A more difficult question to answer than one might think. As usual your definition depends on all or some of: your point of view, how deeply you wish to probe, how many people are sitting on your committee and how long you’ve got to write it before you break for lunch.

Before I get stuck in, it’s worth noting that the term ‘health’ is a non-exact term used loosely in everyday speech. Equally ‘mental health’, ‘mental illness’ and ‘mental disorder’ are used with an comparable lack of precision and the latter two most often interchangeably. In addition psychiatric health/illness/disorder are used synonymously with mental health/illness/disorder. A further problem with this concept is that there is no clear cut off point between mental disorder and mental health; indeed one person’s mental health, might be another’s mental disorder.

With this poverty of precision already built in, it is probably unfair to expect too much. For this posting I will be mostly using the phrase ‘mental disorder’. Whatever their definitions, common sense dictates that ‘mental health’ and ‘mental illness’ are at least related such that as one increases, the other decreases. There is no definition of mental disorder which is either entirely satisfactory or uniformly accepted.

For legal purposes, the UK’s Mental Health Act 2007 defines mental disorder succinctly and thusly:

‘Mental disorder’ means any disorder or disability of the mind (page 7)

It is clear here, even to the casual reader, is that there is a marked circularity to this statement. Verbose as ever the World Health Organisation makes the following submission:

Mental health can be conceptualized as a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.

Furthermore they state emphatically:

Mental health is more than the absence of mental disorders (read the rest)

Inspiration for the definition of mental disorder often comes from the world of general medicine. Whether or not a mental disorder can or should be considered in the same way as, say, a viral illness is a discussion for another day but it is a direction that modern psychiatry is wedded to. Looked at this way mental disorder can be:

An absence of mental health.
A stumbling block here is that health is at least as difficult to define as illness. Always willing to have a bash, the WHO have defined ‘health’ as ‘a state of complete physical, social and mental well-being and not merely an absence of disease or infirmity’.

A presence of significant psychopathology.
This is related to the definition ‘disease is what doctors treat’, in that psychopathology would be identified by a nominated professional (but with their own distinct gaze…). It is another rather circular argument which allows for expansion of the concept which it describes, as when treatments become available for a condition it is more likely to be considered a disease (think of depression).

Similar to defining mental disorder as the presence of psychopathology is the wish to define mental disorder as the ‘presence of suffering’. This defines the group of people most likely to consult doctors, or other health care professionals. However unlike the definition relying on psychopathology, it leaves out people with mental disorders whose main effect is not felt by the sufferer at the time, for example during the manic phase of bipolar disorder or schizophrenia without insight.

Finally depending on our agenda, we can also choose to define mental illness out of existence. Enter the philosopher and anti-psychiatrist Thomas Szasz who wished to define a disease purely in terms of its physical pathology. Since most mental disorders do not have any demonstrable physical pathology, they are by this yardstick not illnesses. Although not sunk, this view has come under considerable attack from research which suggests genetic and neurobiological processes are involved in the aetiology of mental illness.

Further reading:

There’s a chapters in this book
Clare AW (1997) in The Essentials of Postgraduate Psychiatry
and a section in
Shorter Oxford Textbook of Psychiatry

Also Wikipedia

A ‘grand round’ is a term used by doctors to describe a large meeting were doctors who work at the same institution get together and talk about doctory things. Mostly this involves a presentation of an interesting patient, with subsequent discussion. For the habitually parsimonious there is also an added incentive of a free lunch.

I won’t bore you with the fine details of grand round I attended today, but suffice it to say that it concerned a patient with a long psychiatric history who had had several admissions to psychiatric hospital. She had had a very difficult upbringing and, at various times, a pretty broad selection of psychopathology.

Following the presentation, there was a long discussion as to how best to formulate this patient’s problems and with this in mind, how she should be treated. There were five or so experts on hand, and the interesting thing was that they all drew different conclusions from the same information; there was, variously, an animated debate about the possible existence of a personality disorder, a stout defense of the presence of psychosis and suggestion of an affective disorder. One member of the panel, a chaplain but one of only two people in the room who had met the patient, didn’t think that the patient was mentally ill at all; he said this so politely that I didn’t realise at first.

It’s not unusual for a patient with a long term problem with his or her mental health to attract a selection of psychiatric diagnoses over the years. The odd one or two seem quite pleased about this, but I’m sure for most patients and their families this must be quite confusing. A psychiatric diagnosis is made by the elicitation of recognized psychiatric symptoms by (hopefully) a trained professional. There are no tests available and if the constellation of symptoms with which a patient presents changes (the so called ‘clinical picture’) then the diagnosis can also be altered. Diagnoses themselves are standardized in two publications, namely the ICD-10 and DSM-IV. These standards envisage the possibility of patients being given more than one diagnosis at the same time. Which leads to the interesting idea that more than one mental illness can exist in a single brain simultaneously.

That there are no tests, and that psychiatrists themselves find it difficult to agree about individual patients, has often brought into question the validity of psychiatric diagnoses. I will limit myself to two very interesting points here, one a study and one unfortunate woman.

Martha Mitchell, the unfortunate woman and after whom the Martha Mitchell effect was named, was the wife of the attorney general in Nixon’s government. She was considered to have a psychiatric disorder following her allegations of impropriety in Nixon’s government. She was right, and psychiatrists were wrong.

Around the same time as Watergate, in 1973, David Rosenhan conducted a study consisting of two parts. The first involved the use of ‘pseudopatients’ who briefly simulated auditory hallucinations in an attempt to gain admission to 12 different psychiatric hospitals in five different states in the United States. The second involved asking staff at a psychiatric hospital to detect non-existent ‘fake’ patients. In the first case hospital staff failed to detect a single pseudopatient, in the second the staff falsely identified large numbers of genuine patients as impostors.

So what are the use of psychiatric diagnoses at all? Paul and me have been having a polite discussion about this, and despite his making some good points I cannot see the whithering of the ICD-10 yet. Psychiatric diagnoses earn their keep by:

Enabling effective communication between professionals.

Helping avoid unacceptable variations in diagnostic practice.

And allowing more accurate discussion of treatment and prognosis.

But on the other hand they are reductionistic and stigmatizing.

***

Top tip: if you’ve attended a grand round solely to get the free lunch, then make sure you sit near the door, as the doughnuts go quickly.

***

Links

Spurious precision: procedural validity of diagnostic assessment in psychotic disorders

Although psychiatrists cannot claim to ‘run’ mental health services, as things stand they take ultimate responsibility for the individual care of most patients in the mental health system. But good practice in mental health care involves more than just psychiatrists, and other professions such as psychologists and mental health nurses, could also make a valid claim to be in charge of patient care.*

The status of doctors in the treatment of mental health is actually historic. At the time of the establishment of asylums there were no effective treatments on offer for psychiatric disorders so doctors’ medical qualifications were irrelevant. However doctors’ social standing and accountability meant it was felt that they would be effective guardians of against abuse of patients.

One argument for the continuing prominence of psychiatry is the overlap between mental and physical diseases. For instance, thyroid problems can mimic depression and the argument runs that a psychiatrist should be on hand to identify these instances. This argument is not especially solid, as although physical problems are occasionally picked up by psychiatrists, general practitioners should sift these problems out before referring to psychiatrists.

A second argument is that ‘medical model’ of psychiatry is successful at treating mental illness. This is not just simply prescribing drugs for patients, as this could be done by doctors without their current status, but also that a doctor brings to the table a pragmatic approach to the treatment of patients that draws on scientific method. Although the medical model is much maligned, as being too narrow and too dominant, it also entails a benign paternalism and a willingness to accept responsibility, which some, but of course not all, in their time of sickness may welcome.

Consultation by a doctor is often valued by patients and staff alike despite the fact that a lot of patients are seen by psychiatrists do not have problems related to anything that could be characterized as an ‘illness’. Why this should be so has societal roots beyond the scope of this piece. It has not been unusual for me to be asked to give a ‘doctor’s opinion’ on matters of importance when there is no obvious reason for why I should be qualified to do this, except a willingness to stick my neck out. When working in the community I have often felt that, as many people with mental health problems often have very unsatisfactory social situations, patients would be better off seeing a social worker once a month who could then refer onto me if necessary rather than the current situation which is the other way around.

* I am aware the situation is more nuanced than this paragraph portrays. In a CMHT, many patients will go nowhere near a psychiatrist; furthermore the new mental health act contains provision for other professions to become patient RMOs.

Someone who doesn’t agree with this post….