Neither ill nor well: How psychology can help prevent distress from becoming disorder

Peter M. Forster (p.forster@worc.ac.uk)

Institute of Health & Society University of Worcester, Worcester WR2 6AJ, United Kingdom Overview

Estimates of the prevalence of mental disorders are rising. A recent study by Terrie Moffitt and colleagues in New Zealand (Moffitt et al, 2010) says that, using a longitudinal, prospective design, the lifetime prevalence of having a disorder that meets DSM-IV criteria should be revised to about 1 in 2, rather than the more commonly quoted figure of 1 in 4, obtained from retrospective surveys. Most psychologists have also moved away from a medical model of mental disorders in which a person either has a disorder or is mentally healthy, to a biopsychosocial model in which mental health is seen as a continuum. In this model a substantial segment of the population is distressed and experiencing significant problems in many aspects of their lives and yet would not receive a diagnosis of a mental disorder by the criteria of DSM-IV or ICD-10. This paper will provide a brief overview of many of the ways in which psychologists can help prevent the development of disorders, and of how the government can help them through a properly resourced mental healthcare system. Mental distress The criteria for a major depressive episode, for example, are clear and widely known: a person must experience five or more of nine symptoms for at least two weeks and they must include at least one of either depressed mood or loss of interest or pleasure (American Psychiatric Association, 2000). It is possible for someone to fall short of a diagnosis of depression and yet be significantly distressed or impaired in important areas of functioning. The World Health Organisation describe this latter state as a mental health problem rather then the more serious mental disorder. The same can be said of anxiety and a survey by Freeman, Pugh, Antley, Slater, Bebbington, Gittins, et al. (2008) found that 40% of a general, adult population experience paranoid thoughts.

Given that about two thirds of Australians who do have a diagnosable disorder are not able to access treatment, in addition to those with a mental health problem, this represents a significant number of people who are distressed, who are having trouble coping and yet are receiving little or no help. Some of those with sub-clinical symptoms will also go on to eventually develop a diagnosable disorder. Providing further support to the above figures, the Australian Bureau of Statistics reported that in 2007, 45% of all Australians had experienced at least one mental disorder at some point in their lives and 20% had a current problem (Australian Bureau of Statistics, 2007). Although the changes proposed in DSM-5 (American Psychiatric Association, 2010) go some way to at least acknowledging this situation, by including dimensional ratings for more disorders, there is, and will continue to be, a large, underserved population of distressed people. How can they be helped? Preventing distress from becoming a mental disorder Psychologists have many interventions that we can offer to those experiencing mental health problems, to ameliorate their distress and prevent problems from becoming a full-blown mental disorder, not all of which are well known. Counselling and psychotherapy The evidence for the effectiveness of most forms of counselling and psychotherapy is now overwhelming (Mick Coopers excellent book, published in 2008, provides a good summary, for example). In fact the research of Kirsch and colleagues provide good reasons for thinking that counselling and psychotherapy may be more effective than antidepressant drugs for mild to moderate cases of depression (Kirsch, Moore, Scoboria & Nicholls, 2002; Kirsch et al, 2008). As with most mental disorders, anxiety and stress benefit from counselling or psychotherapy (see Rector, Bourdeau, Kitchen, & Joseph-Massiah, 2008, for example). Cooper (2008) also presents evidence supporting the Dodo effect, which suggests that all the major forms of counselling and psychotherapy are about equally effective and each approach will help about 80% of clients. A clear implication, to which I will return, is that, if governments provided more funding to increase access to mental health services

provided by psychologists, counsellors, mental health social workers and so on, they could help treat problems and disorders, get more people back into employment and prevent a great deal of suffering. Exercise Reviews and meta-analyses have demonstrated mental health benefits of exercise in people with mental health problems of varying severity (see Richardson, Faulkner, McDevitt, Skrinar, Hutchinson and Piette, 2005, for example). This study reported exercise benefits for depression, anxiety, phobias, panic attacks and stress-related problems. Pajonk, Wobrock, Gruber, Scherk, Berner, Kaizl et al (2010) found that participating in a three-month aerobic exercise program increased hippocampal volume in adult male patients with chronic schizophrenia; it also improved their short-term verbal memory and relieved schizophrenia symptoms. Simply educating people about the benefits of exercise does not necessarily lead to behaviour change though. However, if people are helped to discover that there is a gap or disconnect between their poor exercise habits and their most deeply held values then it is more likely that they will adopt healthier exercise habits (Anshel, 2006). This suggests that psychologists are among those who are best placed to help people to change their level of activity and exercise to produce mental health benefits. Diet Helping anxiety-prone clients eat a more healthy and balanced diet, avoiding alcohol, nicotine, and caffeine may be very helpful for those with mild anxiety and not doing these things can undermine the effectiveness of other anxiety management techniques in those with more serious issues. There is also understandable reluctance to treat adolescents at high risk of psychosis with anti-psychotic drugs. The side effects and the stigma can be particularly harmful to young people. Yet a safe and simple modification to the diet is showing promise in preventing development to schizophrenia to a greater extent than a placebo by Amminger, Schfer, Papageorgiou, Klier, Cotton, Harrigan et al (2010). In this study the experimental group of adolescents and young adults was placed on a 12-week course of an omega-3 oil supplement. The benefits lingered several months past the end of the trial. The oil also relieved psychotic symptoms and improved functioning. Similarly a recent study by Franois Lesprance and colleagues at Universit de Montral showed a significant reduction in symptoms of depression in 430 middle-aged outpatients from eight Canadian clinics

with moderate depression following eight weeks of omega-3 oil supplement, compared to a placebo of sunflower oil with fish oil added to reduce the possibility of detecting the placebo. However, this reduction was only observed in those with depression symptoms alone rather than those with a co-morbid anxiety disorder, who simply showed a trend towards symptom reduction. The magnitude of the effect was about the same as that of typical antidepressant medication, suggesting a possibly inexpensive alternative to such medication. Such studies need independent replication, but they represent a promising addition to existing interventions. Mindfulness and relaxation Mindfulness practices, including meditation, and relaxation can be helpful for people who experience many of the forms that anxiety can take, from obsessive thoughts to feelings of panic (Kabat-Zinn, Massion, Kristeller, Peterson, Fletcher, Pbert et al, 1992). Diaphragmatic breathing has been recommended for people experiencing anxiety by Rector, Bourdeau, Kitchen, and JosephMassiah, (2008), amongst others. Many people with anxiety are focussing on the future when they experience their symptoms. A mindfulness practice that encourages quiet reflection on present sensations combined with letting go of any thoughts that arise can be very helpful in reducing such symptoms. Mindfulness practices, as part of Mindfulness-based Cognitive Therapy (MBCT) for example, have also been found useful in people with depression, particularly those who have experienced more episodes of depression according to Teasdale, Segal, Williams, Ridgeway, Lau, and Soulsby (2000). Participants reported developing a different, decentred relationship to their depression-inducing thoughts. Social support Helping people to develop a social support network can be useful for those experiencing a number of unpleasant symptoms including depression, anxiety and stress. Family, friends and support groups can help people recognise stressful situations that can trigger symptoms, and remind people of their strengths and their resources when they are feeling low or discouraged, amongst other effects. In a longitudinal study, Williams, Ware and Donald (1981), showed that having social supports such as visiting with others and having close friends, predicted improvements in mental health over time.

Social and cultural factors have been identified as particularly relevant to the mental health and wellbeing of Aboriginal Australians and Torres Strait Islanders (Garvey, 2008). On the larger scale, Western Australias Act-Belong-Commit Mentally Healthy WA campaign reflects our understanding of the importance of social factors in mental health and wellbeing (Donovan, James, Jaileh & Sidebottom, 2006). Act means that people should try to keep themselves physically, socially and cognitively active. Belong refers to being part of a group or organisation to gain a sense of connectedness. Commit refers to people joining organisations or activities and thereby gaining a sense of meaning. Sleep Chronic sleep problems are more likely to affect people with mental health problems than the general population. Sleep problems particularly affect those who experience anxiety, depression, bipolar disorder, and attention deficit hyperactivity disorder (ADHD) (Krystal, 2006). Clinicians have typically viewed sleep disorders as symptoms, but studies suggest that sleep problems may raise the risk for, and even directly contribute to, the development of some mental health problems. Such studies suggest that treating a sleep disorder may also help alleviate the symptoms of a mental health problem. The connection between sleep and mental health is not yet well understood. However, studies suggest that getting enough sleep helps develop mental and emotional resilience, while chronic sleep disruptions predispose some people to negative thinking and emotional vulnerability. Between 65 and 90% of those with major depression experience some kind of sleep disorder, either insomnia or obstructive sleep apnoea. Longitudinal studies have shown that sleep disorders often develop before the signs or symptoms of depression (Gregory, Rijsdijk, Lau, Dahl, & Eley, 2009). Insomnia may also be a risk factor for anxiety, but not to the same extent as for depression. Treatment of insomnia is usually the same, whether someone has a mental health disorder or not and most forms of treatment fall within the remit of psychologists including some or all of lifestyle changes, behavioural strategies and psychotherapy, sometimes supplemented by medication if necessary.

How can the government help? Estimates indicate that the Australian Government spends a little over six percent of its annual healthcare budget on mental health, yet the mental health services are expected to cope with 14 percent of the overall health burden according to McGorry, (2010). This expenditure is well below the levels spent in the countries with which Australia usually compares itself, such as New Zealand, Canada and the nations of Western Europe, where levels of expenditure are more typically around 12 percent of the health budget. So, whereas about 90 percent of Australians with a physical health problem are able to access quality care, only about a third of those with a mental health problem can access care. An estimated 30% of GP consultations in the UK have an underlying mental-health cause (Foresight Mental Capital and Wellbeing Project, 2008). However, many GPs, there and elsewhere, do not currently feel it is their job to help patients address psychological, social and occupational risk factors. Promoting referral from primary care to psychologists and other professionals is likely to be widely beneficial: individuals would benefit from earlier and more effective treatments; GPs would have fewer repeat visits; and there would be net savings to the national care budget. In April 2010, former Prime Minister Rudd of Australia pledged his government to an "historic reshaping of mental health services" when announcing the COAG health agreement. Yet less than a month later, the federal budget of his government widened the health gap by allocating only about two percent of new health money to mental health. And, although some programs expanded, such as Headspace (for mild to moderate mental ill-health) and EPPIC (for psychosis), more services were withdrawn. Social workers and occupational therapists with training in providing mental health services have had their Medicare rebate entitlements withdrawn, thus depriving many lower paid people, particularly in remote areas, of access to mental healthcare. What needs to happen so that those experiencing significant distress or those with a disorder but who are currently unable to access mental health services can receive the help they need? The following changes are likely to help: Bring government funding for mental health services into line with the burden those problems represent to society, which would be in the range 12-14 percent of the total healthcare budget, by conservative estimates;

 Additionally, providing more training and incentives for GPs to assess mental health problems, and also to treat or refer patients with mental health problems to psychologists. Conclusion It is widely acknowledged that mental health problems and disorders are growing faster than the services designed to treat them. Psychologists, in particular, have the knowledge and skills to make a major impact on the rising prevalence of psychological distress and mental disorders through both prevention and treatment. With greater Government investment aimed at improving access to psychological services, there is every reason to hope that this increasing prevalence can be reversed, with concomitant reductions in distress and disability. References
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