As a GP and the son of a psychiatrist, I have been fascinated by mental health from a young age. We are living through an epidemic of mental illness; the WHO ranks depression as the greatest cause of disability in the world. Anxiety, loneliness and personality disorder have become widespread.
According to a recent MIND survey, 40% of GP appointments include a mental health issue.
Psychologists have noticed a surge in personality disordered patients populating their waiting rooms. Politicians, commentators and celebrities now talk openly about mental health issues. However, there is very little analysis of the reasons behind this epidemic.
One contributing factor is almost certainly the increase in the identification and labelling of mental illness, as reflected by the ballooning of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). There is greater awareness amongst the public and more people are able to come forward to get help due to reduced stigma. There is also likely a good deal of over-diagnosis, with millions of children in the US now labelled with – and medicated for – ADHD.
But these factors surely don’t entirely explain why millions of people in the UK are now suffering with mental illness and taking antidepressants. To help us understand, we have to look at how the aetiology of mental illness extends beyond the clinical realm into social and economic spheres. From the 19th century onwards, Marx, Freud and others theorised that mental distress was linked to social changes. Freudo-Marxist Christopher Lasch argued that morally repressive societies such as Victorian Britain promoted neurosis, and that this was overtaken by personality disorder in a more permissive, liberal age.
While the mantras of choice might apply to dating and fashion, most people have very little choice over socioeconomic realities such as jobs, wages and housing
Narcissism specifically may now be the personality paradigm of our deregulated, neoliberal 21st century capitalist era; Jean Twenge and W Keith Campbell argue that narcissistic traits are increasing. And, while narcissistic personality disorder remains relatively rare, it’s remarkable how the check-list of pathological narcissistic traits – excessive self-obsession, grandiosity, superficial charm and shallow affect, all-consuming rage, manipulation and exploitation of others, emptiness with the tendency to mirror others, parasitic attachment, promiscuity and lack of empathy – reflect much of what we are surrounded with. They appear to fit hand in glove with the cult of celebrity and obsession with image promoted by advertising, consumerism and social media.
Furthermore, consumers are bombarded with marketing and advertising focused on aspirational lifestyles. Yet while the mantras of choice and agency might apply to dating, fashion and general behaviour, most people have very little choice over socioeconomic realities such as jobs, wages and housing. This disconnect can generate a sense of failure, frustration, rage and impotence.
All this is certainly in keeping with what we understand today around the social determinants of health generally and how mental illness correlates with socioeconomic status. Indeed, in The Inner Level – the follow-up to their widely acclaimed The Spirit Level – Kate Pickett and Richard Wilkinson argue that rising inequality is connected to the surge in mental illness.
So what are the solutions? Psychological therapies, such as cognitive behavioural therapy (CBT) help some. However, as one psychologist confided to me, CBT appears to be ‘a neoliberal solution in a neoliberal age’. With CBT, both therapist and patient are focused on changing the individual’s negative patterns of thinking and behaviour – admittedly a more manageable task – rather than looking at structural or systemic factors that are impacting on their mental health.
In spite of government rhetoric on parity of esteem for mental health, cuts and closures have hit hard and served to compound the crisis. Children and adolescents are forced to travel hundreds of miles to access inpatient beds. Much of this dates back to the Care in the Community programme of the 1980s leading to the closure of psychiatric institutions. Without the necessary investment in community resources, patients with serious mental illness have been left stranded without the help that they so badly need.
Since 2010, things have only got worse. Austerity has been linked to 120,000 excess deaths in health and social care. The literature on the links between economic crisis and mental health is extensive. It is no surprise that there is a greater burden of depression, anxiety and stress with increasing poverty, deprivation and inequality alongside the housing crisis, benefit sanctions and stoppages as well as cuts to social care for the most vulnerable.
Citizens are, in effect, forced to internalise a failed economic model of global capitalism. The solutions lie not just in increasingly sophisticated therapies but in the way we lead our lives and the structure of our societies.
Dr Youssef El-Gingihy is a GP in east London