The number appears in a whole range of places and it goes back about 5 years, but the source of it remains mysterious.

So I was absolutely fascinated to read that you’d emailed the Time to Change people about it and they hadn’t known either!

The interesting thing is that all of the studies which have tried to estimate lifetime prevalence have returned much higher values, 1 in 3 to 2 in 3 (sic) with 50% being common in US studies. There have been no such studies in the UK to my knowledge.

The WHO in 2001 quoted a lifetime figure of “at least” 25%, which was widely quoted in the media as 1 in 4, but I checked the refs and the studies they cite in fact give estimates of 30-65%.

My suspicion is that 1 in 4 is the number which is high enough to be striking, while not so high as to be outright laughable. if you take the data seriously it should be more like 1 in 2…

I still think that ‘one in four’ or even ‘one in six’ fails basic reality testing. If we think that 16.5% of people have a neurotic disorder at a point in time we should think carefully about our models. It will come as no surprise to some readers that I think that mental health services should restrict themselves to serious mental health disorders and mild/moderate anxiety and depression should be normalized as part of all our lives.

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Incidentally I had a thought today which informs this debate to an extent and also the on-and-off discussion Paul and I have had about psychiatric classification. I think that the ICD-10/DSM IV are useful whereas Paul prefers a treatment on the basis of distress model (Paul I hope I’m not misrepresenting this).

Paul is a psychologist and myself a psychiatrist. As a psychiatrist it’s often my job to decide whether people are qualify as being mentally ill or not. This could be anyone, and all comers and I often see people in A&E. Therefore for me to make a decision of who to treat or admit on the basis of distress would be difficult.

Psychologists on the other hand often have patients referred to them, and have less of a role of weeding out mental illness. Rather than offering patients some help ‘on the spot’ they work with them over a number of sessions. In this instance I can see that a distress based model would work better.

Having spent the majority of my life being happy, supported and much loved, this security disintegrated in recent years because my Father had a breakdown and killed my Mother. He is now sectioned and we are all slowly picking up the pieces.

The one in four statistic seems like it is quite possibly accurate to me now under the circumstances. And I think that for most people, their mental health will at some point suffer, leading to a diagnosis of a mental illness. I have been amazed at how many friends and acquaintances have subsequently disclosed to me that they have been unwell, seeking support from specialists, taking antidepressants and even admission to hospitals – all of which I was completely unaware of.

Not to mention that 1 in 7 pregnant and postnatal women are also affected by mental illness. Male suicide is also another area of mental health that is greatly overlooked. I am personally aware of three men who have taken their own lives in extremely violent ways. All of whom seemed to be unable to find a way to ask for help.

If this campaign can raise awareness of the suffering that so many people go through often desperately alone, then I think that it can only have a positive outcome.

I would love to back all of my comments up with research, facts and figures, but I can’t be arsed!!! I am on my way out to the gym!

As for me, talking, increasing my awareness, helping others to understand, counseling, good friends and still finding a way to laugh in the face of adversity – are coping mechanisms that I use to now fumble my way through daily life without my Mum here with me…

The numbers reflect people meeting criteria for mental health disorders (MHD), but not necessarily those people seeking help. Bebbington et al (2003) found something like a third of people who met MHD criteria had not approached their GP for help in the preceding year.

Of those who do seek help, it seems only about 50% are accurately ‘diagnosed’, or classified as meeting MHD by the GP (Goldberg & Huxley 1992), although this may have changed as training has improved.

Of those who are classified appropriately, many will be given antidepressants and perhaps also referred to primary care mental health. We know many get stuck on a waiting list and often do not attend their assessment. If referred to psychology there are parts of the country where 2-year waiting lists are the norm. I may be wrong but I doubt CMHT’s (and psychiatrists on those teams) will encounter very many people who meet criteria for so-called neurotic conditions, unless they’re suicidal to the point of hospital admission, in crisis or present a risk to others.

In the context of healthy scepticism regarding the concept of mental illness and disorder, I think the 1-in-4 figure is a useful one in terms of normalising and destigmatising the experiences people have. It can also encourage people to question the concept further, and to question the reductionist biological paradigm peddled to them indirectly by drug companies.

The survey finds 16.5% have a neurotic disorder at one point in time, and a further 6% develop one over the following 1.5 years. A further 4.4% have a personality disorder, and 0.5% a psychotic disorder (both are annual prevalences). Total = 27.4%.

The diagnostic tool used to measure ‘neurotic disorders’ (the CSI-R) counts anyone scoring 12+ as having ’significant symptoms’; as a rule of thumb, it is said anyone scoring 18+ is likely to require specialist treatment. Around half of the neurotic disorder group score 18+. So the estimate of the total needing specialist treatment would be around 16.15% (half of the neurotic group plus all of the personality and psychotic groups).

Perhaps this is why you, as a psychiatrist, think the one-in-four sounds too high – because many of these people are not so severely ill they need specialist treatment.

Whether this means they are ill at all is obviously what you are disputing, and yes, the topic of how to diagnose people is very much a live debate in the field. But it seems rather harsh to describe the PMS results as “an untruth sold to them by foolish psychiatrists” – it’s from the UK’s only nationally representative survey, run by the Office of National Statistics, with the advice of many experts, using well-established diagnostic tools.

While I agree completely that mental illness in it’s most insidious or debilitating forms is both under reported and poorly treated, I feel that the claim of 25% is both unhelpful and trivialising.

I think that the disagreement on diagnosis (or classification) amongst psychiatrists for a number of patients represents an unhelpful reliance on a shared ‘vocabulary’, based on ICD10, DSM4 etc, but that face-to face, most psychiatrists, discussing a case in detail, would have a fairly shared understanding of the worries/distress/risks/needs of the person that they see.

Do we all experience worries/distress/risks/needs? I would hope so. We are, after all, human, poetic, comic and tragic. Though not at a level that constitutes illness.

Is there a significant proportion of people who have a significant mental illness? Undoubtedly.

We must, both as a society, and as a smaller group, psychiatrists, consider what we feel to be the amelioration of suffering and the treatment of illness.

Both will begin with kindness. Political matters will, I hope, follow.