Psychiatry - NotesMed

6 2 The scale of the problem work productively and fruitfully, and is able to make a contribution to her or his community. This is a helpful definition, because it clearly defines a mental disorder as a condition that disrupts this state in any way, and sets clear goals of treatment for the clinician. It identifies the fact that a disruption of an individual’s mental health impacts negatively not only upon their enjoyment and ability to cope with life, but also upon that of the wider community. The rest of this chapter will outline the prevalence of mental health disorders worldwide, the impact that these have on both individuals and society, and the public perception of psychiatry and the effect that this has on those with mental disorders. Table 2.2 Epidemiology of mental disorders in the USA in 2008 (from the US National Institute for Mental Health, www.nimh.nih.gov) Condition Prevalence (% population) Median age of onset (years) Anxiety disorders 18.1 21 All mood disorders 9.5 30 Unipolar depression 6.7 32 Post-traumatic stress disorder 3.5 23 Eating disorders 1–7 (females) 17 Bipolar disorder 2.6 25 Schizophrenia 1.1 20 Worldwide prevalence of Obsessive-compulsive disorder 1.0 19 mental disorders ADHD 4.1 7 Autism 0.34 Psychiatric disorders are amongst the most prevalent causes of ill health in humans. One in four adults will suffer from a diagnosable mental disorder at some time in their life, and one in five has one in any given year. This is true across the globe, in both economically developed and developing countries. Table 2.1 outlines the worldwide prevalence of the major psychiatric disorders, with some common physical disorders for comparison. Depression is one of the most prevalent diseases currently seen in humans, only superseded by conditions associated with poverty and poor access to healthcare (e.g. malnutrition, iron-deficiency anaemia, low vision). Approximately 6 per cent of the population have a severe, enduring psychiatric Table 2.1 World prevalence of selected conditions (from WHO The Global Burden of Disease: 2004 update (2008)) Alzheimer’s disease 10% of over-65s 3 72 disorder which impacts upon their functioning in the long term. Schizophrenia, bipolar disorder, and unipolar depression make up the majority of these cases. As an example of the relative prevalence of common mental health disorders seen in developed countries, Table 2.2 shows epidemiological data from the USA collected in 2008. Always remember that patients frequently fit the diagnostic criteria for more than one diagnosis—for example, social phobia and major depressive disorder—and that this is especially true for the mood, anxiety, and behavioural conditions. It is unclear at the moment whether the prevalence of many disorders is increasing, or if rising figures are merely a diagnostic artefact. Time will tell. Condition World prevalence (millions) Unipolar depressive disorders 151.2 Global service provision for Alcohol use disorders 125.0 mental health disorders Schizophrenia 26.3 Bipolar affective disorder 29.5 Alzheimer’s and other dementias 24.2 HIV infection 31.4 Tuberculosis 13.9 Chronic obstructive pulmonary disease Osteoarthritis Symptomatic ischaemic heart disease Diabetes mellitus 63.6 151.4 54.9 220.5 As psychiatry is a medical specialty that affects such a large proportion of the population, it would seem logical for there to be health services at least equivalent to those for other medical conditions available. However, this is not the case. In 2008, the WHO published a report on the global provision of psychiatric services, concluding that those available currently are woefully inadequate. The following are key statistics from the report: Only 62.1 per cent of countries (including 68 per cent of the world population) have a specific mental health policy outlining provision of services.

The impact of mental health disorders upon individuals and society One-third of countries do not have a separate budget for mental healthcare. Thirty-one per cent of the world’s population are not covered by a dedicated mental health law or legislation covering involuntary treatment and human rights. The mean number of psychiatric beds per 10 000 people worldwide is 1.69, compared with 8.9 for physical health conditions. There are just 1.2 psychiatrists per 100 000 population worldwide, of whom 90 per cent work in high-income countries. Table 2.3 lists some drugs that are commonly used in psychiatry, and the percentage of countries with easy access to them. Most of the older typical antipsychotics are now widely available, but other ‘basics’ such as lithium and sodium valproate are still limited to two-thirds of the world. There are currently no data published for selective serotonin reuptake inhibitors (SSRIs) or atypical antipsychotics. Access to medications is a good marker for the level of development of health services. If a doctor does not have access to antidepressants, it is very unlikely that they will have other more complex treatments available, for example cognitive behavioural therapy. In the UK, which has a National Health Service (NHS) funded from taxation, 13.8 per cent of the health budget is allotted to mental health services. This is the highest proportion in Europe, but still there is a distinct shortage of facilities, especially for psychological therapies and specialty services such as those for adolescents or eating disorders. There are 12.7 psychiatrists per 100 000 population, compared with 8.9 as a European average. Table 2.3 Availability of common psychiatric drugs worldwide (from WHO Mental Health Atlas 2005, update (2008)) The impact of mental health disorders upon individuals and society With so many people suffering from mental health disorders, it is unsurprising that these disorders have a major impact on society. Disability is defined as ‘a loss of health’, and is usually used to describe impairments in activities of daily living caused by physical or mental disorders. The disability-adjusted life year (DALY) is a measure of the overall burden of a disease, combining morbidity and mortality into one number. Table 2.4 shows the latest WHO data from the global burden of disease study, which has produced a list of the conditions giving rise to the greatest burden of disability worldwide. Depression is currently at number three, but is predicted to rise to first place by the 2012 edition of the report. Seven of the top 20 conditions are mental health disorders. Whilst the majority of physical diseases tend to be more common in older people, psychiatric conditions predominantly affect the young and middle aged. Table 2.2 shows the median age of onset of various conditions in the USA; most are between 18 and 30 years. This means Table 2.4 Disease and injury causes of disability in descending order by global prevalence: the 20 leading causes of disability worldwide (from WHO The Global Burden of Disease: 2004 update (2008)) 1 Hearing loss 2 Refractive errors 3 Depression 4 Cataracts 5 Unintentional injuries 6 Osteoarthritis 7 Alcohol dependence and problem use 8 Infertility due to unsafe abortion and maternal sepsis 9 Macular degeneration 10 Chronic obstructive pulmonary disease Drug Countries with availability (%) 11 Ischaemic heart disease Carbamazepine 91.4 13 Asthma Valproate 67.4 14 Schizophrenia Amitriptyline 86.4 15 Glaucoma Diazepam 96.8 16 Alzheimer’s and other dementias Haloperidol 91.8 17 Panic disorder Lithium 65.4 18 Cerebrovascular disease Levodopa 61.9 19 Rheumatoid arthritis Chlorpromazine 91.4 20 Drug dependence and problem use 12 Bipolar disorder 7

8 2 The scale of the problem that mental health disorders tend to affect people when they are in the latter stages of education, starting a career and setting up home. In the UK, 44 per cent of claimants of incapacity benefit stated a mental health or behavioural disorder as the principle reason for their disability leading to an inability to work. The impact of psychiatric disorders on the economic success and social coherence of a country is therefore great. Mortality associated with mental health disorders is very variable, depending upon the condition. The most important area is that of deliberate self-harm and completed suicide. Globally, it is estimated that 800 000 people complete suicide each year, 90 per cent of whom have a diagnosable mental health disorder. Two-thirds of those who commit suicide are aged between 15 and 44 years. Suicide is the leading cause of death in men aged 15–34 years in the UK, and for women it is the second most prevalent cause. Four times as many men die by suicide as women, although more women make attempts. Approximately 1 per cent of the population of economically more developed countries will die by completed suicide, a statistic usually unrecognized by most of the general public. The public perception of mental health It is an unfortunate truth that individuals with mental health disorders are subject to significant negative stigma within society. This also occurs in medicine. Those young doctors who express an interest in being psychiatrists are often deemed to be either mad themselves, or unable to get another specialty training post. The UK government has put some effort into identifying and tackling stigma surrounding mental health issues in recent years. In 2007, it published a report entitled Attitudes to Mental Illness, based on the responses of 6000 randomly sampled adults to a short interview. Some of the more striking results included the following: Only 65 per cent of respondents thought that people with mental health problems should have the same right to a job as those without them. Six out of ten adults agreed with the statement ‘one of the main causes of mental illness is a lack of self-discipline and will power’. Young people are the most prejudiced. Thirty-four per cent of respondents felt that ‘all people with mental health problems are prone to violence’. Two-thirds of people said they were scared of those with psychiatric illnesses, and would not want to live next door to one of them. Eighty per cent of respondents underestimated the prevalence of mental health disorders in the UK by at least a factor of ten. This survey is conducted every 2 years in Britain, and the results have been almost static over the last decade. Given that there is good evidence that some of the best outcomes for those with severe mental health problems come with the provision of appropriate housing, employment, and social support, this remains disappointing. One positive finding is that the majority of adults agree that community and outpatient-based interventions are preferable to prolonged hospitalizations. Education surrounding mental health is badly needed the world over, both to help the vast number of people with mental health disorders to cope with them more productively, and to allow the rest of society to include them in a cohesive manner. Further reading Saraceno, B. (2009). Oxford Textbook of Psychiatry, 2nd edn. Ed. M. G. Gelder, J. J. Lopez-Ibor, N. C. Andreasen & J .R. Geddes, pp. 3–13. Oxford University Press, Oxford. Waraich, P., Goldner, E. M., Somers, J. M. & Hsu, L. (2004). Prevalence and incidence studies of mood disorders: a systematic review of the literature. Canadian Journal of Psychiatry 49: 124–38. Henderson, C. & Thornicroft, G. (2009). Stigma and discrimination in mental illness: time to change. Lancet 373 (9679): 1928–30. The World Health Organization website provides copious reading material on all aspects of mental health epidemiology, including a searchable database of psychiatric service provision for all countries. www.who.int/topics/mental health/en/ www.who.int/topics/global burden of disease/en/

Facts, beliefs, and prejudices People’s attitudes to mental disorder vary widely. Often this is because of the extent of their personal experience of mental illness. Some people have experienced a mental illness themselves, whilst others may well have experience of mental illness in a friend or relative. If you have been lucky enough to avoid these personal experiences, it is almost inevitable that you will be exposed to one or the other during your lifetime, and perhaps several times. Of course, because you are reading this book, it is likely that you are, or are intending to be, a healthcare professional. In whatever area of healthcare you work, you will encounter hundreds—if not thousands—of people with mental illness in your professional lifetime. The beliefs that you hold about mental illness and people with mental illness will influence how you respond to them. It is therefore important that you appraise your existing beliefs and, if necessary, consider changing some of them. Appraising and altering our beliefs is difficult. We all tend to assume that what we believe—about ourselves, others, or the world around us—is true. However, only some of the beliefs that we hold are facts. Despite this, our beliefs tend to be ‘static’ and resistant to change, whether or not they are correct. One reason for this is the kind of biases that operate to maintain our system of beliefs. Cognitive therapists use a model which they call ‘the prejudice model’ to describe these biases. What they describe is that most evidence that conflicts with our core beliefs is either not noticed, or is altered in order to fit our core beliefs, whereas most evidence that fits with Chapter contents Facts, beliefs, and prejudices 9 Your mental health 11 Further reading 12 CHAPTER 3 Mental disorder and you

10 3 Mental disorder and you our core beliefs is noticed and used to bolster those beliefs. In this way, the beliefs that we hold tend to be relatively static through time. Common prejudices This section describes a short exercise for you to complete. There are three stages: 1 In Box 3.1, we list several common prejudices about mental illness. Rate each of these statements from 0 to 100 per cent, where the percentage is the extent to which you hold that belief. For example, if you believe that mental illness is indeed a sign of weakness in most cases, you might answer 80 per cent. It is important to be honest, rather than give what you believe to be the ‘correct’ answer. 2 Continue to read this chapter, where we challenge some of these prejudices, largely by comparing mental illness with physical illness. Think carefully about the comparisons and arguments that are offered, and how they fit with or contradict your own beliefs. 3 Re-rate the six statements in Box 3.1. Are there any differences from when you first rated them? Mental illness is a sign of weakness Is physical illness a sign of weakness? We do not commonly associate a fractured neck of the femur, a myocardial infarction, or diabetes mellitus with ‘weakness’, and yet people with mental illness may well be judged to be weak in some way. As you will see, the causes of mental illness are complex, involving physical, psychological, and social factors. In many cases, mental illness appears to have a strong genetic basis, and this is particularly likely in some illnesses, such as bipolar disorder. Furthermore, many people whose lives have demonstrated personal strength or extraordinary ability have also suffered from mental illness. These include Winston Churchill (who, besides his successes as a wartime politician, won the Nobel Prize for Literature), Florence BOX 3.1 Common prejudices about mental illness 1 Mental illness is a sign of weakness 2 Mental illness is something that affects other people 3 People with mental illness should just pull themselves together 4 There are no effective treatments for people with mental illness 5 People with mental illness should be kept in hospital 6 People with mental illness are a risk to others Nightingale (pioneer of modern nursing), Vincent Van Gogh (artist), Isaac Newton (scientist), Linda Hamilton (actress), and JK Rowling (author). It is difficult, in these circumstances, to argue that mental illness is a sign of weakness. Indeed, one common mental illness—bipolar disorder—appears to be strongly represented among successful people, and it has been argued that mood disorder persists in populations because it may present a selective advantage in evolution. Mental illness is something that affects other people This is an important myth to dispel. Many of us are rather blasé about our health, both physical and mental. This may change when we receive an ‘early warning’ that something is wrong (such as high blood pressure or impaired glucose tolerance). Many of us have had short or mild periods of emotional distress, often in the context of personal difficulty such as the end of a relationship or the death of a close relative. Such an episode indicates that we are vulnerable. However, few of us, in those circumstances, seek help or advice, yet mental illness is often seen in healthcare professionals, including doctors and psychiatrists. Mood disorder, anxiety disorder, eating disorder, and alcohol and substance misuse are common. Unfortunately, healthcare professionals can be very slow in acknowledging that there is a problem and in obtaining effective assessment and care. People with mental illness should just pull themselves together If only this were possible. We know from personal experience that, when we have received some kind of setback, or when our energy or confidence are at a low ebb, achieving our goals is more difficult. By its nature, depression is associated with physical fatigue, mental fatigue, pervasive low mood, and negative biases about yourself, the world around you, and the future. Just imagine how difficult it must be to engage with treatment, and to continue with those aspects of life that are either essential or help to keep us going, during such an illness. The more depressed the person’s mood, the more difficult it is for them to ‘just pull themselves together’, and the more dependent they are on others, including healthcare professionals, for support, tolerance, and the instillation of hope. There are no effective treatments for people with mental illness There is no doubt that mental illness can be difficult to treat and that, in some cases, the resulting distress and disability are chronic. However, this is a similar situation to the treatment and prognosis of physical disorders. Some physical illnesses, such as appendicitis, can be cured by a clear, discrete intervention. However, others,

Your mental health such as rheumatoid arthritis or multiple sclerosis, can often not be cured, and the focus of most physical interventions is on reducing disability rather than eliminating disease. Psychiatric treatments, such as selective serotonin reuptake inhib

Introduction to psychiatry Psychiatry is the branch of medicine that specializes in the treatment of those brain disorders which primarily cause disturbance of thought, behaviour, and emotion. These are often referred to as mental, or psychiatric, disorders. The boundary with the specialty of neurology, which also