I have a growing sense of unease about the Americanisation of British society’s attitude towards mental health. In the 1980s, British audiences smiled bemusedly at neurosis-laden Woody Allen films and the normality with which American television and cinema treated notions of therapy, meds and interventions. To a British ear, the protagonists of these human melodramas could seem self-absorbed, foolish and narcissistic; figures of fun to be pitied for their inability to maintain a stiff upper lip and their ignorance of the power of a strong cup of tea. Yet now these are all concepts that have been normalised in Britain too.
Mental health is talked about using the language of epidemics, and has been commoditised into something to be ordered over the counter: professionals, pills and a side of talking therapy. The scale of the problem has been supersized – exaggerated by extending the reach of healthcare well beyond those with serious, diagnosable psychiatric illness to include the worried well. Things that are better seen as a part of normal human life – the ramifications of choices we have made, our personal shortcomings, losses, bereavements, disappointments, unfairnesses, human frailties – are pathologised, and these experiences then conceptualised as illnesses to which there are no satisfactory treatments.
Rates of antidepressant prescription continue to increase year on year – and yet, paradoxically, so does the scale of the problem they ostensibly address. The proportion of sickness benefit claims made in relation to a mental health problem more than doubled in the period from 1995 to 2014 (from 21% to 46%), while more than 40% of absences among the employed are attributed to mental health problems. As a nation we are not unusual: the World Health Organization says that depression has become the “leading cause of disability worldwide”, and that it remains “on the rise globally”.
An excessively medicalised approach to mental health is neither humane nor kind. It fosters a learned helplessness, seeding doubt in the mind of the individual about their ability to endure life without the relentless input of doctors. Many form unhealthy, dependent relationships with healthcare professionals while becoming isolated from the kind of practical, amateur, human support that in many cases would be more helpful. It poses a grave cost to an already overstretched health service because clinicians are forced to spend a high proportion of their time talking to patients about problems they cannot fix, offering advice that could be more easily obtained from the hairdresser or pub landlord. It is all to the detriment of those with serious physical or indeed mental illness, where the clinician may be able to intervene usefully.
Mental ill-health is complex and subjective, and there are pros and cons to mental health awareness campaigns. I am not arguing that they are a bad idea per se, rather that too much is a bad thing. Well-intentioned efforts to “raise awareness” can be frequently counterproductive. The eminent British psychiatrist Simon Wessely was probably not joking when he said his heart sank every time there was a mental health awareness week, on the basis that “we don’t need more people to be aware. We can’t deal with the ones who already are aware.”
Clearly I am not alone in my sense that we have already hit the boundaries of how far we can sensibly apply the paradigm of mental health as a means of understanding and addressing human misfortunes. But Wessely’s remarks are the exception. The politicisation of the issue and the pollyanna-ish expectations of those seeking expedient solutions make opposing points of view unwelcome.
The metaphor of the overcorrecting pendulum is a useful one in this context. It is human nature that when our view on something has previously been uninterested, ignorant and naive, we will tend to overcompensate in our efforts to redress the balance. Attitudes to mental illness 50 years ago were undoubtedly crude and prejudicial, and many patients with treatable problems were denied help that would have transformed their lives because they stayed silent. But our assessment of history should be nuanced. It is also the case that some of the attitudes that once prevailed are likely to have been protective to the mental health of many, and should not be entirely jettisoned.
These include the importance (and expectation) of self-reliance, of getting on with life, of not becoming too self-absorbed or taking ourselves too seriously; and a resistance to imposing demands on a finite healthcare system out of recognition that there are others whose needs are greater. Many who remained well in such a culture would be rapidly and unhelpfully medicalised if they lived in our society today.
If we characterise every unpleasant aspect of human existence as mental illness, we set ourselves up for a fall. The price will be failing healthcare systems, frustrated patients, demoralised healthcare workers, and societies sapped of their confidence. Americans are at the cutting edge of many social changes, but we should not unthinkingly follow them.
One of the things that is most protective to mental health is not to spend too much of our lives consciously obsessing about it.
• Adrian Massey is an occupational physician and the author of Sick Note Britain
