By David Zitner
and Dominic Covvey
Nova Scotia Premier Tim Houston’s recent election campaign emphasized health services, including mental health. Now, federal leaders are also dedicating substantial energy during their election campaigns to discussions of health and mental health.
Mistaken beliefs and our incomplete understanding of the nature of mental health problems lead to undue, often inappropriate, reliance on doctors and overuse of psychotropic medication. The belief that all mental health problems are medical contributes to the failure of successive federal and provincial governments to support timely, useful and cost-worthy mental health services.
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The elements of mental health are thoughts – including attitudes – feelings and behaviour. The purposes of the many non-pharmaceutical and pharmaceutical mental health interventions are to help change the way people think, feel and behave.
Many people, including mental health professionals and political leaders, don’t recognize the five categories that include everyone labelled with mental health problems:
People with easily discoverable medical (biological) causes for mental health problems
Examples include those suffering from the fatigue and depression caused by an underactive thyroid gland or the overactivity and irritability caused by an overactive thyroid gland.
People who hallucinate or have psychotic thinking from brain tumours also have easily diagnosable medical problems.
People with obscure or difficult-to-discover medical (biological) causes for their problems
This group includes patients with porphyria or Addison’s disease, and many other rare diseases. Sometimes it takes years to find the biological abnormality.
Many people endure additional and unnecessary suffering when treated by psychoactive medications that make their medical condition worse or when the diagnosis is delayed because doctors believe the person’s problems are explained by a psychiatric label.
People whose doctors are satisfied with hypothetical or speculated abnormal biology as an explanation
Despite thorough and complete physical examination and testing, these doctors do not find any objective evidence of abnormal biology. There might be an illness but it’s not discoverable with any objective tests because researchers have not yet identified it.
Unfortunately for these patients, doctors sometimes baselessly speculate or conclude that there’s abnormal biology, telling patients they have a “biochemical imbalance.”
When doctors know the exact biological cause of a problem, they tell the patient and treat that cause. For example, when thyroid hormone is high or low, doctors explain the extent of the abnormality and show objective lab results.
Treating a hypothetical, unspecified biochemical imbalance means the clinician has no way of knowing if the proposed medication will reduce the imbalance or make the problem worse. People with hypothetical biological illnesses are often unnecessarily medicated because many doctors (and patients) accept ‘diagnosis by description.’
Telling people who feel sad and lack energy that they have depression is just using different words to describe the problem. The descriptive label doesn’t reveal the cause or what the treatment should be.
People who don’t have abnormal biology but who react in a normal way to their life circumstance
Abnormal biology didn’t cause the twisted behaviour of the children in Charles Dickens’s book Oliver Twist. Nor are the sadness, anger, anxiety and rage many feel when they hear about tragedies like that unfolding in Afghanistan.
People who receive unnecessary mental health attention but are happy with themselves, satisfied with their lives and just a little bit different
Certain teachers value exuberant and curious children, while other teachers regard the same behaviour as evidence of hyperactivity attention deficit disorder (so-called ADHD).
Some creative and productive philosophers and scientists may seem odd only because they’re unable to communicate their profound thoughts to the rest of us.
A cost-worthy and effective approach to mental health problems
People with medical problems causing mental health disturbances should receive treatment for their medical condition, usually by their family doctor, with or without help from specialized advisers including endocrinologists.
For mental health problems not the result of biological disease, doctors, armed with the power of the prescription pad, shouldn’t be the first choice.
For example, the Strongest Families Institute, a now international Nova Scotia initiative, “provides cost-effective solutions to the barriers often associated with receiving mental health care, and has strong, successful outcomes. The organization’s highly trained coaches deliver proven, skills-based programs to families in the comfort of their own homes (by phone and Internet).”
These coaches, who have no medical credentials, are having amazing success helping people to influence and modify the mental health of family members.
People without medical training, including mental health workers (for example psychologists and social workers), friends, clergy and relatives, can provide significant support to people with mental problems. To do that, they learn about the context of the person’s life to find potential environmental or behavioural solutions.
For example, many people who feel tired and depressed improve with better diet, exercise and better sleep. Drugs are usually unnecessary and should be avoided as early interventions because they expose people to the risk of side effects and can deflect diagnostic efforts seeking medical causes (for example, porphyria).
However, if non-medicinal interventions fail, referral to a physician for possible medical treatment is appropriate. Drugs like valium help most people to feel relaxed, and caffeine or amphetamines help most feel energetic, regardless of normal or abnormal biology.
A worthwhile or harmful response to medication doesn’t denote underlying biological disease. Healthy and sick people respond to these drugs in the same way. Using drugs for mental problems is like using Tylenol or Aspirin for pain or fever. The response doesn’t indicate or treat underlying biological pathology.
Mental health care will be more accessible when doctors aren’t the first contact or the key holders to care. Medications when necessary, but not necessarily medication. Doctors when necessary, but not necessarily doctors.
Doctors are the exclusive prescribers of medications. Other mental health professionals, and most helpful and sensitive people, though, can use all the other methods including listening and talking to people or behavioural interventions focused on achieving the desired action.
Using medical and non-medical mental health professionals appropriately will improve access to care for all and produce improved results.
Dominic Covvey, the founding director of the Canadian National Institutes for Health Informatics resides on Mayne Island, B.C. David Zitner, MA, MD, FCFP, is a retired family physician. He was the founding director of the graduate program in Health Informatics Dalhousie University Faculty of Medicine, Halifax, N.S.
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