What causes or prevents mental disorders?

There is so much confusion about what the causes of mental disorders are and what prevents mental disorders.  There is so much confusion about what the concept of “risk factors” means and  what the concept of “protective factors” means.  And for many years, some of the research in these areas has been contributing to this confusion.

One of the most commonly held confusions is that about what causes or prevents depression.  In my opinion, there is probably more nonsense written about those issues than about almost anything else pertaining to mental health and mental illness – except maybe for medications used to treat mental illness. 

Much of this confusion comes from or is related to our very simplistic models of causality – that is, our thinking about what causes what.  We often think of causality as linear – so that something that comes before the event (or diagnosis) is considered to cause that event (or diagnosis).  As we know in our frontal lobes, this kind of linear model is rare.  Mostly causality is multi-factoral and sometimes the most substantive “causal” factors are not readily apparent.  So people get lazy in their thinking and go into brain default mode – choosing to assume that what comes first causes what happens after.  This of course is using our limbic systems as explanation.  Not a good way to be less wrong most of the time.

Depression does not arise in one day.  It takes a long time between when the illness begins and a diagnosis is made.  If you (as most researchers to date have done) look at events preceding the diagnosis of depression you will get a very skewed and biased idea of what may have “caused” the depression.  As a person is getting depressed, they may create events that are due to the depression and not the other way around.  Lazy thinkers then make a completely incorrect causal inference.  They could not be more wrong!

Enter some hard thinking researchers.  They decided to investigate the link between religion and depression.  Many who did earlier cross-section studies found that depressed people went to church less often than those who were not depressed.  So what did they conclude: that being religious prevented depression!  Ouch – and this idea has been around for so long that many people thought it was true!

So here is the new lens.  It’s a prospective study (so not a cross-sectional analysis) that followed people over time led by Dr. Joanna Maselko of Duke University and published in the American Journal of Epidemiology in February 2012: http://bit.ly/AmDqcl. 

And what did they find?  They found that contrary to current mythology, religion does not prevent depression!  What they found is that as people became depressed, they stopped going to church!  Social withdrawal was a result of the depression, not the other way around. 

So, is addressing spirituality for people a waste of time?  Likely not.  Will that prevent depression – no. 

What should we learn from this information?  We need to stop thinking about causality in linear fashion and we need to start doing research that can give us answers to questions in a best evidence way – not jumping to conclusions that reinforce our biases.  Isn’t science grand?  It’s the only system that we have that is independent of our ideologies.  We need to use it more – for everything.   

-Stan

Informing Canadians about mental health: The media has a lot to answer for

Trying to understand how the Canadian media addresses mental health has been a concern of mine for many years now.  Many of my concerns have been about the negative perspectives of that those who live with mental illness that to me seemed over-represented in the pages and airwaves across Canada.   Another huge concern is how treatment for those with mental disorders is portrayed – particularly the use of medications. 

In most media reports addressing the use of medications, what is portrayed is the need to ensure that those who have various illnesses have access to the best care possible – including medicines.  The opposite seems to be true for mental disorders.  Here, highly effective medications for mental disorders are mostly painted by a negative brush.  If you have cancer and you don’t have access to a medicine that may have a minor positive impact of marginally increasing your life-span you are seen as a victim.  If you get terrible side effects, that is seen as an inconvenience. 

Comparatively, if you happen to have ADHD and medications may have a huge positive impact  on all aspects of your life, you are criticized for taking it and minor side effects are portrayed as horrific and terrifying.

There is some good Canadian data demonstrating that media in this country depict mental illness in a very negative light.  The National Post actually reported on this information – good for them.  You can find the information here.

Rob Whitley of McGill University provided the information based on his seminal work on addressing media bias in the  portrayal of mental illness.  Over a third of media reports portrayed violence and dangerousness related to mental illness.  Only about a sixth dealt with recovery or rehabilitation. 

It is interesting that the Harper Government is now committed to building more jails and not in addressing some of the obvious antecedents to crime.  As we well know, up to 60 percent or more of those in jails have mental disorders that are known to be associated with their involvement in crime.  Are our national policymakers getting their information from the media about understanding mental disorders?  Is this driving the building of jails agenda?  Does the Harper Government want to jail those with mental disorders instead of providing care?

As for me, I do not know the answers to those questions.  What I do know is that we need to make sure that this changes.  The stigma against those living with mental disorders and the stigma against not providing most effective treatment for mental illnesses has to stop.  The Carter Center in the USA has special programs for journalists.  Should we do the same here in Canada?  Why not?

-Stan

How can some people be so far out of touch?

Psychiatric diagnoses have always been difficult to develop and to implement.  Primarily this is because as of yet (though things may be changing soon) we have not had robust independent biomarkers to help us validate them.  For example: in the diagnosis of chest pain, a doctor can use an EKG and blood tests to help determine if the patient’s symptoms are more likely to be caused by a heart attack or not.   

While psychiatric diagnoses are built on some good validation criteria for the most part, some are less well buttressed with this evidence than others, and for some, opinion, economics or social influences have quite a measure of impact.

 For example, a recent story in the National Post indicated that some physicians in Alberta were still making a psychiatric diagnosis of homosexuality. Not only does this not make any sense (homosexuality is not a psychiatric diagnosis), but it is offensive and simply wrong-headed.

Frankly, I could not follow the article, and did not understand what the reporter was trying to say – was the problem due to a billing code or was a doctor(s) using that as a diagnostic code (which makes no sense as neither the current ICD-10 nor the DSM diagnostic criteria contain that as a diagnosis)?  Or is Alberta simply so far behind that it is using a medical diagnostic system that is over 25 years out of date?

Whatever the real story here, it is time that psychiatric diagnoses were demanded by the profession and public alike to be more based on the best available science than on opinion, insurance payments or public pressure.  My goodness, if one of the current candidates wins the GOP nomination in the USA who knows what silliness will make its way into diagnostic codes.

--Stan