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Embracing only the biological ignores the psychosocial, to the detriment of all

#ThursdayThoughts, 12 January 2023

For as long as human societies have existed, we have grappled with mental health and tried to find causes and treatments. In ancient times, these were sometimes based on religion or magic, although they also included herbal remedies and ointments and what we now might term peer counselling.

In the Western world, mental health was revolutionised by Sigmund Freud and the rise of talk therapy (also known as psychotherapy). However, in recent decades the discussion has shifted significantly to pharmacological remedies for mental health conditions and a strong focus on biological causes.

Has the conversation swung too far?

Perhaps the first approach to mental health that we would call scientific was in the ninth century CE when Islamic physician Rhazes included mental health conditions in his comprehensive textbook of medicine. Rhazes’ proposed remedies included what we would now call pharmacological treatments and talk therapy, depending on the condition.

Though now largely debunked, Sigmund Freud’s theories in the early 20th century notably popularised talk therapy, which became the primary paradigm of mental health treatment for decades. Talk therapy provides “a safe place to discuss feelings and emotions” to identify issues and develop strategies and solutions to decrease the negative impacts of mental health issues.

However, the mental health treatment landscape changed in the 1950s. In 1952, the American Psychiatric Association (APA) introduced the Diagnostic and Statistical Manual of Mental Disorders (DSM). This publication codified and entrenched categorical diagnostic approaches to mental health, as well as the notion that mental health ‘disorders’ were caused by either impairment of brain function or difficulties in adaptation by the affected person.

Later that decade, the first two specifically antidepressant drugs were introduced, followed in the late 1980s with the first selective serotonin reuptake inhibitors (SSRIs).

Suddenly, many people thought depression and anxiety could be fully treated with a simple daily pill. It was a way to reduce the stigma and shame associated with having a mental health condition: you couldn’t help biology, whereas the general social belief was that people could change their psychosocial situation (such as housing and employment).

This was reinforced by advertising from drug companies. In the US, where direct marketing of pharmaceuticals is allowed, companies often use scientific terminology to appear more trustworthy, and advertising propagates narrowly biological explanations of depression. For example, the first ad for Fluoxetine that appeared in medical journals claimed that “There is considerable evidence that serotonergic function may be reduced in the brains of depressed patients.”

This advertising approach led to the vast majority of people believing that depression is caused by low serotonin levels or a chemical imbalance, even though recent research has found no clear evidence that serotonin levels or activity cause depression.

This belief in a purely biological cause of mental health conditions is linked to a false distinction in much of Western culture: a separation between ‘physical’ and ‘mental’ health, where each is considered independent and treated by different specialists. As noted in the 2000 Diagnostic and Statistical Manual of Mental Disorders (DSM IV):

“the term mental disorder unfortunately implies a distinction between ‘mental’ disorders and ‘physical’ disorders that is a reductionistic anachronism of mind/body dualism. A compelling literature documents that there is much ‘physical’ in ‘mental’ disorders and much ‘mental’ in ‘physical’ disorders. The problem raised by the term ‘mental’ disorders has been much clearer than its solution, and, unfortunately, the term persists in the title of DSM-IV because we have not found an appropriate substitute.”

This dualism contributes to people living with mental ill-health having an average life expectancy of 20 years less than the rest of the population. It also leads many to ignore the psychosocial impacts on mental health, such as relationships, employment, income, housing and trauma, despite significant research demonstrating the linkages.

Part of this ignorance of psychosocial impacts might be because these factors are far more difficult to categorise or treat. They can’t be found in a blood test or addressed with a pill, often leading to them being dismissed during a mental health diagnosis.

However, there is a deeper systemic cause of this damaging approach: neoliberal capitalism, the prevalent political ideology of much of the Western world. The focus on individual responsibility for mental health without considering the wider psychosocial context “fits in with capitalism and its free-market philosophy”. Most talking therapies, popular psychology and self-care programs now follow this approach, putting the responsibility on people with mental health conditions to seek their own supports rather than exploring the structures and socio-cultural contexts that likely contribute to higher rates of mental distress.

As one psychologist noted, “I worry that a purely medicalised, individualised understanding of mental health puts plasters over big gaping wounds, without addressing the source of violence.

In this way, the biological focus of mental health in the last 70 years ignores the many other treatments we should consider for people with mental health conditions. It “distracts us from the task of trying to understand the complex interaction and interdependence of issues related to mental health and illness”.

In addition to clinical responses to individual mental health conditions, we must seek population-level approaches (such as increasing social housing, community connectedness, employment, education and healthcare and decreasing marginalisation and discrimination) to reduce the rates of mental health conditions in our communities.

This is not an easy task. However, it is a task we must undertake if we are ever to counter the increasing levels of people experiencing mental health concerns.

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