Views From The Couch: When it comes to mental health, we’re all in this together

In social events and among strangers, I am somewhat hesitant to mention that I am a psychiatrist.

Not that I’m embarrassed to be one, far from it, I am proud – privileged – to be a member of this profession.

It’s just that the admission would sometimes invite – other than the occasional bad joke – genuinely curious and challenging questions: What are mental illnesses? How do you tell the difference between our day-to-day stresses and strains, and those conditions that require professional help from someone like me? And what are the causes of mental illnesses?

To be totally honest, and because mental health exists on a complex continuum, it is sometimes difficult – at least in the initial stage – to tell when someone has become mentally ill. And what would be defined as a mental disorder also clarifies what is not a mental disorder.

Just being eccentric or unconventional; or violating social norms or experiencing symptoms of anxiety and sadness because of difficult circumstances, does not mean that the person is mentally ill.

But I would tell my interlocutors that there are red flags in most instances when that person has drifted across that blurry line of relative wellness to a state of illness.

This would include an excessive reaction that is way out of proportion to what would be expected of the stressor, and if the distress is unduly prolonged.

There might also be evidence of a breakdown of the usual coping repertoire such as difficulties with studies or work, perhaps turning to alcohol or drugs, withdrawing from others, self-cutting or any of the myriad forms of self-harm, or having suicidal thoughts.

And in some, there is the manifestation of strange and unusual behaviour: acting bizarrely and incoherence of speech.

I would also tell them that mental illnesses are very common: surveys of different populations around the world have consistently found that one in five people have suffered from a mental disorder like anxiety, depression, psychosis, traumatic stress, or substance use in the previous 12 months.

And that each mental illness has its cluster of symptoms, and we make our diagnosis based on the pattern of symptoms that we can elicit from the patient.

The meaning of a diagnosis

Categorising illnesses by patterns of symptoms is fundamental to our current approach to making a diagnosis of mental illness, and there are two diagnostic systems which are in overlapping use around the world.

There is the Diagnostic and Statistical Manual now in its fifth edition and published by the American Psychiatric Association that is widely described – perhaps because of its outsized influence – as “Psychiatry’s Bible”.

And there is the International Classification of Diseases which is developed by the World Health Organisation.

Within each system, a particular disorder listed is accompanied by a set of criteria that describes in fairly precise terms which symptoms define it, how many must be present, and how long they have been present before that diagnosis is made.

And both systems are more like each other than they are different.

This checklist approach to something as complex as mental illness has its fair share of critics who argue that it oversimplifies the complexity and individuality of patients’ experiences.

Most thoughtful and good psychiatrists know this and would consciously make the necessary effort to see their patients as whole unique individuals rather than just a walking collection of symptoms.

And they would also be aware of the various possible implications and ramifications for that patient following a diagnosis for such is its power that it may save lives or ruin them.

For some of my patients and families, a given diagnosis is received with some relief because being able to put a name to their troubles provides a measure of reassurance of knowing how to deal with the problem and having an idea of how the future course of the illness might be.

But for other patients and their families, the reaction is of dismay, distress, dread and sometimes denial.

More than any other sort of medical conditions, being diagnosed with a mental illness can change how a person feels about himself or herself, and even how others feel about them.

And sometimes, it is not even them. To this day, I remember that young man who came to see me with the mother of his girlfriend.

This young man’s sister has schizophrenia. It was his prospective mother-in-law who compelled him to get an assessment and be declared free of any mental illness before she would consent to her daughter marrying him.

Despite the significant progress made in developing a better and more compassionate understanding of mental illnesses as medical conditions and a common human experience, there is still that lingering fear of being stigmatised, which is often a barrier to seeking help.

Among the findings of the recent National Youth Mental Health Study, which were recently made public, was the revelation that one in three young people did not seek help, despite having severe or extremely severe symptoms.

Those who chose not to seek help said it was because they were doubtful that any specialist would be able to help them, or they were worried about what other people might think of them.

Related to this was their fear of having a permanent record of their condition and not being able to keep it private and confidential.

All biological and social

A contributing factor for this obdurate stigma is that we do not know the exact causes of mental illnesses. And ignorance begets myths and misconceptions.

What we do know is that there is no singular cause for any of these mental illnesses.

We may often refer to them as disorders of the brain, but social and psychological factors play a major role in the genesis and course of the mental illness.

One of the leaders of modern psychiatry, Professor Leon Eisenberg of Harvard Medical School, has put it this way: “Psychiatry is all biological and social.

“There is no mental function without brain and social context. To ask how much of mind is biological and how much is social is as meaningless as to ask how much of the area of a rectangle is due to its width and how much to its height.”

The brain (with its 86 billion neurons and 100 trillion connections) is the only organ that can be afflicted by what might be called “existential disease” – where its functioning may be disrupted not only by physical injuries but by impalpable human experiences like loneliness, humiliation, losses or fear, and with the manifestation of symptoms of mental illnesses.

To uncover the exact cause of a disorder is the holy grail of any medical basic science research but this has remained frustratingly elusive for almost all the mental disorders.

Shortly after Dr Thomas Insel stepped down from his post as the director of the National Institute of Mental Health (NIMH), which is the United States’ foremost mental health research agency, he made this startling confession: “I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realise that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs – I think US$20 billion – I don’t think we moved the needle in reducing suicide, reducing hospitalisations, improving recovery for the tens of millions of people who have mental illness.

“I hold myself accountable for that.”

As a clinician and a researcher who had previously been engaged in basic science research, I have much sympathy for Dr Insel’s sentiments.

It would be, I think, more judicious – for now at least – to put our research money in those areas which would help in more tangible ways, the people who currently have mental illness or who are at risk of falling ill – and not in basic research in genomics and neuroscience which may help people in some far-off future.

We need research on the changing state of mental health of the population across the age span and over time; on the predisposing factors and the interplay between these factors; on how treatments and social interventions in the real-world situation can be improved.

And, as the pain and suffering of a serious mental disorder is not limited to the individual sufferers, but extends to their families who are often in an abyss of helplessness and hopelessness, there should also be interventions linked to research in this area.

There is already much that we do know from a large body of local research.

We know how common mental illnesses are and who is particularly vulnerable; we know their reasons for not seeking help – key of which are stigma, the lack of mental health literacy, concerns about costs, and difficulty in accessing help.

We know the enormous economic and social costs that are borne by both their caregivers and the country.

And we know that adverse childhood experiences have long-term and enduring effects on mental health.

Much of that knowledge has probably been taken in for the formulation of the National Mental Health and Well-being Strategy, which was launched in October 2023.

This is a demonstration of the Government’s intent of making mental health and well-being a key priority in the national agenda and which, as Prime Minister Lawrence Wong said, “sets out concrete plans to plug existing gaps and strengthen Singapore’s mental health ecosystem”.

Unintended consequences

We can look forward to a raft of programmes and interventions being rolled out – which would be heartening to people with mental health problems, their families and mental health care providers.

However, we should keep in mind that social theory which posits that all social interventions have unintended consequences, some of which can be foreseen and prevented, and others which cannot be predicted.

The corollary is that interventions need to be carefully evaluated for their unintended consequences; necessary adjustments need to be made to the programmes. If the consequences are serious enough, we should be able to pull the plug.

Policymakers, practitioners and researchers in mental health should be more aware of the limits of our knowledge, to be disciplined to rein in any premature and uncritical enthusiasm, and be wary of easy and untested solutions.

Humility, honesty, and open-mindedness are much needed qualities.

We need to find and implement ways of bringing people with even the most debilitating disorders into the fold where – again to borrow the words of the Prime Minister – “everyone has a place and where everyone belongs”.

To start with, we need to change the way we think of people with mental illness – not as strange, comical, bizarre, or frightening individuals who should either be medicated to the fullest or kept locked away in the Institute of Mental Health – but as part of us.

And we must continue to find solutions that might aid in their healing or, at the least, lessen their suffering.

It is not just good psychiatric care that is needed.

There are many factors that can ameliorate or even prevent some disorders from happening.

Other than a good health system starting from the first instance of having sound obstetric care to managing chronic medical illnesses; there needs to be a stable and safe family environment, an educational system where every student has a place with different pathways other than academic success, humane workplaces, access to housing, and an inclusive and cohesive community, among other things.

The point which has often been made but bears repeating is this: it must be a concerted effort by the whole of society – not just mental health professionals, patients and their families, educators, advocates and policymakers, but the wider community as well.

In my many years as a psychiatrist, I have realised that no matter how careful we try to be, every one of us is still psychologically and emotionally vulnerable, in varying measure and at various times.

Few of us can escape the ravages of mental illness.

We may not suffer it ourselves, but we are not spared the pain it inflicts on friends or family.

So, we’re all in this together, we should all do our part and our best, and we should all work together.