By Professor Thaddeus P. Ulzen*
The problem of mental health is as old as the ages but I am not entirely certain that I have all the new approaches that will be required. I prefer to use the term mental illnesses rather than mental illness because the brain, as complex as it is, can fail a person in numerous ways. Some of the conditions are manageable without a great deal of medical intervention, and many are severe enough to require significant medical treatment over a person’s lifetime.
Mental illnesses refer to a set of medical conditions that affect a person’s thinking, feelings, mood, and behavior and thus their ability to relate to others in daily functioning.
Mental health conditions or psychiatric disorders affect hundreds of millions of people world- wide. As recently as the beginning of this century, the World Health Organization estimated that, globally, over 154 million people suffered from Major Depressive Disorder, 25 million suffered from schizophrenia and over 100 million suffered from alcohol and drug abuse disorders. About a million people die each year from suicide.
This gives us an idea of the scope of the problem and helps us to determine how best to approach the issues that result from undiagnosed and untreated or poorly treated mental illnesses.
Mental functions are a reflection of brain processes. The brain in our field is shared by neurosurgeons, neurologists and psychiatrists. Joel Paris in an editorial in the Canadian Journal of Psychiatry reminded us that neurologists deal with axons and that psychiatrists address synapses.
Neurosurgeons of course handle the gross and obviously visible lesions and malformations of the brain and related structures. The complexity of the brain as an organ has continued to amaze us over time. It is estimated that the average brain has over 200 billion neurons and each neuron is connected to between 5 – 200,000 other neurons. There are 50 times more glial cells than neurons.
We also know that over 50% of the human genome is connected to functions of the brain and the central nervous system.
Over time, we have come to understand that mental illnesses and particularly the more obviously severe ones result from failures of neuro-transmitter function and brain circuitry which lead to symptoms that are cognitive, emotional, and behavioral.
We have also come to understand that many conditions that would be observed quite commonly such as major depression (5%), schizophrenia (1%), or bipolar disorder (3%) are conditions for which obvious signs are present usually by the second decade of life. This means that mental illnesses often have their onset in young people.
In the Ghanaian capital city of Accra, with a population of 4 million, we can expect about 40,000 people with schizophrenia, 200,000 with major depressive disorder and 120,000 with bipolar disorder.
We have come to recognize numerous biological markers for many previously poorly understood problems of the mind. Based on the presence of specific biological markers, social issues such as childhood maltreatment in specific individuals can lead to a trajectory of severe behavioural disorders such as conduct disorders and antisocial personality disorders.
Biological markers have also been identified for major depressive disorders, schizophrenia, post-traumatic stress disorders (PTSD), panic disorders, Alzheimer’s disease, and even for cannabis induced psychosis. In the last year a biological marker, the SKA2 gene, was also found for the risk of completed suicide.
Moving away from neurobiology and moving into the realm of society, stigma continues to be the biggest barrier to access for the appropriate treatment of mental illnesses.
Patients who are suffering tremendously from these distressing and overpowering conditions, postpone or avoid treatment until it is too late because of stigma. Stigma, of course, is based largely on a poor understanding of mental illnesses and also on the false expectation that mentally ill individuals are inherently violent and are destined to do harm to others.
It is important that physicians see themselves as the translators of the basic sciences of the brain (i.e. the clinical neurosciences) to the general public so that these conditions are de-mystified just as other common conditions like diabetes are now better understood by the lay public.
Poorly supported belief systems lead to the deprivation of basic human rights of our fellow citizens and family members who are already disabled by mental illnesses. There is a great deal of therapeutic nihilism around psychiatric disorders which upon the examination of evidence, has no basis at all.
The prevention of psychiatric illnesses should be an important dimension of the public health agenda of any country and more so of developing countries like those in Africa.
The prevention of psychiatric illnesses is primarily related to the identification and reduction of biopsychosocial risk factors that are identified and modifiable with careful long range planning and appropriate interventions.
Prevention is also successful if protective factors and the promotion of resilience form part of the appraisal of our public health view of mental illnesses. We have to begin to apply evidence-based interventions both for prevention and treatment of these disorders.
Prevention examples include the reduction of the incidence of specific disorders such as substance abuse, major depressive disorders, and post-traumatic stress disorders.
The reduction of risky behaviors such as substance use and unsafe sex and the reduction of measurable outcomes such as suicide, teen pregnancy, school dropouts, delinquency and similar variables, when combined with the promotion of mental health and wellness, sets us on the path to a better place.
We all understand that primary prevention relates to reduction of the incidence of new disorders and that secondary prevention is related to the reduction of the prevalence of disorders. Tertiary prevention relates to the reduction of the disability associated with disorders.
All of the principles of basic public health apply to the field of psychiatry in what Gerald Caplan referred to as Population – based Psychiatry. This is particularly important because, as I will point out later, the cost of not treating psychiatric disorders is immensely disproportionate to the cost of neglecting many physical disorders that we pay attention to daily.
The other aspect of prevention includes universal preventive interventions that can be targeted to an entire population; selective preventive interventions that are targeted to members of a population with known higher than average risk of particular conditions; and indicated interventions that are targeted to members of the population with prodromal symptoms of the disorders, such as first episode psychoses.
This would, for example, mean that an adolescent who has marked behavioral change, such as social withdrawal or sudden academic failure may be in the prodrome of a major psychiatric disorder such as major depressive disorder or schizophrenia. If not identified accurately and early or treated it could lead to a poor outcome such as florid psychosis or suicide.
The task of accurate diagnosis in such a situation often falls on a non-psychiatric physician in the community.
So, in our current situation with the limited resources that we have, what is the best way of implementing a preventive psychiatry approach to mental illness? I would say that the point of intervention with the greatest possible impact on the population would be school-based interventions.
In spite of being resource poor, all successive governments in Ghana have invested in the educational infrastructure of the country to some degree. I would propose that mental health nurses, bachelor and masters level psychologists and clinical social workers who are well trained and oriented to preventive psychiatry should become an integral part of every school’s staff.
It is in the education environment that young people who are at risk for developing psychiatric disorders are probably best identified early. Where there are poor school and family bonds the risk for psychiatric disorders increases.
It is also in the school environment that mental health professionals like these can assist teachers and parents with appropriate behavioral interventions and help them in identifying new problems as early as possible.
I do not subscribe to the idea that a child will “grow out of the problem”. Once a problem is identified as such by people who are closest to the child, either in the family context or in the educational context, the problem must be identified and respected as such.
If physicians and other health care providers do not know what the problem is, they must begin to find answers to the problem through consultation with mental health experts including psychiatrists. If they do not, these problems become more complicated with very negative outcomes such as psychotic illnesses or completed suicides.
In secondary schools and tertiary institutions the role of in house mental health professionals is critical because as it is at this stage of development that the first symptoms of major psychiatric disorders emerge.
Issues related to substance abuse, interpersonal relationships, and academic pressures all converge at this stage of life and if our institutions are not well resourced with mental health professionals we fail in our preventive role with the students.
In returning to tertiary prevention, which is more to do with reducing disability through treatment, we are better served by recognizing major psychiatric illnesses as chronic medical conditions. They are as chronic as essential hypertension or diabetes.
All of these conditions tend to have a genetic or biological risk which, in interaction with a person’s environment, can result in the expression of a full blown illness.
As doctors, we must approach major psychiatric illnesses with evidence-based treatments and not with clinical intuition or unsystematic clinical experiences.
We must use treatments that have been rigorously tested and shown to be advantageous. This is no different from how an internist would approach a patient with cardiovascular risk who has significant hypertension or a patient who has type I or type II diabetes.
A few years ago in a class at one of our medical schools – a student expressed pessimism about the outcomes for major psychiatric illnesses to me. He said that you don’t “cure these patients.”
I took a deep breath and I told him that for the last 26 years I have been taking anti-hypertensive medications on a daily basis and that my physician specialist had not cured my hypertension. It was being managed with treatment and in the same way patients with schizophrenia, bipolar disorders, major depressive disorders, and generalized anxiety disorders can have their symptoms well managed enough for them to have a functional life and contribute to society.
Let me turn to cost and disease burden. As we all should know by now, psychiatric conditions account for about 35 per cent of the global disease burden. This is because psychiatric disorders cause relatively more morbidity than mortality except in the case of suicide and premature death from medical illnesses.
Cardiovascular conditions account for 33 per cent of global disease burden and in the year 2010 the cost from lack of productivity globally for cardiovascular conditions was $863 million.
However, the cost in 2010 along the same lines for psychiatric disorders was $2.5 trillion dollars in lost productivity.
In 2030, the estimated cost in loss of productivity in cardiovascular disorders will be $1.04 trillion globally but $6 trillion globally for psychiatric disorders.
I don’t think there is any doubt that a strong preventive approach with early case finding and rigorous treatments will go a long way to prevent the escalation of cost over time.
Where do people go when they begin to have their first symptoms of a psychiatric disorder? In many situations they go to their primary care physician or other health care provider at the district or regional level.
They also speak to family elders, pastors or if their symptoms are flagrant enough they may be sent to a prayer camp where they will lose all their basic human rights, will be chained and will not be provided with any evidence based treatment.
While spirituality is an important component of good health, it is not an alternative to recognized treatment options.
In the primary care context it is now acknowledged that about 15 per cent of patients see a primary care provider primarily for a psychiatric reason and 50 percent have a significant psychiatric problem accompanying the presenting complaint in the primary care setting.
The WHO estimates that 25 percent of all patients using a health service suffer from at least one mental, neurological or behavioral disorder, most of which are undiagnosed or untreated.
Psychiatry therefore is a significant primary care concern. As a medical educator it strikes me that knowing this, the curriculum in undergraduate medicine should reflect this reality and equip graduates with knowledge and diagnostic skills to recognize common psychiatric conditions in the primary care setting.
These would be conditions like major depressive disorder, early schizophrenia, anxiety disorders, substance abuse disorders and, for children, attention deficit hyperactivity disorder and autism spectrum disorder.
In addition to the presentation of psychiatric symptoms in a primary care setting, there are numerous medical illnesses that present first with psychiatric symptoms and health care providers need to be aware of these.
The presence of a psychiatric illness that is untreated tends to worsen medical morbidity and disability as well and medical mortality rates are worsened by psychiatric illnesses. We know that patients with severe and persistent mental illnesses have a mortality that reduces their lifespans by 25 percent.
The mind and the body clearly are separated in our own minds but that is certainly not the human experience.
African governments should develop vigorous public mental health education programs since we all know that the behavioral factors account for up to 50 percent of the social determinants of health.
We must have continued education for doctors and other health care professionals because we must start the de-stigmatization process within the health professional community.
The teaching of psychiatry in medical schools should be more rigorous because most non psychiatric physicians will end up treating many patients with psychiatric disorders in the ambulatory setting and must do so guided by the best scientific evidence.
At the University of Cape Coast School of Medical Sciences (UCCSMS) where I teach regularly, we have a curriculum in psychiatry that is more than 10 weeks in duration. The average length of psychiatric rotation worldwide is 5.5 weeks.
African governments must invest in improving the psychiatric management skills of the generalists because they will be required to do more than those in developed countries.
We also have to examine other educational interventions. I believe for example that offering an additional year of training to family physicians in behavioral health and psychiatry would be a worthwhile investment.
There are also examples of primary care residency programs that are only one year longer that combine psychiatry with internal medicine or combine psychiatry with family medicine or combine psychiatry with neurology.
This approach will help increase the number of primary care and other specialists with skills to address the many patients in need of proper psychiatric evaluations and treatment.
Overall, we must increase our emphasis on inter-professional education and practice and recognize the role that non-physician healthcare providers can play in providing better mental healthcare to the population. Every health unit must have a mental health physician extender present from the district level up. Psychiatrically informed physicians will be effective leaders in educating the general public through patient care and community speaking opportunities on prevention and treatment of psychiatric disorders.
A strategy for prevention of psychiatric disorders centered on our educational infrastructure will have a sustainable impact on the population, reduce costs, lost productivity and promote overall health and wellness.
Every school must have a well-trained mental health professional to lead the prevention effort and liaise with the health care system.
Law enforcement and judicial officials also need formal training in mental health, as many patients come into contact with the legal system and often face inappropriate outcomes with loss of their constitutional protections.
One other important area is workplace mental health and the additional loss of productivity from presenteeism (the act of attending work while sick) when compared to worker absenteeism.
I would be remiss in not mentioning technology as a tool that we have grossly underused. It presents an opportunity for both education of trainees and the treatment for psychiatric disorders. There is no reason why we in Africa cannot develop a technologic network which would allow primary care physicians wherever they are to have access to specialists in and outside their countries, to consult with them on cases that they treat every day.
In conclusion I would like to return to the brain, the organ at the center of these disorders. I wish to highlight the plasticity of the brain. Just as it has strong biological underpinnings, it is also very much an organ that is shaped by the environment in which it lives. Advances in neuroscience research have led to a more sophisticated understanding of how psychotherapy may affect brain functioning.
Mental phenomena arise from the brain, but subjective experience also affects the brain. While psychotherapy and other environmental inputs will not change the genes, they can affect the transcriptional functions of gene expression and as such psychotherapy and other non-medical interventions can have a lasting positive impact on the brain.
It is said that medication may target temperament and psychotherapy character. Studies on the neuroscience of environmental impact on the brain remain preliminary but clearly there is a very large role for psychologists in the treatment of psychiatric disorders on the basis of what we know about the plasticity of the brain and how it changes based on externally derived inputs.
In the same way that trauma can affect the brain to cause post-traumatic stress disorder, psychotherapy can cause the brain to become resilient enough to reduce the risk of psychiatric disorders and to reduce the full expression of already present disorders.
Psychiatric disorders are extremely common. 1 in 4 will have a diagnosable psychiatric disorder in our lifetime and the disability engendered by major psychiatric disorders is significant. The degree of disability caused by major depressive disorder is thought to be equivalent to that of blindness or paraplegia (lower body paralysis.)
Schizophrenia is similarly estimated to cause a degree of disability consistent with quadriplegia (paralysis of all four limbs.) These are not insignificant conditions.
The mind is at the core of who we are but we take good mental health for granted. We have a great task and responsibility to change our thinking about these brain conditions from what prevailed in the 17th century to the integrated understanding that we now have in the 21st century.
I must however remind you that at the turn of the 20th century, Africans were well ahead of Europeans in psychopharmacology. In 1925, when a prominent Nigerian went psychotic in England, there were no effective treatments available. His traditional healer who arrived weeks later from Nigeria treated him effectively with Rauwolfia root. He had better medicine than any European or American psychiatrist of that era.
I have simply touched on a few areas. I would like to end by saying that in the last three that I have been in a practice as a psychiatrist, every decade has come with better and more effective treatments for mental illnesses.
We have a great opportunity to design effective prevention and treatment systems even with the limited resources we have by applying those resources within a different conceptual framework.
*Thaddeus P Ulzen is Professor and Chair, Department of Psychiatry and Behavioral Medicine, University of Alabama School of Medicine, Tuscaloosa, Alabama, USA
(Adapted from a speech delivered at the 12th Annual General & Scientific Meeting of the Ghana College of Physicians and Surgeons on December 9, 2015 in Accra, Ghana.)