Defined simply, this is a disorder of the brain's processes that makes the sufferer feel or seem ill, and may prevent that person from coping with daily life. Psychiatrists – doctors specialising in diagnosing and treating mental illness – have, however, come up with a range of much more complex definitions over the years.
Psychiatrists like to categorise mental illnesses because mental signs and symptoms tend to occur together in clusters or syndromes, each potentially able to respond to certain treatments. The idea that illnesses can be diagnosed simply by recognising their symptom patterns may not seem very scientific in these days of high technology. For most common mental illnesses, however, this is the only method of diagnosis; whatever is going wrong in the brain is usually too poorly understood and too subtle to show up in laboratory tests or computed tomography scans of the brain. And symptom-based definitions of mental illnesses are, generally, a lot more meaningful than the vague lay term ‘nervous breakdown’, which is used to cover an attack of anything from AGORAPHOBIA to total inability to function.
There is still a lot to learn about the workings of the brain, but psychiatry has developed plenty of practical knowledge about the probable causes of mental illness, ways of relieving symptoms, and ways of aiding recovery. Most experts now believe that mental illnesses generally arise from different combinations of inherited risk and psychological STRESS, sometimes with additional environmental exposure – for example, VIRUSES, drugs or ALCOHOL.
The range of common mental illnesses includes anxiety states, PHOBIA, DEPRESSION, alcohol and drug problems, the EATING DISORDERS anorexia and bulimia nervosa, MANIC DEPRESSION, SCHIZOPHRENIA, DEMENTIA, and a group of problems related to coping with life that psychiatrists call personality disorders.
Of these mental illnesses, dementia is the best understood. It is an irreversible and fatal form of mental deterioration (starting with forgetfulness and eventually leading to severe failure of all the brain's functions), caused by rapid death of brain cells and consequent brain shrinkage. Schizophrenia is another serious mental illness which disrupts thought-processes, speech, emotions and perception (how the brain handles signals from the five senses). Manic depression, in which prolonged ‘highs’ of extremely elevated mood and overexcitement alternate with abject misery, has similar effects on the mental processes. In both schizophrenia and manic depression the sufferer loses touch with reality, develops unshakeable but completely unrealistic ideas (delusions), and hallucinates (vividly experiences sensations that are not real, e.g. hears voices when there is nobody there). This triad of symptoms is called psychosis and it is what traditionally people, through fear and lack of understanding, sometimes call lunacy, madness or insanity.
The other mental illnesses mentioned above are sometimes called neuroses. But the term has become derogatory in ordinary lay language; indeed, many people assume that neuroses are mild disorders that only affect weak people who cannot ‘pull themselves together’, while psychoses are always severe. In reality, psychoses can be brief and reversible and neuroses can cause lifelong disability.
However defined and categorised, mental illness is a big public-health problem. In the UK, up to one in five women and around one in seven men have had mental illness. About half a million people in Britain suffer from schizophrenia: it is three times commoner than cancer. And at any one time, up to a tenth of the adult population is ill with depression.
Most people with mental-health problems get the help they need from their own family doctor(s), without ever seeing a psychiatrist. General practitioners in Britain treat nine out of ten recognised mental-health problems and see around 12 million adults with mental illness each year. Even for the one in ten of these patients referred to psychiatrists, general practitioners usually handle those problems that continue or recur.
Psychiatrists, psychiatric nurses, social workers, psychologists, counsellors and therapists often see patients at local doctors’ surgeries and will do home visits if necessary. Community mental-health centres – like general-practice health centres but catering solely for mental-health problems – offer another short-cut to psychiatric help. The more traditional, and still more common, route to a psychiatrist for many people, however, is referral by the general practitioner to a hospital outpatient department.
In many ways, a visit to a psychiatrist is much like any trip to a hospital doctor – and, indeed, psychiatric clinics are often based in the outpatient departments of general hospitals. First appointments with psychiatrists can last an hour or more because the psychiatrist – and sometimes other members of the team such as nurses, doctors in training, and social workers – need to ask lots of questions and record the whole consultation in a set of confidential case notes.
Psychiatric assessment usually includes an interview and an examination, and is sometimes backed up by a range of tests. The interview begins with the patient's history – the personal story that explains how, and to some extent why, help is needed now. Mental-health problems almost invariably develop from a mixture of causes – emotional, social, physical and familial – and it helps psychiatrists to know what the people they see are normally like and what kind of lives they have led. These questions may seem unnecessarily intrusive, but they allow psychiatrists to understand patients’ problems and decide on the best way to help them.
The next stage in assessment is the mental-state examination. This is how psychiatrists examine minds, or at least their current state. Mental-state examination entails asking more questions and using careful observation to assess feelings, thoughts and mental symptoms, as well as the way the mind is working (for example, in terms of memory and concentration). During first consultations, psychiatrists usually make diagnoses and explain them. The boundary between a life problem that will clear up spontaneously and a mental illness that needs treatment is sometimes quite blurred; one consultation may not be enough to put the problem in perspective and help to solve it.
Further assessment in the clinic may be needed, or some additional tests. Simple blood tests can be done in outpatient clinics but other investigations will mean referral to another department, usually on another day.
Psychologists work in or alongside the psychiatric team, helping in both assessment and treatment. The range of psychological tests studies memory, intelligence, personality, perception and capability for abstract thinking.
Blood tests and brain scans may be useful to rule out a physical illness causing psychological symptoms.
Many patients have social difficulties that can be teased out and helped by a psychiatric social worker. In the UK, ‘approved social workers’ have special training in the use of the Mental Health Act, the law that authorises compulsory admissions to psychiatric hospitals and compulsory psychiatric treatments. These social workers also know about all the mental-health services offered by local councils and voluntary organisations, and can refer clients to them. The role of some social workers has been widened greatly in recent years by the expansion of community care.
Mental-health problems causing practical disabilities – for instance, inability to work, cook or care for oneself – can be assessed and helped by occupational therapists.
The aims of psychiatric treatment are to help sufferers shake off, or at least cope with, symptoms and to gain or regain an acceptable quality of life.
This is a widely used ‘talking cure’, particularly in general practice. Counsellors listen to their clients, help them to explore feelings and to find personal and practical solutions to their problems. Counsellors do not probe into clients’ pasts or analyse them.
This is the best known ‘talking cure’. The term psychotherapy is a generalisation covering many different concepts. They all started, however, with Sigmund Freud (see FREUDIAN THEORY), the father of modern psychotherapy. Freud was a neurologist who discovered that, as well as the conscious thoughts that guide our feelings and actions, there are powerful psychological forces of which we are not usually aware. Applying his theories to his patients’ freely expressed thoughts, Freud was able to alleviate many patients’ symptoms, some of which had been presumed completely physical. This was the beginning of individual analytical psychotherapy, or PSYCHOANALYSIS. Although Freud's principles underpin all subsequent theories about the psyche, many different schools of thought (sometimes contradicting each other) have emerged and influenced psychotherapists (see JUNGIAN ANALYSIS; PSYCHOTHERAPY).
This springs from theories of human behaviour, many of which are based on studies on animals. The therapists, mostly psychologists, help people to look at problematic patterns of behaviour and thought and to change them. COGNITIVE BEHAVIOUR THERAPY (CBT) can be very effective, particularly in depression and eating disorders.
The most widely used physical treatments in psychiatry are drugs. Tranquillising and anxiety-reducing BENZODIAZEPINES like diazepam, well known by its trade name of Valium, were prescribed widely in the 1960s and 70s because they seemed an effective and safe substitute for barbiturates. Benzodiazepines are, however, addictive and are now recommended only for short-term relief of anxiety that is severe, disabling, or unacceptably distressing. They are also used for short-term treatment of patients drying out from alcohol.
ANTIDEPRESSANT DRUGS like amitriptyline and fluoxetine are given to lift depressed mood and to relieve the physical symptoms that sometimes occur in depression, such as insomnia and poor appetite. The side-effects of antidepressants are mostly relatively mild, when recommended doses are not exceeded – although one group, the monoamine oxidase inhibitors, can lead to sudden and dangerous high blood pressure if taken with certain foods.
Manic depression virtually always has to be treated with mood-stabilising drugs. Lithium carbonate is used in acute mania to lower mood and stop psychotic symptoms; it can also be used in severe depression. However lithium's main use is to prevent relapse in manic depression. Long-term unwanted effects may include kidney and thyroid problems, and short-term problems in the nervous system and kidney may occur if the blood concentration of lithium is too high – therefore it must be monitored by regular blood tests. Carbamazepine, a treatment for EPILEPSY, has also been found to stabilise mood, and also necessitates blood tests.
Antipsychotic drugs, also called neuroleptics, and major tranquillisers are the only effective treatments for relieving serious mental illnesses with hallucinations and delusions. They are used mainly in schizophrenia and include the short-acting drugs chlorpromazine and clozapine, as well as the long-lasting injections given once every few weeks like fluphenazine decanoate. In the long term, however, some of the older antipsychotic drugs can cause a brain problem called TARDIVE DYSKINESIA that affects control of movement and is not always reversible. And the antipsychotic drugs’ short-term side-effects such as shaking and stiffness sometimes have to be counteracted by other drugs called anticholinergic drugs, such as procyclidine and benzhexol. Newer antipsychotic drugs such as clozapine do not cause tardive dyskinesia, but clozapine cannot be given as a long-lasting injection and its concentration in the body has to be monitored by regular blood tests to avoid toxicity.
The other two physical treatments used in psychiatry are particularly controversial: electroconvulsive therapy (ECT) and psychosurgery. In ECT, which can be life-saving for patients who have severe life-threatening depression, a small electric current is passed through the brain to induce a fit or seizure. Before treatment the patient is anaesthetised and given a muscle-relaxing injection that reduces the magnitude of the fit to a slight twitching or shaking. Scientists do not really understand how ECT works, but it does, for carefully selected patients. Psychosurgery – operating on the brain to alleviate psychiatric illness or difficult personality traits – is extremely uncommon these days. Stereotactic surgery, in which small cuts are made in specific brain fibres under X-ray guidance, has superseded the more generalised lobotomies of old. The Mental Health Act 1983 ensures that psychosurgery is performed only when the patient has given fully informed consent and a second medical opinion has agreed that it is necessary. For all other psychiatric treatments (except another rare treatment, hormone implantation for reducing the sex drive of sex offenders), either consent or a second opinion is needed – not both.
Psychiatric wards do not look like medical or surgical wards and staff may not wear uniforms. Patients do not need to be in their beds during the day, so the beds are in separate dormitories. The main part of most wards is a living space with a day room, an activity and television room, quiet rooms, a dining room, and a kitchen. Ward life usually has a certain routine. The day often starts with a community meeting at which patients and nurses discuss issues that affect the whole ward. Patients may go to the occupational therapy department during the day, but there may also be some therapy groups on the ward, such as relaxation training. Patients’ symptoms and problems are assessed continuously during a stay in hospital. When patients seem well enough they are allowed home for trial periods; then discharge can be arranged. Patients are usually followed up at least once in the outpatient clinic.
Psychiatric emergencies – patients with acute psychiatric illness – may develop from psychological, physical, or practical crises. Any of these crises may need quick professional intervention. Relatives and friends often have to get this urgent help because the sufferer is not fit enough to do it or, if psychotic, does not recognise the need. First, they should ring the person's general practitioner. If the general practitioner is not available and help is needed very urgently, relatives or friends should phone the local social-services department and ask for the duty social worker (on 24-hour call). In a dire emergency, the police will know what to do.
Any disturbed adult who threatens his or her own or others’ health and safety and refuses psychiatric help may be moved and detained by law. In England & Wales, the Mental Health Act of 1983 authorises emergency assessment and treatment of any person with apparent psychiatric problems that fulfil these criteria, while the Mental Capacity Act 2009 governs the safeguards necessary if anyone without capacity is deprived of their liberty, including access to Court proceedings. Analogous legislation is in place in Scotland and Northern Ireland.
Although admission to hospital may be the best solution, there are other ways that psychiatric services can respond to emergencies. In some districts there are ‘crisis intervention’ teams of psychiatrists, nurses, and social workers who can visit patients urgently at home (usually at a GP's request) and, sometimes, avert unnecessary admission. And research has shown that home treatment for a range of acute psychiatric problems can be effective.
Long-term treatment is often provided by GPs with support and guidance from psychiatric teams. That is fine for people whose problems allow them to look after themselves, and for those with plenty of support from family and friends. But some people need much more intensive long-term treatment and many need help with running their daily lives.
Since the 1950s, successive governments have closed most old psychiatric hospitals and have tried to provide as much care as possible outside hospital – in ‘the community’. Community care is effective as long as everyone who needs inpatient care, or residential care, can have it. But demand exceeds supply. Research has shown that some homeless people have long-term mental illnesses and have somehow lost touch with psychiatric services. Many more have developed more general long-term health problems, particularly related to alcohol, without ever getting help.
The NHS and Community Care Act 1990, in force since 1993, established a new breed of professionals called care managers to assess people whose long-term illnesses and disabilities make them unable to cope independently with life. Care managers are given budgets by local councils to assess people's needs and to arrange for them tailor-made packages of care, including services like home helps and day centres. Unfortunately, co-ordination between health and social services has sometimes failed and resources are limited.
Since 1992 psychiatrists have had to ensure that people with severe mental illnesses have full programmes of care set up before discharge from hospital, and are overseen by named key workers. And since 1996 psychiatrists have used a new power called Supervised Discharge to ensure that the most vulnerable patients cannot lose touch with mental-health services. There is not, however, any law that allows compulsory treatment in the community.
There is ample evidence that community care can work and that it need not cost more than hospital care. Critics argue, however, that even one tragedy resulting from inadequate care, perhaps a suicide or even a homicide, should reverse the march to community care. And, according to the National Schizophrenia Fellowship, many of the 10–15 homicides a year carried out by people with severe mental illnesses result from inadequate community care.
Overview of the Mental Health Act is by the Mental Health Act Commission, part of the CARE QUALITY COMMISSION.
Emotional and behavioural problems are common in children and adolescents, affecting up to one-fifth at any one time. But these problems are often not clear-cut, and they may come and go as the child develops and meets new challenges in life. If a child or teenager has an emotional problem that persists for weeks rather than days and is associated with disturbed behaviour, he or she may have a recognisable mental health disorder.
Anxiety, phobias and depression are fairly common. For instance, surveys show that up to 2.5 per cent of children and 8 per cent of adolescents are depressed at any one time, and by the age of 18 a quarter will have been depressed at least once. Problems such as OBSESSIVE COMPULSIVE DISORDER, ATTENTION DEFICIT DISORDER (HYPERACTIVITY SYNDROME), AUTISM, ASPERGER'S SYNDROME and SCHIZOPHRENIA are rare.
Mental-health problems may not be obvious at first, because children often express distress through irritability, poor concentration, difficult behaviour, or physical symptoms. Physical symptoms of distress, such as unexplained headache and stomach ache, may persuade parents to keep children at home on school days. This may occasionally be appropriate, but regularly avoiding school can lead to a persistent phobia called school refusal.
If a parent, teacher or other person is worried that a child or teenager may have a mental-health problem, the first thing to do is to ask the child gently if he or she is worried about anything. Listening, reassuring and helping the child to solve any specific problems may well be enough to help the child feel settled again. Serious problems such as bullying and child abuse need urgent professional involvement.
Children with emotional problems will usually feel most comfortable talking to their parents, while adolescents may prefer to talk to friends, counsellors, or other mentors. If this doesn't work, and if the symptoms persist for weeks rather than days, it may be necessary to seek additional help through school or the family's general practitioner. This may lead to the child and family being assessed and helped by a psychologist or, less commonly, by a child psychiatrist. Again, listening and counselling will be the main forms of help offered. For outright depression, COGNITIVE BEHAVIOUR THERAPY and, rarely, antidepressant drugs may be used.