Destigmatizing Mental Wellness: Be Equipped and Informed

mental health


“When a flower doesn't bloom, you fix the environment in which it grows, not the flower." – Alexander Den Heijer

 Consider this hypothetical scenario:

An otherwise studious teenager, Rose, begins missing home while attending her freshmen year of college. Her father died when she was small, committing suicide because of major depression. But growing up with her mom resulted in a tight bond over the years. Her grades begin to slip because of increasing home sickness. Her academic performance triggers esteem issues. Between the anxiety of knowing she can perform better and not wanting to disappoint her mom, she can’t get sleep. Rose is a loner and doesn’t have close friends she’d consider disclosing her troubles with. She doesn’t want to call her mother as saying goodbye once was enough. She wants to get help but feels no one will understand. She knows about the university therapist but doesn’t want people to think she’s crazy for going to the specialist.  She opts for the local clinic. There she describes her fatigue, brain fog, and stress. The clinician is at a loss to diagnose Rose with anything and suggests psychiatric treatment, which again she dismisses out of fear. Seemingly without anyone to turn to, her feelings of helplessness and depression worsen, until Rose herself is contemplating suicide.

 Last month, we began a series discussing lesser considered components of wellness by considering Social Wellness. This month, for Mental Health Awareness Month, Mental Wellness - and Rose - will be discussed.  

Rose’s scenario is not that far removed from how many people in the world go through life’s stresses. We have all experienced trouble, loss, grief, sadness, and anger. We go through our own versions of separation anxiety whenever we move, change jobs, experience breakups, or lose loved ones.

So, what is different about our responses to these situations and Rose’s responses? The World Health Organization (WHO) defines mental health “as a state of well-being enabling individuals to realize their abilities, cope with the normal stresses of life, work productively and fruitfully, and make a contribution to their communities.” [1] What could have changed about Rose’s situation for her mental health to bloom instead of wither? According to the science, simply more knowledge and awareness from the clinician and Rose herself on the signs and preventability of mental imbalances could have changed the outcome drastically.

Genetics and Chemical Imbalances

Many studies argue that genes determine whether someone will become mentally unstable or not. Family and twin studies assert that two siblings from similar upbringings have completely different levels of mental health, and thus different responses to a shared life stressor. In other words, “despite their shared upbringing, sibling similarity in well-being and mental health appears to be largely, or entirely, attributable to shared genes and not to shared environments.” [2] Genes are inherited, and recent evidences has found specific genes responsible for certain behaviors. Regarding mental wellness, “the loss of another gene, COMT… may also help to explain the increased risk of behavioral problems and mental illness.” [3] Genetics is just one factor of mental wellness, however.

There is also a view that depression is the result of chemical imbalances. “It had been known for several years that, at least in some people, the drug reserpine could lead to a depressed state. Subsequent studies in rabbits showed that reserpine causes reductions in serotonin.” [4] With the information from these studies, the view that depression could be linked to serotonin production levels emerged.

If genes and chemicals alone explained mental wellness, though, then the helplessness and fear Rose felt and the clinician’s inability to deal with Rose’s symptoms would be entirely warranted. “It is common in the United States for depression to be described as resulting from a ‘chemical imbalance.’ As the potentially dominant cultural story of depression etiology, the chemical imbalance explanation may exert a significant effect on treatment-seeking behaviors as well as the structures that are created and maintained for such treatment.” [5] This view would also explain the clinician’s recommendation to a psychiatrist. “Such discoveries also quickened the emergence of psychopharmacology as a discipline and helped lead to the eventual widespread practice of using prescription drugs to treat mental disorders.” [6] And once pharmaceutical companies became emmeshed with mental health, this view of chemical imbalance was “vigorously promoted by pharmaceutical companies and the psychiatric profession at large.” [7] What this all would mean for Rose is that her feeling that mental health is completely out of our control would be confirmed. She has a lost gene, or a chemical imbalance, something she doesn’t quite understand that she needs drugs for to keep from going crazy. That is a scary prospect.

Luckily for Rose, and us all, mental illness is not so simply reduced to genes and chemicals. Many other studies show the fallacies of the genetic argument. The issue with family and twin studies, for instance, is that each sibling is an individual, who still has his or her own unique experiences growing up that can color mental health levels. “Environmental influences do not operate on a family-by-family basis (e.g. parenting style do not have general effects), but rather on an individual-by-individual basis (affect siblings differently).” [8] Thus, it’s more accurate to say “family, twin, and adoption studies have firmly established the roles of both genes and environment in mental disorders.” [9]. For instance, one study found that “having a marriage-like relationship acts as an important protective factor in reducing the impact of inherited liability to symptoms of depression in the general population.” [10] Just because we inherit genes doesn’t mean we express them all. “The reason that heritability varies across environmental contexts is because different environments provide different opportunities for genetic potentials to be actualized.” [11] Therefore “certain features of the environment strongly influence symptoms of anxiety while having little impact on symptoms of depression.” [12] And vice versa. It’s why certain people can have high levels of mental health and wellbeing, too.

Genetic factors do explain why Rose’s family history both played a part that led to the expression of her genetic potential for depression. As expected, “the risk of onset of a major depressive episode in the month following the occurrence of any of four types of severe life events (death of a close relative, assault, divorce or marriage breakup, serious marital conflict) was highest in those at greatest genetic risk.” [13] But coupled with inheritance is Rose’s environmental separation anxiety. “Genetic variance increased with increasing exposure to stressful life events” [14] The stressful demands of college combined with her not coping with separation anxiety made it more likely for Rose to become depressed than simply having the inherited genes.

Regarding the theory on chemical imbalances, it turns out that “there is not a single peer-reviewed article that can accurately be cited to directly support claims of serotonin deficiency in any mental disorder.” [15] Just because our brains release different amounts of chemicals - disposing us to experience different levels of sadness, pain, or anxiety - does not mean we have chemical imbalances. They are often normal responses to situations that alert us to something wrong that needs addressed. The compounding effects of helplessness and having no support group led to Rose’s inability to cope with her chemical fluctuations, which were left unchecked and contributed to actualize the latent genes responsible for mental illness.

Far-reaching Consequences of Misunderstanding

Longstanding misinterpretations in cultures and media, particularly regarding the role of genes and chemical imbalances in mental health, have led to a vast stigmatism of this subject. “The task of treating people with mental illnesses is made even more difficult by the widespread stigma against these individuals in many societies.” [16] Rose’s own fear prevented her from seeking a psychiatrist and instead made her feel more ashamed of her situation. “Studies done in Qatar, a country with a similar cultural background and population demographic to Kuwait, showed that fear of people with mental illnesses is common and that mental disorders are believed to be a result of a punishment from God or possession by evil spirits.” [17]. Whether God or spirits, or genes or chemicals, become the culprit, the theme of helplessness in the face of things beyond our control recurs. Many countries of the world don’t respond much better to mental illness, either.

Even developed countries like the United Kingdom (UK) and United States of America (USA) stigmatize mental illness. “Large scale surveys in the UK have revealed that the general public are embarrassed and frightened of the mentally ill, who are seen as unpredictable and prone to violence.” [18] The United states is no exception. “Even under better-resourced conditions, most people with a mental illness in the USA do not seek assistance. An early national US survey found that less than a third of all people with mental illness received assessment and treatment.” [19] Globally,

“the German community expressed greatest acceptance of people with disabilities, followed by the Anglo, Italian, Chinese, Greek and Arabic groups. However, the relative degree of stigma attached to the various disabilities by the communities was very similar. In all communities, people with asthma, diabetes, heart disease and arthritis were the most, and people with AIDS, mental retardation, psychiatric illness and cerebral palsy, the least accepted of the disability groups.” [20]

No matter where in the world Rose is from, stigmatism needs to be weeded out.

Weeding can be done by uprooting all the pervasive incomplete data about genes and chemical balances previously discussed. Another way is to inform people how widespread mental illness is. For instance, did you know that “about 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders?” [21] Additionally, “The overwhelming majority of the 400 million persons with mental disorders globally are not being provided with even the basic mental health care that we know they should and can receive.” [22] It’s hard to stigmatize over 14% of the world’s population.

Once how many people are affected by mental illnesses are better appreciated, these diseases will no longer have to take a back seat to more ‘serious’ medical conditions like heart disease. “Mental disorders [are] likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions.” [23] Because clinicians and families know about and are concerned about more prominent diseases, “depressive symptoms often go unrecognized or are not taken seriously by clinicians and family members.” [24] Ultimately, because the importance of mental wellness has not been taken seriously enough for research or funding,

“at least a third of all somatic symptoms remain medically unexplained, both in the general population and in general medical-care settings. Common medically unexplained symptoms include pain, fatigue, and dizziness. Syndromes that represent characteristic organ specific groups of medically unexplained symptoms have also been defined: irritable bowel syndrome, fibromyalgia, chronic-fatigue syndrome, chronic pelvic pain, temporomandibular joint dysfunction, and sexual-discharge syndromes.” [31]

Rose’s clinician would have thought of one or more of these explanations for Rose’s symptoms but wouldn’t have enough evidence to properly diagnose her for any of them.

Road Ahead

The important takeaway from this awareness is that while complexities of gene interaction and chemicals do play a role in our mental health, there is no need to fear or stigmatize these aspects. So long as the controllable parts - the ability to cope with life stressors and take charge of the environment we shape for ourselves and each other – is acted on, the signs and symptoms of mental illness will drastically reduce.

At the cultural-societal level,

“the potential for primary prevention in relation to psychosocial factors lies largely outside the remit of clinicians. Psychosocial factors themselves are determined largely by social, political, and economic factors and it is therefore policy makers who influence the structure and function of communities—in the public and private domains—who may have scope for primary prevention.” [26].

Indeed, “contextual factors, including poverty and hunger, conflict and trauma, poor access to health and social care, and social inequity all serve to increase… vulnerability.” [27] But it’s not only major institutions and organizations that can help provide a more nurturing environment.

At an individual and family level, instead of shunning people with mental illness, we can put ourselves in the place of those suffering and help them through rough patches. If we look again at the WHO definition above, we can see that some people are going to be better inclined and equipped for dealing with modern-day stressors than others. Those the best at it will be considered mentally well, and those the worst as mentally ill. Most of us lie somewhere in the middle, and those at the higher end of the spectrum can coach those at the lower. According to Heather Horton, the director of a Wellness Resource Center, “Mental health is something that pertains to everyone. Everyone has mental health, and we move along a continuum, each of us, in terms of where we are at any given point in time.” [28] Following this reasoning, then, preventing mental illness is a matter of building up the skillset of dealing with the stresses of life and developing others on the lower end of the spectrum so they are not as susceptible to the more dangerous symptoms further on down the road.

One skillset that has already seen promise is positivity training. “A meta-analysis of 51 studies of positive interventions, including therapies focusing on mindfulness, positive writing, gratitude, forgiveness, or kindness demonstrated significantly improved well-being and decreased depressive symptoms in people with depression” [29]. Additionally, “positive psychology interventions can be effective in the enhancement of subjective well-being and psychological well-being, as well as in helping to reduce depressive symptoms.” [30] This is good news, but there are plenty of other ways people can boost their mental wellness.

Another skill that helps boost mental wellness is simulation. “Individuals who mentally simulated a stressful life event were better off psychologically than others. Thus, this type of simulation may be operating in disclosive writing—whether about life goals or stressful events.” [31]

Writing is a great way for people who don’t have access to support groups, like Rose, to have an outlet for disclosure. To learn more about this unique form of expression, see our article The Key to journaling for Health.

Combined with other wellness factors that can boost mental wellness, like social wellness, good nutrition, exercise, and sleep, embracing such skillsets can help change the landscape of mental health.

Positivity training and mental simulation for Rose’s situation could have changed the outcome of her scenario. By thinking of the positive aspects of her new campus environment and immersing herself into the experience, she wouldn’t have dwelt so much on how much she was missing home. By journaling her thoughts and anxieties, she could have foreseen plenty of holidays and rehearsed shared stories she could tell her mother the next time she visited. Also by disclosing her thoughts in writing, she could have gotten much needed sleep. Without developing mental health symptoms, her genetic predisposition to depression wouldn’t have been actualized, and the scenario would then have an ending of her confidently maturing and dealing with normal growing pains.

Now it’s time to go and choose your own mental health adventure in response to the stressors in your life. What stories do you have to share? In what way are you shaping the environment of mental wellness for the better? Feel free to share in the comments below. .

References

[1] "Mental Health: Strengthening Our Response." World Health Organization. Accessed May 09, 2019. https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response.

[2] Nes, Ragnhild. (2015). The Nature-Nurture Debate: New Evidence and Good News. Conference paper, Gross National Happiness Conference, Bhutan 2008. P. 158.

[3] ] Zaky, Eman. (2015). Nature, Nurture, and Human Behavior; an Endless Debate Editorial. Journal of Child and Adolescent Behavior. P. 2.

[4] Leo, Jonathan, and Jeffrey R. Lacasse. 2007. “The Media and the Chemical Imbalance Theory of Depression.” Society 45 (1): 35–45. https://doi.org/10.1007/s12115-007-9047-3. P. 35. .

[5] France, Christopher M., Paul H. Lysaker, and Ryan P. Robinson. 2007. “The ‘Chemical Imbalance’ Explanation for Depression: Origins, Lay Endorsement, and Clinical Implications.” Professional Psychology: Research and Practice 38 (4): 411–20. https://doi.org/10.1037/0735-7028.38.4.411. P. 411.

[6] “The ‘Chemical Imbalance’ Explanation for Depression: Origins, Lay Endorsement, and Clinical Implications.” Professional Psychology: Research and Practice 38 (4): 411–20. https://doi.org/10.1037/0735-7028.38.4.411. P. 411.

[7] Leo, Jonathan, and Jeffrey R. Lacasse. 2007. “The Media and the Chemical Imbalance Theory of Depression.” Society 45 (1): 35–45. https://doi.org/10.1007/s12115-007-9047-3. P. 35.

[8] Nes, Ragnhild. (2015). The Nature-Nurture Debate: New Evidence and Good News. Conference paper, Gross National Happiness Conference, Bhutan 2008. P. 158.

[9] Tsuang, M. T., Bar, J. L., Stone, W. S., & Faraone, S. V. (2004). Gene-environment interactions in mental disorders. World psychiatry : official journal of the World Psychiatric Association (WPA), 3(2), 73–83. P. 73.

[10] Heath AC, Eaves LJ, Martin NG. Interaction of marital status and genetic risk for symptoms of depression. Twin Res 1998;1:119-22. P. 122..

[11] Tsuang, M. T., Bar, J. L., Stone, W. S., & Faraone, S. V. (2004). Gene-environment interactions in mental disorders. World psychiatry : official journal of the World Psychiatric Association (WPA), 3(2), 73–83. P. 75.

[12] Fone, K.C., and Porkess, M.V. (2008). Kendler KS, Heath AC, Martin NG et al. Symptoms of anxiety and symptoms of depression. Same genes, different environments? Arch Gen Psychiatry 1987;44:451-7. P. 451.

[13] Tsuang, M. T., Bar, J. L., Stone, W. S., & Faraone, S. V. (2004). Gene-environment interactions in mental disorders. World psychiatry : official journal of the World Psychiatric Association (WPA), 3(2), 73–83. P. 75.

[14] Ibid. pp. 75-76.

[15] Leo, Jonathan, and Jeffrey R. Lacasse. 2007. “The Media and the Chemical Imbalance Theory of Depression.” Society 45 (1): 35–45. https://doi.org/10.1007/s12115-007-9047-3. P. 45.

[16] Almazeedi H, Alsuwaidan MT. (2014). Integrating Kuwait’s Mental Health System to end stigma: A call to action. J Ment Health, 23, 1–3. P. 2.

[17] Ibid.

[18] Coffey, M. (2009) Book review of Thornicroft, G. Shunned: discrimination against people with mental illness. Oxford University Press in Journal of Psychiatric and Mental Health Nursing. 16(1): 108-109. P. 108.

[19] Thornicroft, Graham, Diana Rose, and Nisha Mehta. 2010. “Discrimination against People with Mental Illness: What Can Psychiatrists Do?” Advances in Psychiatric Treatment 16 (1): 53–59. P. 53.

[20] Westbrook MT, Legge V & Pennay M. (1993). Attitudes towards disabilities in a multicultural society. Social Science & Medicine, 36(5), 615–623. P. 615.

[21] Prince, Martin; Patel, Vikram; Saxena, Shekhar; Maj, Mario; Maselko, Joanna; Phillips, Michael R; and Rahman, Atif. 2007. “No Health without Mental Health.” The Lancet 370 (September): 859–77. P. 859.

[22] Patel V, Saraceno B, Kleinman A. Beyond evidence: the moral case for international mental health. Am J Psychiatry 2006; 163: 1312–15. Pp. 1313 - 1314.

[23] Prince, Martin; Patel, Vikram; Saxena, Shekhar; Maj, Mario; Maselko, Joanna; Phillips, Michael R; and Rahman, Atif. 2007. “No Health without Mental Health.” The Lancet 370 (September): 859–77. P. 859.

[24] Bruce ML, Seeman TE, Merrill SS, Blazer DG. The impact of depressive symptomatology on physical disability: MacArthur Studies of Successful Aging. Am J Public Health 1994; 84: 1796–99. P. 1799.

[25] Prince, Martin; Patel, Vikram; Saxena, Shekhar; Maj, Mario; Maselko, Joanna; Phillips, Michael R; and Rahman, Atif. 2007. “No Health without Mental Health.” The Lancet 370 (September): 859–77. P. 862.

[26] Hemingway H, Marmot M. Evidence based cardiology: psychosocial factors in the aetiology and prognosis of coronary heart disease. Systematic review of prospective cohort studies. BMJ 1999; 318: 1460–67 P. 1466.

[27] Votruba, Nicole, Julian Eaton, Martin Prince, and Graham Thornicroft. 2014. “The Importance of Global Mental Health for the Sustainable Development Goals.” Journal of Mental Health 23 (6): 283–86. P. 283.

[28] "Stopping Stigmas with Mental Health Storytelling." Your NAMI Affiliate. Accessed May 09, 2019. https://namicoloradosprings.org/stopping-stigmas-mental-health-storytelling/.

[29] Schrank, Beate & Brownell, Tamsin & Tylee, A & Slade, Megan. (2014). Positive psychology: An approach to supporting recovery in mental illness. East Asian Archives of Psychiatry. 24. 95-103. P. 99.

[30] Bolier L, Haverman M, Westerhof GJ, Riper H, Smit F, Bohlmeijer E. Positive psychology interventions: a meta-analysis of randomized controlled studies. BMC Public Health 2013;13:119. P. 1.

[31] King LA. The health benefits of writing about life goals. Pers Soc Psychol Bull 2001;27:789-807. P. 800.