of UK suicides</a> were among people with comorbid diagnoses of mental health and substance use.</p>
<p>Instead of viewing people through the limiting lens of labels, we should endeavour to see their humanity. Engaging in conversation, extending empathy and showing compassion are powerful actions. A kind word, an understanding nod or a gesture of support can affirm their dignity and spark a connection that resonates with their innate human spirit. Or as John, whose journey I’ve had the privilege to witness, puts it:</p>
<blockquote>
<p>It’s not about the help offered but the meaning behind it. Knowing you’re seen as a person, not just a problem to be solved – that’s what sticks with you.</p>
</blockquote>
<p><em>*All names in this article have been changed to protect the anonymity of the interviewees.</em></p>
<p><em>If you or anyone you know require expert advice about the issues raised in this article, the NHS provides this <a href="https://www.nhs.uk/nhs-services/mental-health-services/where-to-get-urgent-help-for-mental-health/">list of local helplines and support organisations</a>.</em></p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=140&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em>For you: more from our <a href="https://theconversation.com/uk/topics/insights-series-71218?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Insights series</a>:</em></p>
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<li><p><em><a href="https://theconversation.com/insomnia-how-chronic-sleep-problems-can-lead-to-a-spiralling-decline-in-mental-health-224131?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Insomnia: how chronic sleep problems can lead to a spiralling decline in mental health
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<li><p><em><a href="https://theconversation.com/existential-crisis-how-long-covid-patients-helped-us-understand-what-its-like-to-lose-your-sense-of-identity-and-purpose-in-life-211223?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Existential crisis: how long COVID patients helped us understand what it’s like to lose your sense of identity and purpose in life
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<li><p><em><a href="https://theconversation.com/ocd-is-so-much-more-than-handwashing-or-tidying-as-a-historian-with-the-disorder-heres-what-ive-learned-219281?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">OCD is so much more than handwashing or tidying. As a historian with the disorder, here’s what I’ve learned
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<li><p><em><a href="https://theconversation.com/how-music-heals-us-even-when-its-sad-by-a-neuroscientist-leading-a-new-study-of-musical-therapy-214924?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">How music heals us, even when it’s sad – by a neuroscientist leading a new study of musical therapy
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<p><em>To hear about new Insights articles, join the hundreds of thousands of people who value The Conversation’s evidence-based news. <a href="https://theconversation.com/uk/newsletters/the-daily-newsletter-2?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK"><strong>Subscribe to our newsletter</strong></a>.</em></p><img src="https://counter.theconversation.com/content/225827/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Bratt does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>This is the moment of truth. John’s story is no longer trapped in the clinical pages of a case file. ‘I’ve lost everything,’ he says. ‘I might as well be dead.’Simon Bratt, Mental Health Social Worker and PhD Candidate, Staffordshire UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2223642024-03-26T12:48:40Z2024-03-26T12:48:40ZNot having job flexibility or security can leave workers feeling depressed, anxious and hopeless<figure><img src="https://images.theconversation.com/files/581106/original/file-20240311-22-aqasrx.jpg?ixlib=rb-1.1.0&rect=62%2C20%2C6934%2C4637&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Warehouse employees frequently lack control over their own schedules.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/exhausted-warehouse-worker-royalty-free-image/1413866834">Andres Oliveira/E+ via Getty Images</a></span></figcaption></figure><p>When employees don’t have control over their work schedules, it’s not just morale that suffers – mental health takes a hit too. That’s <a href="https://doi.org/10.1001/jamanetworkopen.2024.3439">what my colleagues and I discovered</a> in a study recently published in the medical journal JAMA Network Open.</p>
<p>As a <a href="https://www.bu.edu/sph/profile/monica-wang/">public health expert</a>, I know that the way our jobs are designed can affect our well-being. Research has shown that flexibility, security and autonomy in the workplace are strong <a href="https://doi.org/10.1093/acrefore/9780190236557.013.15">determinants of health</a>.</p>
<p>To understand how powerful they are, my colleagues and I looked at the 2021 <a href="https://www.cdc.gov/nchs/nhis/about_nhis.htm">National Health Interview Survey</a>, a major data collection initiative run out of the <a href="https://www.cdc.gov/nchs/index.htm">National Center for Health Statistics</a>. We analyzed responses from 18,144 working adults across the U.S., teasing out how job flexibility and security may be linked with mental health.</p>
<p>The respondents were asked how easily they could change their work schedule to do things important to them or their family, whether their work schedule changed on a regular basis, and how far in advance they usually knew their schedules. They also rated their perceived risk of losing their job in the next 12 months.</p>
<p>We found that workers who had more flexible work arrangements were less likely to report feelings of depression, hopelessness and anxiety. Similarly, those with greater job security were at lower risk of mental health challenges. We also found that higher job security was linked with fewer instances of missing work over the past year.</p>
<h2>Why it matters</h2>
<p>The average full-time worker dedicates <a href="https://www.gettysburg.edu/news/stories?id=79db7b34-630c-4f49-ad32-4ab9ea48e72b">a third</a> of their lifetime waking hours to work. Given that fact, understanding how job design affects mental health is key to developing policies that bolster well-being.</p>
<p>It’s clear why employers should care: When workers aren’t feeling well mentally, they’re <a href="https://doi.org/10.1007/s40258-022-00761-w">less productive</a> and more likely to <a href="http://doi.org/10.1097/00043764-200104000-00010">miss work</a>. Their <a href="https://www.betterup.com/blog/mental-health-impedes-creativity">creativity</a>, <a href="https://doi.org/10.1080/02678373.2017.1304463">collaboration</a> and ability to <a href="https://www.who.int/news-room/fact-sheets/detail/mental-health-at-work#">meet job demands</a> also suffer, hurting the entire organization.</p>
<p>The impact of job-related stress extends beyond the workplace, affecting families, communities and health care systems. People grappling with work-related mental health challenges often require <a href="http://doi.org/10.1186/1471-244X-14-131">multiple forms of support</a>, such as access to counseling, medication and social services. Not addressing these needs comprehensively can cause <a href="http://doi.org/10.1001/jamahealthforum.2023.3535">serious long-term consequences</a>, including reduced quality of life and increased health care costs.</p>
<p>It’s important to note that the COVID-19 pandemic <a href="https://doi.org/10.1007/s40615-022-01284-9">worsened mental health disparities</a> and that individuals in lower-wage positions, front-line workers and people in marginalized communities continue to face <a href="http://doi.org/10.1111/1475-6773.14136">additional challenges</a>. In this context, understanding exactly how job and work design can affect people’s mental health is all the more important.</p>
<h2>What’s next</h2>
<p>My research team plans to examine how race and gender affect the links between job flexibility, job security and mental health.</p>
<p><a href="http://doi.org/10.1037/a0034016">Previous research</a> suggests that women and people of color experience <a href="http://doi.org/10.1037/a0034016">unique workplace stressors</a> that harm their mental well-being. For instance, women continue to face <a href="https://sgff-media.s3.amazonaws.com/sgff_r1eHetbDYb/Women+in+the+Workplace+2023_+Designed+Report.pdf">barriers to career advancement</a>, <a href="https://www.forbes.com/advisor/business/gender-pay-gap-statistics/#">unequal pay</a> and a <a href="https://doi.org/10.1007/s11205-018-2025-x">higher burden</a> of unpaid care work.</p>
<p>Similarly, employees of color often experience <a href="https://news.gallup.com/poll/328394/one-four-black-workers-report-discrimination-work.aspx">discrimination</a>, <a href="https://hbr.org/2022/05/research-the-real-time-impact-of-microaggressions">microaggressions</a> and <a href="https://www.urban.org/sites/default/files/publication/104761/racial-equity-and-job-quality.pdf">limited opportunities for professional growth</a> at work, all of which can harm <a href="https://milkeninstitute.org/sites/default/files/2023-04/racialequitybrief.pdf">mental health</a>. Understanding gender and racial differences will help researchers and organizations develop targeted interventions and policy recommendations.</p>
<p>Mental health challenges are far from rare: More than 50 million Americans, or nearly <a href="https://www.nimh.nih.gov/health/statistics/mental-illness">1 in 5 adults</a>, live with mental illness. By creating workplaces that <a href="https://doi.org/10.1177/08901171241233398">prioritize employee well-being</a> – through flexible work arrangements, supportive policies and access to mental health resources – organizations can help build a healthier society. </p>
<p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take on interesting academic work.</em></p><img src="https://counter.theconversation.com/content/222364/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Monica Wang does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The way jobs are structured affects employee mental health, an analysis of more than 18,000 workers shows.Monica Wang, Associate Professor of Public Health, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2237072024-03-11T12:25:16Z2024-03-11T12:25:16ZShould people suffering from mental illness be eligible for medically assisted death? Canada plans to legalize that in 2027 – a philosopher explains the core questions<figure><img src="https://images.theconversation.com/files/580759/original/file-20240308-16-9f5ja6.jpg?ixlib=rb-1.1.0&rect=15%2C0%2C2101%2C1409&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In advocates' eyes, expanding access to a medically assisted death helps people protect their autonomy at a crucial time.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/close-up-of-a-young-womans-hand-holding-the-hand-of-royalty-free-image/1408213220?phrase=hands+death+love+bed&adppopup=true">Eva HM/iStock via Getty Images Plus</a></span></figcaption></figure><p>Imagine that you have lived with an illness for years. The suffering this illness has caused is devastating – so much that you wish to die. You no longer feel like the person you were before. You have been to see specialists, have tried the best treatments, but nothing works.</p>
<p>This is many people’s reality, and not only because of physical disorders and disease. Chronic mental illness can be just as crushing. Starting in March 2024, Canada planned to make medical assistance in death, or MAID, available to people with mental illness – <a href="https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html">expanding a program</a> already available to patients with terminal or chronic physical illness. In 2022, more than 13,000 people in Canada died with medical assistance, according to <a href="https://www.canada.ca/content/dam/hc-sc/documents/services/medical-assistance-dying/annual-report-2022/annual-report-2022.pdf">a government report</a>.</p>
<p>In February, however, the government announced <a href="https://www.canada.ca/en/health-canada/news/2024/02/the-government-of-canada-introduces-legislation-to-delay-medical-assistance-in-dying-expansion-by-3-years.html">a three-year delay</a> for the controversial program, saying the health care system needs more time to prepare.</p>
<p>When it is enacted in March 2027, this new provision will make Canada one of the few countries that allow MAID for mental illness. These include <a href="https://doi.org/10.3389/fpsyt.2022.895387">the Netherlands</a> <a href="https://pegasos-association.com/requirements/">and Switzerland</a>. Only a minority of U.S. states, such as Maine and Oregon, <a href="https://deathwithdignity.org/states/">allow any kind of MAID</a>, though many others have debated it – and none allow it for mental illness.</p>
<p>Critics say there are inadequate safeguards and <a href="https://www.cbc.ca/news/opinion/opinion-assisted-dying-maid-legislation-mental-health-1.5452676">a dearth of health care coverage</a> for psychiatric and psychological issues, which could prompt people to view MAID as their only alternative. They also point to the difficulty of predicting whether or not someone’s mental illness will eventually get better.</p>
<p>MAID activists believe that access to this choice for patients with mental illness is morally required. But even people <a href="https://www.cbc.ca/news/politics/medical-assistance-in-dying-mental-illness-delay-1.7098313">not opposed to Canada’s new provision</a> are concerned about whether the system is ready.</p>
<p>As <a href="https://www.gonzaga.edu/college-of-arts-sciences/faculty-listing/detail/kulp">a philosopher</a> who specializes in <a href="https://ecommons.luc.edu/luc_diss/1277/">end of life ethics</a> and physician-assisted death, I research a distinction that is at the heart of this debate. There is a subtle but crucial difference between being acutely suicidal – an experience that may pass – and, after long consideration, desiring death in the face of suffering. </p>
<h2>My body, my decision?</h2>
<p>Plenty of people oppose MAID – often called physician-assisted death – under any circumstances, including terminal physical illness. Some believe it <a href="https://www.cccb.ca/media-release/statement-by-the-canadian-conference-of-catholic-bishops-on-the-non-permissibility-of-euthanasia-and-assisted-suicide-within-canadian-health-organizations-with-a-catholic-identity/">violates the sanctity of human life</a>. </p>
<p>Others have qualms about asking doctors, who are normally concerned about the preservation of human life, <a href="https://www.thepublicdiscourse.com/2019/11/57243/">to participate in ending it</a>. In other words, they emphasize nonmaleficence, the obligation to do no harm – <a href="https://doi.org/10.1159/000509119">one of the core tenets of medical ethics</a>.</p>
<p>Many proponents, on the other hand, base their arguments on two other core tenets: beneficence – the obligation to benefit the patient – and autonomy. <a href="https://doi.org/10.1093/acprof:oso/9780195140279.003.0002">Autonomy arguments</a> usually assume that a government is only justified in restricting citizens’ liberty if exercising that liberty would cause harm to other people.</p>
<p>Advocates of physician-assisted death emphasize that ending one’s own life does not harm other people, suggesting that the government has no business curtailing the patient’s choices. Legalization ensures that citizens can make their own decisions about one of the most personal and value-laden times of life.</p>
<p>In medical ethicists’ view, in order for a person to be considered autonomous, they must be able to act intentionally and with an understanding of the potential consequences of their actions. Additionally, an autonomous person is reasonably free from undue influence – such as family members pressuring them or financial considerations that restrict their choices. </p>
<p>When it comes to physical illness, ethicists who <a href="https://philpapers.org/rec/RIDMAI-2">argue that physician-assisted death is morally permissible</a> view patients as free actors exercising their autonomy if they meet several criteria: they are terminally and chronically ill, have worked with medical professionals over time and have established an unchanging desire to end their suffering.</p>
<h2>Thorny issues</h2>
<p>Experiences of mental illness, however, raise serious questions about patients’ autonomy.</p>
<p>Mental illnesses often limit a person’s ability to govern their own lives free from the effects of their illness. For instance, a patient with <a href="https://theconversation.com/mariah-carey-says-she-has-bipolar-disorder-a-psychiatrist-explains-what-that-is-94893">bipolar I disorder</a> is not fully autonomous during the middle of a manic episode. Were it not for their disease, they would be less likely to engage in the types of behaviors that characterize a manic episode, such as reckless spending or risky sexual encounters.</p>
<p>Yet this is not true for all mental illnesses, or at all times. A person with well-treated bipolar 1 disorder will have periods in which <a href="https://www.samhsa.gov/mental-health/bipolar">their symptoms are under control</a>. In fact, it is in these periods of lucidity when <a href="https://www.nytimes.com/2023/12/27/world/canada/medical-assisted-death-mental-illness.html">some bipolar patients</a> decide their own death would be preferable to the suffering they endure. </p>
<p>Moreover, proponents of <a href="https://www.nytimes.com/2023/04/21/opinion/medical-assistance-dying-mental-illness-maid.html">extending physician-assisted death to mental illness</a> believe that the approval process can protect people who request it when acutely suicidal or who have not yet received adequate treatment.</p>
<p>In Canada’s proposed system, a mentally ill person requesting MAID must have been informed of all reasonable treatment options. They must also demonstrate a sustained desire to receive MAID, including waiting for 90 days after their application. Finally, the patient must have two doctors certify that their suffering is “<a href="https://www.justice.gc.ca/eng/rp-pr/other-autre/ad-am/p1.html">grievous and irremediable</a>” in any way the patient finds acceptable.</p>
<p>One key issue in preparing Canada’s health care system is whether providers have received enough training <a href="https://www.canada.ca/en/health-canada/services/publications/health-system-services/advice-profession-medical-assistance-dying.html#a7">to differentiate someone who is acutely suicidal</a> from someone who is in a frame of mind to make this decision thoughtfully. If someone is experiencing an acute desire to die that may be a symptom of their illness, most ethicists would find MAID morally impermissible. If, however, a mentally ill person <a href="https://www.reuters.com/world/americas/shes-47-anorexic-wants-help-dying-canada-will-soon-allow-it-2023-07-15/">has spent years suffering</a>, has exhausted reasonable treatment and has maintained a desire to die for some time, some ethicists believe MAID is appropriate.</p><img src="https://counter.theconversation.com/content/223707/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maria Kulp does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Assessing a patient’s autonomy can be more difficult when mental illness is the main source of their suffering.Maria Kulp, Associate Professor of Philosophy, Gonzaga UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2240572024-03-04T20:58:06Z2024-03-04T20:58:06ZMAID and mental health: Does ending the suffering of mental illness mean supporting death or supporting better lives?<p>Recent headlines have <a href="https://nationalpost.com/news/canada/psychiatrists-clash-deadline-maid-mental-illness">highlighted debates</a> among federal parties over the proposal to <a href="https://www.canada.ca/en/health-canada/news/2024/02/the-government-of-canada-introduces-legislation-to-delay-medical-assistance-in-dying-expansion-by-3-years.html">extend Medical Assistance in Dying</a> (MAID) to people suffering solely with mental illness. </p>
<p>Proponents of <a href="https://psychiatry.utoronto.ca/news/discussing-medical-assistance-dying-and-mental-illness-canada">expanding Bill C-7 to mental illness claim</a> that delays to do so are based on stigma and stereotypes promoting the belief that a mental disorder renders someone incapable of making a rational choice to die. Those that advocate for delaying an expansion suggest that more work is needed to <a href="https://doi.org/10.1097/yco.0000000000000298">ensure appropriate safeguards</a> are in place to distinguish requests for MAID from illness-induced suicidal ideation. </p>
<p>The recent announcement that including mental illness in MAID will be <a href="https://www.cbc.ca/news/politics/liberals-delay-expanding-maid-1.7101560">delayed until 2027</a> gives provincial and territorial health-care systems more time to prepare for implementation. </p>
<h2>Putting access to MAID in context</h2>
<p>People living with long-term mental illness should have the option to consider MAID, like others facing chronic, debilitating illnesses. However, access to MAID is a small part of a larger conversation we ought to be having about how the health-care system can provide supports and services that empower people with mental health disorders to navigate the long journey of mental illness with dignity and resilience. Extending support to the families that care for them should be considered key. </p>
<p><a href="https://www.camh.ca/en/driving-change/the-crisis-is-real/mental-health-statistics">As the Centre for Addiction and Mental Health (CAMH) reports</a>, mental illness is the leading cause of disability in Canada, and wait lists for services are far too long. For each person with a debilitating mental illness, there are family members — biological, legal or chosen — doing their best to provide support and care. But who supports these families as they navigate the challenges of persistent mental illness? </p>
<p>Despite decades of research demonstrating the <a href="https://doi.org/10.7870/cjcmh-2015-009">importance of family caregivers</a> for supporting people with severe mental illness, and the <a href="https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/Caregiving_MHCC_Family_Caregivers_Guidelines_ENG_0.pdf">beneficial outcomes</a> for all family members when families are supported, vital support services have <a href="https://www.fraserinstitute.org/sites/default/files/mental-health-care-how-is-canada-doing.pdf">declined throughout Canada</a>. Families that are racialized, poor or newcomers are <a href="https://doi.org/10.1177/0840470420933911">getting even less support</a> in a depleted family support service system. </p>
<p>Examples of evidence-based family-focused supports that would help include <a href="https://doi.org/10.1111/j.1752-0606.2011.00256.x">family psychoeducation</a>, <a href="https://doi.org/10.1111/hsc.12689">peer support</a>, and <a href="https://doi.org/10.1177/07067437231197263">community-based, culturally-acceptable services</a> that focus on whole families.</p>
<h2>Supporting patients and families</h2>
<p>In addition to asking health-care systems to prepare to end the suffering of mental illness by facilitating death, we should be asking legislators and policymakers to build a health-care system that supports better lives for people with mental disorders and their families. </p>
<p>Families manage mental illness <a href="https://www.ctvnews.ca/health/relatives-of-people-with-serious-mental-illness-often-bear-brunt-of-stigma-study-1.6374892">out of sight</a> of these leaders and society at large; their suffering is seen as a <a href="https://tspace.library.utoronto.ca/bitstream/1807/94700/1/Caregiving%20under%20siege_Williams.pdf">personal matter</a> that is no one else’s business. But the numbers tell us that ending suffering from mental illness is everyone’s business. It requires <a href="https://cmha.ca/brochure/social-support/">networks of support</a> for those who have been diagnosed and caregivers. Ignoring the families that support individuals with mental illness has <a href="https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/Caregiving_MHCC_Family_Caregivers_Guidelines_ENG_0.pdf">ramifications for everyone’s health</a>. </p>
<p>My research exploring the experiences of Ontario families affected by mental illness has shown there are <a href="http://familyguidetomentalhealth.com/port/harmful-practices/">gaps in the system</a> when it comes to family support. Conversations with families reveal that, whether one is a caregiver or someone who has been diagnosed, those living with mental illness often feel <a href="http://familyguidetomentalhealth.com/port/stigma-isolation/">isolated, alone and overwhelmed</a>. </p>
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<figcaption><span class="caption">In a video from the Family Caregiving Project, family members describe difficult interactions with the health-care system.</span></figcaption>
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<p>Family members who <a href="https://tspace.library.utoronto.ca/bitstream/1807/94700/1/Caregiving%20under%20siege_Williams.pdf">don’t fall into the definition of “traditional family”</a> often report challenges throughout the care process. Families that are part of marginalized or lower-income groups face additional <a href="https://doi.org/10.1177/0840470420933911">challenges to getting help and support</a>, often due to financial barriers, language and cultural barriers, or other social determinants that correspond to inequities in access to health care. </p>
<p>The failure to build proper supports and services that meet the needs of families could worsen an already growing mental health crisis. If the family is stressed, that <a href="https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=c8ae98f27c37c9ca253832a6f7a479f3d322b502">stress will impact everyone within it</a>, caregivers and people struggling with a mental illness alike. This is suffering that can last for decades. The well-being of whole families affected by mental illness must be recognized as an issue of urgent concern.</p>
<h2>Caring for people with long-term mental illness</h2>
<p>Education and training are needed to ensure health professionals have the information they need to better support families. At the same time, more work must be done to promote the general public’s understanding of mental illness and reduce stigma, so people don’t feel ashamed about asking for help. </p>
<p>My work with the Family Caregiving Project to develop <a href="http://familyguidetomentalhealth.com/family-caregiving-project/">free online educational resources</a> is a start. These resources help health-care professionals, educators and community groups better understand and discuss the experiences of families struggling with mental health issues. </p>
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Read more:
<a href="https://theconversation.com/medical-assistance-in-dying-for-mental-illness-ignores-safeguards-for-vulnerable-people-156012">Medical assistance in dying for mental illness ignores safeguards for vulnerable people</a>
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<p>But Canada’s families require government support as well. We need to ensure that our health-care system provides necessary services for families. Last year, we called on the Ontario government to fund targeted support for families living with serious and persistent mental illnesses, <a href="https://www.change.org/p/family-day-includes-families-affected-by-mental-illness-they-need-your-help-0cc2c044-c4bf-4de2-a722-ef5eae4f2d05">collecting nearly 1,500 signatures from people who agree family support needs to be a priority</a>. </p>
<p>Living with a recurrent mental illness and having hopes rise and fall when treatments fail is a source of profound suffering for families all over Canada. People diagnosed with mental illness need to be part of the dialogue surrounding MAID eligibility because long-term mental illness can be devastating. At the same time, we have a health-care system that is focused on the short term of crisis and hospitalization, with little thought or investment for the months and years over which individuals and their families must find ways to carry on. </p>
<p>We need to offer more than assistance to death. We need to offer adequate resources and services that will get people help when needed, and support the mental health and well-being of all family members over the long term.</p><img src="https://counter.theconversation.com/content/224057/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charmaine C. Williams receives funding from the Social Sciences and Humanities Research Council (SSHRC). In the past she has received funding from the Canadian Institutes of Health Research (CIHR), the International Development Research Council (IDRC), the Ontario HIV Treatment Network, and the Ministry of Health and Long-Term Care.</span></em></p>In addition to asking health-care systems to prepare to end suffering of mental illness through Medical Assistance in Dying (MAID), we must ask policymakers to support better lives for families.Charmaine C. Williams, Dean and Professor of Social Work, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2218572024-02-08T19:17:54Z2024-02-08T19:17:54ZWhy are so many Australians taking antidepressants?<figure><img src="https://images.theconversation.com/files/573713/original/file-20240206-26-8fjigm.jpg?ixlib=rb-1.1.0&rect=49%2C16%2C5406%2C3620&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-woman-taking-tablet-glass-water-1498026977">Daisy Daisy/Shutterstock</a></span></figcaption></figure><p>Around <a href="https://australia.cochrane.org/news/new-cochrane-review-explores-latest-evidence-approaches-stopping-long-term-antidepressants">one in seven Australians</a> take antidepressants; more than <a href="https://www.aihw.gov.au/mental-health/topic-areas/mental-health-prescriptions">3.5 million</a> of us had them dispensed in 2021–22. This is <a href="https://www.mja.com.au/journal/2016/204/9/unfulfilled-promise-antidepressant-medications#:%7E:text=Summary,is%20lower%20than%20previously%20thought.">one of the highest</a> antidepressant prescribing rates in the world. </p>
<p>Guidelines mostly recommend antidepressants for <a href="https://www.nice.org.uk/guidance/ng222">more severe depression</a> and <a href="https://www.nice.org.uk/guidance/cg113/resources/generalised-anxiety-disorder-and-panic-disorder-in-adults-management-pdf-35109387756997">anxiety</a> but not as first-line treatment for less severe depression. Less commonly, antidepressants may be <a href="https://www.ncbi.nlm.nih.gov/books/NBK538182/">prescribed for</a> conditions such as chronic pain and migraine.</p>
<p>Yet prescription rates continue to increase. Between 2013 and 2021, the antidepressant prescription rate in Australia <a href="https://www.publish.csiro.au/PY/pdf/PY23168">steadily increased</a> by 4.5% per year. So why are so many Australians taking antidepressants and why are prescriptions rising? </p>
<p>The evidence suggests they’re over-prescribed. So how did we get here?</p>
<h2>Enter the antidepressant ‘blockbusters’</h2>
<p>In the 1990s, pharmaceutical companies <a href="https://www.nature.com/articles/d41573-022-00213-z">heavily promoted</a> new selective serotonin reuptake inhibitor (SSRI) antidepressants, including Prozac (fluoxetine), Zoloft (sertraline) and Lexapro (escitalopram). </p>
<p>These drugs were thought to be less dangerous in overdoses and seemed to have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC181155/">fewer side effects</a> than the tricyclic antidepressants they replaced. </p>
<p>Pharmaceutical companies marketed SSRIs energetically and often exaggerated their benefits, including by paying “key opinion leaders” – <a href="https://www.bmj.com/content/336/7658/1402">high-status clinicians</a> to promote them. This prompted <a href="https://www.mja.com.au/journal/2004/181/7/making-new-choices-about-antidepressants-australia-long-view-1975-2002">substantial growth</a> in the market.</p>
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Read more:
<a href="https://theconversation.com/we-need-new-rules-for-defining-who-is-sick-step-1-remove-vested-interests-114621">We need new rules for defining who is sick. Step 1: remove vested interests</a>
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<p>SSRIs earned billions of dollars for their manufacturers when on patent. While now relatively cheap, they still prove <a href="https://www.prnewswire.com/news-releases/antidepressant-drugs-market-to-reach-15-98-bn-by-2023-globally-at-2-1-cagr-says-allied-market-research-873540700.html">lucrative</a> because of high prescribing levels. </p>
<h2>Why are antidepressants prescribed?</h2>
<p>The majority (85%) of antidepressants are prescribed in <a href="https://www.aihw.gov.au/mental-health/topic-areas/mental-health-prescriptions">general practice</a>. Some are prescribed for more severe depression and anxiety. But contrary to clinical guidelines, GPs also <a href="https://www1.racgp.org.au/ajgp/2021/december/antidepressant-prescribing-in-general-practice">prescribe</a> them as a first-line treatment for less severe depression.</p>
<p>GPs also prescribe antidepressants to patients experiencing distress but who don’t have a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4504011/#:%7E:text=Among%20antidepressant%20users%2C%2069%25%20never,current%20physical%20problems%20(e.g.%2C%20loss">psychiatric diagnosis</a>. A friend dealing with her husband’s terminal illness, for example, was encouraged to take antidepressants by her long-term GP, even though her caring capacity wasn’t impaired. Another, who cried when informed she had breast cancer, was immediately offered a prescription for antidepressants. </p>
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<img alt="GP writes a script" src="https://images.theconversation.com/files/573716/original/file-20240206-30-a4nh4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/573716/original/file-20240206-30-a4nh4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/573716/original/file-20240206-30-a4nh4l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/573716/original/file-20240206-30-a4nh4l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/573716/original/file-20240206-30-a4nh4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/573716/original/file-20240206-30-a4nh4l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/573716/original/file-20240206-30-a4nh4l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Sometimes patients who don’t have a psychiatric diagnosis receive antidepressants.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-patient-consulting-room-gp-surgery-2367985555">Stephen Barnes/Shutterstock</a></span>
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<p>There are several reasons why someone may take antidepressants when they’re not needed. A busy GP might be looking for a convenient solution to a complex and sometimes intractable problem. Other times, patients request a prescription. They may be encouraged by an <a href="https://www.theaustralian.com.au/inquirer/seratonin-theory-of-depression-under-attack-amid-to-push-to-deprescribe-antidepressants/news-story/f74ca1a6018110e3d680b8d5ce01bc2c">acquaintance’s good experience</a> or looking for other ways to <a href="https://www.penguinrandomhouse.com/books/321259/listening-to-prozac-by-peter-d-kramer/">improve their mental health</a>. </p>
<p>Most patients believe antidepressants restore a chemical imbalance that underpins depression. This is <a href="https://www.nature.com/articles/s41380-022-01661-0">not true</a>. Antidepressants are emotional (and sexual) <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC181155/">numbing agents</a> – sometimes sedating, sometimes energising. Those effects suit some people, for example, if their emotions are too raw or they lack energy. </p>
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Read more:
<a href="https://theconversation.com/the-chemical-imbalance-theory-of-depression-is-dead-but-that-doesnt-mean-antidepressants-dont-work-187769">The chemical imbalance theory of depression is dead, but that doesn't mean antidepressants don't work</a>
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<p>For others, they come with <a href="https://www.healthdirect.gov.au/antidepressants">troubling side effects</a> such as insomnia, restlessness, nausea, weight gain. Around half of users have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6007725/">impaired sexual function</a> and for some, this <a href="https://annals-general-psychiatry.biomedcentral.com/articles/10.1186/s12991-023-00447-0">sexual dysfunction persists</a> after stopping antidepressants. </p>
<h2>How long do people take antidepressants?</h2>
<p>Most experts and <a href="https://www.nice.org.uk/guidance/ng222">guidelines</a> recommend specific prescribing regimes of antidepressants, varying from months to two years. </p>
<p>However, most antidepressants are consumed by two categories of people. Around half of patients who start antidepressants don’t like them and <a href="https://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-9-38#:%7E:text=Medication%20possession%20rates&text=Although%20the%20mean%20MPR%20of,group%20difference%20(Table%203).">stop within weeks</a>. Of those who do take them for months, many continue to use them indefinitely, often for many years. <a href="https://www1.racgp.org.au/ajgp/2021/december/antidepressant-prescribing-in-general-practice">Long-term use</a> (beyond 12 months) is driving much of the increase in antidepressant prescribing.</p>
<p>Some people try to stop taking antidepressants but are prevented from doing so by <a href="https://www.sciencedirect.com/science/article/abs/pii/S221503661930032X">withdrawal symptoms</a>. Withdrawal symptoms – including “<a href="https://pubmed.ncbi.nlm.nih.gov/35144325/">brain zaps</a>”, dizziness, restlessness, vertigo and vomiting – can cause significant distress, impaired work function and relationship breakdown. </p>
<p>Across 14 studies that examined antidepressant withdrawal, around 50% of users <a href="https://www.sciencedirect.com/science/article/abs/pii/S221503661930032X">experienced withdrawal symptoms</a> when coming off antidepressants, which can be mistaken for recurrence of the initial problem. We are conducting a <a href="https://adelaideuniwide.qualtrics.com/jfe/form/SV_3QqWrY5TBNUP1YO">survey</a> to better understand the experience in Australia of withdrawing from antidepressants.</p>
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<p>Antidepressants should not be stopped abruptly but gradually tapered off, with smaller and smaller doses. The recent release in Australia of the <a href="https://www.wiley.com/en-au/The+Maudsley+Deprescribing+Guidelines%3A+Antidepressants%2C+Benzodiazepines%2C+Gabapentinoids+and+Z+drugs-p-9781119823025">Maudsley Deprescribing Guidelines</a> provides guidance for the complex regimes required for the tapering of antidepressants.</p>
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Read more:
<a href="https://theconversation.com/antidepressants-can-cause-withdrawal-symptoms-heres-what-you-need-to-know-208224">Antidepressants can cause withdrawal symptoms – here’s what you need to know</a>
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<h2>We need to adjust how we view mental distress</h2>
<p>Overprescribing antidepressants is a symptom of our lack of attention to the <a href="https://onlinelibrary.wiley.com/doi/10.1002/wps.21160">social determinants of mental health</a>. It’s depressing to be poor (especially when your neighbours seem rich), unemployed or in an awful workplace, inadequately housed or fearful of family violence. It’s wrong to locate the problem in the individual when it belongs to society.</p>
<p>Overprescribing is also symptomatic of medicalisation of distress. Most diagnoses of depression and anxiety are <a href="https://karger.com/psp/article-pdf/37/6/259/3489408/000081981.pdf">descriptions masquerading as explanations</a>. For each distressed person who fits the pattern of anxiety or depression, the meaning of their presentation is different. There may be a medical explanation, but most often meaning may be found in the person’s struggle with difficult feelings, their relationships and other life circumstances such as terrible disappointments or grief. </p>
<p>GPs’ overprescribing reflects the pressures they experience from workload, unrealistic expectations of their capacity and misinformation from pharmaceutical companies and key opinion leaders. They need better support, resources and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822978/">evidence</a> about the limited <a href="https://www.thelancet.com/article/S0140-6736(17)32802-7/fulltext">benefits</a> of antidepressants. </p>
<p>GPs also need to ensure they discuss with their patients the potential adverse effects of antidepressants, and when and how to safely stop them. </p>
<p>But the fundamental problem is social and can only be properly addressed by meaningfully addressing inequality and changing community attitudes to distress.</p><img src="https://counter.theconversation.com/content/221857/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jon Jureidini receives research funding from MMRF. He is affiliated with Critical Psychiatry Network Australasia.</span></em></p>Australia has among the highest antidepressant prescribing rates in the world.Jon Jureidini, Research Leader, Critical and Ethical Mental Health research group, Robinson Research Institute, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2180792024-01-31T13:35:29Z2024-01-31T13:35:29ZEating disorders are the most lethal mental health conditions – reconnecting with internal body sensations can help reduce self-harm<figure><img src="https://images.theconversation.com/files/572227/original/file-20240130-29-zz41uv.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An increased disconnect from your body can make it easier to harm yourself, whether by disordered eating or suicide.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/high-angle-view-of-worried-woman-sitting-on-bed-royalty-free-image/1252672806">Maskot/Maskot via Getty Images</a></span></figcaption></figure><p>Did you know that anorexia is the <a href="https://doi.org/10.1002/wps.20904">most lethal mental health condition</a>? One person dies from an eating disorder <a href="https://uncexchanges.org/2020/09/07/every-52-minutes-new-report-released-on-the-social-and-economic-costs-of-eating-disorders-in-the-united-states/">every hour</a> in the U.S. Many of these deaths are not from health consequences related to starvation, but from suicide.</p>
<p>Up to <a href="https://doi.org/10.1001/jamanetworkopen.2019.12925">1 in 5 women and 1 in 7 men</a> in the U.S. will develop an eating disorder by age 40, and <a href="https://doi.org/10.1080/10640266.2023.2196492">1 in 2 people</a> with an eating disorder will think about ending their life. About 1 in 4 people with <a href="https://www.nimh.nih.gov/health/topics/eating-disorders">anorexia nervosa or bulimia nervosa</a> will attempt to kill themselves, and those with anorexia have a risk of death by suicide <a href="https://doi.org/10.1111/j.1600-0447.2010.01641.x">31 times higher</a> than peers without the disorder.</p>
<p>In fact, nonsuicidal self-injury, suicidal ideation, suicide attempts and suicide deaths are <a href="https://doi.org/10.1080/10640266.2023.2196492">all more prevalent</a> among those with any type of eating disorder compared to those without an eating disorder. </p>
<p>Why might that be?</p>
<p>I am a <a href="https://scholar.google.com/citations?user=YZdGYOIAAAAJ&hl=en">clinical psychologist</a> who studies eating disorders and self-harm, and I have spent the past 15 years researching this question. We still don’t have the answer. But new work on perception of the internal state of the body points to some promising possibilities for treatment. And what we’re learning could help anyone improve their relationship with their body.</p>
<h2>Eating disorders and interoception</h2>
<p>To understand why people with eating disorders are at risk of dying by suicide, I first want to ask you to do a little thought exercise. </p>
<p>I’d like you to really think about your body: Think about your hair, face, arms, stomach, chest and legs. What words and feelings come to mind? Are there any things you wish you could change? Feel free to close your eyes and try this out.</p>
<p>I’m guessing as you did this thought exercise, you probably weren’t thinking, “Every part of my body is amazing. Five stars, wouldn’t change a thing!” In fact, many people tend to have pretty <a href="https://theconversation.com/body-image-issues-are-rising-in-men-research-suggests-techniques-to-improve-it-219451">negative and</a> <a href="https://doi.org/10.1002/erv.2201">highly critical thoughts</a> about their bodies.</p>
<p>Here’s another question for you: What do you do with things you don’t like? For instance, what do you do when you encounter someone you dislike, a food you can’t stand or an overwhelming list of chores? Do you care for or accept them? Probably not. Most people tend to avoid, despise or criticize the things they don’t like. This allows them to separate and disconnect themselves from these loathed things.</p>
<p>But when you think negatively about and try to avoid your body, you end up <a href="https://doi.org/10.1016/j.neubiorev.2017.03.017">disconnecting from it</a> and losing the ability to understand what’s going on inside your body. You start to see it not as your body but as an object.</p>
<p>That ability to recognize, interpret and respond to internal signals in your body actually has a name: <a href="https://theconversation.com/interoception-the-sixth-sense-we-use-to-read-hidden-signals-from-our-body-podcast-220863">interoception</a>, also known as the sixth sense. It refers to your ability to recognize, interpret and respond to a variety of bodily sensations, such as emotions, hunger and fullness, temperature and pain. </p>
<p>Interoception can be divided into various components, and <a href="https://doi.org/10.1111/j.1469-8986.1981.tb02486.x">interoceptive accuracy</a>, or how accurately you notice various internal sensations, can be <a href="https://doi.org/10.1016/j.biopsycho.2014.11.004">measured in various ways</a>. These include psychophysiological measures like a heartbeat perception test, which compares a person’s perceived number of heartbeats without taking their pulse to their actual number of heartbeats over a period of time. People with greater discrepancies between their perceived and actual heartbeat counts are thought to be worse at sensing cardiac sensations and thus have worse interoception.</p>
<h2>Interoception and health</h2>
<p><a href="https://www.redslab.org/">My research</a> over the past decade has found that the worse your interoception is, the more disconnected you are from your body and the less aware you are of what’s going on inside it. And the more disconnected you are from your body, the easier it becomes to harm yourself, whether that be through an eating disorder or suicidal behaviors. </p>
<p>Interoception is crucial to understanding and caring for your body. For instance, you need to be able to perceive hunger and fullness in order to properly nourish yourself. If you were unable to perceive pain, you might end up hurting yourself. And you need to be able to understand the emotions you’re feeling in order to respond adaptively to different situations. </p>
<p>Research suggests that interoception is integrally related to mental and physical health, and impaired interoception is considered a <a href="https://doi.org/10.1016/j.bpsc.2017.12.004">risk factor</a> for <a href="https://doi.org/10.1146/annurev-clinpsy-050718-095617">various mental disorders</a>. For example, if you are unable to sense when you’re hungry or full, that could lead to restrictive or binge eating. Conversely, if you are hyperaware of your internal sensations, such as your heart rate and breathing, that could lead to panic disorder symptoms.</p>
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<p>As you lose connection with your body, it becomes easier to harm your body as an object you’ve grown to loathe. Research from my team has found that people who have <a href="https://doi.org/10.1037/abn0000074">attempted suicide</a> have worse interoception than people who haven’t, and people who have <a href="https://doi.org/10.1080/10640266.2018.1418243">attempted suicide multiple times</a> have worse interoception than those who have only attempted suicide once. People with <a href="https://doi.org/10.1111/sltb.12603">more recent</a> <a href="https://doi.org/10.1016/j.psychres.2021.114210">and lethal</a> suicide attempts have worse interoception than those with more distant or less lethal attempts.</p>
<p><a href="https://doi.org/10.1111/sltb.12603">Impairment in interocepton</a> is more strongly associated with suicidal ideation and suicide attempts than other risk factors like hopelessness, gender and post-traumatic stress.</p>
<h2>Reconnecting with the body</h2>
<p>But many people weren’t always this disconnected from their bodies.</p>
<p>I have two young kids who are learning what their bodies can do and are finding their bodies more and more amazing. My 7-year-old son and his friends are delighted when they do gymnastics, standing on one foot or walking across a balance beam. And my daughter, almost 3 now, loves her round tummy: She proudly sticks it out and plays it like a drum. <a href="https://doi.org/10.1016%2Fj.bodyim.2012.09.001">Young kids haven’t yet learned</a> to talk to their bodies in the harsh way many teens and adults do. They haven’t begun to disconnect from their inner senses.</p>
<p>To reduce self-harm, I encourage you to try to regain a sense of connection and care for not only your body but also the bodies of those you love. This isn’t easy, but researchers are studying multiple ways to improve interoception. </p>
<p>For instance, my team has developed a training program to improve interoception called <a href="https://doi.org/10.1111/sltb.12994">Reconnecting to Internal Sensations and Experiences</a>, or RISE. First, we educate participants about interoception and the importance of cultivating awareness of internal sensations for improved mental and physical health. </p>
<p>Then we teach them to bring attention to their muscles through <a href="https://www.healthline.com/health/progressive-muscle-relaxation">progressive muscle relaxation</a> techniques and to <a href="https://theconversation.com/do-you-eat-with-your-eyes-your-gut-or-your-brain-a-neuroscientist-explains-how-to-listen-to-your-hunger-during-the-holidays-217990">hunger and fullness cues</a> through mindful and intuitive eating.</p>
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<a href="https://images.theconversation.com/files/572239/original/file-20240130-19-zfxw2p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person lying on back with eyes closed" src="https://images.theconversation.com/files/572239/original/file-20240130-19-zfxw2p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/572239/original/file-20240130-19-zfxw2p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=395&fit=crop&dpr=1 600w, https://images.theconversation.com/files/572239/original/file-20240130-19-zfxw2p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=395&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/572239/original/file-20240130-19-zfxw2p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=395&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/572239/original/file-20240130-19-zfxw2p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=496&fit=crop&dpr=1 754w, https://images.theconversation.com/files/572239/original/file-20240130-19-zfxw2p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=496&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/572239/original/file-20240130-19-zfxw2p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=496&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Relaxing the body can help bring attention to sensation from the muscles.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/power-nap-is-just-what-i-need-royalty-free-image/1187591660">Delmaine Donson/E+ via Getty Images</a></span>
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<p>After that, we introduce participants to the concept of <a href="https://theconversation.com/8-ways-to-manage-body-image-anxiety-after-lockdown-162224">body functionality</a> by asking them to think of what their bodies can do rather than evaluating their bodies on appearance. For instance, rather than thinking, “I’m getting fat” or “I’m too old” or “I’m too slow,” they can think, “My legs helped get me out of bed today” or “My arms allow me to hug those I love” or “This scar demonstrates my body’s ability to heal.” This is important because body image is <a href="https://doi.org/10.1016/j.bodyim.2019.10.004">linked to multiple aspects</a> of interoceptive awareness.</p>
<p>Finally, we teach participants about recognizing their emotions and changing their behaviors. <a href="https://doi.org/10.1111/j.1467-6494.2011.00717.x">Emotional awareness</a> is a core component of interoception, so we ask participants to think about where they feel those emotions in their body, how they can distinguish between certain emotions, and how they can more effectively respond to stress. </p>
<p><a href="https://www.sapiens.org/culture/kichwa-body-positivity/">Consumer culture</a> doesn’t tend to promote listening to your body, so relearning how to do this may take time and dedicated practice. But I believe the rewards can be literally lifesaving.</p><img src="https://counter.theconversation.com/content/218079/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>April Smith receives funding from the Department of Defense and the National Institute of Health. </span></em></p>Many people with eating disorders die from suicide. Improving perception of internal body states, or interoception, can help everyone better care for their own bodies.April Smith, Associate Professor of Psychological Sciences, Auburn UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2192132024-01-24T17:21:11Z2024-01-24T17:21:11ZVan Gogh’s final months were his most productive<p>Though he had spent the previous year at an asylum in Saint-Rémy-de-Provence in the south of France, <a href="https://www.vangoghmuseum.nl/en/art-and-stories/vincents-life-1853-1890">Vincent van Gogh</a> arrived in the village of Auvers-sur-Oise, just north of Paris, in an optimistic mood. It was here, in 1890, that he would spend the last few months of his life which, despite the depression that would soon return, were his most productive.</p>
<p>The move offered him the prospect of a fresh start, close to his brother Theo, and under the watchful eye of Paul Gachet, a homeopathic doctor with an interest in art and mental wellbeing. Over the course of the next two months, Van Gogh produced no fewer than 74 paintings and more than 50 drawings, which are catalogued chronologically by Nienke Bakker, Emmanuel Coquery, Louis van Tilborgh and Teio Meedendorf in their book, <a href="https://thamesandhudson.com/van-gogh-in-auvers-sur-oise-his-final-months-9780500026731">Van Gogh in Auvers-sur-Oise: His Final Months</a>. </p>
<p>As Van Tilborgh observes in the opening essay, Van Gogh’s final works have “a special, almost existential significance” for us. The paintings most closely identified with his final days include the profoundly melancholic <a href="https://artsandculture.google.com/asset/wheatfield-with-crows/dwFdD5AMQfpSew?hl=en-GB">Wheatfield with Crows</a> (Van Gogh Museum, Amsterdam), whose central path leads us through the golden wheat towards an intensely brooding sky. It was here, in the fields above Auvers, that Van Gogh would shoot himself at the age of 37 in July 1890.</p>
<p>As Meedendorf recounts, Van Gogh was initially enchanted by this “distinctive and picturesque” village nestling in the heart of the countryside. Accessible from Paris by train, it remained surprisingly unspoiled, with thatched whitewashed cottages and a distinctive medieval church.</p>
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<h2>At home in nature</h2>
<p>Unlike previous inhabitants of Auvers, such as the landscape artist and precursor of impressionism, <a href="https://www.nationalgallery.org.uk/artists/charles-francois-daubigny">Charles-François Daubigny</a>, Van Gogh ignored the nearby river Oise. He preferred to record the village, its quaint old buildings merging organically with the landscape and the surrounding vineyards. He also chose surprisingly modern motifs such as the town hall bedecked with flags and bunting on Bastille Day. </p>
<p>Another important subject, explored by Nienke Bakker, was a series of floral still lifes, painted between late May and mid-June 1890. Van Gogh had painted irises and roses as if “in a frenzy” towards the end of his stay at Saint-Rémy and was optimistic that his pictures would find a buyer, despite the fact that they had failed to do so in the past.</p>
<p>He had a preference for wild cornflowers, daisies, poppies, buttercups and thistles, but also painted Chinese asters, carnations and marigolds, blossoming chestnuts and acacia, rendered in rhythmic patterns that dominated the picture space.</p>
<p>Flowers and ears of wheat appear also in his portraits, most memorably in the two of Dr Gachet, leaning on his elbow in a <a href="https://www.theartnewspaper.com/2019/11/15/where-is-the-portrait-of-dr-gachet-the-mysterious-disappearance-of-van-goghs-most-expensive-painting">classic melancholic pose</a> and clutching a sprig of foxglove, which he used in his homeopathic remedies.</p>
<p>Gachet was an important early supporter, not only of Van Gogh, but of the impressionist artists <a href="https://www.camille-pissarro.org/biography.html">Camille Pissarro</a>, who lived at nearby Pontoise, and <a href="https://www.paul-cezanne.org/biography.html">Paul Cézanne</a>, who painted Gachet’s distinctive white house at Auvers.</p>
<h2>The final days</h2>
<p>The book includes a useful map of Auvers-sur-Oise which identifies many of the sites at which Van Gogh set up his easel. One of these is <a href="https://www.theguardian.com/artanddesign/2020/jul/28/location-van-gogh-final-painting-tree-roots-postcard">Tree Roots</a>(Van Gogh Museum, Amsterdam), recently identified as the final work produced by the artist.</p>
<p>It is one of a series of 13 works that were distinctive for their double-square format. As Emmanuel Coquery explains, the format derived from Daubigny, who is referenced in the third canvas in the series, <a href="https://www.vangoghmuseum.nl/en/collection/s0104v1962">Daubigny’s Garden</a> (Rudolf Staechelin Collection).</p>
<p>Daubigny is still celebrated today in the village. His house and studio, decorated by his friend Camille Corot, and also his children, have been preserved for posterity. So, too, has the room at the Auberge Ravoux, in which Van Gogh died on 29 July 1890. </p>
<p>Fittingly, the last two essays in this brilliantly researched and colourfully illustrated book focus on Van Gogh’s final days. Following a visit to Theo in early July, the artist was beset by an extended period of depression, brought on by feelings that he was becoming a burden to his brother.</p>
<p>In his letters he wrote: “My life … is attacked at the very root, my step also is faltering.” He described his latest landscapes as expressions of “sadness, extreme loneliness”. Eventually he shot himself in the chest with a revolver and died in Theo’s arms nearly two days later.</p>
<p>His body was laid to rest in a spacious, sunny plot in the graveyard, close to the wheatfields he loved so much. In 1914, Theo’s remains were transferred to the same ivy-covered grave, remarkable for its simplicity.</p>
<p>As the final essay by Bregje Gerritse and Sara Tas shows, even before his death, Van Gogh was beginning to be appreciated by critics such as Gustave Kahn and Albert Aurier.</p>
<p>He made his only recorded sale when the Belgian artist Anna Boch purchased <a href="https://www.theartnewspaper.com/2022/02/04/how-did-the-only-painting-sold-by-van-gogh-in-his-lifetime-end-up-in-russia">The Red Vineyard</a> (Pushkin State Museum of Fine Arts, Moscow) for 400 francs. Before long he would posthumously achieve the fame and commercial success he had so longed for.</p>
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<img alt="" src="https://images.theconversation.com/files/536131/original/file-20230706-17-460x2d.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/536131/original/file-20230706-17-460x2d.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/536131/original/file-20230706-17-460x2d.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/536131/original/file-20230706-17-460x2d.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/536131/original/file-20230706-17-460x2d.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/536131/original/file-20230706-17-460x2d.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/536131/original/file-20230706-17-460x2d.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p class="fine-print"><em><span>Frances Fowle does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Despite his mental anguish, Van Gogh produced some of his greatest paintings in the last few months of his life.Frances Fowle, Personal Chair of Nineteenth-Century Art, History of Art, The University of EdinburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2207992024-01-19T13:03:14Z2024-01-19T13:03:14ZEmotional problems in young people were rising rapidly even before the pandemic<figure><img src="https://images.theconversation.com/files/569863/original/file-20240117-27-ejuhzp.jpg?ixlib=rb-1.1.0&rect=53%2C0%2C6000%2C3943&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Adolescence is an age when people are particularly vulnerable to mental health problems.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/depression-anxiety-concept-woman-fetal-position-773688718">Thomas Andre Fure/Shutterstock</a></span></figcaption></figure><p>It wasn’t just the virus that spread during the pandemic – anxiety, depression and other mental health concerns saw a worrying rise as well. But <a href="https://acamh.onlinelibrary.wiley.com/doi/10.1111/jcpp.13924">new research</a> from my colleagues and I confirms there had already been a substantial increase in emotional problems among young people even before COVID-19. </p>
<p>Adolescence is an age when people are particularly <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31013-X/fulltext">vulnerable</a> to mental health problems, which may then continue <a href="https://www.nature.com/articles/s41380-023-02202-z">into adulthood</a>. Studies have highlighted concerning trends showing a <a href="https://www.jahonline.org/article/S1054-139X(21)00646-7/fulltext">steep rise</a> in mental health issues in recent decades. </p>
<p>However, the reasons most frequently given for this rise, such as changes in family life, school factors and social media, do not fully explain all <a href="https://link.springer.com/referenceworkentry/10.1007/978-981-10-0753-8_9-1">the issues</a>. </p>
<p>We wanted to know if rates of emotional problems had increased in young people in Wales between 2013 and 2019 – and if any trends varied between groups of young people, such as boys and girls or richer or poorer families. We also wanted to determine whether changes in friendship quality and the prevalence of bullying over time mirrored any increase in adolescent emotional problems, and whether these factors could explain a part of this rise.</p>
<p>Good quality friendships are associated with <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0153715">better</a> self-esteem and mental health, whereas bullying is linked with <a href="https://pubmed.ncbi.nlm.nih.gov/30475016/">poorer</a> mental health.</p>
<p>We used data from secondary school children which is collected every two years via the <a href="https://www.shrn.org.uk/">School Health Research Network</a>. This is used to increase our understanding of risk factors for health, and to help schools and other organisations improve the lives of young people in Wales. </p>
<p>Students answered questions about emotional problems, including how often they felt low, irritable, nervous and had sleep difficulties. They also answered questions about friendship quality and bullying, both in person and online. In total, we looked at data from more than 200,000 students aged between 11 and 16 from three surveys of Welsh secondary schools in 2013, 2017 and 2019. </p>
<h2>Rise in emotional problems</h2>
<p>We found a substantial increase in emotional problems among young people in Wales between 2013 and 2019. The proportion of young people with high numbers of emotional problems rose from 23% to 38%. Our findings are in line with <a href="https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017">increasing rates</a> of emotional disorders, <a href="https://www.health.org.uk/publications/reports/improving-children-and-young-peoples-mental-health-services">referrals</a> to child and adolescent mental health services, and youth <a href="https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-021-03235-w">self-harm and suicide</a> during this period. </p>
<p>Our study highlights that existing mental health inequalities were getting worse even before 2020. This is a particularly concerning trend as it predates COVID, which is known to have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9373888/">exacerbated</a> mental health problems. Girls and those from poorer families experienced steeper increases in emotional problems. </p>
<p>The reasons for this finding are complex. While our study doesn’t examine potential reasons, <a href="https://onlinelibrary.wiley.com/doi/10.1002/wps.21160#:%7E:text=These%20structural%20conditions%20include%20factors,to%20access%20acceptable%20and%20affordable">other research</a> suggests that being richer allows families to access better housing, adequate food, better healthcare and less stressors more generally. </p>
<p>There are several <a href="https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(16)30348-0/fulltext">possible reasons</a> for worse mental health among girls, including sex hormones, lower self-esteem, more interpersonal stressors, gender-based violence and – on a societal level – a lack of gender equality and discrimination. But not enough research has been conducted in this field.</p>
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<img alt="A girl in the foreground looks at her phone while a group of girls behind her laugh." src="https://images.theconversation.com/files/569867/original/file-20240117-29-bx3ipk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/569867/original/file-20240117-29-bx3ipk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/569867/original/file-20240117-29-bx3ipk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/569867/original/file-20240117-29-bx3ipk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/569867/original/file-20240117-29-bx3ipk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/569867/original/file-20240117-29-bx3ipk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/569867/original/file-20240117-29-bx3ipk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Girls and those from poorer families experienced steeper increases in emotional problems.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pre-teen-girl-being-bullied-by-636363332">Daisy Daisy/Shutterstock</a></span>
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<p>The proportion of students experiencing bullying increased slightly between 2013 and 2019, and friendship quality decreased slightly. However, while we found a strong association between the quality of adolescent social relationships and emotional problems, social relationships such as friendship quality and bullying did not appear to explain these population-level increases in mental health problems. </p>
<h2>Mental health support</h2>
<p>Our findings highlight a growing need for mental health support for young people to address the steep increase in their emotional problems over the past decade, particularly among poorer families. Currently, <a href="https://endchildpoverty.org.uk/wp-content/uploads/2022/07/Local-child-poverty-indicators-report-2022_FINAL.pdf">one in three</a> Welsh children live below the poverty line. We need to pay particular attention to supporting these young people, and others <a href="https://link.springer.com/article/10.1007/s00787-019-01305-9">across the UK</a>, who are at greater risk of emotional problems.</p>
<p>While social relationship measures didn’t follow the same steep trend as emotional symptoms, improving the quality of young people’s social relationships and reducing bullying are still important priorities. There is currently a move towards a <a href="https://www.gov.wales/framework-embedding-whole-school-approach-emotional-and-mental-wellbeing">whole school approach</a> in Wales, which involves providing a supportive context for healthy relationships in schools more generally. </p>
<p>The growing needs of young people with mental health issues are adding to our already <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8353214/">significantly strained</a> child and adolescent mental health services. Much more investment needs to be made to support our young and most vulnerable people. </p>
<p>Policy-makers, schools and practitioners should pay particular attention to this steep rise in emotional problems, particularly among girls and young people from less-affluent families.</p><img src="https://counter.theconversation.com/content/220799/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca E Anthony receives funding from the Wolfson Foundation</span></em></p>New research looking at data from 200,000 children in Wales has found a substantial increase in mental health issues.Rebecca E Anthony, Research Associate at the Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement and Wolfson Centre for Young People's Mental Health, Cardiff UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2169802023-12-21T21:37:49Z2023-12-21T21:37:49ZThe Douglas-Bell Canada Brain Bank: a goldmine for research on brain diseases<figure><img src="https://images.theconversation.com/files/557356/original/file-20231005-26-rmh9lm.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4000%2C1508&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The experimental methods available today allow us to break the brain down into its elementary components in order to understand its functions and dysfunctions.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Human beings have always been fascinated by the brain. </p>
<p>Although scientific knowledge about this 1.3 kg of fragile substance embedded in our cranium has long been incomplete, dazzling technical breakthroughs made in recent years are now ushering in a Golden Age of molecular neuroscience. </p>
<p>These breakthroughs have been made possible partly thanks to brain banks, which preserve human brains in the best possible conditions for scientific research. Here in Montréal, we have one of the world’s largest such banks, the Douglas-Bell Canada Brain Bank (DBCBB), <a href="https://douglasbrainbank.ca">founded in 1980 at the Douglas Hospital</a>. </p>
<p>The DBCBB, which receives several brains each month, has collected over 3,600 specimens to date. Every year, its team processes dozens of tissue requests from scientists in Québec, Canada and abroad, preparing some 2,000 samples for research. </p>
<p>Over the past 40 years, these efforts have led to a considerable number of discoveries about different neurological and psychiatric diseases. </p>
<p>As a full professor in the department of psychiatry at McGill University, researcher at the Douglas Research Centre and director of the DBCBB since 2007, I work in close collaboration with <a href="https://www.mcgill.ca/psychiatry/gustavo-turecki">Dr. Gustavo Turecki</a>, co-director of the DBCBB and responsible for the component devoted to psychiatric illnesses and suicide.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&rect=14%2C2%2C1535%2C1231&q=45&auto=format&w=1000&fit=clip"><img alt="cerebral hemisphere" src="https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&rect=14%2C2%2C1535%2C1231&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=475&fit=crop&dpr=1 600w, https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=475&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=475&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=596&fit=crop&dpr=1 754w, https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=596&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=596&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Douglas-Bell Canada Brain Bank, which receives several brains each month, has collected over 3,600 specimens to date.</span>
<span class="attribution"><span class="source">(Naguib Mechawar)</span>, <span class="license">Fourni par l'auteur</span></span>
</figcaption>
</figure>
<h2>A brief history of research on the human brain</h2>
<p>Scientists only began to identify the microscopic elements that make up the human brain in the second half of the 19th century. </p>
<p>That was when brains were preserved for the first time in formalin, a solution that preserves biological tissue so that it can be handled more easily and stored over a longer term.</p>
<p>At the same time, precision instruments and protocols were being developed that made it possible to examine the microscopic characteristics of nervous tissue.</p>
<p>Until the middle of the 20th century, researchers were mainly satisfied with preserving the brains of patients, taken during autopsies, so they could use them to identify possible macroscopic or microscopic changes linked to either neurological or psychiatric symptoms.</p>
<p>This is in fact what the German neurologist Alois Alzheimer did when he analyzed the brain of one of his patients suffering from dementia. In 1906, he described, for the first time, the microscopic lesions which characterize the disease that now bears his name.</p>
<p>Until the end of the 1970s, numerous collections of brain specimens preserved in formalin were built in hospital environments, a bit like the cabinets of curiosities of olden days.</p>
<p>Towards the end of the 20th century, new experimental approaches were developed allowing the high-resolution analysis of cells and molecules within biological tissues.</p>
<p>It then became necessary to collect and preserve human brains, obtained with the consent of the individual or his or her family, in conditions compatible with modern scientific techniques.</p>
<p>Researchers began freezing one of the cerebral hemispheres in order to measure its various molecular components. The other hemisphere was preserved in formalin to be used for macroscopic and microscopic anatomical studies.</p>
<p>This was the context in which the Douglas-Bell Canada Brain Bank was created.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="The DBCBB premises" src="https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Montréal is home to one of the world’s largest brain banks, the Douglas-Bell Canada Brain Bank, which was founded in 1980 at the Douglas Hospital.</span>
<span class="attribution"><span class="source">(Naguib Mechawar)</span>, <span class="license">Fourni par l'auteur</span></span>
</figcaption>
</figure>
<h2>New experimental approaches are yielding results</h2>
<p>Leading researchers from many universities around the world now use DBCBB samples to advance their research. This, of course, includes a number of teams in Québec.</p>
<p>For example, with his team from the Douglas Research Centre, which is affiliated with McGill University, <a href="https://douglas.research.mcgill.ca/judes-poirier/">Judes Poirier</a> discovered that the APOE4 gene is a <a href="https://doi.org/10.1016/0140-6736(93)91705-Q">risk factor for Alzheimer’s disease</a>. More recently, the team of <a href="https://crhmr.ciusss-estmtl.gouv.qc.ca/en/researcher/gilbert-bernier">Gilbert Bernier</a>, professor in the department of neuroscience at Université de Montréal, discovered that the lesions characteristic of this disease are associated with <a href="https://doi.org/10.1038/s41598-018-37444-3">abnormal expression of the BMI1 gene</a>.</p>
<p>With regard to psychiatric illnesses, and more specifically depression, major progress has been made recently by the <a href="https://douglas.research.mcgill.ca/mcgill-group-suicide-studies-mgss/">McGill Group for Suicide Studies</a>. </p>
<p>Using cutting-edge methods to isolate and analyze human brain cells, Turecki’s team has succeeded in precisely identifying the cell types whose function is affected in men <a href="https://doi.org/10.1038/s41593-020-0621-y">who have suffered from major depression</a>, and then discovering that the cell types involved in this illness differ <a href="https://doi.org/10.1038/s41467-023-38530-5">between men and women</a>. </p>
<p>These experimental approaches generate huge data sets that can be examined in subsequent studies. This is the case, for example, of work carried out in my laboratory, which identified signs of persistent changes in neuroplasticity within the prefrontal cortex of people with a history of <a href="https://doi.org/10.1038/s41380-021-01372-y">child abuse</a>. In fact, the studies mentioned above enabled us to discover at least one of the cell types involved in this phenomenon. </p>
<p>In short, the experimental methods we have today allow us to break the brain down into its elementary components in order to understand its functions and dysfunctions.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Cerebral hemispheres preserved in formalin" src="https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Leading researchers from many universities around the world benefit from Douglas-Bell Canada Brain Bank samples to advance their research.</span>
<span class="attribution"><span class="source">(Naguib Mechawar)</span>, <span class="license">Fourni par l'auteur</span></span>
</figcaption>
</figure>
<h2>Identify, prevent, screen and treat</h2>
<p>Thanks to the hard work and dedication of the entire DBCBB team, as well as the unfailing support of all its partners, patrons (often anonymous) and funding bodies — particularly the FRQS research fund and Québec’s suicide research network, the <a href="https://reseausuicide.qc.ca">Réseau québécois sur le suicide, les troubles de l'humeur et les troubles associés</a> — this invaluable resource has not only managed to survive, but to grow and become one of the largest brain banks in the world. </p>
<p>There is every reason to believe that, in the years to come, the DBCBB will play an important role in the increasingly precise identification of the biological causes of brain diseases, and, as a result, will contribute to the identification of new targets for better approaches to prevention, screening and treatment.</p><img src="https://counter.theconversation.com/content/216980/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Naguib Mechawar has received funding from CIHR, NSERC, HBHL (CFREF) and FQRS (NEURON ERA-NET and RQSHA).</span></em></p>Montréal is home to one of the world’s largest brain banks, the Douglas-Bell Canada Brain Bank, where discoveries about different neurological and psychiatric diseases are made.Naguib Mechawar, Neurobiologiste, Institut Douglas; Professeur titulaire, Département de psychiatrie, McGill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2180452023-12-17T19:17:20Z2023-12-17T19:17:20ZIs it OK to take antidepressants while pregnant?<figure><img src="https://images.theconversation.com/files/564779/original/file-20231211-15-ucu6di.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3834%2C2160&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sad-pregnant-woman-holding-belly-sitting-1497946568">Motortion Films/Shutterstock</a></span></figcaption></figure><p>Mental health conditions including <a href="https://aps.onlinelibrary.wiley.com/doi/abs/10.1111/cp.12058">anxiety</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/34036464/">depression</a> are among the most common disorders affecting women <a href="https://pubmed.ncbi.nlm.nih.gov/25455248/">during pregnancy and after birth</a>. </p>
<p>Evidence shows <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4879174/">mental health conditions</a> in pregnancy increase the risk of complications for the mother and baby.</p>
<p>However, there is <a href="https://www.smh.com.au/national/new-guidelines-aim-to-lift-stigma-around-antidepressants-during-pregnancy-20231109-p5eivo.html">some stigma</a> around taking antidepressants while pregnant or breastfeeding. So how should women decide whether or not to take antidepressants during these periods?</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/antidepressants-and-pregnancy-study-didnt-find-they-actually-cause-autism-81271">Antidepressants and pregnancy: study didn't find they actually cause autism</a>
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<h2>Mental health in pregnancy and after birth</h2>
<p>Untreated <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4879174/">anxiety and depression</a> in pregnancy have been linked to an increased risk of stillbirth, premature birth, low birth weight and low APGAR scores (a test done at birth to check the baby’s health in various domains).</p>
<p>In addition, anxiety or depression during pregnancy may lead to increased maternal weight gain, substance use or smoking. These lifestyle factors can also <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-023-06090-7#">lead to complications</a> for the baby. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/30196868/">Anxiety and depression</a> during and <a href="https://pubmed.ncbi.nlm.nih.gov/27993226/">after pregnancy</a> can affect bonding between mother and baby, and hinder the child’s behavioural and emotional development.</p>
<p>Meanwhile, complications in the pregnancy may worsen mental health symptoms for the mother.</p>
<figure class="align-center ">
<img alt="A pregnant woman looks out a window." src="https://images.theconversation.com/files/564782/original/file-20231211-23-wy06kc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/564782/original/file-20231211-23-wy06kc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/564782/original/file-20231211-23-wy06kc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/564782/original/file-20231211-23-wy06kc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/564782/original/file-20231211-23-wy06kc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/564782/original/file-20231211-23-wy06kc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/564782/original/file-20231211-23-wy06kc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women may be reluctant to take medications while pregnant.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/love-joy-mother-1007992423">Tapao/Shutterstock</a></span>
</figcaption>
</figure>
<p>Not coping during pregnancy and especially after giving birth is demoralising and puts women at risk of self-harm. Suicide is a <a href="https://www.aihw.gov.au/reports/mothers-babies/maternal-deaths-australia#cause">leading cause</a> of maternal death in Australia in the <a href="https://clinicalexcellence.qld.gov.au/sites/default/files/docs/safety-and-quality/qmpqc-report-2021.pdf">year after giving birth</a>. </p>
<h2>Treatment options</h2>
<p>Depending on the severity of symptoms, treatment options for women during and after pregnancy range from social and emotional support (for example, support groups) to psychological interventions (such as cognitive behavioural therapy) to medical treatments (for example, antidepressants).</p>
<p>Understandably, many women <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013560.pub2/full">are reluctant</a> to take medications during pregnancy and while breastfeeding due to concerns the drugs may cross over to the baby and cause complications. Historical instances such as the use of thalidomide for morning sickness, which resulted in severe structural abnormalities in thousands of children, naturally make pregnant women worried.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/thalidomide-survivors-are-receiving-an-apology-for-the-pharmaceutical-disaster-that-changed-pregnancy-medicine-218691">Thalidomide survivors are receiving an apology for the pharmaceutical disaster that changed pregnancy medicine</a>
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</em>
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<hr>
<p>Robust evidence about medication use in pregnancy is lacking. This may be due to ethical limitations around trialling medications in pregnant women. The limited data available, mainly from observational studies on selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6096863/">most commonly prescribed</a> antidepressants during pregnancy, has mixed results. </p>
<p>While some studies have reported no noticeable increase in the risk of <a href="https://www.psychiatrist.com/jcp/antidepressant-exposure-during-pregnancy-congenital/">congenital malformations</a>, evidence has shown a marginal rise in abnormalities such as <a href="https://www.nice.org.uk/guidance/cg192">heart defects</a> (an extra two cases per 1,000 babies with SSRIs). </p>
<h2>Collaborative decisions</h2>
<p>There is a delicate balance to strike between treating the mother and preventing harm to the baby. To make well-informed decisions, an open discussion between the patient and specialised mental health care providers on the benefits and risks of starting or continuing antidepressants is essential. </p>
<p>Given the mother’s poor mental health increases the risk of adverse outcomes for the baby, it may well be that taking antidepressants is the best way to protect the baby.</p>
<p>For women already taking antidepressants, it’s not usually necessary to stop using them during pregnancy. Sudden cessation of antidepressants increases the risk <a href="https://pubmed.ncbi.nlm.nih.gov/16449615/">of relapse</a>.</p>
<p>Continuing breastfeeding on antidepressants is likely the best decision because of the low <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013560.pub2/full">levels of drugs</a> infants are exposed to in breast milk, the advantages of breastfeeding for the baby, and the risks of not taking antidepressants when indicated. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/20-of-pregnant-australian-women-dont-receive-the-recommended-mental-health-screening-139979">20% of pregnant Australian women don't receive the recommended mental health screening</a>
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<p>Recently revised <a href="https://www.cope.org.au/health-professionals/health-professionals-3/">guidelines</a> on mental health care in the perinatal period (during pregnancy and after birth) warn health professionals against the dangers of failing to prescribe necessary medication:</p>
<blockquote>
<p>Be aware that failure to use medication where indicated for depression and/or anxiety in pregnancy or postnatally may affect mother-infant interaction, parenting, mental health and wellbeing and infant outcomes.</p>
</blockquote>
<p>These guidelines also recommend repeated screening for symptoms of depression and anxiety for all women during the perinatal period. This is crucial to providing women with an early referral to perinatal mental health services if needed.</p>
<p>At present, mental health conditions during pregnancy and after birth often go undetected and untreated. </p>
<figure class="align-center ">
<img alt="A pregnant woman talks to a therapist." src="https://images.theconversation.com/files/564784/original/file-20231211-26-u02x0q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/564784/original/file-20231211-26-u02x0q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/564784/original/file-20231211-26-u02x0q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/564784/original/file-20231211-26-u02x0q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/564784/original/file-20231211-26-u02x0q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/564784/original/file-20231211-26-u02x0q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/564784/original/file-20231211-26-u02x0q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There are a range of treatment options for perinatal anxiety and depression.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/depressed-pregnant-woman-consultation-psychologist-2064159131">Pormezz/Shutterstock</a></span>
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</figure>
<h2>Supporting perinatal mental health</h2>
<p>Mental illness in pregnancy is a significant public health problem. Screening is not always <a href="https://theconversation.com/20-of-pregnant-australian-women-dont-receive-the-recommended-mental-health-screening-139979">delivered effectively</a>, and currently, there is <a href="https://www.aihw.gov.au/reports/mothers-babies/data-opportunities-in-perinatal-mental-health-scre/contents/about">no national data</a> regarding perinatal mental health screening service use or outcomes. </p>
<p>Mine and my colleagues’ <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-019-2320-9">research</a> on pregnant women’s engagement with perinatal mental health services indicated only one-third of eligible women accepted a referral, and less than half attended their appointment. Women may be reluctant to engage due to stigma, time restraints, and lack of childcare or social support.</p>
<p>To address this, we should create strategies and resources in collaboration with pregnant women to identify solutions that work best for them. This might include assistance with childcare, access to telehealth, visits from a perinatal mental health professional, or written information on medications. </p>
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Read more:
<a href="https://theconversation.com/considering-going-off-antidepressants-heres-what-to-think-about-first-198880">Considering going off antidepressants? Here's what to think about first</a>
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<p>Care must be holistic and include partners who may be best placed to support pregnant women in making complex decisions. Health-care providers need to be respectful of individual needs and provide compassionate care to engage vulnerable mothers who may understandably feel uncertain regarding their options.</p>
<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.</em></p><img src="https://counter.theconversation.com/content/218045/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alka Kothari does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Guidelines on mental health during pregnancy and after birth emphasise antidepressants should be prescribed if they’re needed.Alka Kothari, Associate Professor, Faculty of Medicine, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2192812023-12-07T17:28:07Z2023-12-07T17:28:07ZOCD is so much more than handwashing or tidying. As a historian with the disorder, here’s what I’ve learned<figure><img src="https://images.theconversation.com/files/563995/original/file-20231206-25-yjbxqt.jpg?ixlib=rb-1.1.0&rect=15%2C22%2C5077%2C3328&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/woman-touching-her-temples-hands-suffering-2196452389">Elena Abrazhevich/Shutterstock</a></span></figcaption></figure><p><em>Readers are advised that this article contains explicit discussion of suicide and suicidal and obsessional thoughts. If you are in need of support, contact details are included at the end of the article.</em> </p>
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<p>At the age of 12, “out of nowhere”, Matt says he started having repetitive thoughts concerning whether he wanted to end his life. Every time he saw a knife, he would ask himself: “Am I going to stab myself?” Or, when he was near a ledge: “Am I going to jump?”</p>
<p>Matt had heard a lot about teenage depression, and thought this must be what was going on. But it was confusing, he says: “I didn’t feel suicidal, I really enjoyed my life. I just had an intense fear of doing something to hurt myself.”</p>
<p>Shortly afterwards, pre-empted by hearing about a notorious banned film, Matt began questioning whether he, like the central character, might be a serial killer. These thoughts “kept coming and coming” and he would lie in bed running over scenarios, trying to work out whether he was “going crazy”:</p>
<blockquote>
<p>I really needed help. I didn’t know who to talk to. But it wasn’t on my radar to think about this as OCD.</p>
</blockquote>
<p>Obsessive-compulsive disorder (OCD) is a significant mental health diagnosis in the 21st century. The World Health Organization (WHO) lists it as <a href="https://www.bmj.com/content/348/bmj.g2183.long">one of the ten most disabling illnesses</a> in terms of loss of earning and reduced quality of life, and OCD is frequently cited as the fourth most common mental disorder globally after depression, substance abuse and <a href="https://www.nhs.uk/mental-health/conditions/social-anxiety/#:%7E:text=Social%20anxiety%20disorder%2C%20also%20called,better%20as%20they%20get%20older.">social phobia</a> (anxiety about social interactions).</p>
<p>Yet everything Matt knew about OCD, he tells me, came from daytime talkshows where “people were washing their hands 1,000 times a day – it was all about external and really extreme behaviours”. And that didn’t feel like what he was going through.</p>
<hr>
<p><em>Across the world, we’re seeing unprecedented levels of mental illness at all ages, from children to the very old – with huge costs to families, communities and economies. <a href="https://theconversation.com/uk/topics/tackling-the-mental-health-crisis-147216?utm_source=TCUK&utm_medium=ArticleTop&utm_campaign=MentalHealthSeries">In this series</a>, we investigate what’s causing this crisis, and report on the latest research to improve people’s mental health at all stages of life.</em></p>
<hr>
<p>A similar experience is recounted in the 2011 book <a href="https://overcoming.co.uk/582/Taking-Control-Of-OCD---VealeWillson">Taking Control of OCD</a> by John (not his real name) who, after a colleague had taken their own life, became “inundated with thoughts” about what he might do to himself. Every time he crossed the road, John thought: “What would happen if I stopped moving and was run over by a bus?” He also had thoughts of murdering those he loved. John recalled:</p>
<blockquote>
<p>Try as I might, I just couldn’t chase the thoughts out of my head … When I tried to explain what was going on to my girlfriend, I couldn’t find a way of articulating what was happening to me … At the time, I thought OCD was all about triple-checking you had locked the front door and that your drawers were tidy.</p>
</blockquote>
<p>Despite the prevalence of OCD in contemporary society, the experiences of Matt and John reflect two important features of this disorder. First, that the stereotype of OCD is one of washing and checking behaviours – the <a href="https://www.nhs.uk/mental-health/conditions/obsessive-compulsive-disorder-ocd/overview/">compulsions</a> aspect, defined clinically as “repetitive behaviours that a person feels driven to perform”. And that obsessions – defined as “<a href="https://www.nhs.uk/mental-health/conditions/obsessive-compulsive-disorder-ocd/overview/">unwanted, unpleasant thoughts</a>” often of a harmful, sexual or blasphemous nature – are viewed as obscure, confusing and unrecognisable as OCD.</p>
<p>People who experience obsessional thoughts are therefore frequently unable to identify their symptoms as OCD – and <a href="https://pubmed.ncbi.nlm.nih.gov/26132683/">neither</a>, very often, are the experts they see in clinical settings. Due to mischaracterisations of the disorder, OCD sufferers with non-typical, less visible presentations usually <a href="https://www.sciencedirect.com/science/article/pii/S2666915321001578?via%3Dihub">go undiagnosed for ten or more years</a>.</p>
<p>When John visited his GP, he was diagnosed with depression. He recalled that the GP concentrated more on the visible effects of his distress - a lack of appetite and disrupted sleeping patterns. The thoughts remained invisible. As he put it:</p>
<blockquote>
<p>I don’t know how you’re supposed to tell someone you don’t know that you have thoughts about killing people you love.</p>
</blockquote>
<p>Even for those with “textbook” OCD such as my friend Abby, “the compulsion is just the tip of the iceberg”. Abby was able to self-diagnose at the age of 12, when she experienced handwashing and locking door compulsions. She says people still think of her as “Abby [who] likes to wash her hands a lot”.</p>
<p>Now, she tells me, “I realise that I have no interest in washing my hands – I’m a pretty messy person, and I don’t mind other people being messy.” Rather than a love of cleaning, her acts were related to the altogether scarier obsessional thought: “What if I am going to hurt other people?”</p>
<p>Clinical guidelines, such as those provided in the UK by the <a href="https://www.nice.org.uk/guidance/cg31/resources/obsessivecompulsive-disorder-and-body-dysmorphic-disorder-treatment-pdf-975381519301">National Institute for Health and Care Excellence</a>, define OCD as being characterised by both compulsions <em>and</em> obsessions. So, why do the difficulties encountered by Matt, John and Abby – of recognising the internal thoughts that dominate their lives – appear to be <a href="https://letsqueerthingsup.com/2018/05/12/i-didnt-know-i-had-ocd-heres-why-the-stereotypes-are-so-harmful/">so common</a>?</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Wordcloud for obsessive-compulsive disorder (OCD)" src="https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=383&fit=crop&dpr=1 600w, https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=383&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=383&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=481&fit=crop&dpr=1 754w, https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=481&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=481&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">OCD is a multifaceted disorder, yet understanding tends to focus on the visual, compulsive aspect.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/obsessive-compulsive-disorder-ocd-word-cloud-1786299122">Colored Lights/Shutterstock</a></span>
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<h2>My experience of OCD</h2>
<p>From the age of 16, I have also suffered with thoughts that I later came to associate with OCD, but which began as invisible and tormenting. An article I wrote in 2014, entitled <a href="https://www.ocduk.org/the-unseen-obsession/">The Unseen Obsession</a>, described my experience of having left university midway through my studies due to a single thought that gathered “such power that I even ended up attacking my body in an attempt to eliminate its force”. I wrote:</p>
<blockquote>
<p>I have suffered with obsessional thoughts for the last four years, and can safely say that [OCD] is far from being about clean hands.</p>
</blockquote>
<p>My obsessions have taken many forms since my teenage years. They began with me wondering whether things really existed, whether my parents were really who they said they were, and whether I wanted to harm – and was a risk to – my family, friends, even my dog.</p>
<p>Many of us know what it is like to ruminate about a person, a conflict, or something else we feel anxious about. But for those with obsessional thoughts (diagnosed or otherwise), this is quite different to simply “overthinking”. As I attempted to explain in my article:</p>
<blockquote>
<p>Conversations falter as the thought leaps through your mind. Other topics seem less important, and time to yourself provides space to assess, analyse, and look for evidence of the thought being ‘true’ … [Obsessing] is like fighting: you push and shove your thoughts away and they come back with twice as much force. You spend time trying to avoid them and they pop up everywhere, taunting and mocking your failed attempt at running away.</p>
</blockquote>
<p>It took me six months of weekly therapy sessions before I felt able to voice my obsessional thought to my therapist – someone I had known for a number of years. My unwillingness to be open about it was not only tied up with feelings of shame about its taboo content, but also my inability to see such thinking as part of a recognised disorder.</p>
<p>The question of what constitutes OCD, why we understand – and misunderstand – it as we do, as well as my own experience of living with it, led me to study <a href="https://www.cambridge.org/core/journals/british-journal-for-the-history-of-science/article/visible-compulsions-ocd-and-the-politics-of-science-in-british-clinical-psychology-19481975/D431B7D6003860F9E6ABE50476BA46A4">how OCD became recognised and categorised as a mental health disorder</a>.</p>
<p>In particular, my research shows that there are important insights to be gained from the research decisions made by a group of influential clinical psychologists in south London in the early 1970s – shedding light on why so many people, myself included, still struggle to recognise and make sense of our obsessional thoughts.</p>
<h2>The origin of the concepts</h2>
<p>Categories of mental illness are not stable across time. As medical, scientific, and public knowledge about an illness changes, so does how it is experienced and diagnosed.</p>
<p>Prior to the 1970s, “obsessions” and “compulsions” did not exist in a unified category – rather, they appeared in an array of psychiatric classifications. At the start of the 20th century, for example, British doctor James Shaw <a href="https://www.cambridge.org/core/services/aop-cambridge-core/content/view/8D219344EF697D92E69BF9ED60F8508B/S000712500016204Xa.pdf/verbal-obsessions.pdf">defined</a> verbal obsessions as “a mode of cerebral activity in which a thought – mostly obscene or blasphemous – forces itself into consciousness”.</p>
<p>Such cerebral activity could, according to Shaw, arise in hysteria, <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/neurasthenia">neurasthenia</a>, or as a precursor to delusions. One of his patients – a woman who experienced “irresistible, obscene, blasphemous and unutterable thoughts” – was diagnosed with obsessional melancholia, a “form of insanity”.</p>
<p>The symptom arose from what Shaw defined as “nervous weakness”, an explanation that reflected the <a href="https://academic.oup.com/book/25373/chapter-abstract/192459930?redirectedFrom=fulltext">broader 19th-century view</a> that obsessional thoughts were indicative of a fragile nervous system – either inherited, or weakened through overwork, alcohol or promiscuous behaviour (described as “<a href="https://pubmed.ncbi.nlm.nih.gov/3514404/">degeneration theory</a>”). Notably, Shaw did not mention any form of repetitive behaviour in relation to these verbal obsessions.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Bearded man holding a cigar" src="https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=844&fit=crop&dpr=1 600w, https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=844&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=844&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1061&fit=crop&dpr=1 754w, https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1061&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1061&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sigmund Freud, founder of psychoanalysis.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Sigmund_Freud_LIFE.jpg">Max Halberstadt via Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>At a similar time to Shaw’s writings, Sigmund Freud, the Austrian founder of psychoanalysis, developed his psychoanalytic category of “<a href="https://journals.sagepub.com/doi/10.1177/0957154X9800903504">Zwangsneurose</a> – translated in Britain as "obsessional neurosis” and in the US as “compulsion neurosis”. In Freud’s <a href="https://www.mhweb.org/freud/ratman1.pdf">writings</a>, the “Zwang” referred to persistent ideas that emerged from a repressed conflict between unresolved childhood impulses (those of love and hate) and the critical self (ego).</p>
<p>Freud’s <a href="https://ia802907.us.archive.org/17/items/SigmundFreud/Sigmund%20Freud%20%5B1909%5D%20Notes%20Upon%20A%20Case%20Of%20Obsessional%20Neurosis%20%28The%20Rat%20Man%20Case%20History%29%28James%20Strachey%20Translation%201955%29.pdf">most famous case study</a>, published in 1909, featured the “Rat Man”, a former Austrian army officer who possessed a variety of elaborate symptoms. In the first instance, he had become obsessed that he would fall victim to a horrific rat-based punishment that had been recounted to him by a colleague. The patient also expressed that if he had certain desires such as a wish to see a woman naked, his already-deceased father “will be bound to die”.</p>
<p>The Rat Man was described by Freud as engaging in a “system of ceremonial defences” and “elaborate manoeuvres full of contradictions” that have been read by some as the behavioural aspects of what would become OCD. However, there are crucial differences between the “defences” of Freud’s client and the compulsions of OCD, including that the former largely involved thinking rather than acting, and were by no means consistent or stereotyped.</p>
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<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><strong><em>This article is part of Conversation Insights</em></strong>
<br><em>The Insights team generates <a href="https://theconversation.com/uk/topics/insights-series-71218">long-form journalism</a> derived from interdisciplinary research. The team is working with academics from different backgrounds who have been engaged in projects aimed at tackling societal and scientific challenges.</em></p>
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<p>The psychoanalytic category of “obsessional neurosis” was adopted and modified in Britain during the first world war, and became a staple – but inconsistently defined – diagnosis in British psychiatric textbooks of the inter-war period. Up to the 1950s, the terms “obsession” and “compulsion” were being used interchangeably in psychiatric writing. The complexity surrounding their meaning is demonstrated in the <a href="https://www.google.co.uk/books/edition/Inquiries_in_Psychiatry_Clinical_and_Soc/JsZrAAAAMAAJ?hl=en">writings of Aubrey Lewis</a>, a leading figure in post-war British psychiatry, who referred to “obsessional illnesses” as being made up of “compulsive thoughts” and “compulsive inner speech”.</p>
<p>Like Freud, Lewis mentioned the “complex rituals” of the obsessional – such as the patient “who is perpetually putting himself in the greatest trouble to ensure that he never steps on a worm inadvertently”. But he cautioned against “the dangers of associating any kind of repetitious activity with obsessionality”, writing that “it certainly cannot be judged on behaviourist grounds”.</p>
<h2>Defining OCD by visible behaviour</h2>
<p>OCD began to emerge in the form we recognise it today from the early 1970s – and was established as a formal psychiatric disorder through its inclusion in the third and fourth editions of the American Psychiatric Association’s <a href="https://aditpsiquiatriaypsicologia.es/images/CLASIFICACION%20DE%20ENFERMEDADES/DSM-III.pdf">Diagnostic and Statistical Manual</a> (commonly known as DSM-III and DSM-IV) in 1980 and 1994.</p>
<p>The centrality of visible and measurable behaviours in the categorisation of OCD – particularly washing and checking – can be traced back to a series of experiments conducted by clinical psychologists in the early 1970s at the Institute of Psychiatry and the Maudsley Hospital in south London.</p>
<p>Under the direction of South African psychologist Stanley Rachman, the complex array of symptoms contained in the categories of obsessional illness and obsessional neurosis were divided into two: “visible” compulsive rituals, and “invisible” obsessional ruminations. While Rachman and his colleagues conducted a large research programme on compulsive behaviours, obsessions were relegated to the backburner.</p>
<p>For example, in <a href="https://www.sciencedirect.com/science/article/pii/000579677190009X">their investigation</a> of ten psychiatric inpatients diagnosed with obsessional neurosis, “compulsions had to be present for entry into the trial and patients complaining of ruminations were excluded” – a statement reiterated throughout subsequent experiments.</p>
<p>Indeed, this study did not merely require patients to exhibit some form of visible compulsion. The ten patients included were exclusively those with “visible handwashing” behaviour, which was viewed as the “easiest” symptom to experiment on. Likewise, the second round of studies only included patients who engaged in visible “checking” behaviour, such as whether a door was unlocked.</p>
<p>In a <a href="https://www.sciencedirect.com/science/article/pii/0005796771900088">1971 paper</a>, Rachman offered his rationale for taking this approach, explaining how “obsessional ruminators raise special problems for the clinical psychologist because of their subjective, private nature”. This, he argued, was in contrast with “the other main feature of obsessional neurosis, compulsive behaviour, which can be approached with greater ease. It is visible, has a predictable quality, and many reproducible analogies in animal research”.</p>
<p>Rachman viewed compulsions as “visible” and “predictable” in large part due to the way clinical psychology had developed as a new profession in Britain, at the Maudsley Hospital in particular, in the decades following the second world war. To differentiate their practice from the existing mental health professions of psychiatry (medically trained doctors specialising in mental health) and psychoanalysis (talking therapy derived from Freud), these early clinical psychologists presented themselves as “<a href="https://www.bps.org.uk/psychologist/eysenck-and-development-cbt">applied scientists</a>” who brought scientific methods from the laboratory to a clinical setting. Their conception of science was rooted in empiricism – with an emphasis on visibility, measurability and experimentation.</p>
<p>As part of this commitment to empirical science, these clinical psychologists adopted a <a href="https://psycnet.apa.org/doiLanding?doi=10.1037%2Fh0054288">model of anxiety</a> derived from 20th-century behaviourism. This focus on observable behaviour was <a href="https://www.cambridge.org/core/journals/journal-of-mental-science/article/abs/learning-theory-and-behaviour-therapy/38CA4A9BC0CA773F6BEE93EDDC71584F">viewed as</a> having much greater scientific value than psychoanalysis, which dealt with the “<a href="https://www.taylorfrancis.com/books/mono/10.4324/9780203766767/causes-cures-neurosis-psychology-revivals-eysenck-rachman">unverifiable</a>” and “unscientific” realm of thoughts and thinking.</p>
<p>So, when obsessional ruminations gained a renewed focus in the mid-1970s, it was through this lens of visible compulsive behaviours. Rachman and his colleagues started talking about “mental compulsions” (such as saying a good thought after a bad thought) as “equivalent to handwashing”- rather than focusing on the importance and content of these thoughts in their own right.</p>
<p>In the early 1980s, clinical psychology came under pressure from cognitive psychologists (those concerned with thinking and language) for its reductive focus on behaviour. But despite this move to <a href="https://www.sciencedirect.com/science/article/abs/pii/0005796785901056">include cognitive approaches</a>, the centrality of visible behavioural compulsions has continued to characterise perceptions of OCD in cultural and clinical domains. </p>
<p>This is perhaps most evident in media portrayals of the disorder – a critique taken up by cultural scholars such as <a href="https://www.tandfonline.com/doi/abs/10.1080/01639625.2013.872526">Dana Fennell</a>, who look at representations of OCD in TV and film.</p>
<p>The archetypal portrayal of OCD has <a href="https://www.ocduk.org/david-beckham-documentary-our-statement/">not been helped</a> by the recent publicity given to David Beckham and his <a href="https://www.mirror.co.uk/news/health/david-beckham-ocd-update-football-31102545">extensive tidying</a>. When I ask Abby what she thought about the <a href="https://www.theguardian.com/football/2023/apr/28/david-beckham-ocd-obsessive-compulsive-disorder-netflix-documentary">attention</a> that Beckham’s OCD was receiving in the media, she replies: “It’s so boring. It’s the same presentation that always gets thought of as OCD.”</p>
<h2>Limitations to the ‘gold standard’ treatment</h2>
<p>This archetypal portrayal of OCD also relates to how it is treated. The <a href="https://www.dovepress.com/getfile.php?fileID=54942">“gold standard” treatment</a> in the UK today is the behavioural technique of <a href="https://www.ocduk.org/overcoming-ocd/accessing-ocd-treatment/exposure-response-prevention/">exposure and ritual prevention</a> (ERP), either on its own or combined with cognitive therapy. ERP gained acceptance from the experiments of Rachman and colleagues in the early 1970s, when they were exclusively working with patients with observable behaviours.</p>
<p>One of their <a href="https://www.sciencedirect.com/science/article/abs/pii/S0005796772800032">key studies</a> involved patients from the Maudsley Hospital who repeatedly washed their hands. They were told to touch smears of dog excrement and put hamsters in their bags and in their hair, while being prevented from washing for increased lengths of time.</p>
<p>Such experiments were again governed by observability and measurability. The “success” of ERP treatment – and its perceived superiority over psychiatric and psychoanalytic methods – was demonstrated by a reduction in the patients’ visible handwashing behaviour.</p>
<p>Today, if you are diagnosed with OCD by a psychiatrist and given OCD-specialist treatment via the NHS, you will most likely be told to undergo the same kind of ERP procedure that hospital inpatients were experimentally given in the 1970s: touching a set of items that you fear (exposure) while being prevented from engaging in your usual compulsive behaviour.</p>
<p>An identical method is also used when it comes to obsessional thoughts. Patients are asked to identify their worrying obsession, then either expose themselves to provoking situations or repeat the thought in their mind without engaging in “mental compulsions” – such as counting, replacing a bad thought with a good thought, or trying to “solve” the content of the obsessional thought.</p>
<p>It’s certainly true that this form of behavioural therapy can be <a href="https://www.dovepress.com/getfile.php?fileID=54942">hugely helpful</a> in the treatment of OCD symptoms. Abby, after undergoing ERP for 14 years, said she had “developed a lot of practices around not giving into my [washing and checking] compulsions”.</p>
<p>I also found the approach beneficial in reducing the threatening quality of my obsessional thoughts. Repeating “I want to hurt my family” or “I don’t really exist” to myself over and over again, without actually trying to solve these issues, reduced the time I spent ruminating.</p>
<p>However, while being a huge advocate of ERP, Abby also observed that “sometimes when I get rid of a compulsion, it doesn’t mean I just get rid of the obsession.” While the “outward compulsions” disappear, “it doesn’t mean my mind stops cycling and mental questioning”.</p>
<p>Some contemporary clinicians have referred to ERP, designed around visible symptom reduction, as a “<a href="https://www.justinkhughes.com/wp-content/uploads/2021/03/ocd_texas_talk_with_molly_and_justin_2019__22common_pitfalls_of_erp_for_ocd_22.pdf">whack-a-mole technique</a>” – you get rid one symptom (obsession or compulsion) and another pops up.</p>
<p>ERP is frequently accompanied with cognitive therapy techniques, such as <a href="https://www.apa.org/pubs/books/supplemental/Treatment-for-Postdisaster-Distress/Handout-27.pdf">cognitive restructuring</a> (identifying beliefs and providing evidence for and against them), or being told that obsessions are “just thoughts”, that they are meaningless, and that you do not want to enact them.</p>
<p>Despite the success of cognitive-behaviour therapy (CBT) and ERP in scientific trials, a <a href="https://www.sciencedirect.com/science/article/pii/S0010440X21000018?via%3Dihub">major review of evidence</a> in 2021 questioned whether the effects of the approach in treating OCD had been overstated – reflecting the high proportion of OCD cases that are designated as “<a href="https://www.ncbi.nlm.nih.gov/books/NBK551808/">treatment resistant</a>”. </p>
<p>I also believe there are some crucial limitations to contemporary treatments for OCD. Exposure (ERP) techniques stem from a period in which thoughts were not being considered at all by clinical psychologists, while CBT designates the content of obsessional thoughts as unimportant. Matt, like me, has found that CBT “can only take you so far”, explaining:</p>
<blockquote>
<p>Part of this was that [CBT therapists] are so committed to the idea that thoughts don’t have meaning … [They] treat your symptom and once those are gone, you should get on with your life. I didn’t find that there was a way of thinking about [my] ruminations in the context of my whole life.</p>
</blockquote>
<h2>Experiences of alternative treatments</h2>
<p>So much of my understanding about OCD has changed since I first wrote about it for <a href="https://www.rethink.org/aboutus/">Rethink Mental Illness</a> almost a decade ago. Thinking about the historical development and categorisation of OCD has, it turns out, given me a greater sense of ease regarding this widely misunderstood condition. I feel less bound by our current conceptual frameworks, and more able to reflect on what I think is helpful in terms of how to successfully manage my obsessional thoughts.</p>
<p>For example, despite being warned away from psychoanalysis from a young age (my mum is a clinical psychologist, and psychologists are often fervently anti-psychoanalytic!), I have found psychoanalysis incredibly helpful in becoming comfortable with my thoughts. </p>
<p>This is because CBT typically focuses on present symptoms without looking into their meaning or how they relate to your personal history, and this comes into tension with my desire, as a historian, to think about the past. In contrast, psychoanalysis locates obsessional thoughts in history – pointing to childhood as a crucial point of psychic development. I have been able to understand my obsessions as the result of a deep childhood fear concerning the death of my loved ones, from which I developed a rigid desire for control.</p>
<p>As a young teenager trying to determine what was going on with him, Matt went to the public library and took out a <a href="https://ia903102.us.archive.org/15/items/petergay1989freudreader/Adam%20Phillips%20%5B2006%5D%20Penguin%20Freud%20Reader.pdf">Freud reader</a>. He describes this as “the worst possible thing for a 14-year-old to read”, as it made him believe “that I did really have all these [murderous suicidal] impulses and all my fears are true”.</p>
<p>Despite this experience, while training to become a social worker, he “got into psychoanalysis as an alternate way to think about therapy and think about my own experience”. For him, psychoanalysis revealed the opposite to the image of “OCD as handwashing”.</p>
<p>Instead, he says, it focused on the aspects of “obsessionality that are internal”, showing him that the “mind is so powerful that it can produce a lot of imaginary fears”. It also allowed him to see “OCD symptoms as wrapped up with my whole life”.</p>
<p>Particularly profound in psychoanalytic thought is the acceptance of the complexity and unknowability at the heart of human experience. As Jaqueline Rose, professor of humanities at Birkbeck, University of London, <a href="https://fitzcarraldoeditions.com/books/the-plague">wrote:</a>: </p>
<blockquote>
<p>Psychoanalysis begins with a mind in flight, a mind that cannot take the measure of its own pain. It begins, that is, with the recognition that the world – or what Freud sometimes refers to as ‘civilisation’ – makes demands on human subjects that are too much to bear.</p>
</blockquote>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of a woman with eyes closed holding her temples." src="https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/woman-touching-her-temples-hands-suffering-2156846349">Elena Abrazhevich/Shutterstock</a></span>
</figcaption>
</figure>
<p>This idea of “a mind in flight” has helped me think about my obsessions – whether my parents are really who they say they are; am I going to hurt those I love? – as part of a battle for certainty and control that is both unattainable and understandable, considering the world we live in.</p>
<p>The aim of psychoanalytic treatment is not to eradicate symptoms but to bring to light the difficult knots that humans have to deal with. Matt refers to psychoanalysis as acknowledging “a sort of messiness of the mind … I’ve found the psychoanalytic view of accepting your own messiness extremely helpful”. Rose similarly describes psychoanalysis as “the opposite of housework in how it deals with the mess we make”.</p>
<p>In the UK, psychoanalysis has been rejected within NHS service provision. And I believe this is, at least in part, a result of historical critiques levelled at it by clinical psychologists as they developed behaviour therapies to treat OCD in the late 20th century.</p>
<h2>‘A lot of emotion and sadness’</h2>
<p>While compulsive behaviour such as handwashing and checking is widely perceived as “representative” of OCD, the tormenting experience of having obsessional thoughts is still rarely acknowledged and discussed. The <a href="https://www.theguardian.com/commentisfree/2019/feb/21/ocd-sex-disorder-pure-rose-cartwright">shame and confusion</a> attached to such thoughts, coupled with the feeling of being misunderstood, make this an important issue to address, particularly when <a href="https://www.madeofmillions.com/articles/pure-o-an-exploration-into-a-lesser-known-form-of-ocd">misdiagnosis of OCD</a> is so high.</p>
<p>My <a href="https://www.cambridge.org/core/journals/british-journal-for-the-history-of-science/article/visible-compulsions-ocd-and-the-politics-of-science-in-british-clinical-psychology-19481975/D431B7D6003860F9E6ABE50476BA46A4">PhD on the history of OCD</a> has also showed me the ways in which psychological research shapes how we conceive of diagnostic categories – and consequently, ourselves. While psychology’s commitment to objectivity, empiricism and visibility has provided tools that are tremendously useful in the clinic, my research sheds lights on how the often-exclusive focus on visible symptoms has at times trumped the appreciation of the complex experience of having obsessional thoughts.</p>
<p>I first met Matt in 2019 at the first <a href="https://ocdinsociety.wixsite.com/home/2019">OCD in Society</a> conference, held at Queen Mary University of London, where he was giving a presentation on the “multiple meanings of OCD”. We discussed our own experiences of the disorder, and what we thought that history, psychoanalysis and anthropology could contribute to understandings of OCD.</p>
<p>Matt was 34, and he told me this was the first time he “had ever voiced the internal stuff out loud, and heard other people talk about it”. Recalling how this made him feel, he continued:</p>
<blockquote>
<p>I felt a lot of emotion and sadness. The isolation had been such a big part of my life that I had stopped noticing it. Then being out of the isolation was such a relief, it made me realise how bad it had been.</p>
</blockquote>
<hr>
<p><em>If you are experiencing suicidal thoughts and need support, you can call your GP, <a href="https://www.nhs.uk/nhs-services/urgent-and-emergency-care-services/when-to-use-111/">NHS 111</a>, or free helplines including <a href="https://www.samaritans.org/">Samaritans</a> (116 123), <a href="https://www.thecalmzone.net/">Calm</a> (0800 585858) or <a href="https://papyrus-uk.org/">Papyrus</a> (0800 068 4141).</em></p>
<p><em>In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Hotlines in other countries can be found <a href="http://www.suicide.org/international-suicide-hotlines.html">here</a>.</em></p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=140&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em>For you: more from our <a href="https://theconversation.com/uk/topics/insights-series-71218?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Insights series</a>:</em></p>
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<li><p><em><a href="https://theconversation.com/how-to-solve-our-mental-health-crisis-214776?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">How to solve our mental health crisis</a></em></p></li>
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<p class="fine-print"><em><span>Eva Surawy Stepney receives funding from the Arts and Humanities Research Council (AHRC) via the White Rose College of the Arts and Humanities (WRoCAH). </span></em></p>Research decisions made by clinical psychologists in the 1970s can help explain why so many people, myself included, struggle to make sense of our obsessional thoughts.Eva Surawy Stepney, PhD Candidate in History, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2163192023-11-16T06:05:41Z2023-11-16T06:05:41ZCreative minds are vulnerable to mental illness – but magicians escape the curse<figure><img src="https://images.theconversation.com/files/557995/original/file-20231107-25-ya20uw.jpg?ixlib=rb-1.1.0&rect=132%2C114%2C3650%2C2420&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/magician-playing-cards-fantasy-card-black-1006971310">1STudio.az/Shutterstock</a></span></figcaption></figure><p>Can you think of a comedian, actor, poet or writer who suffered from mental illness? Maybe the actor <a href="https://www.cbsnews.com/news/robin-williams-mental-health-zak-son/">Robin Williams</a> or comedian <a href="https://www.independent.co.uk/life-style/health-and-families/stephen-fry-mental-health-bipolar-disorder-fearne-cotton-podcast-happy-place-a8274051.html">Stephen Fry</a> came to your mind. Perhaps it was the writer <a href="https://www.scielo.br/j/rbp/a/zPQjcnbcv4Kyy3cHkyJJQ7z/#:%7E:text=Virginia%20went%20through%20several%20severe,the%20severity%20of%20the%20episode.">Virginia Woolf</a>. All three have had well-documented struggles with bipolar disorder.</p>
<p>Mental illnesses have been associated with creative thinking for a long time. For instance, mathematician <a href="https://www.nobelprize.org/prizes/economic-sciences/1994/nash/facts/">John Nash’s</a> battle with schizophrenia was immortalised in the film <a href="https://www.imdb.com/title/tt0268978/">A Beautiful Mind</a> (2001).</p>
<p>Research supports this link, showing that people with mental illnesses such as schizophrenia are more likely to work in <a href="https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/creativity-and-mental-disorder-family-study-of-300-000-people-with-severe-mental-disorder/D45848CE35BFC3397FD3CC4F3E15055F">creative jobs</a>. It also shows that creative groups, including <a href="https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/psychotic-traits-in-comedians/AB69ACDB8B48B934DC4DE15B0EA3E2A8">stand-up comedians</a>, artists and scientists, are often more likely to face challenges with their mental health.</p>
<p>But are all creative people created equal? Our new <a href="https://www.cambridge.org/core/journals/bjpsych-open/article/psychotic-and-autistic-traits-among-magicians-and-their-relationship-with-creative-beliefs/A404241D8126664D0EDD1989288F431D">study</a> aimed to explore whether a unique creative group that had never been studied before – magicians – exhibited similar proclivities to some mental illnesses such as schizophrenia. We also looked at whether they were more likely to have a neurodivergent difference, such as autism.</p>
<p>Many researchers believe that both mental illness and neurodivergence can enhance creative thinking. Scientist <a href="https://www.britannica.com/biography/Temple-Grandin">Temple Grandin</a> is a famous example of this. She credits her experience of being on the autism spectrum for the development of a <a href="https://truhugs.com/research-science/do-weighted-blankets-work-temple-grandin-hugging-machine/">hug machine</a> that helps handle livestock in a more humane way, and was later adopted by other autistic people. </p>
<p>Mental health conditions may range from anxiety or depression to personality disorders or psychosis. When someone experiences psychosis, it is measured on a <a href="https://pubmed.ncbi.nlm.nih.gov/16417985/">continuum</a>, with only those experiencing certain patterns and episodes being diagnosed with schizophrenia. </p>
<p>People not clinically diagnosed with schizophrenia, for example, such as those with fewer episodes or less intense symptoms of psychosis, sometimes experience mind wandering and disorganised thinking. This can be challenging for focus but may be beneficial for fostering creativity.</p>
<p>Magicians are unique in that they both create their own shows and perform them. In this sense, they are similar to comedians. Most other creative groups either create or perform but not both. However, unlike comedians, there is much more at stake in a magic performance. If a comedian’s joke falls flat, it may be unpleasant, but it’s unlikely to ruin the entire show. </p>
<p>With a few good jokes that make the audience laugh, the comedian can get back on track. In contrast, one failed magic trick can be disastrous and opportunities to recover during the act can be few and far between.</p>
<p>Magicians, therefore, need to be extremely precise in their performance and possess highly technical skills, all while entertaining the audience simultaneously. This unique work environment and skill set make them an intriguing creative group to study. We carried out our own research with the assistance of a professional magician.</p>
<h2>Magical thinking</h2>
<p>Our study included 195 magicians, primarily from the UK and the US, with an average of 35 years of experience in performing magic. This included close-up magicians, mentalists, card experts and large-stage magicians. The magicians completed questionnaires assessing their tendencies toward autistic and psychotic traits. These were then compared to a sample of non-magicians with a similar age range and and gender distribution, as well as other creative groups such as comedians, poets, actors and musicians.</p>
<figure class="align-center ">
<img alt="Hieronymus Bosch painter of a magician." src="https://images.theconversation.com/files/557993/original/file-20231107-25-2m00rf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/557993/original/file-20231107-25-2m00rf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=499&fit=crop&dpr=1 600w, https://images.theconversation.com/files/557993/original/file-20231107-25-2m00rf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=499&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/557993/original/file-20231107-25-2m00rf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=499&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/557993/original/file-20231107-25-2m00rf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=627&fit=crop&dpr=1 754w, https://images.theconversation.com/files/557993/original/file-20231107-25-2m00rf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=627&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/557993/original/file-20231107-25-2m00rf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=627&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hieronymus Bosch painter of a magician.</span>
<span class="attribution"><span class="source">wikipedia</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>The magicians did not exhibit any predisposition for autistic traits, scoring similarly to the general population. However, magicians scored lower on nearly every psychotic symptom compared to the general sample and other creative groups.</p>
<p>In particular, these magicians demonstrated a very high ability to concentrate, lower levels of social anxiety and fewer instances of unusual experiences, distorted thoughts and hallucinations. All these traits are highly advantageous for the work of magicians, as they enable them to focus and pay attention to their craft without distractions. </p>
<p>The magicians we studied also did not display any tendency for anti-social behaviour and had good self-control. While these traits are valuable for many creative groups, such as artists and comedians, they are less critical for a magic performance. Magic performances are social events, often involving the audience and sometimes using assistants. So being friendly and affable is a key ingredient for a successful show.</p>
<p>In this regard, magicians are more similar to scientists who also score low on psychotic symptoms. Both require high levels of organisation and perseverance in their work. Moreover, just as scientists often explore different solutions to the same problem, magicians can perform the same magic trick in multiple ways.</p>
<p>Magicians vary in the level of creativity in their performances. While some magicians can be edgy and innovative (just watch David Copperfield’s famous flying illusion below), many magicians can build successful careers by performing familiar tricks, sometimes with their own tweaks, without the need to create new tricks. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/112EIHu5gFc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>Unlike other creative groups who have more flexibility in their work and may improvise during their performances, magic shows require discipline and need to be repeated exactly the same way for the tricks to work.</p>
<p>The magician’s oath not to reveal the secrets behind the tricks allows them to perform the same tricks repeatedly without the audience getting bored and also preserves the mystery of the act.</p>
<p>So unlike with other creative endeavours, mental illness and developmental differences may be counterproductive to magician’s work. It is possible that aspiring magicians with higher levels of psychotic and autistic traits find it very difficult to succeed in this profession.</p>
<p>Ultimately, our study illustrates that not all creative individuals are created equal, and the association between creativity and psychopathology is more complex than previously thought.</p><img src="https://counter.theconversation.com/content/216319/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gil Greengross does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Research suggests magicians lack magical thinking.Gil Greengross, Lecturer in Psychology, Aberystwyth UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2168142023-11-14T13:24:49Z2023-11-14T13:24:49ZMass shootings often put a spotlight on mental illness, but figuring out which conditions should keep someone from having a gun is no easy task<figure><img src="https://images.theconversation.com/files/557887/original/file-20231106-23-j6y1eu.jpg?ixlib=rb-1.1.0&rect=34%2C8%2C5687%2C3791&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The mass shooting in Lewiston, Maine -- the worst in the state's history -- was carried out by a gunman with a known history of mental illness.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/MaineShooting/2b2097e7f3514fddb03d55ee1bd4db36/photo?hpSectionId=a91e5e04eacf4709a84586d6c00d3577&st=hpsection&mediaType=text,photo,video,graphic,audio&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=1758&currentItemNo=128">AP Photo/Matt York</a></span></figcaption></figure><p>Every time the country is shaken by a tragic mass shooting and the loss of innocent lives, mental illness and its role in the actions of the mass shooter come under scrutiny.</p>
<p>Mental illness again became a central theme after the mass shooting in Maine on Oct. 25, 2023, in which records suggest that the shooter had a <a href="https://www.cbsnews.com/news/who-is-robert-card-confirmed-details-maine-shooting-suspect-person-of-interest/">history of serious mental health issues</a>. Months before the tragedy, the family of gunman Robert Card, as well as Army Reserve staffers, had contacted law enforcement expressing high levels of concern about his mental health and noting his access to guns.</p>
<p>Since 1999, 19 states along with the District of Columbia have <a href="https://www.poynter.org/reporting-editing/2022/19-states-have-red-flag-laws-but-they-are-rarely-used-to-stop-gun-violence/">passed legislation</a>, commonly known as <a href="https://www.pbs.org/newshour/politics/michigan-governor-signs-red-flag-gun-law-as-questions-linger-over-enforcement">red flag laws</a>, that allow law enforcement and other people in a person’s life to petition for removal of firearms when there are imminent safety concerns about a gun owner. However, <a href="https://www.poynter.org/reporting-editing/2022/19-states-have-red-flag-laws-but-they-are-rarely-used-to-stop-gun-violence/">reports suggest that this law is rarely used</a>.</p>
<p>Maine, though, has what’s known as a <a href="https://www.cbsnews.com/boston/news/yellow-red-flag-gun-laws-massachusetts-maine/">yellow flag law</a>. It requires reporting to local law enforcement that a person poses an imminent threat, but it then relies on the police to take the person into custody, order a mental health evaluation and request a court order to have that person’s guns removed. The yellow flag law <a href="https://www.cnn.com/2023/11/05/us/robert-card-lewiston-shooting-maine-yellow-flag-law/index.html">was not used</a> in Card’s case.</p>
<p>The relationship between mental illness and guns, and risk mitigation, is complicated. Specifically, there is no clear and uniform consensus on who should determine when to restrict access to firearms – should it be a psychiatrist, an independent forensic psychiatrist, a committee of psychiatrists or a judge? The majority of people with mental illness <a href="https://www.nimh.nih.gov/health/statistics/mental-illness">do not seek treatment</a>. </p>
<p>In that light, it might make sense to mandate a psychiatric examination into the background check process for purchasing a gun. As severe mental illness can start at any point in life, will gun owners need periodic psychiatric assessment, akin to a vision exam for renewing a driver’s license? If so, who will pay for the visits? </p>
<p>I am a <a href="https://www.starclab.org">trauma psychiatrist</a> who regularly deals with the outcome of gun violence, whether in victims or first responders. In my book “<a href="https://rowman.com/ISBN/9781538170380/Afraid-Understanding-the-Purpose-of-Fear-and-Harnessing-the-Power-of-Anxiety">Afraid</a>: Understanding the Purpose of Fear and Harnessing the Power of Anxiety,” I have examined mental health issues related to gun violence and the social consequences of mass shootings.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/T93fbFGvRNI?wmode=transparent&start=59" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Maine has a ‘yellow flag’ law aimed at restricting access to firearms when a person is deemed potentially dangerous.</span></figcaption>
</figure>
<h2>The complexity of defining mental illness</h2>
<p>The term <a href="https://www.nimh.nih.gov/health/statistics/mental-illness">“mental illness”</a> covers a wide range of conditions, and there are more than 200 diagnoses listed in the most recent version of the <a href="https://www.psychiatry.org/psychiatrists/practice/dsm">Diagnostic Statistical Manual of Mental Disorders</a>, which is the gold standard for psychiatric diagnosis in the U.S. Mental illness includes diverse conditions like phobias, <a href="https://www.mayoclinic.org/diseases-conditions/social-anxiety-disorder/symptoms-causes/syc-20353561">social anxiety disorder</a>, <a href="https://adaa.org/learn-from-us/from-the-experts/blog-posts/consumer/what-trauma-what-ptsd-who-affected-and-how-get">post-traumatic stress disorder</a>, <a href="https://www.nhs.uk/mental-health/conditions/trichotillomania/#">hair-picking disorder</a>, <a href="https://www.psychiatry.org/patients-families/gambling-disorder/what-is-gambling-disorder">gambling disorder</a>, <a href="https://www.psychiatry.org/patients-families/schizophrenia/what-is-schizophrenia#">schizophrenia</a>, <a href="https://www.cdc.gov/aging/dementia/index.html#">dementia</a>, various forms of <a href="https://www.psychiatry.org/patients-families/depression/what-is-depression">depression</a> and personality disorders, such as antisocial personality disorder.</p>
<p>Mental illnesses are also very common: Nearly <a href="https://www.nami.org/learn-more/mental-health-by-the-numbers">1 in 5 people experience clinical depression</a> during their lives; 1 in 5 people experience an anxiety disorder; <a href="https://www.nimh.nih.gov/health/statistics/schizophrenia.shtml">1 in 100 experience schizophrenia</a>; and <a href="http://www.ptsdunited.org/ptsd-statistics-2/">nearly 8 in 100</a> of the general population experiences PTSD. People with higher exposure to trauma, <a href="https://www.ptsd.va.gov/professional/PTSD-overview/epidemiological-facts-ptsd.asp">such as veterans</a> and <a href="https://theconversation.com/the-aching-blue-trauma-stress-and-invisible-wounds-of-those-in-law-enforcement-146539">first responders</a>, have higher rates of PTSD, up to about 30%. </p>
<p>So when suggesting that gun access should be restricted for people with mental illness, does that mean all of these conditions? Or just some, or some in defined circumstances? For example, should all veterans with PTSD or those with social anxiety disorder have their guns removed? Neither of these conditions is known to commonly impair judgment. </p>
<p>Defining the specific conditions that can impair judgment or significantly increase risk of harm to self or others is an important step in this process, which needs serious involvement of mental health professionals, stakeholders, law enforcement and policymakers. </p>
<h2>Knowing when a person could be a risk of harm</h2>
<p>The majority of mental illnesses <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686644/">do not pose a risk</a> to others. When there is a risk, in the majority of cases when someone is involuntarily admitted to a psychiatric inpatient unit, it is not because the person poses a risk to others. Rather, it is more often the case that the person is at <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686644/">risk of self-harm</a>, as in the case of a depressed, suicidal patient. Sadly, people with severe mental illness are <a href="https://doi.org/10.3389/fpsyt.2020.563860">often the victims of violence and abuse</a>.</p>
<p>In psychiatric disorders, concerns typically arise in acutely psychotic patients with paranoid delusions that convince them to harm others. This may happen in – but is not limited to – schizophrenia, dementia, severe <a href="https://www.webmd.com/depression/psychotic-depression">psychotic depression</a> or <a href="https://www.healthline.com/health/bipolar-disorder/bipolar-psychosis">psychotic bipolar illness</a>.</p>
<p>These conditions are rather strongly associated with <a href="https://psychiatryonline.org/doi/pdf/10.5555/appi.books.9781615371099">increased risk of suicide</a>, not homicide. Therefore, more realistic gun laws in regards to mental illness could also save many lives from suicide.</p>
<p>Substance use is a <a href="https://doi.org/10.1093%2Fepirev%2Fmxaa006">major contributor to violence</a> in mental illness, and it needs to be included in the calculations when it comes to gun restriction. Other situations with increased risk of harm to others are personality disorders with a high level of impulsivity or lack of remorse, such as <a href="https://www.mayoclinic.org/diseases-conditions/antisocial-personality-disorder/symptoms-causes/syc-20353928">antisocial personality disorder</a>. </p>
<p>But the reality is that most people with personality disorders do not seek treatment and are not known to mental health providers. </p>
<p>It is also worth noting that most countries have a similar prevalence of severe mental illness compared with the U.S., yet they have <a href="https://www.who.int/news-room/fact-sheets/detail/mental-disorders#">much lower rates of mass murder</a> than the U.S.</p>
<h2>The harms of using ‘mental illness’ so vaguely</h2>
<p>Every time <a href="http://blogs.bmj.com/bmj/2017/10/06/doctors-need-to-speak-up-against-the-use-of-mental-illness-as-an-insult/">mental illness is linked by the media or politicians to acts of violence</a>, the highly charged emotions of the moment can affect those with mental illness and their families, and that can perpetuate stigma.</p>
<p>When “mental illness” is <a href="https://www.nytimes.com/2012/12/18/health/a-misguided-focus-on-mental-illness-in-gun-control-debate.html">vaguely addressed in gun debates</a>, those with a psychiatric condition such as anxiety or phobia but without an increased risk of violence or impairment in judgment may avoid seeking treatment.</p>
<h2>Mental illness gun laws that can have real preventive impact</h2>
<p>In my view, to turn the focus on the role of mental illness in gun violence into meaningful actions, the following steps are needed:</p>
<p>– Clear, uniform criteria need to be established on when mental illness justifies restriction of access to firearms. Would this be specific mental disorders or specific mental disorders in crises? This requires defining signs of imminent threat to self or others, and also defining how and when a person is relieved of that status. A great deal of discussion and coordination will be needed between mental health, legal and law enforcement experts.</p>
<p>– As it was noted before, the majority of patients with mental illness do not seek care. A comprehensive preventive plan would necessitate screening everybody who applies to purchase a firearm. This step ensures meaningful screening, as well as avoiding discrimination. Other countries such as Japan, Canada, New Zealand and Austria <a href="https://www.nytimes.com/interactive/2018/03/02/world/international-gun-laws.html">have such requirements</a>.</p>
<p>– Since potentially dangerous psychiatric conditions can begin at any age in an otherwise healthy person, regular mental health screening for gun owners would be justified, similar to eye exams for drivers.</p>
<p>– There should be clear mechanisms for determining lack of mental fitness for access to firearms when concerns are raised by those who know the person or by law enforcement. Red flag gun laws are a good beginning for this path.</p>
<p>The bottom line is that determining who may or may not have access to firearms based on mental illness, as outlined, is indeed very challenging and requires more serious work. And the common denominator in all these tragedies still is the access to assault rifles.</p>
<p><em>This is an updated version of <a href="https://theconversation.com/mental-illness-and-gun-laws-what-you-may-not-know-about-the-complexities-92337">an article</a> that was originally published on Feb. 26, 2018.</em></p><img src="https://counter.theconversation.com/content/216814/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arash Javanbakht does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Red flag laws are an important step in the right direction, but much more work is needed to determine the role of mental health in the lead-up to and aftermath of mass shootings.Arash Javanbakht, Associate Professor of Psychiatry, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2147762023-10-27T10:44:22Z2023-10-27T10:44:22ZHow to solve our mental health crisis<figure><img src="https://images.theconversation.com/files/554870/original/file-20231019-21-lgmepp.jpeg?ixlib=rb-1.1.0&rect=298%2C51%2C3414%2C2098&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Advert for a universal basic income (UBI) scheme in New York, May 2016. Such schemes could offer significant benefits for recipients' mental health.</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:BASIC_INCOME_COMMING_SOON_-_31857924093.jpg">Generation Grundeinkommen via Wikimedia</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>When BBC journalist Rory Carson <a href="https://www.bbc.co.uk/programmes/m001m0f9">sought online consultations</a> for a potential mental health issue, three private clinics diagnosed him with <a href="https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/">attention deficit hyperactivity disorder</a> (ADHD). They charged between £685 and £1,095 for these consultations, which lasted between 45 and 100 minutes, and all prescribed him medication.</p>
<p>ADHD is a <a href="https://reaktionbooks.co.uk/work/hyperactive">highly controversial disorder</a> which emerged in the US in the late 1950s during the <a href="https://theconversation.com/adhd-how-race-for-the-moon-revealed-americas-first-hyperactive-children-120393">cold war</a>, and quickly became associated with stimulant drugs such as <a href="https://theconversation.com/ritalin-at-75-what-does-the-future-hold-121591">Ritalin</a>. Now diagnosed <a href="https://academic.oup.com/shm/article/30/4/767/2919401">throughout the world</a>, ADHD is central to many debates about <a href="https://www.autisticuk.org/neurodiversity">neurodiversity</a>.</p>
<p>While Carson’s Panorama investigation into its treatment attracted <a href="https://www.huffingtonpost.co.uk/entry/bbc-panorama-adhd-diagnosis-twitter_uk_64621f2fe4b018d846bf19ee">plenty of criticism</a>, the fact that this disorder could apparently be diagnosed quite casually online is concerning. When he subsequently had a more rigorous (but free) three-hour, in-person consultation with an NHS psychiatrist, he was told that he did not, in fact, have ADHD.</p>
<hr>
<p><em>Across the world, we’re seeing unprecedented levels of mental illness at all ages, from children to the very old – with huge costs to families, communities and economies. <a href="https://theconversation.com/uk/topics/tackling-the-mental-health-crisis-147216?utm_source=TCUK&utm_medium=ArticleTop&utm_campaign=MentalHealthSeries">In this series</a>, we investigate what’s causing this crisis, and report on the latest research to improve people’s mental health at all stages of life.</em></p>
<hr>
<p>Society’s increasing <a href="https://www.sciencedirect.com/science/article/pii/S0732118X2300003X">awareness of mental health issues</a> and <a href="https://www.nhsconfed.org/articles/analysis-rise-mental-health-demand">demand for mental health support</a> has been driven, in part, by social media and easier access to information online. While this is no bad thing in many ways, the related <a href="https://www.psychologytoday.com/gb/blog/our-new-discontents/202209/the-appeal-and-the-peril-self-diagnosis">increase in self-diagnosis</a> (including among <a href="https://www.sciencedirect.com/science/article/pii/S0010440X22000682">children and adolescents</a>) is clearly open to abuse by some organisations offering costly diagnoses and treatments.</p>
<p>But there is another reason for this <a href="https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/mental-health-pressures-data-analysis#:%7E:text=Mental%20health%20services%20in%20England,mental%20health%20services%20steadily%20rising.">rapid growth in private mental healthcare</a>. In England alone, the NHS spends around <a href="https://www.theguardian.com/society/2022/apr/24/nhs-paying-2bn-pounds-a-year-to-private-hospitals-for-mental-health-patients">£2 billion per year</a> on private hospital care for mental health patients – equating to 13.5% of its total mental health spend. Due to the reduction in <a href="https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/hospital-beds">NHS bed provision</a>, nine out of ten privately-run mental health beds are now filled by NHS patients.</p>
<p>While the UK government says it is committed to <a href="https://www.gov.uk/government/news/mental-health-services-boosted-by-150-million-government-funding">spending more money on mental health</a>, private investment companies are <a href="https://www.theguardian.com/commentisfree/2023/aug/17/private-equity-nhs-hospital-crisis">reportedly</a> queuing up to “seize the opportunities offered up to them by the NHS crisis”. <a href="https://www.business-reporter.co.uk/management/tackling-the-mental-health-crisis-how-the-private-sector-can-help-improve-nhs-mental-health-services">Private providers</a> say they can do more to help avert a mental health emergency exacerbated by the COVID pandemic, yet a dozen of the <a href="https://www.carehome.co.uk/mental-health-hospitals/index.cfm/searchcountry/England/orderid/-1">80-odd</a> privately-run mental health hospitals in England were <a href="https://www.independent.co.uk/news/uk/home-news/mental-health-hospitals-inadequate-map-cqq-b2360777.html">rated as “inadequate”</a> in the Care Quality Commission’s latest report, which has <a href="https://www.bbc.co.uk/news/uk-65761273">warned of possible closures</a>.</p>
<p>As a health historian, I find our worsening <a href="https://www.bma.org.uk/bma-media-centre/shameful-statistics-show-a-mental-health-crisis-that-is-spiralling-out-of-control-as-demand-far-outweighs-capacity-warns-bma">mental health crisis</a> sadly predictable. Governments around the world have been involved in tackling mental illness <a href="https://www.britannica.com/science/mental-disorder/Treatment-of-mental-disorders">since at least the early 19th century</a>. While not all of their attempts were successful, many important lessons remain unlearned.</p>
<p>At the heart of them is this: amid ageing populations and the spiralling <a href="https://www.lse.ac.uk/News/Latest-news-from-LSE/2022/c-Mar-22/Mental-health-problems-cost-UK-economy-at-least-118-billion-a-year-new-research">costs of mental illness</a> to national economies, investing in people’s future mental health, based on what the key <a href="https://www.mentalhealth.org.uk/explore-mental-health/statistics/poverty-statistics">socioeconomic factors</a> that we know are underlying it, is the only effective, long-term way to reduce this burden. As a major coalition of UK mental health organisations <a href="https://www.centreformentalhealth.org.uk/wp-content/uploads/2023/09/AMentallyHealthierNation_Digital.pdf">recently reported</a>: </p>
<blockquote>
<p>The risks to mental health, and the poor outcomes that follow, do not fall evenly across the population. People living in poverty, those with physical disabilities and illnesses, people with neurodevelopmental conditions, children in care, people from racialised communities, and LGBTQ+ people all experience much poorer mental health outcomes because of intersecting disadvantage and discrimination.</p>
</blockquote>
<p>This all adds up to the life expectancy of a person with a severe mental illness being about 20 years shorter than someone without a diagnosis – and that gap is getting bigger. We understand the reasons why – so why do we seem unable to do anything about it?</p>
<h2>Learning from history: the emergence of asylums</h2>
<p>The first asylum in Britain was <a href="https://en.wikipedia.org/wiki/Bethlem_Royal_Hospital">Bethlehem Hospital</a> near London’s Bishopsgate, which began to specialise in insanity by the 15th century. Commonly referred to as “Bedlam”, what is now Bethlem Royal Hospital was often depicted negatively – including in <a href="https://www.tate.org.uk/research/features/hogarth-rakes-progress-paintings-to-prints">A Rake’s Progress</a>, a series of eight paintings by the 18th-century English artist William Hogarth.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/554873/original/file-20231019-17-935x2j.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Painting of naked man being attended to in a madhouse." src="https://images.theconversation.com/files/554873/original/file-20231019-17-935x2j.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554873/original/file-20231019-17-935x2j.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554873/original/file-20231019-17-935x2j.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554873/original/file-20231019-17-935x2j.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554873/original/file-20231019-17-935x2j.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554873/original/file-20231019-17-935x2j.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554873/original/file-20231019-17-935x2j.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">‘In The Madhouse’ (1732-1735) by William Hogarth, from his series A Rake’s Progress.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:William_Hogarth_019.jpg">Wikimedia</a></span>
</figcaption>
</figure>
<p>Across the Atlantic, the treatment of patients in American asylums also proved very controversial. When Ebenezer Haskell escaped the Pennsylvania Hospital for the Insane in 1868, he immediately sued the hospital for unjust confinement and published an <a href="https://wellcomecollection.org/works/h367tupx/items?canvas=109">account of his ordeal</a>, writing in the foreword:</p>
<blockquote>
<p>The object of these pages is … simply to speak a few plain unvarnished truths [on] behalf of the poor, helpless and suffering patients put in these [institutions], and to show why a strong and positive legislative action should be taken for their protection.</p>
</blockquote>
<p>The pamphlet included depictions of Haskell being punished and tortured, sometimes in the guise of treatment. In one, he is shown naked and lying on his back on the floor, restrained by four men while another performs “<a href="https://www.psychologytoday.com/gb/blog/short-history-mental-health/201510/the-healing-waters">hydrotherapy</a>” – dumping a bucket of water on Haskell’s face as a second man stands ready with another bucket.</p>
<p>Public perceptions of the brutal forms of care provided in mental asylums – and private “<a href="https://historicengland.org.uk/research/inclusive-heritage/disability-history/1660-1832/the-age-of-the-madhouse/">madhouses</a>” – continue to be heavily influenced by films such as <a href="https://www.imdb.com/title/tt1130884/">Shutter Island</a> (2010), <a href="https://www.imdb.com/title/tt0172493/">Girl, Interrupted</a> (1999) and, perhaps most notably, <a href="https://www.imdb.com/title/tt0073486/">One Flew Over the Cuckoo’s Nest</a> (1975). Such films, and the novels that inspired them, portray asylums as harsh, unforgiving places run by mostly callous or sadistic staff. While this is justified in some cases, such portrayals mask the impressive ambition, care and expense that went into the building of many asylums by governments around the world during the 19th century.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/OXrcDonY-B8?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Trailer for One Flew Over the Cuckoo’s Nest (1975)</span></figcaption>
</figure>
<p>The provision of care for the mentally ill has long been considered a public responsibility. In Britain, the <a href="https://en.wikipedia.org/wiki/Madhouses_Act_1774">1774 Madhouses Act</a> was a response to concerns about abuse in private madhouses. Soon after, the <a href="https://www.countyasylums.co.uk/history/">County Asylum Act of 1808</a> and <a href="https://en.wikipedia.org/wiki/Lunacy_Act_1845">Lunacy Act of 1845</a> were passed in England and Wales to create dedicated public facilities for the mentally ill, so they wouldn’t languish in <a href="https://en.wikipedia.org/wiki/Workhouse">workhouses</a>. Dozens of asylums began popping up all over Britain, regulated by the newly established <a href="https://en.wikipedia.org/wiki/Commissioners_in_Lunacy">Lunacy Commission</a>.</p>
<p>Encouraged by the <a href="https://www.bl.uk/restoration-18th-century-literature/articles/the-enlightenment">Age of Enlightenment</a>, which spurred the idea that science could solve most of the world’s problems, Britain was among the pioneers embracing the concept of <a href="https://www.healthcareers.nhs.uk/career-planning/resources/brief-history-public-health">public health</a>, with governments investing in public infrastructure to prevent infectious disease. In the case of asylums, <a href="https://www.glasgowlive.co.uk/news/history/inside-glasgows-abandoned-gartloch-hospital-24459623">little expense was spared</a> even for so-called “pauper lunatics”. </p>
<p>At this time, asylums would have been among the <a href="https://www.psychologytoday.com/gb/blog/short-history-mental-health/201901/cathedrals-the-mind">most impressive buildings</a> people would have seen – overshadowed only by cathedrals. However controversial, they were the first concerted, state-led effort to deal with mental illness. And while few mental health experts would recommend a return to the asylum era today, they might well envy the commitment that governments in Britain and elsewhere demonstrated in the facilities they provided for their mentally ill. </p>
<h2>The disease that linked mental illness to poverty</h2>
<p>Nineteenth-century experts provided numerous explanations for insanity. Some, such as <a href="https://wellcomecollection.org/works/b4y4n6pn">masturbation</a>, we would laugh at today. But financial insecurity, <a href="https://en.wikipedia.org/wiki/Neurasthenia">overstudy and overwork</a>, or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8953002/pdf/atlantajrecmed141958-0005.pdf">problems related to giving birth</a> seem much more reasonable and still relevant. Just as <a href="https://www.britannica.com/science/heredity-genetics">heredity</a> was cited as a cause in the past, today we cite <a href="https://www.nimh.nih.gov/health/publications/looking-at-my-genes#:%7E:text=Certain%20mental%20disorders%20tend%20to,factors%20also%20play%20a%20role.">genetic predisposition</a>.</p>
<p>As governments began to invest more in hospital infrastructure to treat physical ills, due in particular to advancements in germ theory and surgery, asylum buildings and care standards were often left to deteriorate. In Alabama’s <a href="https://en.wikipedia.org/wiki/Searcy_Hospital">Mount Vernon Insane Hospital</a>, for example, scandal surrounded the death of 57 African-American patients in 1906. But the cause of these deaths, pellagra – a disease that <a href="https://www.psychiatrist.com/blog/pellagra-niacin-deficiency-and-mental-illness/#:%7E:text=The%20relevance%20of%20pellagra%20to,it%20may%20lead%20to%20death.">can affect the brain</a> and cause severe psychiatric symptoms – has an important place in the history of public mental health treatment.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/554936/original/file-20231020-25-pr3fqp.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Wax head-and-shoulders model of a woman with pellagra" src="https://images.theconversation.com/files/554936/original/file-20231020-25-pr3fqp.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/554936/original/file-20231020-25-pr3fqp.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=845&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554936/original/file-20231020-25-pr3fqp.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=845&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554936/original/file-20231020-25-pr3fqp.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=845&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554936/original/file-20231020-25-pr3fqp.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1061&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554936/original/file-20231020-25-pr3fqp.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1061&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554936/original/file-20231020-25-pr3fqp.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1061&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Waxwork model of a pellagra patient in Bologna, Italy.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Museo_delle_cere_anatomiche_(Bologna)_abc2_pellagra.jpg">Patafisik via Wikimedia</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
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<p>In northern Italy from the 1850s and the American South from the 1900s, asylums were suddenly filling up with pellagra sufferers. At this time, the disease was thought to be hereditary or contagious, and those afflicted, known as pellagrins, <a href="https://www.psychiatrist.com/blog/pellagra-niacin-deficiency-and-mental-illness/#:%7E:text=The%20relevance%20of%20pellagra%20to,it%20may%20lead%20to%20death.">were shunned</a>. </p>
<p>In fact, the real reason they were succumbing to pellagra was poverty. In both regions, landowners had introduced corn due to its high yields and attractiveness as a cash crop. At the same time, in <a href="https://link.springer.com/book/10.1007/978-3-031-22496-6">Italy</a>, a deterioration in agricultural working conditions meant that, by the 1870s, many workers relied on cheap corn for food in the form of <a href="https://en.wikipedia.org/wiki/Polenta">polenta</a>.</p>
<p>Similarly, in the post-Civil War <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6451741/">American South</a>, landowners devoted most of their property to growing cotton, leaving little room for other crops or livestock. So, tenant farmers relied on corn for food in the form of grits or <a href="https://www.bloomsbury.com/us/us-history-in-15-foods-9781350211971/">corn pone</a>, which left many suffering from malnutrition and, in particular, a severe deficiency of vitamin B3 (niacin). </p>
<p>This was the real cause of pellagra – but at this time, the role of <a href="https://www.nytimes.com/2013/12/12/science/learning-from-the-history-of-vitamins.html">vitamins</a> in health was little understood. And even when the link between people’s over-reliance on corn in their diets, lack of niacin and mental illness <a href="https://www.ncbi.nlm.nih.gov/books/NBK557728/">was established by scientists</a>, policymakers were hesitant to acknowledge the role of poverty and malnutrition in this explosion of mental illness.</p>
<p>In the US, New York physician Joseph Goldberger discovered the <a href="https://history.nih.gov/pages/viewpage.action?pageId=8883184">link between pellagra and poor diet</a> in the mid-1910s – yet the overwhelming evidence he provided was rejected in the American South. For nearly 20 years, southerners <a href="https://www.jstor.org/stable/25605634">were too proud</a> to accept the disease was rooted in poverty, and continued to conduct fruitless research on other causes.</p>
<p>Even today, knowing that a poor diet contributes to poor mental health is one thing; tackling the poverty that leads to a bad diet is quite another. As researchers crystallise the link between <a href="https://journals.sagepub.com/doi/full/10.1177/2167702616641050">diet and mental health</a> – now widely framed in terms of the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5641835/">gut-brain axis</a> – the need for governments to tackle the social determinants of a poor diet is <a href="https://commonslibrary.parliament.uk/research-briefings/cbp-9209/#:%7E:text=According%20to%20the%20Department%20for,%2C%20including%2021%25%20of%20children.">clear and urgent</a>. Namely, <a href="https://www.theguardian.com/society/2023/oct/24/more-than-1-million-uk-children-experienced-destitution-last-year-study-finds">poverty</a> and the <a href="https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/food-insecurity">food insecurity</a> that goes with it.</p>
<h2>When governments got serious about prevention</h2>
<p>In 1929, a 13-year-old girl turned up to a Chicago social service agency, reporting that she had been raped by her brother-in-law. After a medical examination, <a href="https://cup.columbia.edu/book/the-first-resort/9780231203937">her case was taken on</a> by a team of social workers who visited her and her family, all Polish immigrants. The social workers took note of the family’s financial circumstances and helped the family press charges against the rapist, who was given a prison sentence. The girl attended counselling sessions for many months.</p>
<p>The agency overseeing this case was one of hundreds of <a href="https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.16.1.22">mental hygiene and child guidance clinics</a> founded in the US during its “<a href="https://en.wikipedia.org/wiki/Progressive_Era#:%7E:text=The%20Progressive%20Era%20(1896%E2%80%931917,monopoly%2C%20waste%2C%20and%20inefficiency.">Progressive Era</a>” in the early 20th century. This was a period of political reform and social activism dedicated to countering the problems associated with industrialisation, urbanisation and immigration, and these child guidance and mental hygiene movements soon spread to <a href="https://www.routledge.com/Child-Guidance-in-Britain-19181955-The-Dangerous-Age-of-Childhood/Stewart/p/book/9781138662315">Britain</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5287990/">elsewhere</a>.</p>
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<img alt="" src="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><strong><em>This article is part of Conversation Insights</em></strong>
<br><em>The Insights team generates <a href="https://theconversation.com/uk/topics/insights-series-71218">long-form journalism</a> derived from interdisciplinary research. The team is working with academics from different backgrounds who have been engaged in projects aimed at tackling societal and scientific challenges.</em></p>
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<p>Prevention was the cornerstone of these movements, which espoused that it was much more efficient <a href="https://pubmed.ncbi.nlm.nih.gov/30601725/">to prevent mental illness</a> than treat it. In the US, the clinics were often funded by charities such as the <a href="https://www.commonwealthfund.org/">Commonwealth Fund</a> and the <a href="https://dimes.rockarch.org/collections/kpoaALEcdxhvPyFBRby8nS">Laura Spelman Rockefeller Fund</a>. But the state played an important role too – more so in other parts of the world.</p>
<p>In Britain, social welfare departments established to run similar clinics began to hire new types of mental health worker, such as psychiatric social workers and psychiatric nurses. From the 1930s, <a href="https://www.historyandpolicy.org/docs/john_stewart.pdf">education authorities</a> became more involved in child guidance activities, which were included in the <a href="https://journals.sagepub.com/doi/abs/10.1177/146642404606600204?journalCode=rsha">1944 Education Act</a>. </p>
<p>While some conclusions drawn at this time appear shocking today – some mental hygienists and child guiders, for example, were sympathetic to <a href="https://www.genome.gov/about-genomics/fact-sheets/Eugenics-and-Scientific-Racism#:%7E:text=Eugenics%20is%20the%20scientifically%20erroneous,ills%20through%20genetics%20and%20heredity.">eugenic explanations</a> for mental illness, even if they also acknowledged the role of environmental causes – overall, the existence of child guidance and mental hygiene during the first half of the 20th century demonstrates how seriously preventive mental health was taken. </p>
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Read more:
<a href="https://theconversation.com/unlocking-new-clues-to-how-dementia-and-alzheimers-work-in-the-brain-uncharted-brain-podcast-series-194773">Unlocking new clues to how dementia and Alzheimer's work in the brain – Uncharted Brain podcast series</a>
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<p>Today, this is not the case. As in most areas of healthcare, the majority of public and private funding for mental health is funnelled towards <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4471962/">researching and prescribing pharmaceutical treatments</a>, rather than prevention.</p>
<p>Such investment has resulted in some effective medications, such as drugs to reduce the symptoms of schizophrenia or bi-polar disorder - although there <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8751557/">are heated debates</a> about this. But it has also distracted from the need to prevent upstream causes of mental illness, while pharmaceutical companies continue to aggressively lobby governments and politicians <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8224875/">in the UK</a>, <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2762509">US</a> and elsewhere for more funding.</p>
<h2>The peak of care in the community</h2>
<p>In 1948, American journalist Albert Deutsch’s landmark book <a href="https://en.wikipedia.org/wiki/The_Shame_of_the_States">The Shame of the States</a> exposed the parlous position of state-run mental hospitals throughout the US. In contrast to the good intentions that had led to the asylum era, Deutsch showed that many of these hospitals were now under-resourced, overcrowded and poorly staffed institutions characterised by deprivation, violence and abuse.</p>
<p>Around the same time, <a href="http://cup.columbia.edu/book/the-first-resort/9780231203937">social psychiatry research</a> was confirming what reformers had long believed: that poor socioeconomic conditions were a <a href="https://apps.who.int/iris/bitstream/handle/10665/112828/9789241506809_eng.pdf">significant factor in the mental illness</a> suffered by millions of people.</p>
<p>Dissatisfaction with mental hospitals and faith in psychiatry’s ability to prevent mental illness led to the <a href="https://en.wikipedia.org/wiki/Community_mental_health_service">community mental health movement</a>. Proponents had two main arguments: that the mentally ill were best treated in their home communities, and that such illness could largely be prevented through community intervention.</p>
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<figcaption><span class="caption">JFK’s ‘special message’ to the US on mental illness and mental retardation, February 5 1963.</span></figcaption>
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<p>In the US and elsewhere, political will for radical change was strong. In February 1963, President <a href="https://www.jfklibrary.org/asset-viewer/archives/JFKPOF/052/JFKPOF-052-012">John F. Kennedy argued</a> that prevention should be central to the US’s approach to mental illness, highlighting the “harsh environmental conditions” in which it flourished. This momentum culminated in the 1963 <a href="https://en.wikipedia.org/wiki/Community_Mental_Health_Act">Community Mental Health Act</a> – the first time the US federal government had invested significantly in mental healthcare. Its ambition was to replace the traditional asylum system with some 2,000 community mental health centres, designed to both provide treatment and engage in preventive work. Fewer than 800 were ultimately built.</p>
<p>Not every psychiatrist wanted to work in community mental health, so other mental health workers were recruited including social workers, psychologists, nurses and “<a href="https://scholarworks.wmich.edu/cgi/viewcontent.cgi?article=1214&context=jssw#:%7E:text=The%20indigenous%20paraprofessionals%20can%20be,those%20experienced%20by%20their%20clients.">indigenous paraprofessionals</a>” – people from the local community who lacked formal mental health qualifications. They worked closely with members of the public to help resolve the socioeconomic problems that were fuelling their poor mental health, and also liaised with schools, landlords, welfare officers, the justice system and medical professionals on behalf of their patients.</p>
<p>Yet despite their <a href="https://link.springer.com/article/10.1007/BF00125554">effectiveness</a>, indigenous paraprofessionals were often an awkward fit within community mental health centres. In New York’s South Bronx neighbourhood, for example, their attempts to unionise, receive training and be respected resulted in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5024401/">rising tensions</a> with the professional healthcare staff. Racism was one of the contributing factors, as most of these paraprofessionals were black or Latinx, while most of the professional staff were white.</p>
<p>In 1969, the South Bronx <a href="https://footagefarm.com/reel-details/personalities/albert-einstein/lincoln-hospital#/">paraprofessionals went so far as to lock out</a> their centre’s managers and run it themselves for more than two weeks, supported by the <a href="https://en.wikipedia.org/wiki/Black_Panther_Party">Black Panther Party</a> – which further irked the management. While they eventually agreed to some of the paraprofessionals’ demands, the underlying tensions were not resolved and, when funding for community mental health decreased, the budgets for paraprofessionals were the <a href="https://pubmed.ncbi.nlm.nih.gov/758837/">first to be cut</a>.</p>
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<figcaption><span class="caption">The story of the Lincoln Hospital occupation. Documentary by the New York Times.</span></figcaption>
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<p>By 1970, little preventive activity was occurring in community mental health centres. It turned out that President Lyndon B. Johnson’s “<a href="https://en.wikipedia.org/wiki/War_on_poverty">war on poverty</a>” was more focused on “improving” the poor than progressive structural reform. Many social psychiatrists agreed that disadvantaged people <a href="https://psyche.co/ideas/mental-health-is-not-an-individual-matter-but-a-political-one">needed to be “transformed”</a> into upstanding citizens, rather than given material resources. This centuries-old idea of <a href="https://theconversation.com/free-school-meals-debate-shows-how-victorian-attitudes-about-undeserving-poor-persist-149130">deserving and undeserving poor</a> persists today throughout most of the world.</p>
<p>In the US, an increasing number of mentally ill people became <a href="https://pubmed.ncbi.nlm.nih.gov/6479924/">homeless</a>. Others ended up <a href="https://www.apa.org/monitor/2014/10/incarceration#:%7E:text=The%20committee%20found%20that%20the,to%20prisons%20and%20jails%20instead.">in prison</a> or in <a href="https://journals.sagepub.com/doi/full/10.1177/23337214221101260">nursing homes</a>, while an increasing number were cared for <a href="https://link.springer.com/chapter/10.1007/978-3-319-45360-6_12">by family members</a>. In short, this marked a gradual return to the situation prior to the asylum era, when there was little public support for the mentally ill.</p>
<h2>A shift towards treating the individual</h2>
<p>The rise and fall of community mental health in the US is a cautionary tale. In the UK too, history shows that preventive approaches to mental health are soon weakened if not accompanied by <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6025145/">genuinely progressive social policies</a> that reduce poverty, inequality, racism, social isolation and community disintegration.</p>
<p>Following the election of US president Ronald Reagan in 1981 with a promise to <a href="https://www.govinfo.gov/content/pkg/COMPS-10576/pdf/COMPS-10576.pdf">reduce the role of government</a> in most areas including healthcare and social support, and not long after his political soulmate Margaret Thatcher had come to power in the UK, the community mental health movement lost all momentum on both sides of the Atlantic. </p>
<p>But there was another reason for this: the publication, in 1980, of the third edition of the <a href="https://www.psychiatry.org/psychiatrists/practice/dsm/about-dsm/history-of-the-dsm">Diagnostic and Statistical Manual of Mental Disorders</a> (DSM-III). This “bible of psychiatry”, published by the American Psychiatric Association (a new edition emerges roughly every couple of decades), determines what constitutes a psychiatric disorder and how to diagnose it. In the US, if you want your psychiatric treatment covered by health insurance, you must be diagnosed with a disorder found in DSM.</p>
<p>Its third edition marked a major shift away from addressing mental health at a population-wide level, in favour of a focus on individual mental disorders. This led psychiatrists and patients away from environmental explanations for mental illness towards genetic and neurological explanations, or <a href="https://en.wikipedia.org/wiki/Biological_psychiatry">biological psychiatry</a>.</p>
<p>This shift was mirrored by the rise of <a href="https://en.wikipedia.org/wiki/Psychopharmacology">psychopharmacology</a> – the ever-growing use of drug therapies to treat psychiatric patients. <a href="https://en.wikipedia.org/wiki/Listening_to_Prozac">Faith in these medications</a> – in particular, antidepressants such as Prozac – further reduced demands for preventive psychiatry. A <a href="https://www.health.harvard.edu/blog/astounding-increase-in-antidepressant-use-by-americans-201110203624">2011 study</a> found that antidepressant use in the US roughly quadrupled over two decades from 1998. More recently, <a href="https://pharmaceutical-journal.com/article/news/antidepressant-prescribing-increases-by-35-in-six-years#:%7E:text=Prescriptions%20of%20antidepressants%20rose%20by,the%20sixth%20consecutive%20annual%20increase.&text=The%20number%20of%20antidepressants%20prescribed,annual%20increase%20in%20a%20row.">antidepressant use</a> in England rose by 35% between 2015 and 2021.</p>
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<figcaption><span class="caption">The role of fentanyl in the US opioid crisis. (Bloomberg)</span></figcaption>
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<p>But psychopharmacology has not proved the panacea the pharmaceutical companies promised. One <a href="https://www.bmj.com/content/378/bmj-2021-067606">major study in 2022</a> found that only around 15% of participants in randomised, placebo-controlled trials experienced a substantial antidepressant effect. The fact that long-term use of antidepressants is <a href="https://www.sciencedirect.com/science/article/pii/S0924977X13001454?casa_token=Ti1Ee8v4NagAAAAA:0aYFC0HuA-2CjPooL5_Lxhl8MHSYnQYqIMd0nza66klDbCT6Fz8iLJgs34R3ijoCGZnYaKkHJVk">likely to cause side effects</a>, such as weight gain and sexual dysfunction, also raises questions about their widespread use.</p>
<p>The <a href="https://www.cdc.gov/opioids/basics/epidemic.html">opioid crisis</a> in the US indicates that we cannot rely on pharmaceutical companies to always do what is in our best interest. Sadly, it has also showed us that <a href="https://www.ncbi.nlm.nih.gov/books/NBK448203/#:%7E:text=Three%20million%20US%20citizens%20and,in%20a%20year%20time%20period.">millions of Americans</a>, and countless millions more around the world, are struggling to cope with mental as well as physical pain, and are desperate for solutions.</p>
<h2>The dangers of privatised mental healthcare</h2>
<p>In the UK, US and most other countries, there has probably never been more awareness of mental health issues among the general public – particularly in the wake of the COVID pandemic, whose impact on mental health has often led <a href="https://www.theguardian.com/world/2022/aug/27/covid-pandemic-mental-health">media headlines</a> and dominated <a href="https://www.mind.org.uk/about-us/our-policy-work/coronavirus-research/">scientific discussions</a>.</p>
<p>There is also much better evidence for what works – including, for example, the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5942544/">efficacy of talking therapies</a>. In part because of concerns about the overprescription and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6998955/">ineffectiveness</a> of drugs used to treat mental illness, the 21st century has seen a growth in popularity of talking therapies such as <a href="https://www.mind.org.uk/information-support/drugs-and-treatments/talking-therapy-and-counselling/cognitive-behavioural-therapy-cbt/#:%7E:text=work%20for%20me%3F-,What%20is%20CBT%3F,affect%20your%20feelings%20and%20actions.">cognitive behavioural therapy</a> (CBT) in the west.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/554939/original/file-20231020-29-wl67fd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Cycle diagram explaining cognitive behavioural therapy (CBT)" src="https://images.theconversation.com/files/554939/original/file-20231020-29-wl67fd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554939/original/file-20231020-29-wl67fd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554939/original/file-20231020-29-wl67fd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554939/original/file-20231020-29-wl67fd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554939/original/file-20231020-29-wl67fd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=753&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554939/original/file-20231020-29-wl67fd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=753&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554939/original/file-20231020-29-wl67fd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=753&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Cycle diagram explaining cognitive behavioural therapy (CBT)</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/cbt-cognitive-behavioral-therapy-cycle-diagram-320312924">artellia/Shutterstock</a></span>
</figcaption>
</figure>
<p>However, accessing state-provided psychoanalytic treatments is very difficult, particularly in less well-off regions. In the UK, average waiting times for the NHS’s <a href="https://www.england.nhs.uk/mental-health/adults/nhs-talking-therapies/">Talking Therapies</a> programme <a href="https://www.theguardian.com/society/2020/jan/25/mental-health-care-postcode-lottery-nhs-talking-therapies">vary enormously</a> depending on where you live. There are nearly <a href="https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2017/09/11/postcode-lottery-for-psychiatric-care">three times</a> as many NHS consultant psychiatrists per 100,000 people in parts of London than there are in Yorkshire. <a href="https://www.independent.co.uk/news/health/child-mental-health-waiting-times-b1972830.html">Vulnerable children</a> in some parts of the UK can wait two years for a first appointment, while those elsewhere are seen within a week.</p>
<p>Overall, while the number of successful referrals for talking therapies such as CBT have increased since the NHS programme’s inception in 2008, so have demands, and it has recently been <a href="https://www.nuffieldtrust.org.uk/resource/improving-access-to-psychological-therapies-iapt-programme">missing its targets</a> by about a third. As a result, an increasing number of people are reported to be seeking <a href="https://www.mentalhealthtoday.co.uk/news/awareness/rise-in-demand-for-private-counsellors-as-patients-say-nhs-waiting-lists-are-too-long">private treatment</a> – despite the expense, and amid concerns about the reliability of some services offering these treatments.</p>
<p>As with physical health services, people also opt out of the NHS by purchasing private health insurance or <a href="https://www.totalhealth.co.uk/blog/waiting-list-fast-passes">waiting list “fast passes”</a>. All of this creates a <a href="https://www.ippr.org/research/publications/state-of-health-and-care-2022">two-tier system</a> that undermines the principles of universality and accessibility that are meant to underpin the NHS.</p>
<p>Most private mental health providers, like drug companies, are also <a href="https://www.theguardian.com/society/2018/jul/04/who-profits-private-providers-health-services-nhs-70">motivated by profit</a> and the demands of their shareholders. It is not in their interest to invest in preventive strategies with long-term, non-<a href="https://www.investopedia.com/terms/c/commoditization.asp">commoditisable</a> outcomes. Equally, with people living longer and <a href="https://www.mentalhealth.org.uk/explore-mental-health/statistics/older-people-statistics#:%7E:text=Depression%20affects%20around%2022%25%20of,at%20all%20from%20the%20NHS.&text=It%20is%20estimated%20that%20the,predicted%20to%20double%20by%202030.">populations ageing rapidly</a>, the future cost of not investing in preventive mental healthcare that makes a difference across whole populations will only grow with every year that passes. The onus is on governments to act now.</p>
<h2>Three preventive strategies</h2>
<p>The annual <a href="https://www.lse.ac.uk/News/Latest-news-from-LSE/2022/c-Mar-22/Mental-health-problems-cost-UK-economy-at-least-118-billion-a-year-new-research">cost of mental illness</a> to the UK economy is estimated to be at least £117.9 billion, or 5% of the UK’s annual GDP. Almost three-quarters of this cost is <a href="https://www.mentalhealth.org.uk/sites/default/files/2022-06/MHF-Investing-in-Prevention-Full-Report.pdf">explained</a> by the lost productivity of people living with mental health conditions and the unpaid, informal carers who look after them.</p>
<p>A <a href="https://www.barnardos.org.uk/news/barnardos-calls-government-provide-missing-link-youth-mental-health-support">new report</a> by the children’s charity Barnardo’s has called for a national strategy for <a href="https://www.barnardos.org.uk/sites/default/files/2023-10/report-missing-link-social-prescribing-children-young-people.pdf">social prescribing</a>, suggesting that “every pound spent on helping young people access activities and support in the community could save nearly twice as much in dealing with longer-term mental health problems”.</p>
<p>There are many different potential strategies that could be introduced. Here are three of my favoured options – based not only on new research into the social determinants of health, but also on <a href="https://link.springer.com/book/10.1007/978-3-319-98699-9">historical approaches to preventive mental healthcare</a>.</p>
<p><strong>1. To address malnutrition, eradicate food inequality</strong></p>
<p>Today, we are returning to an idea that <a href="https://en.wikipedia.org/wiki/Food_and_diet_in_ancient_medicine">physicians of the past</a> would have taken for granted: that food is a major contributor to our <a href="https://www.mentalhealth.org.uk/explore-mental-health/a-z-topics/diet-and-mental-health">brain’s health</a>, as well as our body’s. New research on diet and mental health often centres on the “<a href="https://www.health.harvard.edu/diseases-and-conditions/the-gut-brain-connection">gut-brain axis</a>”: a varied diet consisting of whole grains, legumes, nuts, seeds, fruits and vegetables is thought to provide the type of bacteria needed to maintain good <a href="https://www.bbc.com/future/article/20190218-how-the-bacteria-inside-you-could-affect-your-mental-health">gut-brain health</a>.</p>
<p>But people in deprived communities often live in so-called “<a href="https://www.theguardian.com/society/2018/oct/12/more-than-a-million-uk-residents-live-in-food-deserts-says-study">food deserts</a>”, where most of the food available is <a href="https://www.bbc.co.uk/iplayer/episode/m001mp67/panorama-ultraprocessed-food-a-recipe-for-ill-health">highly processed</a>, <a href="https://www.rutgersuniversitypress.org/an-alternative-history-of-hyperactivity/9780813550169">laden with chemicals</a> and high in sugar, salt and fat. A bolder approach to food policy is needed that ensures everyone has access to healthy food – and the skills and means to prepare it.</p>
<p>During the first world war, <a href="https://drbryceevans.wordpress.com/2017/03/29/the-national-kitchens-of-ww1/">national kitchens</a> were established to provide people with inexpensive, healthy food in attractive communal settings. The <a href="https://www.hippocraticpost.com/poverty/bring-back-wartime-era-national-kitchens/">return of such facilities</a> would be welcome today amid the cost of living crisis – and they could also play a role in preventing mental illness.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/554942/original/file-20231020-17-a2se2z.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Women serving food to children around a long table" src="https://images.theconversation.com/files/554942/original/file-20231020-17-a2se2z.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554942/original/file-20231020-17-a2se2z.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=420&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554942/original/file-20231020-17-a2se2z.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=420&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554942/original/file-20231020-17-a2se2z.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=420&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554942/original/file-20231020-17-a2se2z.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=528&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554942/original/file-20231020-17-a2se2z.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=528&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554942/original/file-20231020-17-a2se2z.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=528&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A first world war ‘national kitchen’ serving children in Kent.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Ministry_of_Information_First_World_War_Official_Collection_Q30637.jpg">Imperial War Museums via wikimedia</a></span>
</figcaption>
</figure>
<p><strong>2. To address poverty, introduce universal basic income</strong></p>
<p>Interest in <a href="https://theippo.co.uk/basic-income-what-is-it-and-what-it-isnt/">universal basic income schemes</a> (UBI) – which provide everyone with a guaranteed income with no conditions attached – surged during the pandemic, when many countries introduced furlough or other income replacement schemes. Although UBI pilots have rarely studied mental health specifically, <a href="https://www.sciencedirect.com/science/article/pii/S0277953621007061">there is still evidence</a> that a secure and sufficient income improves the mental health of participants.</p>
<p>UBI could <a href="https://www.thersa.org/reports/universal-basic-income-anxiety-depression-mental-health-crisis-interim-report">prevent mental illness</a> in <a href="https://www.compassonline.org.uk/publications/treating-causes-not-symptoms-basic-income-as-a-public-health-measure/">numerous ways</a> – from alleviating the stress associated with financial insecurity and which can cause <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6491771/">inflammation</a> in the brain, to reducing so-called <a href="https://pubmed.ncbi.nlm.nih.gov/31172197/">diseases of despair</a> that are associated with rising inequality, including the damaging <a href="https://cpag.org.uk/sites/default/files/CPAG-Povertyarticle-stigma-0213.pdf">stigma</a> associated with welfare benefits (and the stress for people who work in the welfare system as <a href="https://onlinelibrary.wiley.com/doi/10.1111/spol.12527">gatekeepers</a>).</p>
<p>It would also show people currently working as <a href="https://www.mind.org.uk/information-support/helping-someone-else/carers-friends-family-coping-support/your-mental-health/">unpaid carers</a> that their labour is valued. Many people find that <a href="https://newsroom.clevelandclinic.org/2022/11/28/why-volunteering-can-benefit-your-mental-health/">volunteering</a> benefits their mental health, and the efforts of volunteers <a href="https://independentsector.org/resource/value-of-volunteer-time/">contribute significantly</a> to our communities. But it is often a privilege for those with time and money. A UBI would empower everyone to contribute to rebuilding their communities.</p>
<p><strong>3. To tackle depression and isolation, get in touch with nature</strong></p>
<p>During the COVID lockdowns, many people remarked how <a href="https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(22)00282-0/fulltext">spending time in nature</a> was their <a href="https://www.bbc.co.uk/sounds/brand/m001ng76">salvation</a>. This built on <a href="https://www.nationaltrust.org.uk/our-cause/nature-climate/nature-conservation/everyone-needs-nature">existing evidence</a> about the <a href="https://www.cambridge.org/core/journals/journal-of-the-marine-biological-association-of-the-united-kingdom/article/blue-gym-what-can-blue-space-do-for-you-and-what-can-you-do-for-blue-space/2409C4FCED48391786A65146D8A5C51D">positive impact</a> nature can have on our mental health.</p>
<p>However, much like access to healthy food, not everyone has <a href="https://ww3.rics.org/uk/en/journals/land-journal/why-access-to-nature-is-a-social-justice-issue-.html">access</a> to natural beauty. Governments could do a great deal to reduce this inequality – for example, by providing inexpensive or free public transportation to national parks and other places of natural beauty. A priority should be ensuring that <a href="https://www.theguardian.com/teacher-network/2018/mar/01/improving-childrens-access-nature-addressing-inequality-bame-low-income-backgrounds">children from deprived urban backgrounds</a> have regular access to nature.</p>
<p>In addition, more can be done to create new areas of natural beauty while protecting existing areas. Schemes that tackle biodiversity loss and climate change would reduce the <a href="https://wellcome.org/news/explained-how-climate-change-affects-mental-health">clear impact</a> these issues have on some people’s mental health – in part because worries about the climate are also known to trigger <a href="https://www.imperial.ac.uk/news/240094/what-impact-climate-crisis-having-mental/">anxiety and depression</a>.</p>
<h2>Governments have a critical role to play</h2>
<p>Responsibility for mental health should not lie solely with the individual. Sure, most of us can do something to improve our own mental wellbeing. But our lifetime mental health course is largely determined by socioeconomic, genetic and other factors, such as exposure to traumatic events, that may be mostly out of our control.</p>
<p>As centuries of evidence have shown us, governments play a <a href="https://www.gov.wales/review-evidence-socio-economic-disadvantage-and-inequalities-outcome-summary-html">critical role</a> in creating the socioeconomic conditions that <a href="https://www.theguardian.com/society/2023/sep/27/policy-must-tackle-root-causes-of-englands-record-mental-ill-health-says-report">determine the mental health of their citizens</a>. Yet, relatively speaking, many are doing less to address this today than they were decades ago. Until and unless this changes, state health providers such as the NHS will never be able to cope with the resulting demand for individual treatments. Those fortunate enough to do so will turn to the private sector. But what about everyone else?</p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=140&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
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</figure>
<p><em>For you: more from our <a href="https://theconversation.com/uk/topics/insights-series-71218?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Insights series</a>:</em></p>
<ul>
<li><p><em><a href="https://theconversation.com/unlocking-new-clues-to-how-dementia-and-alzheimers-work-in-the-brain-uncharted-brain-podcast-series-194773?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Unlocking new clues to how dementia and Alzheimer’s work in the brain – Uncharted Brain podcast series
</a></em></p></li>
<li><p><em><a href="https://theconversation.com/existential-crisis-how-long-covid-patients-helped-us-understand-what-its-like-to-lose-your-sense-of-identity-and-purpose-in-life-211223?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Existential crisis: how long COVID patients helped us understand what it’s like to lose your sense of identity and purpose in life
</a></em></p></li>
<li><p><em><a href="https://theconversation.com/gp-crisis-how-did-things-go-so-wrong-and-what-needs-to-change-208197?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">GP crisis: how did things go so wrong, and what needs to change?
</a></em></p></li>
<li><p><em><a href="https://theconversation.com/its-like-being-in-a-warzone-aande-nurses-open-up-about-the-emotional-cost-of-working-on-the-nhs-frontline-194197?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">‘It’s like being in a warzone’ – A&E nurses open up about the emotional cost of working on the NHS frontline</a></em></p></li>
<li><p><em><a href="https://theconversation.com/loneliness-loss-and-regret-what-getting-old-really-feels-like-new-study-157731?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Loneliness, loss and regret: what getting old really feels like – new study
</a></em></p></li>
</ul>
<p><em>To hear about new Insights articles, join the hundreds of thousands of people who value The Conversation’s evidence-based news. <a href="https://theconversation.com/uk/newsletters/the-daily-newsletter-2?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK"><strong>Subscribe to our newsletter</strong></a>.</em></p><img src="https://counter.theconversation.com/content/214776/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Matthew Smith receives funding from the Royal Society of Edinburgh, the AHRC and the Wellcome Trust. He is affiliated with the Scottish Green Party. </span></em></p>Investing in people’s future mental health, based on the key socioeconomic factors underlying it, is the only way to address this rising problem.Matthew Smith, Professor in Health History, University of Strathclyde Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2121062023-10-19T19:03:26Z2023-10-19T19:03:26ZInsomnia and mental disorders are linked. But exactly how is still a mystery<figure><img src="https://images.theconversation.com/files/546862/original/file-20230907-15-5fhfee.jpg?ixlib=rb-1.1.0&rect=7%2C14%2C4985%2C2979&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/psychologist-consulting-mental-problem-solving-brainstorm-2087426509">Shutterstock</a></span></figcaption></figure><p><em>This article is the next in The Conversation’s six-part series on insomnia, which charts the rise of insomnia during industrialisation to sleep apps today. Read other articles in the series <a href="https://theconversation.com/au/topics/insomnia-series-144018">here</a>.</em></p>
<hr>
<p>The 2004 movie <a href="https://www.imdb.com/title/tt0361862/">The Machinist</a> gives us a striking depiction, albeit a fictional one, of the psychological effects of chronic insomnia.</p>
<p>When people don’t have enough sleep, <a href="https://doi.org/10.1007/s11910-017-0799-x">their</a> memory and concentration are impaired in the short term. They are also less able to regulate their emotions.</p>
<p>If sleeping difficulties continue, longer-term psychological effects <a href="https://doi.org/10.1111/jsr.13930">can include</a> anxiety, depression, mania and psychosis. Indeed, Christian Bale’s character in The Machinist has increasingly vivid visual hallucinations and paranoid delusions as his insomnia deepens.</p>
<p>The relationship between insomnia and mental disorders is complex. It’s not just a case of “which comes first, the insomnia or the mental disorder?” Insomnia and mental disorders are interrelated in ways we don’t yet fully understand.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-short-history-of-insomnia-and-how-we-became-obsessed-with-sleep-211729">A short history of insomnia and how we became obsessed with sleep</a>
</strong>
</em>
</p>
<hr>
<h2>What is insomnia? Is it a mental disorder?</h2>
<p>Insomnia is, by far, the most common disorder of sleep. <a href="https://www.sleephealthfoundation.org.au/special-sleep-reports/chronic-insomnia-disorder-in-australia">An estimated 12-15%</a> of Australian adults at any one time meet criteria for insomnia.</p>
<p>People with insomnia have frequent and ongoing difficulties in falling and staying asleep, and/or going back to sleep after early waking. Insomnia not only affects people’s quality of sleep, but how they function the next day.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1678293771539161089"}"></div></p>
<p>Many of the factors that trigger insomnia and help maintain its negative long-term effects are psychological or behavioural. These include:</p>
<ul>
<li><p>psychosocial stressors (such as money, work or family problems)</p></li>
<li><p>attentional bias and worry about sleep (the more we think and worry about sleep, the worse it gets)</p></li>
<li><p>poor sleep habits (such as irregular sleep and wake times).</p></li>
</ul>
<p>Insomnia is not a mental disorder in the same way that, say, depression and anxiety are mental disorders. Insomnia is a recognised <a href="https://aasm.org/clinical-resources/international-classification-sleep-disorders/">sleep disorder</a> that nonetheless has close links to a wide variety of mental disorders.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/whats-insomnia-like-for-most-people-who-cant-sleep-youd-never-know-from-the-movies-211823">What's insomnia like for most people who can't sleep? You'd never know from the movies</a>
</strong>
</em>
</p>
<hr>
<h2>Many people have both insomnia and a mental disorder</h2>
<p><a href="https://doi.org/10.1016/S0022-3956(02)00052-3">Around half</a> of all people diagnosed with insomnia also have an associated mental disorder. The most common ones associated with insomnia are depression, anxiety, bipolar disorder, post-traumatic stress disorder, and substance-related disorders.</p>
<p>We don’t (yet) know why we see such high levels of mental disorders in people with insomnia. But there are several leading theories, including:</p>
<ul>
<li><p>a <a href="https://doi.org/10.1038/s41588-018-0333-3">shared genetic risk</a> for insomnia and a mental disorder. In other words, some people’s genes may predispose them to both conditions</p></li>
<li><p>a <a href="https://doi.org/10.1038/nrn.2017.55">shared neurobiological</a> response. How the brain responds to sleep loss may be connected to how systems in the brain control cognition, emotion and reward. Disturbances of these brain functions are implicated in a range of mental disorders</p></li>
<li><p><a href="https://doi.org/10.3389/fpsyt.2020.00071">inflammation</a> and/or dysfunction of the immune system may underlie both insomnia and mental disorders.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-dangerous-is-insomnia-how-fear-of-what-its-doing-to-your-body-can-wreck-your-sleep-212248">How dangerous is insomnia? How fear of what it's doing to your body can wreck your sleep</a>
</strong>
</em>
</p>
<hr>
<h2>Which comes first?</h2>
<p>Further complicating the picture <a href="https://doi.org/10.1016/S2215-0366(20)30136-X">is evidence</a> showing insomnia can occur <em>before</em> someone develops a mental disorder, or <em>afterwards</em>. Researchers call this a “bidirectional” relationship.</p>
<p>We can’t say one causes the other. We can only say there is a clear link between them.</p>
<p>This link means diagnosis and treatment of one <a href="https://doi.org/10.1016/j.smrv.2021.101556">can have implications</a> for diagnosis and treatment of the other. For instance, if you don’t adequately treat insomnia, this can worsen symptoms of someone’s mental disorder, <a href="https://doi.org/10.31887/DCNS.2008.10.4/plfranzen">increasing</a> both the severity and risk of relapse.</p>
<p>A type of talking therapy known as cognitive behavioural therapy for insomnia (<a href="https://doi.org/10.1016/j.sleep.2017.03.017">CBTi</a>) aims to change the unhelpful thoughts, feelings, emotions and behaviours that contribute to insomnia. And, in many cases, successful treatment of insomnia with CBTi <a href="https://doi.org/10.1016/j.smrv.2022.101597">can also treat</a> someone’s mental disorder (and vice versa).</p>
<p>CBTi is particularly <a href="https://doi.org/10.1016/j.smrv.2022.101597">effective</a> at treating insomnia plus depression, substance use or post-traumatic stress disorder. But it is less effective at treating insomnia plus psychosis or bipolar disorder.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/546880/original/file-20230907-25-hikaoh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Man having counselling or therapy, with therapist filling in questionnaire on clipboard" src="https://images.theconversation.com/files/546880/original/file-20230907-25-hikaoh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/546880/original/file-20230907-25-hikaoh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/546880/original/file-20230907-25-hikaoh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/546880/original/file-20230907-25-hikaoh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/546880/original/file-20230907-25-hikaoh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/546880/original/file-20230907-25-hikaoh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/546880/original/file-20230907-25-hikaoh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Fixing the sleep problem can often resolve the mental disorder (and vice versa).</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/male-patient-having-consultation-doctor-psychiatrist-731147215">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Filling the gaps</h2>
<p>There’s much we don’t know about the link between insomnia and mental disorders. Last year an international panel of experts <a href="https://wellcome.org/reports/sleep-circadian-rhythms-and-mental-health-advances-gaps-challenges-and-opportunities">outlined</a> the research needed to plug the knowledge gaps. Recommendations included:</p>
<ul>
<li><p>longer-term studies starting in childhood and adolescence that collect data on sleep and mental health using wearable or smartphone technologies. The aim is to provide more objective measurement of insomnia and mental health in these younger age groups, and to intervene early if needed</p></li>
<li><p>more studies involving people from <a href="https://doi.org/10.1038/466029a">diverse</a> social and cultural backgrounds. Sleep practices are often <a href="https://doi.org/10.3390/ijerph18042005">culturally-determined</a>. So researching diverse populations would provide a more comprehensive picture of insomnia and mental disorders</p></li>
<li><p>a greater recognition of people’s daytime behaviours and environmental exposures, and their contribution to insomnia and poorer mental health. This <a href="https://doi.org/10.3390/ijerph18126626">includes</a>, eating fast food, having disrupted sleep routines (for example, shift work) and using technology excessively.</p></li>
</ul>
<p>Results of this research will have profound implications for accurate diagnosis of both insomnia and mental disorders, and their treatment. The aim is to reduce <a href="https://www.sleephealthfoundation.org.au/special-sleep-reports/rise-and-try-to-shine-the-social-and-economic-costs-of-sleep-disorders">the burden</a> when these conditions occur together, both for <a href="https://www.health.gov.au/resources/publications/national-preventive-health-strategy-2021-2030">individuals and society</a> more broadly.</p>
<hr>
<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14. <a href="https://www.sleephealthfoundation.org.au/sleep-categories/mental-health-sleep">Free information</a> about insomnia and mental health is available from the Sleep Health Foundation.</em></p><img src="https://counter.theconversation.com/content/212106/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ben Bullock receives funding from Australian Rotary Health and the Barbara Dicker Brain Sciences Foundation. He is a member of the Sleep Health Foundation.</span></em></p>Insomnia and mental disorders are inter-related in a way we’ve yet to fully understand. But treating one can often help the other.Ben Bullock, Senior Lecturer, Psychology, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2135192023-09-25T21:37:11Z2023-09-25T21:37:11ZEntrepreneurs are facing a mental health crisis — here’s how to help them<figure><img src="https://images.theconversation.com/files/549670/original/file-20230921-22-bt79xv.jpg?ixlib=rb-1.1.0&rect=44%2C26%2C5935%2C3953&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Almost half of Canadian entrepreneurs are experiencing mental health challenges related to stress and finances.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/entrepreneurs-are-facing-a-mental-health-crisis-heres-how-to-help-them" width="100%" height="400"></iframe>
<p>Mental health is a pressing concern in the startup community. Entrepreneurs face a number of unique challenges, including securing funding and meeting gruelling performance targets — all while trying to achieve a work-life balance. These demands can take a significant toll on someone’s mental health.</p>
<p>According to a <a href="https://www.bdc.ca/en/about/mediaroom/news-releases/entrepreneurs-mental-health-has-decreased-significantly-compared-to-last-year-warns-new-survey-results-from-bdc">report from the Business Development Bank of Canada</a>, almost half of Canadian entrepreneurs are experiencing mental health challenges, mostly related to stress and finances.</p>
<p><a href="https://doi.org/10.1007/s11187-018-0059-8">Entrepreneurs are</a> twice as likely to report a lifetime history of depression, three times more likely to have bipolar disorder and three times more likely to experience substance abuse and addiction. They are also twice as likely to attempt suicide or be hospitalized in a psychiatric institution. </p>
<p>Despite this, many entrepreneurs have difficulty accessing mental health support. Cost is the biggest barrier, but the risk of being seen as too vulnerable is also an issue. Many entrepreneurs fear that being seen as too weak or timid could <a href="https://pitchbook.com/news/articles/vcs-founders-mental-health">jeopardize their chances of securing funding</a>. </p>
<p>Since <a href="https://www.oecd.org/cfe/leed/entrepreneurship.htm">entrepreneurship is the backbone of economic growth</a>, the importance of mental health support for entrepreneurs cannot be overstated. Recognizing and addressing mental health is not just a matter of compassion, but also an essential investment in society at large.</p>
<h2>The ‘founder’s dilemma’</h2>
<p>Steve Jobs, the founder of Apple, once likened starting a venture to <a href="https://www.businessinsider.com/steve-jobs-famous-quote-misunderstood-laurene-powell-2020-2">putting a dent in the universe</a>. In other words, it’s extremely difficult. Many are drawn to entrepreneurship, but <a href="https://www.investopedia.com/articles/personal-finance/040915/how-many-startups-fail-and-why.asp">few manage to thrive commercially</a>. And many quit for reasons they shouldn’t.</p>
<figure class="align-center ">
<img alt="A man sitting at a table in a dimly lit room rests his head against his hand" src="https://images.theconversation.com/files/549669/original/file-20230921-29-bvlp96.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/549669/original/file-20230921-29-bvlp96.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549669/original/file-20230921-29-bvlp96.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549669/original/file-20230921-29-bvlp96.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549669/original/file-20230921-29-bvlp96.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549669/original/file-20230921-29-bvlp96.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549669/original/file-20230921-29-bvlp96.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Entrepreneurs often struggle to maintain a healthy work-life balance.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Noam Wasserman, dean of Yeshiva University’s business school, <a href="https://hbr.org/2008/02/the-founders-dilemma">wrote about the “founder’s dilemma” in 2008</a>. According to him, this dilemma revolves around the tension between accepting money from outside investors and resisting losing control over one’s company and, sometimes, being ousted altogether. </p>
<p>Fast forward 15 years, and things have changed in the startup space. Early investors are now able to secure generous stock option grants or loans from founders. Being in onerous debt amid financial uncertainty <a href="https://insight.kellogg.northwestern.edu/article/debt-crises-innovation">puts a firm’s flexibility and capacity for innovation at risk</a>. </p>
<p>Out of financial self-preservation, some founders fall into a cycle of constant fundraising to get them out of debt. The quixotic drive to balance short-term financing with long-term operational excellence can drive any entrepreneur into distress.</p>
<h2>Mounting pressure</h2>
<p>The pressure that startup founders face today is more intense than it has been for two decades. Entrepreneurs are now grappling with whether the hustle is still worth it.</p>
<p>First, their cash runway is a cliff face. <a href="https://pitchbook.com/news/reports/q2-2023-pitchbook-venture-first-look">During the first half of 2023</a>, global venture capital funding slid by 48 per cent compared to last year. In North America, second-quarter venture spending was the lowest in over three years.</p>
<p>Second, <a href="https://startupsmagazine.co.uk/article-uk-recruiters-struggle-access-talent-2023-skills-gap-widens">talent is scarce and expensive</a>. Third, exit opportunities for later-stage founders — through an initial public offering or a sale to a bigger firm — are vanishing. This leads to <a href="https://techcrunch.com/2023/09/19/tech-industry-layoffs-2023/">layoffs amid intensifying pressures to find a “path to profitability”</a> while <a href="https://techcrunch.com/2023/06/20/tiger-global-liquidity-latestage/">early financial backers seek to liquidate their investments</a>.</p>
<p><a href="https://news.crunchbase.com/ma/us-startup-acquisitions-lag-databricks/">According to <em>Crunchbase News</em></a>, mergers and acquisitions for venture capital-backed companies based in the United States this year are on course to be the slowest since 2013. Investments in what were only last year considered booming sectors, such as health technology, have shrunk dramatically.</p>
<p>In this high-interest rate, scarce money, no-exit environment, startup founders are facing a financial and mental health crisis.</p>
<h2>Addressing mental health challenges</h2>
<p><a href="https://cmha.ca/news/entrepreneurs-and-mental-health-study/">Past research on business and entrepreneurial mental health</a> can guide us toward promising new solutions. There are many potential low-cost or no-cost solutions to founders’ mental health troubles in this current investment climate.</p>
<p>First, outside investors in private ventures need to be qualified not only in terms of net income or net worth, but also on the basis of their commitment to population health in general, and mental health in particular. </p>
<p>This builds on the wisdom and research behind the <a href="https://www.founderpledge.com/">Founder Mental Health Pledge</a> pioneered by serial entrepreneurs Naveed Lalani and Brad Baum and supported by founders globally. The pledge aims to de-stigmatize mental health and treat it as a business expense, including therapy, coaching and group support.</p>
<figure class="align-center ">
<img alt="A group of people having a conversation around a conference table" src="https://images.theconversation.com/files/549671/original/file-20230921-15-nud0c8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/549671/original/file-20230921-15-nud0c8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549671/original/file-20230921-15-nud0c8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549671/original/file-20230921-15-nud0c8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549671/original/file-20230921-15-nud0c8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549671/original/file-20230921-15-nud0c8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549671/original/file-20230921-15-nud0c8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There are many potential low-cost or no-cost solutions to founders’ mental health troubles in the current investment climate.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Investors should acknowledge the importance of protecting a founder’s mental health by including the potential harms that may befall a startup on the term sheets. Practically, this could mean paying for more mental health benefits and memberships in peer support networks for founders. This strategy can build investor awareness and reduce the stigma surrounding mental health challenges.</p>
<p>Second, firms should establish expert advisory committees dedicated to protecting founders’ mental health. This would encourage founders to speak openly to the committee about hardships they encounter. This would be another important step in the uphill battle to de-stigmatize mental illness and steer founders toward mental health supports.</p>
<p>Perhaps the most important way we can help entrepreneurs is to send honest messages about both entrepreneurial hardship <em>and</em> hope. Nurturing a venture from birth to commercial maturity can be emotionally exhausting. And yet, with the right psychological supports, entrepreneurship can ignite passion, purpose and result in prosperity.</p><img src="https://counter.theconversation.com/content/213519/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Neil Seeman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Recognizing and addressing the mental health struggles of entrepreneurs is not just a matter of compassion, but is also an essential investment in society at large.Neil Seeman, Senior Fellow, Institute of Health Policy, Management and Evaluation, University of Toronto, and Adjunct Professor, Dalla Lana School of Public Health, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2074282023-09-21T20:06:51Z2023-09-21T20:06:51ZFriday essay: my father was always told his mother was dead, but a birthday card revealed she was living in a mental institution<figure><img src="https://images.theconversation.com/files/548947/original/file-20230919-15-7z704n.png?ixlib=rb-1.1.0&rect=17%2C5%2C3976%2C1988&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ada, the author's grandmother, is pictured at right.</span> </figcaption></figure><p>As a child, I found a small, brown suitcase in my wardrobe. It had two silver latches and a squeaky wooden handle. I didn’t recognise the name inscribed on the bottom in pencil: <em>Ada</em>. </p>
<p>I asked my mother, “Whose suitcase is this?” Mum replied, “Your grandmother’s.” </p>
<p>I was confused about who my grandmother was. Born in the early sixties, I grew up with my parents and two older brothers in Melbourne’s eastern suburbs. Dad had grown up without his mother and was cared for by his paternal grandmother. </p>
<p>It was around the time of my birth when Dad accidentally discovered the secret of his mother’s whereabouts. Ada was living in a mental institution. </p>
<p>As a young child, I remember waiting with my family for Ada in the foyer of a boarding house in Melbourne. This memory is like a single snapshot of a dimly lit, wood-panelled foyer, marked by the tension of my two brothers being scolded for their noisy behaviour as we waited for Ada to join us for a family outing. </p>
<p>Another time, I recall Ada sitting in the lounge room of our family home, smoking cigarettes. I tried to engage her, but she would not smile, and her face and eyes lacked expression. I knew there had been something wrong with Ada. I am uncertain when I learned she had been removed from her children and locked away. </p>
<p>As my father grew to know her more, stories of her absence from his childhood emerged. It was impossible for me as a child to understand Dad was getting to know his mother for the first time as an adult: a parent with his own children. </p>
<p>For a long time, I had the sense Ada had problems related to her menstrual cycle and that once a month, her periods threw her off balance, and she was placed in the sick ward of the mental hospital for one week out of every month.</p>
<p>The notion that being female caused her sickness gave me some foreboding as a young girl. But of course, that wasn’t true: it was just one example of the lies we were told about what had happened to her.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/548952/original/file-20230919-19-z1l47p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/548952/original/file-20230919-19-z1l47p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/548952/original/file-20230919-19-z1l47p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=420&fit=crop&dpr=1 600w, https://images.theconversation.com/files/548952/original/file-20230919-19-z1l47p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=420&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/548952/original/file-20230919-19-z1l47p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=420&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/548952/original/file-20230919-19-z1l47p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=528&fit=crop&dpr=1 754w, https://images.theconversation.com/files/548952/original/file-20230919-19-z1l47p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=528&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/548952/original/file-20230919-19-z1l47p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=528&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ada (far right) with her daughter-in-law and two grandsons, after being reconnected with family.</span>
</figcaption>
</figure>
<h2>A hidden mother, revealed</h2>
<p>Dad had been raised from a baby by his paternal grandmother (a widow), who he knew as Gran. His older sister, Hannah, was placed, aged four, into a Melbourne boarding school for girls, Lowther Hall in Essendon. Dad’s father, who lived elsewhere in the same town, visited the children on Sundays at Gran’s.</p>
<p>The children were reunited when Hannah returned to Gran’s care, aged eight, when Lowther Hall was requisitioned for American military requirements in 1942. Dad grew up assuming his mother was no longer alive.</p>
<p>Dad married my mother in his early twenties. Together, they lived with Dad’s father, who I called Pop. Soon after, Dad and Mum built a new home in the outer suburbs of Melbourne and notified the local post office about their change of address. Dad received a birthday card redirected from his former address. It was signed <em>Mother</em>. </p>
<p>He thought it must have been a mistake. Dad drove to his father’s house, determined to get to the bottom of the situation. He waited a few hours, his mind swirling, before Pop returned home. Finally, he questioned Pop about the card. </p>
<p>Pop admitted it was a genuine birthday card from Dad’s mother: Ada had been living in a mental institution all this time. Pop then produced a bundle of letters and cards Ada had written to her children over more than 20 years. Pop was instrumental in keeping Ada a secret from her children. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/548967/original/file-20230919-23-ikags5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/548967/original/file-20230919-23-ikags5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/548967/original/file-20230919-23-ikags5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/548967/original/file-20230919-23-ikags5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/548967/original/file-20230919-23-ikags5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/548967/original/file-20230919-23-ikags5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/548967/original/file-20230919-23-ikags5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/548967/original/file-20230919-23-ikags5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ada had written to her children for over 20 years, with her letters kept a secret from them.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/pile-of-letters-in-envelopes-1768060/">Suzy Hazelwood/Pexels</a></span>
</figcaption>
</figure>
<p>Now, the secret was out: Ada was alive and living in a Melbourne mental hospital. It is difficult to understand why Pop had kept Ada’s letters all this time without saying anything. One can only guess he had intercepted and confiscated Ada’s letters to her children to protect them from the shame and stigma of mental illness. </p>
<p>It seems likely Pop intended to continue Ada’s long estrangement, had that birthday card not slipped into Dad’s hands that day. </p>
<p>Over 20 years of letters and cards, and not one reply. Ada never forgot her children. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/friday-essay-a-lament-for-the-lost-art-of-letter-writing-a-radical-art-form-reflecting-the-full-catastrophe-of-life-197420">Friday essay: a lament for the lost art of letter-writing – a radical art form reflecting 'the full catastrophe of life'</a>
</strong>
</em>
</p>
<hr>
<h2>The first of many visits</h2>
<p>Soon after finding that fateful card, Dad contacted the mental hospital – and met his mother for the first time he could remember. He recalled his first meeting with Ada in the early 1960s at <a href="https://www.findingrecords.dhhs.vic.gov.au/CollectionResultsPage/Mont-Park-Hospital-Macleod">Mont Park mental hospital</a> in Bundoora, Melbourne. He waited to meet Ada in a small walled garden and was told she would not be much longer. </p>
<blockquote>
<p>I was nervous and unsure of what she would look like and what to say to her. I waited for 20 long minutes, and my anxiety increased. When she opened the door, there she was. But six people followed her to take a look at her son. I didn’t know whether to give her a kiss or give her a hug. The first thing she said to me was: “You look just like your father.” They were the last words I wanted to hear at that moment.</p>
</blockquote>
<p>As Pop had hidden his mother from him, Ada’s comment had a painful sting. This was the first of many visits together. Dad recalled taking us to collect Ada from Carmel House, where I remembered waiting in the foyer for her. We took her on outings and occasional weekends to our family home. He recalled:</p>
<blockquote>
<p>When we went to pick her up from Carmel House, she was always late and I remember waiting in that timber-panelled foyer, looking searchingly at the stairs, until she made her entrance. When I was working in the city, Mum used to go and get her hair done on her days off, and we would meet afterwards at the Town Hall corner, and go off to Coles Cafeteria, her favourite eating place. But then she would go into the toilets and wash her hair out, so sometimes when I met her, she looked a bit wild and woolly, like she had been diving in the Yarra River. She certainly had her eccentricities.</p>
</blockquote>
<p>As Dad and Ada got to know each other and tentatively forged their new relationship, it was still unclear why Ada was committed to a mental institution in the first place. </p>
<p>Dad and his older sister Hannah had little contact or knowledge of Ada’s family of origin. They were surrounded by the silence of his mother’s whereabouts throughout their upbringing, until Ada’s card arrived for him in his twenties. </p>
<h2>‘I felt closer to Ada’</h2>
<p>Dad and I wanted to understand the events that precipitated her committal. We found we could access Ada’s mental-patient files by applying for a Freedom of Information request. We discussed it together, and Dad agreed as Ada’s next-of-kin. I purchased Ada’s birth and wedding certificates, to make sure I requested the correct person’s files. </p>
<p>I found out Ada was the younger sister of five brothers. She married in 1934 at 21 years old, and her occupation was stated on her marriage certificate as a “comptometer operator”. A <a href="https://www.pcmag.com/encyclopedia/term/comptometer">comptometer</a> is a key-driven mechanical calculator, which was operated predominantly by women, and her occupation suggests Ada had completed a specialised business course. Advances in office technology in the early 1930s gave many young and unmarried women like Ada new opportunities for employment in clerical positions. </p>
<p>However, most industries excluded married women, and it’s likely Ada left her job when she married my grandfather in 1934, and moved to the country.</p>
<p>Three months after making the request, we received Ada’s mental-patient files, which ranged from her original committal in 1936 to her death in 1972. Ada’s records include the committal certificates, diagnoses, notes on trial leave, experimental treatments, and her final years as an outpatient at Carmel House. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/548954/original/file-20230919-27-ww4vm9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/548954/original/file-20230919-27-ww4vm9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/548954/original/file-20230919-27-ww4vm9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=684&fit=crop&dpr=1 600w, https://images.theconversation.com/files/548954/original/file-20230919-27-ww4vm9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=684&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/548954/original/file-20230919-27-ww4vm9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=684&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/548954/original/file-20230919-27-ww4vm9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=860&fit=crop&dpr=1 754w, https://images.theconversation.com/files/548954/original/file-20230919-27-ww4vm9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=860&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/548954/original/file-20230919-27-ww4vm9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=860&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ada’s photo from her medical files.</span>
</figcaption>
</figure>
<p>As I opened the files for the first time, Ada’s headshot appeared on the first page of her first admission certificate in 1936. Her shoulders are angled and her gaze is focused to the right of the camera’s lens.</p>
<p>At age 24, Ada is youthful and smiling. She wears a dress with a large, white collar, possibly the same clothes she wore when she left home. I was shocked to see our similar physical appearance. I could see my face in hers: the same high forehead, small eyes, fair skin and wavy hair. I felt closer to Ada. </p>
<p>Ada’s patient files show her mental health began to deteriorate following the birth of her second child. She experienced auditory hallucinations when committed to the Royal Park Receiving House in Melbourne in 1936, two weeks after giving birth. The doctor described her as lucid, with “nervous symptoms that alternate between depression and exaltation along with auditory hallucinations”. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/girl-interrupted-interrogates-how-women-are-mad-when-they-refuse-to-conform-30-years-on-this-memoir-is-still-important-199211">Girl, Interrupted interrogates how women are 'mad' when they refuse to conform – 30 years on, this memoir is still important</a>
</strong>
</em>
</p>
<hr>
<h2>‘Puerperal insanity’ – associated with giving birth</h2>
<p>The cause of her attack is noted as “<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8953002/pdf/atlantajrecmed141958-0005.pdf">puerperal insanity</a>”, which psychiatrists associated with Ada giving birth two weeks before. </p>
<p>Hilary Marland, in her book <a href="https://link.springer.com/book/10.1057/9780230511866">Dangerous Motherhood</a>, argues puerperal insanity is a 19th-century diagnosis that links insanity to recent childbirth – and links lactation, pregnancy and miscarriage to mental illness. Marland found that in the 19th century, puerperal insanity accounted for approximately 10% of admissions in English asylums. </p>
<p>I found a similar rate of birth-related committals had occurred in Victoria in the early 20th century, in my PhD thesis <a href="https://researchportal.scu.edu.au/esploro/outputs/doctoral/Maternal-insanity-in-Victoria-Australia/991012821132602368">Maternal Insanity in Victoria, Australia 1920-1973</a>. </p>
<p>Alexander Wallis’ article <a href="https://press-files.anu.edu.au/downloads/press/n7444/pdf/08_wallis.pdf">Unnatural Womanhood</a> suggests puerperal insanity, in today’s terms, is understood as <a href="https://www.betterhealth.vic.gov.au/health/healthyliving/postnatal-depression-pnd">postnatal depression</a>.</p>
<p>Four days following Ada’s first admission, her doctor recorded his observations:</p>
<blockquote>
<p>The patient is cheerful and talkative. She says that lately, she has had numerous auditory and visual hallucinations. She is quite disorientated as regards time and place. Her answers to questions are quite irrelevant and she smiles and talks cheerfully most of the time.</p>
</blockquote>
<p>I researched the history of “puerperal insanity” and its association with dangerous mothers and infanticide. A dark and taboo subject, it conjures the “madwoman” trope in our cultural imagination and is rooted in popular discourses of the murderous mother, the crazy wife in the attic, or the suicidal mother. </p>
<p>The horror of maternal insanity plays on our worst fears: as vulnerable young babies, we depend on our mothers to care for us.</p>
<p>It’s upsetting that an outdated 19th-century diagnosis was still being used to commit mothers like Ada in 1936. In the 100 years that had passed since “puerperal insanity” was coined, psychiatry had still not developed a better understanding of motherhood, or mental illness.</p>
<p>Within the first two months of her committal, the doctor described Ada as “restless, apathetic, and erratic in behaviour”. The timing of giving birth and the changes in Ada’s behaviour led to the diagnosis of “puerperal insanity” and her committal in 1936.</p>
<p>Yet her files lack information on the length of her labour, delivery method and the health of the mother or the newborn child. Unfortunately, Ada had given birth at a time in Victoria when mothers faced severe health risks during childbirth, due to <a href="https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/ajo.13317">poor standards in obstetrics</a>.</p>
<p>A difficult or protracted delivery may have contributed to Ada’s deteriorating mental health, but the details of birth events are rarely included in a mother’s mental files. Despite the lack of information on Ada’s birth experience, her psychiatrists continued to tie childbirth with maternal insanity, as they had in the past.</p>
<p>Nine months after her original committal, Ada went home on trial leave. By March 1938, she was fully discharged as recovered. Ada spent the next two years at home with her family. Then, she became pregnant with her third child. </p>
<p>Unfortunately, Ada’s behaviour became erratic during pregnancy. With consent from her husband, she underwent a “therapeutic abortion” and sterilisation. </p>
<p>I found these procedures a disturbing part of Ada’s files. Her history of puerperal insanity likely provided the psychiatric grounds to proceed, but it did not bring her peace of mind. </p>
<p>In May 1940, soon after the therapeutic abortion and sterilisation, Ada was re-committed back into a mental institution, this time to Mont Park Hospital for the Insane in Melbourne – where she was when Dad found her in the early 1960s.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/548956/original/file-20230919-21-v4agzu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/548956/original/file-20230919-21-v4agzu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/548956/original/file-20230919-21-v4agzu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=455&fit=crop&dpr=1 600w, https://images.theconversation.com/files/548956/original/file-20230919-21-v4agzu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=455&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/548956/original/file-20230919-21-v4agzu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=455&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/548956/original/file-20230919-21-v4agzu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=572&fit=crop&dpr=1 754w, https://images.theconversation.com/files/548956/original/file-20230919-21-v4agzu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=572&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/548956/original/file-20230919-21-v4agzu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=572&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Mont Park Hospital (circa 1920), where Ada was when her son found her in the early 1960s.</span>
<span class="attribution"><span class="source">State Library Victoria</span></span>
</figcaption>
</figure>
<h2>‘A world divorced from reality’</h2>
<p>Ada underwent a series of <a href="https://www.britannica.com/science/insulin-shock-therapy">insulin-coma treatments</a> (ICT) for the next three months. ICT involves giving patients daily injections of insulin to induce hypoglycemia and coma. <a href="https://www.britannica.com/biography/Manfred-J-Sakel">Manfred Sakel</a> developed ICT in Europe and at Mont Park the therapy was implemented by Dr Farran-Ridge and Dr Reynolds. </p>
<p>Under the supervision of Dr Reynolds, Ada showed “marked improvement” following ICT every morning for three months:</p>
<blockquote>
<p>Mentally much improved – states she is no longer hallucinatory although remembers that she was so and seemed to have gained full insight into her condition. A satisfactory remission.</p>
</blockquote>
<p>ICT appeared to aid Ada’s recovery by ending her auditory hallucinations for the first time, but these effects did not last. It proved a dangerous and experimental treatment when <a href="https://www.webmd.com/schizophrenia/features/insulin-coma-therapy">some patients died</a> due to complications. Ada experienced a short-lived remission and again returned home for six months of trial leave. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/548959/original/file-20230919-17-13lt4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/548959/original/file-20230919-17-13lt4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/548959/original/file-20230919-17-13lt4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=419&fit=crop&dpr=1 600w, https://images.theconversation.com/files/548959/original/file-20230919-17-13lt4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=419&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/548959/original/file-20230919-17-13lt4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=419&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/548959/original/file-20230919-17-13lt4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=527&fit=crop&dpr=1 754w, https://images.theconversation.com/files/548959/original/file-20230919-17-13lt4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=527&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/548959/original/file-20230919-17-13lt4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=527&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ada was treated with insulin coma therapy. ICT treatments are pictured being performed in Stockholm in the 1930s.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/Insulin_shock_therapy">Wikipedia</a></span>
</figcaption>
</figure>
<p>Upon her return to the institution, Ada suffered grandiose delusions. It is hard not to believe going home on trial leave, considered helpful in some instances, contributed to Ada’s worsening mental health. Her doctor described her delusions of grandeur in January 1942:</p>
<blockquote>
<p>She claims she arranged the introductions between Duke & Duchess of Kent. She is willing to oblige for a fee of 1000 pounds to do same for the royal personages. She stated this country is now known as L’Aurolia Republic – it was Australia prior to the revolution in 1900. She says she is a member of Russian Royal family and her real name is Lily Vertel Rose Alvaradora Icebel and says herself “Alvara Russia”.<br></p>
<p>She has numerous other fantastic and bizarre delusions. Naturally she is somewhat exalted. She admits hearing voices talking about British Secret Service work so cannot divulge subjects discussed. She is cheerful and cooperative, her mood is cheerful, but she is living in a world divorced from reality.</p>
</blockquote>
<p>Dad and I marvelled at Ada’s audacity, intellect, and creativity in her grandiose delusions as a Russian princess and British spy. We wondered if our royal status had gone awry. </p>
<p>Further examples of her grandiose delusions are evident in two letters Ada wrote and held within her files. The first letter is Ada’s application to join the <a href="https://www.awm.gov.au/learn/understanding-military-structure/ran/wrans">Women’s Royal Australian Naval Services</a> in 1943. It is her response to a recruitment drive that sought women to help with increased naval demands. She offered her medical services as a trained doctor and surgeon, fabricated her educational credentials and persisted in her claim of royal birth. </p>
<p>The hospital surveilled all patient letters and prevented Ada’s application from being sent. The address she provided for correspondence was the Female Ward, Mont Park Mental Hospital, which indicates Ada had some grasp on her present reality. </p>
<p>Like the other thousand women who enlisted with the Women’s Royal Australian Naval Services by the end of 1942, Ada wanted to help in war service and gain employment.</p>
<p>The second letter in her files, written in 1943, is addressed to her husband. It reads in part:</p>
<blockquote>
<p>One of the patients here has been friendly and helps to pass the time. With your consent, we are planning to go to England together as I must see to my English affairs, being of Russian titled birth. I inherited from my father about twenty-six years ago, various properties in England, America and Australia, also Europe, these properties, and affairs await my attention in London. Also my Army Commission, with the British Secret Service, which commission continues from my last visit to London.<br></p>
<p>And lastly, my enormous will, I must change it to include yourself, my husband, and only two children, and those several titles to descend upon both, also a ducal title upon yourself from marriage (to me), now Alva.</p>
</blockquote>
<p>Ada certainly did not see herself as any ordinary mental patient. Instead, her grandiose delusions illustrate her desire for social mobility and increased status – by casting herself as a wealthy Russian royal working as a British spy. Such grand ideas likely provided Ada with a sense of purpose, power and optimism. </p>
<p>In Victoria Shepherd’s book, <a href="https://www.simonandschuster.com/books/A-History-of-Delusions/Victoria-Shepherd/9780861545308">A History of Delusions: The Glass King, a Substitute Husband, and a Walking Corpse</a>, the author argues delusions are a far preferable alternative to the dramatic loss of status that occurs when a life goes catastrophically wrong. Delusions serve to reconcile a fallen and lowly existence. </p>
<p>We can see this in Ada’s grand delusions: acting as royalty and a highly educated spy gave her ambitions direction and a sense of purpose, as a patriotic Australian and loyal subject to the British Crown and the Commonwealth during wartime. The Women’s Royal Australian Naval Services application attests to this. Shepherd also reminds us that by listening very closely, we can gain a deeper understanding of people experiencing delusions. </p>
<p>I hear Ada’s demand for dignity and respect as her response to the injustice she suffered – and to the loss of her autonomy, power, freedom and the ability to mother her two children. Unfortunately for Ada, displaying her grand delusions meant no further trial leave, following her return to Mont Park in 1943. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/friday-essay-black-bile-malaria-therapy-and-insulin-comas-a-brief-history-of-mental-illness-206580">Friday essay: 'black bile', malaria therapy and insulin comas – a brief history of mental illness</a>
</strong>
</em>
</p>
<hr>
<h2>A schizophrenia diagnosis</h2>
<p>Ada spent the next 20 years in several mental institutions in Victoria without trial leave, which was often a pathway to discharge for patients with supportive families. Her files are brief throughout the rest of the 1940s and mid-1950s, following Ada’s grandiose delusion letters. </p>
<p>In 1948, her doctor noted Ada was “considerably improved, is much quieter, works in the wards and is no trouble in any way”. A further entry states she is a “delusional schizophrenic whose moods are variable”. </p>
<p>This is the first time “schizophrenic” has been used in Ada’s files. By 1954, Ada is transferred from B ward to A ward. She: </p>
<blockquote>
<p>works daily in B ward, which she calls going to the office. Some delusions. Wishes to go home and finish her studies at the university. </p>
</blockquote>
<p>The mention of her ward work as “going to the office” shows her sense of humour and is a reminder of the days she worked in an office, as a comptometer operator, before her marriage. </p>
<p>And her desire to complete university points to her desire for social mobility through educational aspirations.</p>
<h2>Domestic service</h2>
<p>In the 1950s, Ada worked as a domestic servant for Dr Donnan and his family, when he was a medical officer at Mont Park mental hospital. After one year, Dr. Donnan was promoted to Chief Superintendent Psychiatrist at Beechworth Mental Hospital in regional Victoria, and the family took Ada with them. </p>
<p>Sally, Dr. Donnan’s youngest daughter, recalls travelling with her family and Ada from Melbourne to Beechworth for her father’s new position:</p>
<blockquote>
<p>There were five of us, including my elder sister, driving up to Beechworth in Dad’s Alvis vintage car with lots of luggage. It got dark and none of us were that comfortable being in the middle of the bush at night. The car conked out at a river crossing, water was running over the road, in the dark. Ada was sitting between us two kids in the back, gripping our hands. Anyway we got going again, though I don’t remember the rest of the trip.</p>
</blockquote>
<p>Ada lived in the Donnan’s family home located within the grounds of the mental hospital and continued to work as their domestic servant. The Beechworth Mental Asylum was built in 1867, and by the 1970s it was renamed <a href="https://tour.maydayhills.org.au">Mayday Hills Psychiatric Hospital</a>. It still stands today. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/548742/original/file-20230918-15-yknd4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/548742/original/file-20230918-15-yknd4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/548742/original/file-20230918-15-yknd4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=362&fit=crop&dpr=1 600w, https://images.theconversation.com/files/548742/original/file-20230918-15-yknd4u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=362&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/548742/original/file-20230918-15-yknd4u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=362&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/548742/original/file-20230918-15-yknd4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=455&fit=crop&dpr=1 754w, https://images.theconversation.com/files/548742/original/file-20230918-15-yknd4u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=455&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/548742/original/file-20230918-15-yknd4u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=455&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Asylum, Beechworth, circa 1920s.</span>
<span class="attribution"><span class="source">Courtesy of the Bourke Museum, Beechworth Victoria</span></span>
</figcaption>
</figure>
<p>Sally recalls Ada and her mother working together in their home:</p>
<blockquote>
<p>Everything was on time, the routine, brushing hair, cleaning shoes, preparing school uniforms and meals. I seem to remember Ada being dressed very neatly every day, usually in a black skirt and white shirt. She wore her hair in a well-cut bob. I always remember her wearing thick beige stockings and stout black shoes. Pink complexion, blue eyes. She never wore makeup.</p>
</blockquote>
<p>By 1963, Dr. Donnan transferred to Brierly Mental Hospital in Warrnambool, Victoria, but this time the Donnan family could not take Ada with them. </p>
<p>Ada transferred back to Mont Park in Melbourne, and in the doctor’s transfer request, he wrote:</p>
<blockquote>
<p>She spent all her time working for Dr Donnan. She worked quite satisfactorily and seemed very happy with Dr Donnan and his family. After Dr Donnan left the hospital she is missing the family very much and would like to return to Mont Park.</p>
</blockquote>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/548958/original/file-20230919-25-itb0rx.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/548958/original/file-20230919-25-itb0rx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/548958/original/file-20230919-25-itb0rx.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/548958/original/file-20230919-25-itb0rx.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/548958/original/file-20230919-25-itb0rx.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/548958/original/file-20230919-25-itb0rx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/548958/original/file-20230919-25-itb0rx.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/548958/original/file-20230919-25-itb0rx.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Donnan residence, where Ada lived and worked as a domestic servant at the Beechworth Mental Asylum.</span>
</figcaption>
</figure>
<h2>Late days</h2>
<p>It was around this time Dad first met Ada, anxiously waiting for her in that walled garden at Mont Park. In 1964, a year and a half later, Ada moved to Carmel House, a residential boarding house for female patients in Preston, Melbourne. From there, she continued to work as a domestic servant and regularly met my father for lunch at Coles cafeteria in the city. </p>
<p>By this time Ada’s condition was described as a “chronic schizophrenic, with auditory hallucinations, and has delusions that she is related to royalty”.</p>
<p>The antipsychotic drugs <a href="https://www.webmd.com/drugs/2/drug-6572/stelazine-oral/details">Stelazine</a> and <a href="https://www.webmd.com/drugs/2/drug-6901/mellaril-oral/details">Mellaril</a> were prescribed for the first time. Ada’s grandiose beliefs persisted well into the 1960s, as my father recalls:</p>
<blockquote>
<p>The first time Mum stayed at our place for the weekend, she turned to me and
said “Tell me, do you still use your title?” “Er, what title’s that, Mum?” I asked, surprised. “Lord …” she replied, as if everyone knew. “No Mum. People don’t use their titles much these days.” “What a pity,” she said and dropped the matter.</p>
</blockquote>
<p>Ada lived at Carmel House until she died in 1972, aged 60. When I was 11, I accompanied my father there, shortly after Ada’s death. It seemed forever that I waited for him in the car, the sun burning through the glass. </p>
<p>Dad returned and placed that small, brown suitcase, which would later make its way into my childhood bedroom, on the back seat. It was the total of his mother’s personal effects. “Not much for a life,” he said.</p><img src="https://counter.theconversation.com/content/207428/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alison Watts does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Alison Watt’s grandmother was diagnosed with ‘puerperal insanity’ and institutionalised not long after giving birth to her father. He didn’t meet her – or know she was alive – until his early 20s.Alison Watts, Adjunct Lecturer, Faculty of Health, Southern Cross UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2110172023-09-15T12:31:04Z2023-09-15T12:31:04ZAnxiety can often be a drag on creativity, upending the trope of the tortured artist<figure><img src="https://images.theconversation.com/files/546477/original/file-20230905-19-xuho6l.jpg?ixlib=rb-1.1.0&rect=0%2C487%2C5145%2C3245&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Creative journeys often entail entering the unknown -- and doing it on your own.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/man-on-a-mission-royalty-free-image/1369468881?phrase=minimalism+minimal+surreal+journey">DNY59/iStock via Getty Images</a></span></figcaption></figure><p>In the U.S., anxiety disorders affect about <a href="https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder">one-third of the population</a>. So it’s no surprise that a good number of artists and writers also suffer from anxiety and depression.</p>
<p>But whereas some critics see Vincent Van Gogh’s striking paintings and Sylvia Plath’s confessional poetry <a href="https://www.thecollector.com/sylvia-plath-famous-poet/">as the direct result of their psychosis and depression</a>, I tend to be less romantic about this subject. I see their brilliant output as having happened in spite of – rather than because of – their mental anguish.</p>
<p>In my new book, “<a href="https://rowman.com/ISBN/9781538170380/Afraid-Understanding-the-Purpose-of-Fear-and-Harnessing-the-Power-of-Anxiety">Afraid</a>,” I explore the interaction between fear, anxiety and creative work. </p>
<p>They’re more intertwined than you might think: Depending on the situation, fear and anxiety can either inspire or impede. But when anxiety becomes overwhelming, creative work often stalls.</p>
<h2>Anxiety as a roadblock</h2>
<p>The most basic way anxiety can hinder creative work is by shifting attention away from that work and toward fears and worries. </p>
<p>If a writer is worried about losing her day job, it’s harder for her to focus on her writing. Excessive anxiety bypasses all nonthreat-related tasks, and people regress <a href="https://www.verywellmind.com/learning-brain-vs-survival-brain-6749311">to basic survival mode</a>. Most attention, thinking and emotions will be focused on dealing with the source of the danger, whether it’s real or imagined. And creative minds are especially adept at the latter.</p>
<p>Because fears center on survival, <a href="https://www.psychologytoday.com/us/blog/fixing-families/202212/are-you-too-routinized-too-rigid-maybe-youre-anxious">people become less flexible and more wary</a> when they’re scared and anxious. At that point, going down a known path is far more appealing than taking risks and venturing into the unknown. Suffice to say, an aversion to the unknown won’t often lead to creative breakthroughs.</p>
<p>Another way fear can hinder creativity has to do with fear of rejection.</p>
<p>Friends, family, colleagues and critics <a href="https://www.theatlantic.com/business/archive/2014/10/why-new-ideas-fail/381275/">often resist</a> unusual ideas or those that stray from established artistic norms. Aside from arising out of envy and competition, these reflexive reactions also make sense from <a href="https://doi.org/10.1098/rstb.2009.0134">an evolutionary perspective</a>: Norms and agreed-upon ways of thinking cultivate group harmony. History is filled with the rejection, mockery and oppression of novel ideas and styles deemed too “out there” – painters <a href="https://www.famsf.org/stories/memorable-rejections-monet-and-the-artists-struggle-part-one#">Claude Monet</a> and <a href="https://truthout.org/articles/honoring-radical-women-worldwide-who-have-positively-changed-history/">Frida Kahlo</a> and author <a href="https://www.pbs.org/wgbh/americanexperience/features/whaling-biography-herman-melville/">Herman Melville</a> were all harshly criticized, dismissed or persecuted by their contemporaries.</p>
<p>To create something truly original, an artist must often break from the status quo. </p>
<p>So it’s only natural that any creative endeavor will lead to fear of criticism, rejection or failure. The road less traveled might be more dangerous. It might even be fruitless. And sometimes the cost is one’s life: <a href="http://www.pbs.org/empires/thegreeks/keyevents/399.html">Socrates was executed</a> on charges that his probing questions were corrupting young people, while Italian philosopher Giordano Bruno <a href="https://blogs.scientificamerican.com/observations/was-giordano-bruno-burned-at-the-stake-for-believing-in-exoplanets/">was burned to death, in part, for his heretical claims</a> that the Earth was not the center of the universe.</p>
<h2>When anxiety inspires</h2>
<p>This is not to say that being cool as a cucumber is a requisite for great art. Some level of anxiety can serve a purpose. </p>
<p>While being truly terrified can paralyze you, being bored and feeling languid <a href="https://link.springer.com/referenceworkentry/10.1007/978-3-319-01384-8_288#:%7E:text=Optimal%20arousal%20is%20a%20psychological,and%20the%20intensity%20of%20readiness.">can grind your motivation to a halt</a>.</p>
<p>There’s a sweet spot of anxiety that actually harnesses motivation and cognition and directs all attention to the task at hand.</p>
<p>With the deadline for “Afraid” fast approaching, I felt a pang of anxiety that propelled me to the finish line: I decided to tuck myself away in a resort next to the mountains in Tucson for two weeks and work 12-hour days to wrap up the book. The anxiety of not meeting the deadline was enough to inspire me to buckle down and get the job done. </p>
<p>Then there’s the specter of death. </p>
<p>No one is spared. Yet, even as geniuses like Michelangelo and Charles Dickens met the same fate as their peers, their brushstrokes and words became eternal.</p>
<p>Creative work is a way to achieve a certain level of immortality – art and books and articles that live on past your expiration date. </p>
<p>American anthropologist Ernest Becker argued that fear of death <a href="https://doi.org/10.1177/0146167213490804">motivated humans to compose</a> stories, myth and legends about the afterlife and immortality, and it inspired great works of architecture like the Egyptian pyramids.</p>
<p>This existential dread <a href="https://theconversation.com/i-want-to-stare-death-in-the-eye-why-dying-inspires-so-many-writers-and-artists-128061">has also motivated authors and artists</a> to seek a form of immortality through their work. I find it somewhat comforting that after I am dead, some of my scientific discoveries and writings might continue to live through others. </p>
<p>In fact, you might be reading this piece long after I am gone.</p>
<h2>What you can and can’t control</h2>
<p>Creative work entails traversing a mental landscape that can be treacherous, whether you’re mining your imagination, plotting your next steps or plumbing your memories. Failure always looms. </p>
<p>This uncertainty can elicit fear and doubt. </p>
<p>Interestingly, fear is solely focused on survival, while creativity operates at its best <a href="https://www.simplypsychology.org/maslow.html">when basic survival needs are met</a>. Furthermore, fear is a primitive emotion, whereas art, science and culture are among humankind’s most evolved abilities. </p>
<p>But fear and creativity are also similar in that both possess automatic and intuitive processes. The best works of art are not the sole result of logical thinking. Like a fetus, art grows inside the artist autonomously while the artist keeps feeding it; when the time comes, delivery happens. Fear is also mostly autonomous: When you notice a car barreling toward you, you leap out of the road before thinking about the driver’s intentions. </p>
<p>In that sense, people don’t fully control their fear and creativity. For both to work productively, a balanced harmony needs to exist between the unconscious and the conscious mind.</p>
<h2>Cultivating your creativity</h2>
<p>Still, there are elements of your consciousness that you can influence.</p>
<p>If you want to create something but feel inhibited by <a href="https://theconversation.com/the-5-000-year-history-of-writers-block-190037">writer’s block</a>, hesitancy or insecurity, think about which kind of fear might be holding you back.</p>
<p>Is it fear of failure or judgment? Fear of your own inner critic? Or is there a different day-to-day challenge or responsibility that’s soaking up most of your attention?</p>
<p>Once you’ve identified the source of the anxiety, see if you can reframe the fear in an objective way that liberates you from its shackles. Maybe you can recognize failure as a possibility but ultimately something that won’t kill you: You can always just try again.</p>
<p>Another option is to engage your brain’s <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8992377/#:%7E:text=The%20mesolimbic%20system%2C%20also%20known,and%20cognitive%20processing%20of%20reward.">reward circuitry</a> – say, thinking of the possible positive outcomes of your work, including immortality. Or you could use the fear network to your advantage, remembering a deadline, a promotion that might hinge on the work or the crummy feeling of not completing a task. Breaking the work into pieces will also make it seem more doable and less scary. </p>
<p>Sometimes, shaking things up with a change of scenery can help. When I went away to finish “Afraid,” I chose the desert not only because I find the landscape inspiring. There’s also something about the starkly different and empty geography that clears my head from all of the clutter of daily life back in Michigan.</p>
<p>Just as there are many paths to take as you pursue a creative endeavor, there are a range of strategies to combat or use all of the little fears that crop up along the way.</p><img src="https://counter.theconversation.com/content/211017/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arash Javanbakht does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A psychiatrist explains the many ways anxiety can hinder, color or compel creativity.Arash Javanbakht, Associate Professor of Psychiatry, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2065802023-08-24T20:20:46Z2023-08-24T20:20:46ZFriday essay: ‘black bile’, malaria therapy and insulin comas – a brief history of mental illness<p>Possibly the earliest account of a disturbed mind is recorded in a 3,500-year-old <a href="https://en.wikipedia.org/wiki/Vedas">Hindu text</a> that describes a man who is “gluttonous, filthy, walks naked, has lost his memory and moves about in an uneasy manner”.</p>
<p>In the Bible’s Old Testament, in the first <a href="https://www.britannica.com/topic/Books-of-Samuel">Book of Samuel</a>, we read that King David simulated madness to gain safety: </p>
<blockquote>
<p>And he changed his behaviour … and feigned himself mad in their hands, and scrabbled on the doors of the gate, and let his spittle fall down upon his beard.</p>
</blockquote>
<p>In the <a href="https://www.britannica.com/topic/The-Book-of-Daniel-Old-Testament">Book of Daniel</a>, we find a vivid description of King Nebuchadnezzar’s mental state: </p>
<blockquote>
<p>And he was driven from men, and did eat grass as oxen, and his body was wet with the dew of heaven, till his hairs were grown like eagles’ feathers, and his nails like birds’ claws.</p>
</blockquote>
<p>The ancient Greeks made early attempts to explain madness. In the 5th century BC, <a href="https://fherehab.com/learning/humors-ancient-mental-health">Hippocrates</a> viewed it as seated in the brain and influenced by four bodily fluids: blood, phlegm, black bile and yellow bile. </p>
<p>The Greek physician Galen, who practised in Rome 600 years later, argued that depression was caused by an excess of black bile (hence the term “melancholia”, from <em>melan</em>, black, and <em>khole</em>, bile). </p>
<p>His contemporary, <a href="https://www.britannica.com/biography/Aretaeus-of-Cappadocia">Aretaeus of Cappadocia</a>, colourfully described how, if black bile moves upwards in the body, “it forms melancholy; for it produces flatulence and eructations [or, belches] of a fetid and fishy nature, and it sends rumbling wind downwards, and disturbs the understanding”. </p>
<h2>A troubled mind, possessed</h2>
<p>During the Middle Ages, monasteries preserved the view of madness as an illness, and of those afflicted as sick rather than sinful. At the same time, the more sinister belief that the <a href="https://pubmed.ncbi.nlm.nih.gov/25208453/">principal cause</a> of the troubled mind was possession by spirits or the devil prevailed.</p>
<p>Sufferers were taken to sanctioned healers for <a href="https://theconversation.com/exorcisms-have-been-part-of-christianity-for-centuries-107932">exorcisms</a>, a practice still carried out today in some cultures. People who failed to respond to such treatment might then seek out a celebrated expert. </p>
<p>Consider Hwaetred, a young man living in what is now England in the 7th century, who became tormented by an “evil spirit”. So terrible was his madness that he attacked others with his teeth and killed three men with an axe when they tried to restrain him. Taken to several sacred shrines, he obtained no relief. His despairing parents then heard of Guthlac, a monk who lived a hermit life north of Cambridge. After three days of prayer and fasting, Hwaetred was purportedly cured.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=439&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=439&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=439&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=552&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=552&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=552&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">St Francis Borgia Helping a Dying Impenitent – Goya (1788)</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>Over time, the role of religious authorities in mental illness dwindled, and the medical profession claimed the exclusive practice of the healing arts. Insanity once more came to be seen more as a physical malady than a spiritual taint. Even so, life for the mentally ill could be appalling. </p>
<p>During the 17th century, religiously inspired persecution of the mentally ill was justified by the clerical hierarchy, and treatment was often some combination of neglect and bestial restraint. </p>
<p>Psychiatrists Martin Roth and Jerome Kroll <a href="https://books.google.com.au/books/about/The_Reality_of_Mental_Illness.html?id=pCQ4AAAAIAAJ&redir_esc=y">describe</a> the insane in this period as “miserable individuals, wandering around in village and in forest, taken from shrine to shrine, sometimes tied up when they became too violent”.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-invention-of-satanic-witchcraft-by-medieval-authorities-was-initially-met-with-skepticism-140809">The invention of satanic witchcraft by medieval authorities was initially met with skepticism</a>
</strong>
</em>
</p>
<hr>
<h2>A watershed: asylums</h2>
<p>The late 18th century was a watershed in the history of psychiatry. The insanity of England’s <a href="https://www.bbc.com/news/magazine-22122407">King George III</a> revealed society’s ambivalence to the mentally ill (vividly captured in the 1994 film <a href="https://www.imdb.com/title/tt0110428/">The Madness of King George</a>). </p>
<p>In France, <a href="https://www.britannica.com/biography/Philippe-Pinel">Philippe Pinel</a> released the chains that had fettered the “lunatic” for centuries, ushering in an unprecedented phase of benevolent institutional care. </p>
<p><a href="https://dictionary.apa.org/moral-therapy">Moral therapy</a>, a form of individualised care in small hospital settings, was promoted by English Quakers at the <a href="https://en.wikipedia.org/wiki/The_Retreat">York Retreat</a> and gradually supplanted inhumane physical treatments such as purging, bleeding and dunking in cold water.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/BHNSAK8d3qc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">English society’s ambivalence to the mentally ill in the 18th century is depicted in the 1994 film, The Madness of King George.</span></figcaption>
</figure>
<p>As populations grew and urbanised, the sheer numbers of mentally ill people in burgeoning city slums demanded action. An institutional solution emerged. </p>
<p>Asylums (from the Greek word meaning “refuge”) were built in rural settings with the best of intentions, planned to be havens in which patients would receive humane care. In the serenity of the countryside, and through carrying out undemanding tasks, they could be distracted from their internal torment and find dignity far from the bustling crowd. </p>
<p><a href="https://www.britannica.com/biography/Daniel-Defoe">Daniel Defoe</a>, the English writer, remained unconvinced: “This is the height of barbarity and injustice in a Christian country; it is a clandestine Inquisition, nay worse.”</p>
<p>Although conceived in a spirit of optimism, asylums tended to deteriorate into centres of hopelessness and demoralisation. They soon became overcrowded dumps. Institutions built for a few hundred people were soon holding thousands. Very few residents were discharged; many stayed for decades. Brutal oppression replaced anything that might have resembled treatment; malnutrition and infectious disease became rife.</p>
<p>In the grim environment, people were shut away and forgotten. With them out of sight and out of mind, a loss of public interest and political neglect became the norm.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=483&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=483&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=483&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=607&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=607&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=607&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Asylums were conceived optimistically, but more often housed oppression than treatment. Picture: The Hospital of Bethlehem.</span>
<span class="attribution"><span class="source">Wellcome Collection</span></span>
</figcaption>
</figure>
<p>The brooding building on the hill came to symbolise the stigma and fear attached to mental illness. By the mid-19th century, critics were voicing concerns that asylums had become human warehouses that entrenched mental illness rather than curing it. </p>
<p>The combination of powerless patients, hospitals run more for the convenience of staff than for the benefit of the sick, inadequate inspection by state bodies, and lack of resources led at times to quite disgraceful conditions. Unwittingly, the spread of asylums also triggered the movement of psychiatry away from the mainstream of medicine.</p>
<p>The conditions of the asylums are evocatively described in Henry Handel Richardson’s Australian novel <a href="https://www.textpublishing.com.au/books/the-fortunes-of-richard-mahony">The Fortunes of Richard Mahony</a>. We read of Richard’s decline, probably from syphilis affecting the brain, which at that time afflicted a large proportion of mental patients.</p>
<p>Towards the end of the novel, his wife comes to visit him in the asylum:</p>
<blockquote>
<p>She hung her head … while the warder told the tale of Richard’s misdeeds. 97B was, he declared, not only disobedient and disorderly, he was extremely abusive, dirty in his habits … he refused to wash himself, or to eat his food … she had to keep a grip on her mind to hinder it from following the picture up: Richard, forced by this burly brute to grope on the floor for his spilt food, to scrape it together, and either eat it or have it thrust down his throat … There was not only feeding by force, the straitjacket, the padded cell. There were drugs and injections, given to keep a patient quiet and ensure his warders their freedom.</p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-case-for-the-fortunes-of-richard-mahony-by-henry-handel-richardson-24474">The case for The Fortunes of Richard Mahony by Henry Handel Richardson</a>
</strong>
</em>
</p>
<hr>
<h2>Great and desperate cures</h2>
<p>In the asylum, psychiatry turned into a modern medical discipline. The
accumulation of thousands of patients provided the first opportunity
to study mental illness systematically and to develop theories about its
causes. </p>
<p>The idea that these conditions were due to brain alterations, and especially degenerative processes, became dominant, encouraged by the discovery of the cerebral pathology associated with <a href="https://www.healthline.com/health/neurosyphilis">neurosyphilis</a> and <a href="https://theconversation.com/what-causes-alzheimers-disease-what-we-know-dont-know-and-suspect-75847">Alzheimer’s disease</a>. A similar degenerative process was proposed by the great German psychiatrist <a href="https://www.britannica.com/biography/Emil-Kraepelin">Emil Kraepelin</a> to cause <a href="https://www.sciencedirect.com/topics/computer-science/dementia-praecox">dementia praecox</a> – later renamed “schizophrenia” – leading to pessimism about the possibility of recovery.</p>
<p>But the priority for asylums was to relieve the suffering of overwhelming numbers of disturbed patients. Psychiatrists grasped for “great and desperate cures”. <a href="https://en.wikipedia.org/wiki/Henry_R._Rollin">Henry Rollin</a>, an English psychiatrist and medical historian, captures the intense zeal:</p>
<blockquote>
<p>The physical treatment of the frankly psychotic during these centuries makes spine-chilling reading. Evacuation by vomiting, purgatives, sweating, blisters, and bleeding were considered essential […] There was indeed no insult to the human body, no trauma, no indignity which was not at one time or other piously prescribed for the unfortunate victim.</p>
</blockquote>
<p>Treatments were sometimes based on rational grounds. Malaria therapy, for instance, was launched as a treatment for neurosyphilis by the Viennese psychiatrist <a href="https://www.britannica.com/biography/Julius-Wagner-Jauregg">Julius Wagner-Jauregg</a> in 1917, earning him a Nobel Prize ten years later. </p>
<p>The high fever caused by the malarial parasite disabled the <a href="https://www.britannica.com/science/spirochete">spirochete</a> that caused neurosyphilis, but the hope that it would be equally effective for other forms of psychosis was soon dashed. The wished-for panacea was not to be.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Malaria therapy, a treatment for neurosyphilis, earned its inventor a Nobel Prize.</span>
<span class="attribution"><span class="source">Jimmy Chan/Pexels</span></span>
</figcaption>
</figure>
<p><a href="https://www.britannica.com/science/insulin-shock-therapy">Insulin-coma therapy</a> was introduced by Manfred Sakel in the 1930s in Vienna and was soon being used in many countries to treat schizophrenia. An insulin injection was administered six days a week for several weeks, producing a state of light coma lasting about an hour, because of reduced glucose reaching the brain. </p>
<p>Many years later, an investigation carried out in the Institute of Psychiatry in London, a leading research centre at the time, showed conclusively that the coma itself was of no therapeutic value. Any positive change was probably due to the staff’s painstaking care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/girl-interrupted-interrogates-how-women-are-mad-when-they-refuse-to-conform-30-years-on-this-memoir-is-still-important-199211">Girl, Interrupted interrogates how women are 'mad' when they refuse to conform – 30 years on, this memoir is still important</a>
</strong>
</em>
</p>
<hr>
<h2>ECT and lithium</h2>
<p>The first widely available and effective biological treatments for mental illness were developed in the asylum. The discovery in 1938 of <a href="https://theconversation.com/electroconvulsive-therapy-a-history-of-controversy-but-also-of-help-70938">electroconvulsive therapy</a> (ECT) by <a href="https://www.psychiatrictimes.com/view/ugo-cerletti">Ugo Cerletti</a> and Lucio Bini, two Italian psychiatrists, led to a dramatically effective treatment for people with severe depression. </p>
<p>ECT was eagerly adopted in practice, but its history illustrates a typical pattern of treatment in psychiatry: unbridled early enthusiasm is later tempered by a protracted process of scientific evaluation. </p>
<p>The same can be said of the use of brain surgery to modify psychiatric symptoms. This was pioneered in 1936 by Portuguese neurologist <a href="https://www.britannica.com/biography/Antonio-Egas-Moniz">António Egas Moniz</a> (another Nobel Prize winner in the field of psychiatry) and surgeon Almeida Lima, and remains controversial in psychiatry to this day.</p>
<p>A momentous breakthrough was the discovery in 1949 by <a href="https://www.nature.com/articles/d41586-019-02480-0">John Cade</a>, an Australian psychiatrist, of lithium as a treatment for manic excitement. The lithium story reveals how the incorporation of a new medication into psychiatric practice is not always smooth. </p>
<p>Several US and Danish psychiatrists had experimented with lithium in the 1870s and 1890s, only to have their work ignored until Cade’s rediscovery. It was another 18 years before lithium was shown to prevent the recurrence of severe changes of mood, its primary clinical use now.</p>
<p>Major tranquillisers were added to the growing range of psychiatric medications after being discovered fortuitously in 1953. An antihistamine used to calm patients undergoing surgery was shown to reduce the torment of psychotic patients, but without making them sleepy. </p>
<p>Shortly after this, the US psychiatrist <a href="https://www.nytimes.com/1983/02/14/obituaries/nathan-kline-developer-of-antidepressants-dies.html">Nathan Kline</a> discovered that a drug being tested for its effect in patients with tuberculosis had antidepressant properties — the forerunner of medications for depression. All these drugs radically transformed the practice of psychiatry. </p>
<h2>Freud, ‘talking cures’ and shell shock</h2>
<p>A very different aspect of mental health care arose in the 1890s, outside
the asylum. Concerned with neurotic conditions, the new treatment grew chiefly out of neurology but was also influenced by a scientific interest in hypnosis and the unconscious. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=816&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=816&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=816&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1025&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1025&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1025&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sigmund Freud.</span>
<span class="attribution"><span class="source">Max Halberstadt/Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>Sigmund Freud conceived a dynamic model of the mind in which, through the mechanism of repression, painful or threatening emotions, memories and impulses are prevented from escaping into conscious awareness. </p>
<p><a href="https://theconversation.com/a-dangerous-method-in-defence-of-freuds-psychoanalysis-5989">Psychoanalysis</a> grew to become an integrated set of concepts about normal and abnormal mental functioning and personality development, and spawned a new method of psychologically based treatment. Psychoanalysis emerged as a major theoretical underpinning of contemporary “talking cures” (psychotherapies), and its influence spread far beyond treating mental ill-health.</p>
<p>Both world wars profoundly influenced the field. The high incidence of “<a href="https://theconversation.com/shell-shock-treatments-reveal-the-conflict-in-psychiatrys-heart-29822">shell shock</a>” in World War I drove home the lesson that mental illness could affect not only those genetically predisposed, but even the supposedly robust. It soon emerged that anyone exposed to traumatic experiences was vulnerable. </p>
<p>A positive outcome from World War II was the development of techniques for screening large numbers of recruits, which revealed the substantial prevalence of emotional problems among young adults. </p>
<p>The need to treat numerous psychiatric casualties led to the development of group therapies. These paved the way for the so-called <a href="https://en.wikipedia.org/wiki/Therapeutic_community">therapeutic community</a>, based on the idea that an entire ward of patients could be an integral part of treatment.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ehPcYibzUKc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Group therapy, as depicted in One Flew Over the Cuckoo’s Nest.</span></figcaption>
</figure>
<p>The idea of deinstitutionalisation began to gather pace in the 1960s, driven by a burgeoning civil-rights movement. <a href="https://www.penguin.com.au/books/asylums-9780241548004">Asylums</a>, an influential book at the time by sociologist Erving Goffman, containing his minute observations of the sense of oppression experienced by patients in these “total institutions”, was one catalyst for their closure. </p>
<p>Hundreds of thousands of long-stay patients began to be transferred to alternative accommodation and specialist care in the community, a process that is still in progress.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-body-keeps-the-score-how-a-bestselling-book-helps-us-understand-trauma-but-inflates-the-definition-of-it-184735">The Body Keeps the Score: how a bestselling book helps us understand trauma – but inflates the definition of it</a>
</strong>
</em>
</p>
<hr>
<h2>What is mental illness?</h2>
<p>It is challenging to define what makes a pattern of behaviour and experience a mental disorder. Generally, such a pattern – or “syndrome” – is considered to be a disorder if it is associated with psychological distress, such as intense and prolonged anxiety or sadness, or significant dysfunction, such as a serious impairment in functioning in one or more key areas of daily life. </p>
<p>If the pattern is short-lived, relatively mild, or entirely understandable in light of the trials and tribulations of the person’s life, it should be seen as a problem in living rather than a mental disorder. Such problems may still benefit from consultation with a mental health professional despite not being diagnosable disorders.</p>
<p>This definition of what counts as a mental disorder also clarifies what is not a mental disorder. Merely being unusual or violating social norms does not mean a person has a disorder. </p>
<p>It is difficult sometimes to decide whether a new kind of behaviour is a mental disorder. For instance, should <a href="https://theconversation.com/no-youre-probably-not-addicted-to-your-smartphone-but-you-might-use-it-too-much-89853">excessive smartphone use</a> or <a href="https://theconversation.com/gambling-on-pokies-is-like-tobacco-no-amount-of-it-is-safe-51037">compulsive gambling</a> be counted as diagnosable addictions?</p>
<h2>Troubling cases</h2>
<p>These decisions about what to include under the umbrella of mental illness are fraught, and there have been some troubling historical cases when disturbing decisions were made or proposed. </p>
<p>In the 1850s, for example, Samuel Cartwright, a physician from Alabama, proposed a new diagnosis called “<a href="https://www.nytimes.com/2000/01/15/arts/bigotry-as-mental-illness-or-just-another-norm.html">drapetomania</a>” to explain why African-American slaves would wish to escape their servitude. </p>
<p>He recommended slaves should be treated kindly and humanely to prevent the disorder, but whipped if this treatment failed. A more patent abuse of the concept of mental illness would be hard to imagine, and it should be noted that other physicians ridiculed Cartwright’s proposal at the time.</p>
<p>Two other controversial cases date to the last century. In the early 1970s, one of us (Sidney) stumbled across disturbing media reports that many political and religious dissenters and human-rights activists in the Soviet Union were being labelled as mentally ill and detained in mental hospitals indefinitely or until they renounced their “disturbed ideas”. </p>
<p>For instance, <a href="https://en.wikipedia.org/wiki/Petro_Grigorenko">General Pyotr Grigorenko</a> criticised the privileges of the Soviet elite and publicly espoused the rights of the <a href="https://en.wikipedia.org/wiki/Crimean_Tatars">Crimean Tatar</a> ethnic minority group. He was diagnosed with paranoid tendencies, one symptom being his “reformist ideas”, and forcibly committed to a psychiatric facility. </p>
<p>In effect, Soviet psychiatry’s definition of mental illness, and psychosis in particular, was so broad that political beliefs about the desirability of social change were recast as delusions.</p>
<p>The second case comes from the US. <a href="https://daily.jstor.org/how-lgbtq-activists-got-homosexuality-out-of-the-dsm/">Until 1973</a>, homosexuality was defined as a sexual deviation and included in the set of recognised mental disorders. Under pressure from civil, women’s and gay rights activists, it was removed from the diagnostic manual.</p>
<p>Noting such cases, whenever the boundary of a mental illness is expanded to include new diagnoses or loosen old ones, some critics will worry we are treating normal behaviour as a pathology and that we will harm people by labelling them. And whenever the boundary contracts, others will worry that people with psychological troubles are being excluded from clinical care. </p>
<p>Deciding what is and isn’t a mental illness is difficult, but has marked consequences.</p>
<hr>
<p><em>This is an edited extract from <a href="https://scribepublications.com.au/books-authors/books/troubled-mindSees-9781922585875">Troubled Minds: Understanding and treating mental illness</a> by Sidney Bloch and Nick Haslam (Scribe Publications), published 29 August 2023.</em></p><img src="https://counter.theconversation.com/content/206580/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nick Haslam receives funding from the Australian Research Council.</span></em></p><p class="fine-print"><em><span>Sidney Bloch does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Humans have attempted to understand and treat mental illness for centuries – from ancient Greek medicine, Middle Ages exorcisms and the rise of asylums, to modern medical breakthroughs.Sidney Bloch, Emeritus Professor in Psychiatry, The University of MelbourneNick Haslam, Professor of Psychology, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2092612023-07-20T18:06:04Z2023-07-20T18:06:04ZMental illness in fathers may increase the risk of preterm birth – new research<figure><img src="https://images.theconversation.com/files/538283/original/file-20230719-17-ovqac7.jpg?ixlib=rb-1.1.0&rect=18%2C0%2C5988%2C4007&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/worried-stress-man-sitting-on-bed-1178105212">MiniStocker/Shutterstock</a></span></figcaption></figure><p>Mothers with a mental illness are more likely to give birth too early, according to <a href="https://pubmed.ncbi.nlm.nih.gov/32671543/">research</a>.</p>
<p>But the risk of preterm birth can also be affected by a father’s mental health.
In our <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004256">new study</a> published in the journal PLOS Medicine, we found that fathers’ mental illness increases the risk of preterm birth and that the risk is even greater when both parents are affected.</p>
<p>Preterm birth refers to <a href="https://www.who.int/news-room/fact-sheets/detail/preterm-birth">delivery before 37 weeks</a> of pregnancy, and is associated with a greater risk of negative health outcomes for the child. For example, babies born preterm have higher rates of neurodevelopmental conditions such as <a href="https://pubmed.ncbi.nlm.nih.gov/32960896/">autism spectrum disorder</a>. The earlier the baby is born, the higher the risk of complications.</p>
<p>Growing evidence suggests that risks of adverse health outcomes are elevated not only for infants born preterm, but also for infants born “<a href="https://pubmed.ncbi.nlm.nih.gov/32960896/">early term</a>” (at 37 to 38 weeks of pregnancy).</p>
<h2>1.5 million babies</h2>
<p>We included data on 1.5 million infants born in Sweden between 1997 and 2016. We obtained information about the parents’ mental health from the <a href="https://pubmed.ncbi.nlm.nih.gov/21658213/">National Patient Register</a>, which records all psychiatric diagnoses by clinical specialists in Sweden. We ascertained length of pregnancies in weeks (gestational age) from the <a href="https://pubmed.ncbi.nlm.nih.gov/36595114/">Medical Birth Register</a> where all Swedish births are recorded.</p>
<p>Some 15% of the infants had at least one parent with a mental health disorder. Children of parents with mental illness tended to have a shorter gestational age.</p>
<p>Compared with children where neither parent had a mental illness, infants whose fathers but not mothers had a mental illness had a 12% increased risk of being born preterm, whereas the risk increased by 31% if only the mother had a mental illness. If both parents did, the risk increased by 52%.</p>
<p>In absolute numbers, for parents without mental illness, one in 17 children were born preterm. A diagnosis in fathers increased the risk to one in 16, in mothers to one in 14, and in both parents to one in 12 children. We observed a similar pattern of risk for infants born at early term.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/perinatal-anxiety-one-in-five-women-experience-it-but-many-still-suffer-alone-before-or-after-childbirth-133667">Perinatal anxiety: one in five women experience it – but many still suffer alone before or after childbirth</a>
</strong>
</em>
</p>
<hr>
<p>Of all the mental health conditions we looked at, stress-related disorders, such as post-traumatic stress disorder, were associated with the highest risk of preterm birth. The risk increased by 23% if the father had a stress-related disorder, 47% if the mother suffered from a stress-related disorder, and 90% if both parents had a diagnosis, compared with children where neither parent had a stress-related disorder.</p>
<p>The risk was also increased if parents had multiple different psychiatric disorders. For example, children of a mother with depression were 25% more likely to be born preterm compared to children of a mother without a psychiatric disorder. When the mother had depression and schizophrenia at the same time, the risk increased by 39%. If the mother had depression, schizophrenia and anxiety disorder, the risk increased by 65%. </p>
<p>Similar patterns were seen when the father had multiple disorders.</p>
<figure class="align-center ">
<img alt="A premature baby girl in an incubator." src="https://images.theconversation.com/files/537540/original/file-20230714-16-ttindx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/537540/original/file-20230714-16-ttindx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/537540/original/file-20230714-16-ttindx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/537540/original/file-20230714-16-ttindx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/537540/original/file-20230714-16-ttindx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/537540/original/file-20230714-16-ttindx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/537540/original/file-20230714-16-ttindx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Being born early increases the risk of health complications for the baby.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/premature-newborn-baby-girl-hospital-incubator-396467248">OndroM/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Why the link?</h2>
<p>Previous studies have linked mental illness in <a href="https://pubmed.ncbi.nlm.nih.gov/32671543/">mothers</a> with an increased risk of preterm birth, but we’ve known much less about the father’s role in this regard. Our study demonstrates the significance of a father’s mental illness in the risk of preterm birth.</p>
<p>The underlying mechanism is likely to be complex – we can only really speculate on what is behind these trends. </p>
<p>Maternal stress has been linked to higher levels of stress hormones, which may induce <a href="https://pubmed.ncbi.nlm.nih.gov/20147718/">premature contractions</a>. Suffering from a mental illness, or having a partner with a mental illness, will probably be a source of stress for an expectant mother.</p>
<p>Research suggests that a father’s <a href="https://pubmed.ncbi.nlm.nih.gov/20066551/">support during pregnancy</a> can moderate the effects of maternal stress. In one study, women with chronic stress who had better support from the baby’s father (including emotional and financial support) had a lower risk of preterm delivery. When both parents have a mental illness, such support is probably more likely to be lacking.</p>
<p>Also, some social and environmental disadvantages that increase the risk of preterm birth, such as <a href="https://pubmed.ncbi.nlm.nih.gov/31811316/">substance abuse</a>, smoking, and <a href="https://pubmed.ncbi.nlm.nih.gov/20147718/">low socioeconomic status</a>, may cluster in families where one or both parents <a href="https://pubmed.ncbi.nlm.nih.gov/28219896/">have a mental illness</a>. These factors may play a role in the association between parental mental illness and preterm births.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-maternal-deaths-in-the-uk-are-rising-194885">Why maternal deaths in the UK are rising</a>
</strong>
</em>
</p>
<hr>
<p>Roughly <a href="https://www.who.int/news-room/fact-sheets/detail/mental-disorders">one in eight people</a> in the world have a mental disorder. Future studies should examine whether additional social support and prenatal care for families with mental illness could lessen the risk of preterm birth, as well as the potential effects of psychiatric medications and treatments.</p><img src="https://counter.theconversation.com/content/209261/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A new study from Sweden looked at around 1.5 million births.Weiyao Yin, Postdoctoral researcher, Department of Medical Epidemiology and Biostatistics, Karolinska InstitutetJonas F. Ludvigsson, Professor, Department of Medical Epidemiology and Biostatistics. Senior Pediatrician, Örebro University Hospital., Karolinska InstitutetSven Sandin, Associate Professor, Icahn School of Medicine at Mount Sinai, New York, Karolinska InstitutetLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2096362023-07-17T16:05:23Z2023-07-17T16:05:23ZHow childhood trauma can lead to obesity in people with serious mental illness<figure><img src="https://images.theconversation.com/files/537128/original/file-20230712-24-tjrwvy.jpg?ixlib=rb-1.1.0&rect=0%2C6%2C4031%2C2257&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research suggests childhood trauma has a big part to play in obesity.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/silhouette-woman-sitting-on-bed-beside-1439614217">Ken stocker/Shutterstock</a></span></figcaption></figure><p>People with a serious mental illness (SMI), like schizophrenia, often experience obesity. And in the UK, such people are almost <a href="https://www.gov.uk/government/publications/severe-mental-illness-smi-physical-health-inequalities/severe-mental-illness-and-physical-health-inequalities-briefing#:%7E:text=This%20analysis%20shows%20that%20compared,the%20difference%20is%20not%20significant">twice as likely</a> to be obese compared to those without a diagnosis. </p>
<p>People with SMI also have a greater risk of having other obesity related illnesses such as type 2 diabetes, respiratory disease, cardiovascular disease and heart failure. The result is a life expectancy that is <a href="https://pubmed.ncbi.nlm.nih.gov/28237639/">15 years less than</a> the general population. </p>
<p>Many experts believe the greater risk of obesity is due to the medications used to treat mental illness. Antipsychotics, for example, have <a href="https://pubmed.ncbi.nlm.nih.gov/37159349/">frequently been shown</a> to impact body weight. </p>
<p>But that explanation does not consider the role that deeper psychological factors play in obesity. There is a body of research that suggests childhood trauma <a href="https://pubmed.ncbi.nlm.nih.gov/33506595/">has a big part to play</a> too.</p>
<h2>Psychological trauma and obesity</h2>
<p>Psychologists often refer to the trauma experienced in childhood as “adverse childhood experiences” (ACEs). Such experiences include abuse and neglect (both physical and emotional), mental illness and substance abuse in the home, witnessing domestic abuse and having an incarcerated relative. </p>
<p>This type of trauma is <a href="https://link.springer.com/article/10.1007/s00787-021-01938-9">strongly associated</a> with the development of mental illnesses in later life. This may explain why many people who are treated in psychiatric hospitals have had such experiences. For example, <a href="https://nccu.nhs.wales/qais/national-reviews/making-days-count/mdc-documents/making-days-count1/">70% of people</a> in forensic psychiatric hospitals have at least one ACE, compared to 47% of the population of Wales. </p>
<p>Research also shows trauma can effect the way people behave. A <a href="https://academic.oup.com/eurpub/article/26/suppl_1/ckw167.009/2448496">recent study</a> found someone who has experienced four or more adverse childhood experiences is twice as likely to have an unhealthy diet. This may explain why there is a <a href="https://www.sciencedirect.com/science/article/pii/S003193842030278X?ref=pdf_download&fr=RR-2&rr=7e5964419ba4730c">46% increase</a> in the odds of adult obesity following exposure to multiple ACEs. </p>
<p>Despite this knowledge, however, little attention is paid by policymakers to the impact childhood trauma can have on obesity in people with serious mental illness. </p>
<p>Why is it that people who experience trauma in childhood have a greater risk of being obese? It is well known that people who have experienced traumatic childhoods engage in behaviour that isn’t particularly healthy, such as self-harming, abusing drugs and binge eating. These people do this as a form of avoidance, to distract themselves from the difficult thoughts and feelings they experience. </p>
<p>The term used to describe this behaviour is <a href="https://www.verywellmind.com/experiential-avoidance-2797358#:%7E:text=Experiential%20avoidance%20is%20an%20attempt,in%20contact%20with%20internal%20experiences.">“experiential avoidance”</a>.</p>
<h2>Eating our emotions</h2>
<p>Experiential avoidance can take many forms, but a common method is emotional eating, which is the tendency to eat in response to negative emotions. It is associated with the consumption of tasty food that is high in calories. </p>
<p>When someone emotionally eats, they can experience the numbing of intense negative emotion, can be distracted and <a href="https://link.springer.com/article/10.1007/s40519-016-0301-9">feel a sense of comfort</a>. This is because when we eat food with lots of fat and sugar, it activates the reward and pleasure areas centres of the brain. Eating foods high in fats and sugar is fine in moderation, of course. But the positive effects of eating tasty, high calorie foods are often short lived. </p>
<figure class="align-center ">
<img alt="A selection of food, including chips, doughnuts, ice cream and cakes are laid out on a blue table." src="https://images.theconversation.com/files/537485/original/file-20230714-25-kx7uff.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/537485/original/file-20230714-25-kx7uff.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/537485/original/file-20230714-25-kx7uff.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/537485/original/file-20230714-25-kx7uff.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/537485/original/file-20230714-25-kx7uff.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/537485/original/file-20230714-25-kx7uff.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/537485/original/file-20230714-25-kx7uff.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Eating food high in sugar and fat activates the reward and pleasure areas centres of our brain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/unhealthy-products-food-bad-figure-skin-1062629861">beats1/Shutterstock</a></span>
</figcaption>
</figure>
<p>So, people who engage in experiential avoidance may rely on these foods and consume them to excess. This, <a href="https://www.sciencedirect.com/science/article/pii/S0195666315001397?casa_token=-bqvrnAs3uIAAAAA:KJr48KBwRoU3lPcRkV-OOURVvgJ78F8gUnEkMxsNrcEVRqt3j0-esBpn5kBS_uoTjbvazswR3PQ">according to research</a>, is what can lead to weight gain and obesity. </p>
<p>Currently, the <a href="https://www.nice.org.uk/sharedlearning/improving-physical-health-for-people-with-serious-mental-illness-smi">treatment guidelines</a> for people with SMI do not consider the impact that ACEs can have on obesity in this group of people. This is probably due to the emphasis placed on antipsychotic drugs as the main contributor to excessive weight gain. </p>
<p>And despite the negative impact that obesity can have on people with a serious mental illness, psychiatric services often <a href="https://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.2008.01211.x">overlook physical health issues</a> because some psychiatric staff feel they are <a href="https://onlinelibrary.wiley.com/doi/10.1111/j.1747-0080.2011.01568.x">not adequately trained</a> to deal with the physical health of their patients.</p>
<p>To improve physical health in people with a serious mental illness, it is important that mental health professionals and policymakers consider the impact that psychological trauma has on obesity in this group of people. </p>
<p>Promoting a trauma-informed approach to both psychiatric and physical health care is vital. In essence, this would involve care teams having a <a href="https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/">complete picture</a> of their patient, mentally and physically, and providing adequate training around the impact that psychological trauma can have on a person’s behaviour.</p><img src="https://counter.theconversation.com/content/209636/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joseph Lloyd Davies does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Deep psychological factors play a part in obesity, including childhood trauma.Joseph Lloyd Davies, Lecturer in Applied Psychology, Cardiff Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2032412023-05-30T01:06:03Z2023-05-30T01:06:03Z‘It’s actually a human person, undergoing real emotions’: how podcasts can impact attitudes around mental health<figure><img src="https://images.theconversation.com/files/527649/original/file-20230523-15-ztqkj5.jpg?ixlib=rb-1.1.0&rect=5%2C0%2C3652%2C2445&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Ross Sneddon/Unsplash</span></span></figcaption></figure><p><a href="https://www.buzzsprout.com/blog/podcast-statistics">Millions of people</a> listen to podcasts each year. Podcast content is diverse, with popular genres including true crime, comedy, and society and culture. </p>
<p>In our research, we’re specifically interested in podcasts that talk about mental health. </p>
<p>People listen to mental health-themed podcasts <a href="https://www.tandfonline.com/doi/full/10.1080/10510974.2023.2196433?src=">for many reasons</a>: to understand mental health issues better, to learn self-help strategies to support their mental health, and for inspiration or motivation. </p>
<p>Podcasts can also bring attention to issues faced by marginalised communities. </p>
<p>People living with mental health issues <a href="https://nationalstigmareportcard.com.au/">regularly face stigma and discrimination</a>, such as being unfairly treated in workplaces and healthcare settings. </p>
<p>Podcasts have the potential to raise awareness about unfair treatment and challenge myths. There are certain features of podcasts which can potentially impact listeners’ knowledge and attitudes around mental health.</p>
<p>In our <a href="https://formative.jmir.org/2023/1/e44412/">newly published research</a>, we have explored how podcasts about mental health can be designed in a way that reduces stigma and discrimination in the community.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/depression-too-often-gets-deemed-hard-to-treat-when-medication-falls-short-198282">Depression too often gets deemed 'hard to treat' when medication falls short</a>
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<h2>Powerful storytelling</h2>
<p>Podcasts can be “edutainment”: a great way to draw listeners’ attention to important topics and explore complex issues. </p>
<p>Conversational language, expert interviews, compellingly crafted stories and clever use of sound and music can help make these topics dynamic and interesting. </p>
<p>Podcast listening is intimate. People often listen to podcasts alone via headphones, making the experience immersive. Many podcast listeners feel very connected to podcast hosts and guests. They also connect with other listeners through online communities. </p>
<p>Podcasters can use these features to connect with listeners around complex topics like mental health. As a result, listeners may absorb and trust messages received through the podcast.</p>
<p><a href="https://www.tandfonline.com/doi/full/10.1080/10410236.2018.1485078">Researchers argue</a> engaging with personal stories can help people experience empathy – like they are stepping into the shoes of someone else. They can be taken on an emotional journey, which can help them see things differently. </p>
<p>TV host and media personality Osher Günsberg speaks candidly with Todd Sampson about mental illness on Günsberg’s podcast Better Than Yesterday. <a href="https://open.spotify.com/episode/3vjc3Gq10oulW853qVkwRR?si=f01939a555574566">Across a two-part episode</a> Günsberg dives into his experiences with alcohol use, intense anxiety, psychosis and post-traumatic stress. </p>
<iframe style="border-radius:12px" src="https://open.spotify.com/embed/episode/3vjc3Gq10oulW853qVkwRR?utm_source=generator" width="100%" height="152" frameborder="0" allowfullscreen="" allow="autoplay; clipboard-write; encrypted-media; fullscreen; picture-in-picture" loading="lazy"></iframe>
<p>The episodes challenge listeners’ perceptions about what it means to be unwell, demonstrating how a person can seem to be thriving on the outside, while struggling on the inside. Günsberg also talks openly about how stigma prevented him from accessing therapy and medication when he first needed it. </p>
<p>It’s an emotional episode. Both Günsberg and Sampson shed tears by the end – and some listeners probably did, too.</p>
<h2>Voices that matter</h2>
<p>Contact with people living with mental health issues is an <a href="https://www.sciencedirect.com/science/article/abs/pii/S0140673615002986">effective way</a> to reduce stigma. This contact does not have to be face-to-face to be effective. </p>
<p>Many popular podcasts centre around hearing directly from people with lived experience. In the podcast <a href="https://mentalpod.com/">Mental Illness Happy Hour</a>, host Paul Gilmartin explores mental illness, trauma, and addiction through real stories – both his own, and his guests’ experiences. </p>
<iframe style="border-radius:12px" src="https://open.spotify.com/embed/episode/0n2ldgKy9nsddXfUDjdhmT?utm_source=generator" width="100%" height="152" frameborder="0" allowfullscreen="" allow="autoplay; clipboard-write; encrypted-media; fullscreen; picture-in-picture" loading="lazy"></iframe>
<p>Some podcasters also share lived experience on podcasts which are not specific to mental health. </p>
<p>Author and activist Aubrey Gordon regularly speaks about her experience with eating disorders while co-hosting the podcast <a href="https://www.maintenancephase.com/">Maintenance Phase</a>, which debunks health fads and wellness scams. Her personal disclosures make the episodes even more engaging, and illustrate the real-life impact of these fads and scams.</p>
<iframe style="border-radius:12px" src="https://open.spotify.com/embed/episode/29LkABbU6Yc09aTCkWnUBY?utm_source=generator" width="100%" height="152" frameborder="0" allowfullscreen="" allow="autoplay; clipboard-write; encrypted-media; fullscreen; picture-in-picture" loading="lazy"></iframe>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-power-and-the-pitfalls-of-personal-storytelling-the-best-podcasts-of-2022-195924">The power and the pitfalls of personal storytelling – the best podcasts of 2022</a>
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<hr>
<h2>Personal stories</h2>
<p>As part of our research, we have been talking with people who have lived experience of complex mental health issues, media professionals, healthcare professionals and workplace mental health champions. </p>
<p>We looked at the features of podcasts they felt could effectively combat stigma. </p>
<p>Our participants felt real stories from people with lived experience, shared via podcast episodes, are impactful: </p>
<blockquote>
<p>This is mental health, and it’s stigma, but at the root of it, it’s stories, it’s personal stories. It’s lived experience and that’s what people are resonating with. And that’s what connects [with listeners]. And it’s kind of from that, the behaviours, the awareness, the behaviour change kind of gets a jumping off.</p>
</blockquote>
<p>Our participants also told us they appreciated episodes that explicitly talked about stigma and discrimination, rather than just talking about lived experience generally. </p>
<blockquote>
<p>It would be nice to have a podcast that is actually going to deep dive into some of the real issues […] and why people struggle.</p>
</blockquote>
<p>Though stories can be powerful on their own, participants also felt podcasts could also highlight the very real impacts of marginalisation and inform listeners how they can make positive change. As one participant told us:</p>
<blockquote>
<p>[With] real stories, they can relate to it more, to the human face to it […] it’s not just an abstract thing that they see like a statistic or TV or like, things that they cannot really see […] it’s actually a human person, undergoing real emotions.</p>
</blockquote>
<p>It makes sense many mental health organisations and advocacy groups are releasing podcasts – they are popular, accessible, engaging, and a novel way to share real stories. We suspect podcasts will continue to be used in the fight against stigma and discrimination.</p>
<p>Our next steps are to release our own mental health podcast which we hope will impact listeners’ attitudes in a positive way. We have taken on the advice from those we interviewed, and we are currently exploring the impact of listening to this podcast on listeners’ attitudes and behaviours towards complex mental health issues. We plan to release it to the public later in 2023. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/should-you-tell-your-boss-about-your-mental-illness-heres-what-to-weigh-up-200907">Should you tell your boss about your mental illness? Here's what to weigh up</a>
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<img src="https://counter.theconversation.com/content/203241/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elise Carrotte works for SANE. She currently hosts a podcast unrelated to this body of work. This study was funded by the National Stigma Report Card project, which is led by SANE in partnership with the Melbourne School of Psychological Sciences with the support of the Paul Ramsay Foundation. </span></em></p><p class="fine-print"><em><span>Lisa Phillips does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In our new research, we have explored how podcasts about mental health can be designed in a way that reduces stigma and discrimination.Elise Carrotte, PhD Candidate, The University of MelbourneLisa Phillips, Professor, Melbourne School of Psychological Sciences, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2060492023-05-25T12:26:20Z2023-05-25T12:26:20ZWhat is vernacular art? A visual artist explains<figure><img src="https://images.theconversation.com/files/527842/original/file-20230523-29-vkachs.jpg?ixlib=rb-1.1.0&rect=36%2C22%2C4883%2C3231&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Henry Darger worked as a hospital custodian. After his death in 1973, hundreds of his illustrations were discovered.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/amberjol/26616919145">Brooklyn Taxidermy/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p><a href="https://www.artnews.com/art-news/news/the-error-of-margins-vernacular-artists-and-the-mainstream-art-world-5067/">Vernacular art</a> is a genre of visual art made by artists who are usually self-taught. They tend to work outside of art academies and commercial galleries, which have traditionally been the purview of white, affluent artists and collectors.</p>
<p>In the U.S., vernacular art – which can also be called folk art or outsider art – is dominated by the works of African American, Appalachian and working-class people. In many cases these artists took up making paintings, sculptures, quilts or textiles outside of a day job, or later in life. </p>
<p>In early 2023, Christie’s held an <a href="https://www.christies.com/en/auction/outsider-and-vernacular-art-29693/overview">auction of outsider and vernacular art</a>. Featuring work by American artists such as <a href="https://www.moma.org/artists/28600">Henry Darger</a>, <a href="https://www.newyorker.com/magazine/2018/10/08/the-utterly-original-bill-traylor">Bill Traylor</a>, <a href="https://www.soulsgrowndeep.org/artist/thornton-dial">Thornton Dial</a>, <a href="https://high.org/exhibition/really-free-the-radical-art-of-nellie-mae-rowe/">Nellie Mae Rowe</a>, <a href="https://americanart.si.edu/artist/minnie-evans-1466">Minnie Evans</a> and <a href="https://www.moma.org/artists/26683">Joseph Yoakum</a>, the sale grossed more than US$2 million.</p>
<p>Awareness and recognition of this genre has grown over the past few decades, with the Smithsonian Museum of American Art in Washington, D.C.; the American Visionary Art Museum in Baltimore; Atlanta’s High Museum; and the Milwaukee Art Museum building significant collections.</p>
<h2>Art history as artist history</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/528039/original/file-20230524-7504-jrqr6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Colorful drawing." src="https://images.theconversation.com/files/528039/original/file-20230524-7504-jrqr6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/528039/original/file-20230524-7504-jrqr6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=808&fit=crop&dpr=1 600w, https://images.theconversation.com/files/528039/original/file-20230524-7504-jrqr6k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=808&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/528039/original/file-20230524-7504-jrqr6k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=808&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/528039/original/file-20230524-7504-jrqr6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1016&fit=crop&dpr=1 754w, https://images.theconversation.com/files/528039/original/file-20230524-7504-jrqr6k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1016&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/528039/original/file-20230524-7504-jrqr6k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1016&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Adolf Wölfli’s ‘General view of the island Neveranger’ (1911).</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/a/ab/Adolf_W%C3%B6lfli_General_view_of_the_island_Neveranger%2C_1911.jpg">Wikimedia Commons</a></span>
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<p>In the 1940s, the French artist Jean Dubuffet came up with the term “<a href="https://blog.artsper.com/en/a-closer-look/definition-of-art-brut/">art brut</a>,” which translates as “raw art,” to describe art made by mental patients, prisoners or children. The drawings of <a href="https://www.britannica.com/biography/Adolf-Wolfli">Adolf Wölfli</a>, who died in 1930, inspired Dubuffet’s term.</p>
<p>Wölfli was a patient with schizophrenia in a mental hospital in Bern, Switzerland, who was given pencils and paper as a form of therapy. Working mostly in pencil, Wölfli created elaborate drawings with decorative borders that included symbols, letters and his own system of musical notation.</p>
<p>In an effort to promote this genre, in 1972 the British art historian Roger Cardinal advanced the term “<a href="https://mediumisticart.com/publications/outsider-art/">outsider art</a>” to expand the canon and include more artists, such as <a href="https://madgegill.com/">Madge Gill</a>, who died in 1961. Gill, a British self-taught artist who spent much of her childhood in an orphanage, started making highly patterned drawings at the age of 38, claiming to compose the works while communicating with spirits.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/527802/original/file-20230523-17-a6sb7o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Drawing featuring faces and patterns." src="https://images.theconversation.com/files/527802/original/file-20230523-17-a6sb7o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/527802/original/file-20230523-17-a6sb7o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/527802/original/file-20230523-17-a6sb7o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/527802/original/file-20230523-17-a6sb7o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/527802/original/file-20230523-17-a6sb7o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/527802/original/file-20230523-17-a6sb7o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/527802/original/file-20230523-17-a6sb7o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A detail from Madge Gill’s ‘The Transformation.’</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/gogginsworld/48537908822">Goggins World/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>In his 2004 book “<a href="https://press.uchicago.edu/ucp/books/book/chicago/E/bo3621838.html">Everyday Genius: Self-Taught Art and Culture of Authenticity</a>,” sociologist Gary Allen Fine explains that a common facet of vernacular art is an emphasis on the artist’s biography: their personal, family and employment history. Fine observed that to collectors and dealers, these stories seemed to imbue the art with more meaning – and value. <a href="https://arttable.org/cubeportfolio/brooke-davis-anderson/">Some curators</a> have argued that vernacular art should be included in exhibitions of contemporary art and not merely exist in its own siloed category.</p>
<p>But the relationship between vernacular artists and their promoters can be complicated.</p>
<p>In her 1998 book “<a href="https://go.gale.com/ps/i.do?p=LitRC&u=googlescholar&id=GALE%7CA61185779&v=2.1&it=r&sid=googleScholar&asid=da1ead40">The Temptation: Edgar Tolson and the Genesis of Twentieth-Century Folk Art</a>,” sociologist Julia Ardery explored the ways that <a href="https://americanart.si.edu/artist/edgar-tolson-4834">Tolson</a>, a self-taught woodcarver from rural Kentucky, interacted with faculty and students from the University of Kentucky, and she analyzed their influence on his art.</p>
<p>Much of Tolson’s work was acquired by Michael Hall, who taught at the University of Kentucky at the time. Hall helped Tolson receive a <a href="https://www.jstor.org/stable/3675514">National Endowment for the Arts Individual Artist Fellowship in 1981</a>, but he also ended up selling a portion of his collection to the Milwaukee Art Museum in 1989 <a href="https://www.nytimes.com/1995/02/26/arts/arts-artifacts-folk-art-with-an-eye-toward-the-modern.html">for $1.5 million</a>. </p>
<p>As the sale of Tolson’s work shows, when huge sums of money enter the picture, the line between appreciation and exploitation gets blurred.</p>
<h2>Why vernacular art matters</h2>
<p>Vernacular art extends the artistic canon in the same way that folk music reflects broader traditions of expression. It reminds everyone that art is a universal human pursuit.</p>
<p>As the late Chris Strachwitz, the founder of <a href="https://folkways.si.edu/arhoolie">Arhoulie Records</a>, has pointed out, Black traditions of blues and roots music were not formally taught but were passed down from one generation to the next in local communities.</p>
<p>Similarly, the architect <a href="https://www.nytimes.com/2018/09/19/obituaries/robert-venturi-dead.html">Robert Venturi</a> promoted vernacular architecture in his 1972 book “<a href="https://en.wikipedia.org/wiki/Learning_from_Las_Vegas">Learning from Las Vegas</a>.” In it, he highlighted the ways that Las Vegas casinos and hotels were designed to accommodate the automobile and were meant to be seen as symbols, with massive, outlandish signs – an approach that most schools of architecture would have scoffed at. In doing so, Venturi ushered in <a href="https://blogs.ethz.ch/prespecific/2013/09/18/venturi-learning-from-las-vegas/">more playful forms</a> of architecture.</p>
<p><a href="https://volweb.utk.edu/%7Eblyons/spelvinissues.htm">Concepts of authenticity</a> are central to the appeal of vernacular art. Fine art and culture can sometimes be esoteric and exclusionary, and in a time when artificial intelligence has put authorship in question, vernacular art has even more resonance. It is made by the artists’ hands, using common materials, in ways that reflect their own unique life and artistic visions. </p>
<p>This work represents a pre-digital form of expression, accessible to anyone, that showcases what it means to be resourceful, creative and human.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/qpYGAeenvy0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Nellie Mae Rowe wasn’t able to pursue her artistic ambitions until she was in her late 60s.</span></figcaption>
</figure><img src="https://counter.theconversation.com/content/206049/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>I once created a traveling exhibition of fictive folk art as a parody of the genre. </span></em></p>The genre – also known as ‘folk art’ or ‘outsider art’ – serves as a reminder that art is a universal human pursuit.Beauvais Lyons, Chancellor’s Professor of Art, University of TennesseeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2009072023-05-17T20:07:36Z2023-05-17T20:07:36ZShould you tell your boss about your mental illness? Here’s what to weigh up<figure><img src="https://images.theconversation.com/files/525012/original/file-20230509-15-nmoa1z.jpg?ixlib=rb-1.1.0&rect=24%2C131%2C5439%2C3506&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/thoughtful-anxious-asian-business-woman-looking-1408495376">Shutterstock</a></span></figcaption></figure><p>Whether you know about it or not, it’s likely someone you work with or manage has a mental illness. <a href="https://www.aihw.gov.au/reports/mental-health-services/mental-health">One in five Australians</a> have experienced a mental illness in the last 12 months. </p>
<p>Many people stay silent about their mental illness at work. Roughly <a href="https://pubmed.ncbi.nlm.nih.gov/28073386/">50%</a>–<a href="https://pubmed.ncbi.nlm.nih.gov/23083627/">70%</a> of employees choose not to disclose their condition. This may leave employees vulnerable, as employers can’t provide individual support without disclosure. </p>
<p>Over the years, many experts and commentators <a href="https://www.smh.com.au/business/workplace/poor-understanding-of-mental-health-stifles-employment-20210628-p584z3.html">have suggested</a> workers stay silent about mental illness, for fear of stigma and discrimination, and to protect their jobs.</p>
<p>But the evidence suggests there are often benefits to disclosing a mental health condition at work.</p>
<h2>What does the research say?</h2>
<p>The <a href="https://pubmed.ncbi.nlm.nih.gov/28073386/">largest Australian study of stigma</a>, from 2018, found employees who disclosed their mental health conditions to their employers were well supported. They reported receiving accommodations such as flexible work arrangements and time off for appointments. They also felt supported by their colleagues and managers.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3610943/">Other research</a> shows disclosure can, for some people, lead to increased social support and better mental health. Being open about a mental health condition <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3610943/">reduces</a> self-stigma (negative beliefs people develop about themselves due to societal stigma and discrimination), increases empowerment and facilitates a sense of power and control.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1520134877609439233"}"></div></p>
<p>Our team conducted a <a href="https://pubmed.ncbi.nlm.nih.gov/31413183/">randomised controlled trial</a> involving 107 adults considering disclosing their mental health concerns at work. Participants used our newly developed <a href="https://www.readydat.com.au/">online decision aid</a> to make an informed decision about disclosing their mental health concerns to their employers. It includes seven modules to guide users to consider the potential outcomes, benefits and challenges of disclosing. </p>
<p>A review of the decision aid found the people who disclosed their mental health condition at work reported a reduction in symptoms of depression and stress (from severe to moderate), on average, compared to those who chose to stay silent. This finding was based on self-reported clinical diagnostic scales for depression and validated measures of stress.</p>
<p>The <a href="https://www.readydat.com.au/">decision aid</a> is now <a href="https://www.sira.nsw.gov.au/resources-library/law-and-policy-or-corporate/publications/recovery-at-work-toolkit">publicly available</a> and free to use through the New South Wales State Insurance Regulatory Authority.</p>
<figure class="align-center ">
<img alt="Man looks at phone" src="https://images.theconversation.com/files/525019/original/file-20230509-23-uslr52.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/525019/original/file-20230509-23-uslr52.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/525019/original/file-20230509-23-uslr52.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/525019/original/file-20230509-23-uslr52.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/525019/original/file-20230509-23-uslr52.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/525019/original/file-20230509-23-uslr52.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/525019/original/file-20230509-23-uslr52.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Tools are available to guide you through the pros and cons.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/handsome-serious-senior-man-wearing-glasses-2258555247">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Changing the culture</h2>
<p>Many people with mental illnesses worry disclosing their condition will result in negative consequences, such as losing their job, being passed over for promotions, or being treated unfairly by colleagues. </p>
<p>These worries are <a href="https://www.frontiersin.org/articles/10.3389/fpsyt.2018.00684/full">major barriers to disclosure</a> – and can become a reality for some people who disclose. </p>
<p>However, the world of work is changing. Employees are seeking jobs that prioritise mental health, with many <a href="https://www.ukg.com/resources/article/mental-health-work-managers-and-money">saying</a> they would take a pay cut for an organisation that promotes and implements measures focused on employees mental health and happiness.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-its-more-important-than-ever-for-workplaces-to-have-staff-well-being-plans-186807">Why it's more important than ever for workplaces to have staff well-being plans</a>
</strong>
</em>
</p>
<hr>
<p>People who are open about their experiences with mental ill-health can <a href="https://link.springer.com/article/10.1007/s10597-021-00786-w">experience</a> increased self-acceptance and feelings of connectedness. Disclosure can help people feel more understood and supported by others, which in turn can lead to greater feelings of self-worth and belonging. </p>
<p>Sharing their experiences helps to break down the stigma surrounding mental illness and foster a culture of openness, understanding and empathy among peers. It can also help colleagues overcome the fear of stigma. </p>
<h2>So how can employers create safe environments for disclosure?</h2>
<p>Managers have a huge responsibility when it comes to their employee’s mental health. According to <a href="https://www.ukg.com/resources/article/mental-health-work-managers-and-money">recent research</a>, managers have just as much impact on an employee’s mental health as their partner, and significantly more than their doctor or therapist. </p>
<p>Managers need to ensure they provide a safe and supportive environment in which to disclose mental ill-health. This <a href="https://pubmed.ncbi.nlm.nih.gov/29563195/">requires</a> knowledge and confidence. Managers can emphasise the support and resources available to employees who choose to disclose, rather than dwelling on what the staff member might lose or the potential impact on the organisation.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1653020125006577665"}"></div></p>
<p>People who perceive their disclosure positively <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0091053">tend to have</a> supportive managers. As “David” from our research told us:</p>
<blockquote>
<p>Five years ago, and at the very tail-end of my career, I thought I’d confide in a boss. His first words were, ‘What can we do to help you?’ With those simple words, he instantly won my undying loyalty.</p>
</blockquote>
<p>With an increasing focus on mental wellbeing at work, it’s time our mental health advocates moved away from messages to stay silent. Instead, we need to ensure all staff with mental health conditions can access much-needed workplace support and accommodations. </p>
<p>By creating environments where employees feel safe and supported to share their experiences, we can begin to break down the barriers to disclosure and create workplace cultures that prioritise mental health and wellbeing. For many, disclosure can be positive and we have the tools to help.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/its-ruok-day-but-how-can-i-help-might-be-a-better-question-to-ask-190064">It's RUOK Day – but 'how can I help?' might be a better question to ask</a>
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</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/200907/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Stratton receives funding from State Insurance Regulatory Authority (SIRA). Elizabeth Stratton co-owns the Intellectual Property developed in READY?, however, this is a non-profit tool not to be commercialised. </span></em></p><p class="fine-print"><em><span>Nick Glozier has received funding from ARC, movember, and SIRA. He is affiliated with WHO (and helped formulate their Guidelines on Mental Health at Work), NSW Personal Injury Commission, the NSW Centre for Work, Health and Safety Research Foundation, and the insurers IAG and TAL.</span></em></p>In the past, workers have been warned not to disclose their mental illness at work for fear of discrimination. But there can be many positives to telling your boss.Elizabeth Stratton, Postdoctoral Research Fellow, University of SydneyNick Glozier, Professor of Psychological Medicine, BMRI & Disciplne of Psychiatry, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2023432023-05-02T20:42:18Z2023-05-02T20:42:18ZExercise can help prevent and treat mental health problems, and taking it outside adds another boost to those benefits<figure><img src="https://images.theconversation.com/files/523463/original/file-20230428-22-4jbvw5.jpg?ixlib=rb-1.1.0&rect=465%2C1008%2C4837%2C2819&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Levels of the stress hormone cortisol are reduced with as little as 20 minutes in a city park.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/exercise-can-help-prevent-and-treat-mental-health-problems--and-taking-it-outside-adds-another-boost-to-those-benefits" width="100%" height="400"></iframe>
<p>Mental health problems affect <a href="https://cmha.ca/brochure/fast-facts-about-mental-illness/">one in five people every year</a>. The Canadian Mental Health Association estimates that by the age of 40, about half of people will either have had a mental illness or will currently be dealing with one. </p>
<p><a href="https://doi.org/10.24095/hpcdp.37.5.04">Behavioural therapy and medications</a> are common first options for treatment. However, research has shown the importance of exercise in not only preventing mental illness, but also treating it. And when exercise is taken outdoors, the benefits can be even greater.</p>
<p><a href="https://www.canada.ca/en/public-health/services/about-mental-illness.html">Mental illnesses</a> include depression, addictions and anxiety, as well as personality disorders. Of these, anxiety and depression are the most common, with <a href="https://apps.who.int/iris/handle/10665/254610">depression being the leading cause of disability worldwide</a>. Left untreated, these diseases can result in physical illness and premature death.</p>
<p>My research focuses on the benefits of physical activity to prevent and manage disease, and ways to make it easier for people to be active. In December 2021, I was diagnosed with major depressive disorder, and exercise and spending time in nature were vital to my recovery.</p>
<h2>Exercise can make you happy</h2>
<figure class="align-center ">
<img alt="Female soccer players training on the field" src="https://images.theconversation.com/files/523464/original/file-20230428-18-ecf5ph.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523464/original/file-20230428-18-ecf5ph.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523464/original/file-20230428-18-ecf5ph.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523464/original/file-20230428-18-ecf5ph.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523464/original/file-20230428-18-ecf5ph.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523464/original/file-20230428-18-ecf5ph.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523464/original/file-20230428-18-ecf5ph.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It also doesn’t matter what type of activity you do. Whether it’s team sports, cycling, walking, running or aerobics, all provide benefits.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Exercise and activity have long been known to improve mood. A study of more than 1.2 million adults in the United States reported those who exercised had <a href="https://doi.org/10.1016/S2215-0366(18)30227-X">1.5 fewer days in the past month of poor mental health</a>. And the greatest benefits occurred in those people who exercised 45 minutes or more for three or more days per week.</p>
<p>But even shorter sessions can make a difference. As little as ten minutes of activity was enough to <a href="https://doi.org/10.1007/s10902-018-9976-0">improve happiness</a>. Over time, regular exercise can result in <a href="https://doi.org/10.1176/appi.ajp.2017.16111223">less likelihood for getting depression</a> and <a href="https://doi.org/10.1016/j.amepre.2019.05.012">anxiety</a>. It also doesn’t matter what type of activity you do. Whether it’s team sports, cycling, walking, running or aerobics, all provide benefits. Even <a href="https://doi.org/10.1016/S2215-0366(18)30227-X">active household chores can reduce the chances for depression</a>.</p>
<h2>Exercise as treatment for mental illness</h2>
<p>Numerous studies indicate exercise as an effective treatment for people with existing depression and other mental illnesses. A meta-analysis revealed as little as four weeks of <a href="https://doi.org/10.1002/da.22842">exercise reduced symptoms of depression</a> in people with major depressive disorder. This is less time than it takes for most antidepressant medications to work.</p>
<figure class="align-center ">
<img alt="A woman in exercise gear outside, with a towel around her neck" src="https://images.theconversation.com/files/523657/original/file-20230501-1462-hmu9o0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523657/original/file-20230501-1462-hmu9o0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523657/original/file-20230501-1462-hmu9o0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523657/original/file-20230501-1462-hmu9o0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523657/original/file-20230501-1462-hmu9o0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523657/original/file-20230501-1462-hmu9o0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523657/original/file-20230501-1462-hmu9o0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Numerous studies indicate exercise as an effective treatment for people with existing depression and other mental illnesses.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>While exercise is beneficial at all intensity levels, it appears <a href="http://dx.doi.org/10.1136/bjsports-2022-106195">higher intensity exercise may be more effective than low intensity</a>. <a href="https://doi.org/10.1001/jamapsychiatry.2018.0572">Strength training can also reduce symptoms</a> in people with depression. And a recent review of studies totalling 128,119 participants reported <a href="http://dx.doi.org/10.1136/bjsports-2022-105964">exercise is as effective as antidepressants</a> for treating non-severe depression. Exercise has also been found to reduce symptoms in people with <a href="https://doi.org/10.1186/s12913-018-3313-5">clinical anxiety</a> and <a href="https://doi.org/10.3389/fpsyt.2018.00167">schizophrenia</a>.</p>
<h2>How exercise works to improve mental well-being</h2>
<p>Exercise may improve mental well-being due to the release of hormones and brain function. Exercise results in the release of <a href="https://doi.org/10.2165/00007256-199724010-00002">endorphins</a> and <a href="https://doi.org/10.1097/00001756-200312020-00015">endocannabinoids</a>. Endorphins are the feel-good hormones that reduce pain or discomfort associated with activity. Endocannabinoids work on the same system affected by marijuana, reducing pain and improving mood.</p>
<p>In the brain, <a href="https://doi.org/10.1016/j.bj.2020.01.001">low levels of brain-derived neurotrophic factor (BDNF)</a> and a <a href="https://doi.org/10.1038/s12276-021-00587-x">smaller hippocampus</a> have been associated with a number of mental illnesses. BDNF is important for the growth of nerves in the brain and development of new neural connections, while the hippocampus is associated with learning, memory and mood. Exercise can <a href="https://doi.org/10.3389/fpsyt.2018.00037">increase BDNF levels in people with depression</a>, as well as <a href="https://doi.org/10.1016/j.neuroimage.2017.11.007">increase hippocampus volume</a>.</p>
<h2>Take it outside</h2>
<p>Exercising in nature can further improve mental well-being. <a href="https://dictionary.apa.org/rumination">Rumination</a> is a negative pattern of repetitive thinking and dwelling on things. It is associated with greater chances for mental illness, but can be reduced with a <a href="https://doi.org/10.1073/pnas.1510459112">walk through a natural environment</a>. And people who spent at least two hours in nature over the course of a week reported <a href="https://doi.org/10.1038/s41598-019-44097-3">higher well-being</a> compared to those who had no contact with nature.</p>
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<img alt="A man with a backpack standing on a wooded trail." src="https://images.theconversation.com/files/523658/original/file-20230501-22-110x55.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523658/original/file-20230501-22-110x55.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523658/original/file-20230501-22-110x55.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523658/original/file-20230501-22-110x55.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523658/original/file-20230501-22-110x55.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523658/original/file-20230501-22-110x55.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523658/original/file-20230501-22-110x55.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Parks Canada recognized the benefits of exercising in nature by partnering with a health organization to allow doctors to prescribe Adult Parks Canada Discovery Passes to patients to enable them to spend time outdoors.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>There are a number of reasons why nature is good for us. Trees are known to give off compounds called phytoncides, which have been associated with <a href="https://doi.org/10.1007/s12199-009-0086-9">multiple health benefits</a>. In addition, <a href="https://doi.org/10.3389/fpsyg.2019.00722">levels of cortisol (the stress hormone) are reduced</a> with as little as 20 minutes spent in a park.</p>
<p>The value of being outdoors to physical and mental health was recognized by Parks Canada in January 2022, when they <a href="https://www.parkprescriptions.ca/">partnered with PaRx</a>, an organization led by health professionals who prescribe time in nature to their patients, to allow <a href="https://www.parkprescriptions.ca/blogposts/announcing-a-new-collaboration-between-parx-and-parks-canada">doctors to prescribe Adult Parks Canada Discovery Passes</a>. </p>
<p>With these passes, patients can access Canada’s national parks, national historic sites and national marine conservation areas. This follows <a href="https://www.weforum.org/agenda/2022/02/green-prescriptions-health-wellbeing/">similar programs in many other countries</a> such as New Zealand, Japan, the United States and the United Kingdom.</p>
<p>With all the benefits of exercise and nature on mental health, it’s important to recognize some people with a mental illness can find simple daily tasks challenging. For these people taking an antidepressant and behavioural therapy may be more suitable. But for others, exercising in nature is a simple and cost-saving activity to maintain your mental health and treat mental illnesses.</p>
<p><em>Scott Lear writes a biweekly blog <a href="https://drscottlear.com/">Become Your Healthiest You</a> and co-hosts a monthly podcast <a href="https://open.spotify.com/show/1xsvY0F6qbBKDG8INVvy5T">How to Health</a>.</em></p><img src="https://counter.theconversation.com/content/202343/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Scott Lear receives funding from the Canadian Institutes of Health Research and Hamilton Health Sciences, and has received funding from the Heart and Stroke Foundation, Novo Nordisk, and the Robert Wood Johnson Foundation.</span></em></p>Numerous studies indicate exercise as an effective treatment for people with existing depression and other mental illnesses, and exercising in nature can further improve mental well-being.Scott Lear, Professor of Health Sciences, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.