One of the things debated and discussed in blogs such as this, and in a lot of other places, is the nature of “mental illness”. Is it biochemistry? Is it genes? Is it the result of stress? Does it exist at all? Is it a construction arising from oppressive political influences? Take your pick and follow the trail that leads from it.
This is all very interesting and entertaining for those of us who enjoy debate and discussion, but it can leave the distressed, anxious or confused person who is seeking help somewhat lost. Do I need medication? Have I got faulty genes? Should I seek a less stressful situation? Am I making all this up? Is it someone else’s fault? Perhaps it is just as well the British Journal of Psychiatry has recently published a special supplement which offers clarification.
Before you go rushing off to find this Holy Grail, let me explain. The January 2013 edition of the British Journal of Psychiatry includes a short supplement of some nine papers edited by Swaran Singh and Max Birchwood which is entitled “Youth mental health: appropriate service response to emerging evidence”. What is notable about this is not so much what each of these papers says, directly, but how what they say, collectively, can be interpreted as a meta-message of much wider application and interest.
It is significant that the authors are all established mental health research professionals with a recognised track record of publications in mainstream medical journals, grants-winning success and senior academic posts. Their research is respected and influences practice and practitioners, and as a result it is of interest to look closely at what they are saying. It might be different from what is expected, or even from what they intend.
In essence there are three messages which interweave. The first is led by Peter Jones, Professor of Psychiatry at the University of Cambridge, England. His first sentence reads: “Adult mental health disorders begin in adolescence.” 1 The substance of his paper, which follows this assertion, is careful and convincing evidence from clinical studies, clinical epidemiology, secondary analysis of birth cohort data and cross-sectional surveys which support it. If conventional definitions are accepted, that 50% population will experience a DSM-IV mental health disorder during their lifetime, then a staggering half of these disorders will have begun by the age of 14. This ranges from 11 as the age when half of all anxiety disorders might have begun to 30 for the same assessment of mood disorders. Jones’ paper is a clear and authoritative summary of empirical, positivist data.
They inescapably identify what we call mental illnesses, as difficulties which have their origins in adolescence. He chooses to associate these findings with what is known about human brain development through childhood, puberty and adolescence but there is no evidential or epistemological justification for privileging this causative connection over explanations based upon emotional wellbeing and appropriate parental nurture. Jones’ statement: “Adult mental health disorders begin in adolescence.” is firmly supported by data. It doesn’t point to earlier developmental stages, and by adolescence he means the period that extends into early adult life. It is not a re-statement of psychodynamic dogma. In fact there is something intuitively obvious about it.
A second message is that there is value in attempting to do something about this, proactively, and preventatively. Patrick McGorry illustrates some of the benefits from such approaches, bemoans the scale of challenges of doing so, champions “early intervention” as a more realistic institutional approach, but at the same time draws attention to the inescapably harmful labelling that comes with this2. In contrast Paul Stallard and Rhiannon Buck describe how it is quite realistic to include a resilience-promoting programme in the school curriculum and reduce the risk of “depression”3. It seems to work. In another paper Andrew Chanen and Louise McCutcheon discuss ways in which earlier intervention amongst younger, more vulnerable individuals might mitigate the development of distressing patterns of interaction which are conventionally known as Borderline Personality Disorder4.
The third message is that we don’t listen to these first two messages. The core theme of the supplement is that current Irish, UK and Australian services are poorly matched to what the editors describe as young people’s needs. In particular the clear evidence that most so-called mental health difficulties apart from dementia begin in adolescence or early adulthood is not matched by services that focus upon this period. Instead, conventional child and adolescent mental health services provide for young people to the age of eighteen. After this, professional input is provided by the same service and with the same approach and philosophy as that providing for older adults to the age of sixty five.
Several papers draw attention to the consequences of discontinuity, as young people receiving professional mental health input transfer from child and adolescent services to adult services at eighteen, right in the middle of the period of vulnerability Jones and others identify. Inevitably recommendations about how things might be done differently have to be constrained by reluctances to change, but also by the fact that in the UK, in Australia and in most other countries an individual’s legal status changes as they reach the age of eighteen. This is important.
It is important because growth and maturation are, by definition, progressive processes. Becoming an adult is not something that suddenly happens on a particular day. These papers are also important because they draw attention to the fact that a very large proportion of what is conventionally called “mental illness” begins during the time when children are changing into adults … during a time when their identities are forming and when they are still vulnerable to influences beyond closer family ties and, during adolescence, increasingly exposed to them.
Most of us navigate this period safely and successfully, though I guess few would look back on it as a trouble free time. What Jones reminds us is that the cost for those who don’t can be very high. From many points of view “mental illness” is a self-fulfilling prophecy; disabling medication, sick role, stigmatisation and reduced ambitions and expectations are all so easy to fall into, and very difficult to escape.
Locating the origin of many “mental health difficulties” in adolescence also forces a review of what they are. The prevailing “illness” model identifies them as something alien that has afflicted the individual from outside, rather like an infecting parasite, or as something that has assaulted them such as an injury or the development of a malignant growth. If most actually begin during a time of vulnerability, then rather than identifying the condition itself as the problem, it would seem more appropriate to focus upon the vulnerability. It isn’t a big step, then, from identifying vulnerable young people as tomorrow’s psychiatric patients, to recognising that much might be done by being available to and responding accordingly. I am not advocating widespread methylphenidate for ADHD, or any of the other misguided misapprehensions which contribute to the growing number of medicalised young people. They have already been damaged by diagnosis. For all of us who can recall anything of it … or indeed observe it amongst our own family and friends, what makes for a successful adolescence and what hinders it? Acceptance, rather than pathologising? Respect and encouragement rather than criticism? Consistency?
Adolescence might be uncomfortable to observe or to experience, but it isn’t an obscure mystery. I wonder if we are giving it the attention it deserves? Perhaps what we call mental health problems really are largely due to the fact that not everyone gets the love and support they need when they are growing up. It’s a no brainer but an awfully difficult one to really get hold of … even harder to correct or prevent, yet if this is where the facts point us, shouldn’t we follow?
- Jones, P.B. (2013) Adult mental health disorders and their age at onset. British Journal of Psychiatry 202, s5 – s10.
- McGorry, P. (2013) Prevention, innovation and implementation science in mental health: the next wave of reform. British Journal of Psychiatry 202, s3 – s4.
- Stallard, P. & Buck R. (2013) Preventing depression and promoting resilience: feasibility study of a school-based cognitive-behavioural intervention. British Journal of Psychiatry 202, s18 – s23.
- Chanen, A.M. & McCutcheon. L (2013) Prevention and early intervention for borderline personality disorder: current status and recent evidence. British Journal of Psychiatry 202, s24 – s29.