Reviews

Time to abandon the term mental illness

When we use the term "mental illness," not "brain illness," do we put our patients in harm's way? This is an appropriate time to ask, because it has become apparent in recent years that disorders of the brain and nervous system are among the most serious and prevalent health problems globally.

By 2020, diseases arising from nervous system disorders will make up 14.7% of all diseases worldwide (up from 10.5% in 1990), according to the Global Burden of Disease (GBD) Study recently carried out by the World Health Organization and other institutions (www.hsph.harvard.edu/organizations/bdu/gbdmain.html).

Although nervous system disorders comprise only 1.4% of all deaths, this study estimated that they account for a remarkable 28% of all years of life lived with a disability. Moreover, much of the burden of illness due to road traffic incidents, violence, war, and falls is a consequence of nervous system dysfunction. The president of the World Federation of Neurology, James F Toole, has highlighted brain dysfunction among world leaders as one of the greatest threats to global peace, and therefore the health of populations.

In making their estimates, the GBD researchers took into account that chronic illnesses differ in their impact on people, including the differential impact resulting from the way friends, coworkers, and society at large react and respond to each illness. For example, there is little doubt that people with nervous system disorders are more likely to be subjected to discrimination and stigmatisation than people with, say, disorders of the heart and lung. Employers try to avoid hiring people with a history of nervous system disorders, and otherwise compassionate people may avoid contact with such individuals in social settings. Health ministries or private insurance companies may deprive some people with serious brain disorders of the opportunity to consult with a psychiatrist or neurologist.

Our reflections upon the stigma and prejudice that apply differentially to people with nervous system disorders have led us to conclude that the mental health and mental illness labels traditionally and commonly used to characterise certain brain disorders contribute to these twin sources of unnecessary suffering. We propose that these terms be abandoned in favour of "brain health" and "brain illness."

The concept of mind and mental effort is deeply woven within the western intellectual tradition as a fundamental concept of philosophy. Metaphysics is that branch of philosophy that studies the nature of matter (ontology), of mind (philosophical psychology), and of the ways that matter and mind interact in sense perception and the acquisition of knowledge (epistemology). "That in the soul which is called mind," Aristotle writes, is "that whereby the soul thinks and judges." Philosophers, theologians, and children wonder whether mind is a uniquely human possession, whether other animals have minds, or whether there is a transcendent intelligence, an absolute mind, in the universe. However, in proposing that we replace the mental illness label with the brain label, we are arguing not from a philosophical position but within the domains of public health and clinical medicine, as an essential step to promote the improvement of human health.

Last week's World Health Day 2001 commendably highlighted nervous system disorders. Although the six disorders underscored in this project were all brain disorders (depressive disorders, schizophrenia, dementia, alcohol dependence, epilepsy, and mental retardation), the event was widely known as World Health Day 2001 on Mental Health. Advances in neuroscience during the past 50 years have left us not knowing how or where to draw a line between brain and mental problems, or between psychiatric and neurological disorders, as is customarily done. From our angle of vision, there are only brain disorders that psychiatrists prefer to treat and other brain disorders that neurologists (and neurosurgeons) prefer to treat.

To be sure, there are many social problems and problems in living that most healthcare workers would agree do not reflect brain disorders. We frequently meet people with complex presentations, leaving us uncertain whether any brain disorder is present. We should honestly admit this uncertainty, and await the results of further research without retreating into the ambiguity of the "mental" paradigm.

We suggest that it is unscientific, misleading, and harmful to millions of people worldwide to declare that some brain disorders are not physical ailments. Neurology and psychiatry must end the 20th century schism that has divided their fields. There must be closer collaboration in neuroscience research and clinical practice. And we must build partnerships with our patients and with societies at large. Only then will we advance the prevention and treatment of brain and nervous system disorders.

Mary Baker, president of the European Parkinson's Disease Association,  Matthew Menken, World Federation of Neurology liaison representative,. 

World Health Organization