Mental Health in Québec
On January 31, 2018, Bell hosted the “Bell Let’s Talk” initiative to create awareness and to encourage open discussion on mental illness and to break the taboos surrounding it. The fundraising campaign is already under way (in fact it has been successfully completed). “Mental Health is an issue that concerns everyone”. This is so true: nobody is protected from depression and nobody should be ashamed to suffer from manic depression. “Seriously! Would you be ashamed if you had arthrosis? Why then would you feel ashamed if you were stricken with mental illness?” You’ve certainly heard this before, and it’s not an easy issue. I agree! Then why are we still uneasy talking about this in 2018?
I wanted to take this opportunity to write a blog post on mental health and neurological conditions. I wondered whether or not mental health conditions were different from neurological disorders and how people live with them. For example, how is depression different for a person who has a spinal cord injury? How is a personality disorder differ in a patient with Multiple Sclerosis? The list of possible questions (which are all interesting in themselves) is endless, which lead me to ask the ultimate question of “Which one do I chose?”
In doing my research, I discovered an open scientific debate. It’s a touchy subject, but could lead us to answer the first question of “Why are we still uneasy discussing mental illness in 2018?”
Mental Health and Neurological Health from a Scientific Point of View
Let me explain: We would consider schizophrenia to be a mental illness and Multiple Sclerosis a neurological disorder. Up to this point, things are very clear and undebatable.
But what about Alzheimer’s? Is it neurological or mental? And what about autism, Down Syndrome or ADD?
I guarantee that you will not find a clear-cut answer. One scientific article from the British Medical Journal gives a solid summary and analysis around the current situation. It is titled “Time to end the distinction between mental and neurological illnesses”. The paper was authored by White (Professor of psychological medicine), Rickard (consultant neuropsychiatrist) and Zeman (Professor of cognitive and behavioural neurology). Here is a plain language summary.
According to the current medical literature, here is how we would define disorders:
Neurological Disorder: “Neurological disorders are diseases of the central and peripheral nervous system. In other words, the brain, spinal cord, cranial nerves, peripheral nerves, nerve roots, autonomic nervous system, neuromuscular junction, and muscles.(2)”
Important to retain from this definition: Concerns the brain.
Mental Disorder: It’s interesting that the World Health Organization does not define Mental Disorder, but rather provides a definition of Mental Health(3). As for the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.(4)”.
Let’s take for example Alzheimer’s dementia. Some would say it is unquestionably a neurological disorder. After all, it’s a neurological impairment, right? That’s what is stipulated in the definition of neurological disorder. The senile plaques can be seen on a scan. However, clinical observation reveals “….impairment in cognitive function is commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation.(5)”
Confused yet? Wait a second, it gets worse! If you consult the “International Classification of Diseases (ICD-10)(6), you will find that Alzheimer’s is listed as a Neurodevelopmental Disorder and that Alzheimer’s Dementia (the same illness) is a Mental Disorder. These types of double classifications are ubiquitous; Alzheimer’s is, unfortunately, not the only example of this.
Arguments in favour of a change in terminology:
White, Rickards and Zeman (2012) propose an end to this type of distinction. Why not simple say that these are all central nervous system disorders? Here is some of the evidence that would support such a change:
Increased understanding in knowledge on the mind and the brain
Brain imaging has allowed much greater observation. We are able to see abnormalities in schizophrenia, bipolar disorder, chronic depression, post-traumatic stress disorder and obsessive compulsive disorder. The central nervous system, or the brain, has been shown to have structural differences when specific mental conditions are present.
“Functional brain imaging has shown that both normal and abnormal emotions have neural representations”, or that they are observables in brain activity during scans.
It is also becoming clearer that mental disorders can alter the brain.
Brain chemistry can affect mood and behaviour. Furthermore, dramatic events (such as witnessing a natural catastrophe) can also affect the way the brain functions. In the same way, medication, such as anti-depressants, can change the way our brain functions (such as our mood). Other non-medical treatments, such as cognitive therapy, can also alter brain activity.
Crossroads between mental and neurological
As research progresses we are realizing that certain areas of the brain which were once thought to control motor function or touch can actually influence our mood and our emotions too.
Research(1) has also shown that psychological manifestations happen frequently with those affected by neurological conditions. Sometimes this is a natural response like when depression is linked to a loss of autonomy or having a chronic, degenerative disease. Other times these manifestations are associated with changes in the brain like in the case of subcortical dementia in multiple sclerosis patients.
Also, as was previously mentioned, outside factors can affect brain function and bring about psychological manifestations like depression or post-traumatic stress disorders. These outside influences can be social, environmental or psychological. These are the factors that so shocking and life-changing in certain neurological conditions, and which in turn can lead to psychological manifestations.
It has been proven that the best care that can be provided takes into consideration the biology of the brain (i.e. medication, behavioural therapy, etc.) and environmental factors. Better patient care will be provided when working on both the neurological and psychological aspects at the same time. It would be counterproductive to deal with a disorder of the central nervous system without dealing with psychiatric disorders at the same time.
And how does this help?
First it would end discrimination and stigmatizing aimed at those with mental illness. Everyone can have a knee problem at one time or another. Anyone can have a problem with their brain at any given moment – the electrical part, the mechanics, either part can fail us. We must not forget that our brain is part of our body!
Also, it will be beneficial for healthcare workers to better delineate the notions of neurology and psychology and to see each individual as a whole – body and mind – as the two greatly influence each other. Healthcare providers will then be able to react more appropriately to psychological symptoms which can appear in neurological conditions, especially when these symptoms are treated without considering the flip-side of the equation or even worse, dissociated from one another! Improved patient care will happen in a biopsychosocial framework (bio=physical, the brain. Psycho=psychology, Social=environmental and social factors).
There will be advantages for those dealing with “mental disorders”, but also those with neurological conditions who can benefit from improved care of their psychological symptoms.
Changes in terminology won’t have an immediate affect on current healthcare, but “It will epitomise an intellectual shift with far reaching beneficial consequences”(1).
- Mental disorders are disorders of the brain.
- The mind requires attention in the field of medicine. (Both in general medicine and in neurology).
Do we all agree?
Maybe not! But the authors of this paper value the contribution of each field of expertise: psychiatry, psychology, neuropsychology, neurology, general practice, etc. Each one has possesses their expertise and needs to collaborate with the others for the benefit of the patient.
Furthermore, according to this text, the mind and the body are indivisible. The authors do not downplay the role of the mind, but rather emphasize that it has an important role in the patient’s well-being.
I would like to add that this progress explains a lot of things, will benefit our lives, but does not yet explain the unexplainable. I don’t think that this proposal attempts to explain questions surrounding life after death and the existence of the soul.
And how do you react to this? I trust that this will cause you to reflect on how you view mental health.
To find out more……
1 – White, P. D., Rickards, H., & Zeman, A. J. (2012). Time to end the distinction between mental and neurological illnesses. BMJ (Clinical Research Ed.), 344e3454. doi:10.1136/bmj.e3454
3- Organisation Mondiale de la Santé [en ligne] https://www.who.int/mediacentre/factsheets/fs220/fr/ Consulté le 2018-01-23 English Version : https://www.who.int/mediacentre/factsheets/fs220/en/
4 -American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders DSM-5 (5e éd.). Arlington, VA : American Psychiatric Publishing.
5 – Organisation Mondiale de la Santé [en ligne] https://www.who.int/mediacentre/factsheets/fs362/fr/ Consulté le 2018-01-23 English Version : https://www.who.int/mediacentre/factsheets/fs362/en/.
6 – Morgan C., McKenzie K., Fearon P., Society and Psychosis, Cambridge Medicine, 2008. Organisation mondiale de la santé, Classification internationale des troubles mentaux et des troubles du comportement, 10e édition (cim–10), 1 vol., Paris, Masson, 1993. (English Link : https://www.who.int/classifications/icd/revision/icd11faq/en/).