Multiple questionnaires have shown that there has been a dramatic increase in psychiatric disorders in recent decades. It is true that there often appears to be a mental health crisis evolving in our health system, with some figures suggesting one in four suffer from some category of psychological ailment. Recent disasters like the Cornelia Rau fiasco add fuel to this apparent fire.
But in my experience working as both a psychiatry registrar on the frontline of the public hospital system and as a general practitioner, it is not so clear. Mental health remains, as it has in the history of human knowledge, a controversial topic. Its status remains clouded and it struggles to be accepted by its more prestigious medical brethren in fields like surgery or general medicine.
I think this is warranted. Psychiatry has the greatest overlap with socio-economics and the boundary between it and the social sciences is not crystal clear. As a result to what extent psychological disorders are a product of society or the individual is always debatable.
The greatest influence on the recent history of psychiatry and mental health, as it has been pretty much with everything else, has been the market and its corresponding social upheaval. Industrialisation, urbanisation and growing labour mobility have resulted in looser ties between family and communities. This decline has meant many of the old functions performed by the extended family are now performed by the state or the private sector. The childcare operators on the rich list are a testament to this trend.
Many relatively minor difficulties that now fall under mental health, like adjustment disorders or dysthymia, would previously have been cushioned by family ties or presented to other kinds of community leaders such as priests. A significant portion of what general practitioners and, to a lesser degree, psychiatric institutions do is a form of advanced baby sitting. As soon as it presents to a doctor, it becomes a health problem.
Nowhere has the mental health consequences of the rapid embrace of the market been more clearly illustrated than in China. The suicide rate, especially among females, has nearly tripled in the past decade. This is a direct result of rural farmers heading into urban centres to find work and leaving their wives to rear young families back in the village. Many are not coping with such a responsibility.
The other way the market and modern civilisation has affected mental disorders is the utter focus on individualism it tends to encourage. The 20th century has been described in a BBC documentary as the “century of the self”. Depression is often characterised by a kind of self-absorption, a process of impaired information processing where all negatives are attributable to the self. This is debilitating in its severe forms and requires expert psychiatric help.
But the kind that presents to general practitioners and is counted in statistics as part of the growing crisis in mental health is a different kind of malaise, better described as affluenza than depression. It is a kind of dissatisfaction with the complexities of modern life that now gets medicalised as anxiety or neurosis.
The apparent rise in people experiencing mental health ailments is more a reflection of medicine’s success in capturing more and more market share in treating the problems of living.
Drug companies have now decided that psychiatric disorders represent an enormous opportunity in capturing lucrative new markets. This is particularly true since many patents for the drugs treating common medical disorders are expiring and cheaper generic competitors are eating away at profit margins.
Marcia Engell, a former editor of the New England Journal of Medicine - the most prestigious medical publication in the world, writes in her book, The Truth About Drug Companies, that the new strategy of Big Pharma is to create diseases for which they can market their drugs, rather than create drugs to treat known diseases. This is reflected in the range of new disorders being accepted by the psychiatric establishment. Diseases like social anxiety disorder or pre-menstrual dysphoric disorder are a testament to the rapacious need to create new markets.
This should be qualified by saying that everyday I see patients who benefit enormously from the range of medications and resources that the health sector offers. Sometimes, this is even life-saving. Bipolar disorder, major depression and schizophrenia are the ailments which psychiatry and mental health can genuinely improve.
At the same time, I see a range of disorders that very much feel like social problems that have nowhere else to present other than the health services. Alcoholism and drug addiction, Aboriginal disadvantage and loneliness can present medically as substance abuse, personality disorder or adjustment disorder. But in practice, I feel almost powerless to have any lasting impact on many of these presentations for their roots lie in deeper social, economic or spiritual malaise. Despite Mark Latham’s recent discouragement to those wishing to work in politics, working in mental health actually inspires me to do just that.
There will continue to be cries to better fund mental health services. The case is apparent considering at 8 per cent of our health budget, we spend the lowest proportion in the OECD on mental health services. But I do not think there is a crisis in mental health. It’s just that mental health now bears the burden of our search for meaning in a complex and secular world.