Simon Wessely: “Every time we have a mental health awareness week my spirits sink”

I thank everyone who has taken the trouble to reply to the points raised in Sophie Arie’s interview with me (BMJ 2017: 358: j4305). This was an “exit interview” on the occasion of my stepping down as President of the Royal College of Psychiatrists, and covered a wide range of topics. Most attention has naturally focussed on the more eye catching content – that is the nature of good journalism. It is clear also not just from rapid responses, but elsewhere, that there are a wide variety of responses, both pro and anti. However, I think that the differences are more than outweighed by points of agreement, and that actually what we are talking about is more about the question of priorities and emphasis than fundamental disagreements.
As ever in our business, words and definitions so often lead to misunderstanding and misinterpretation. Are we talking mental illness, mental disorder, mental health or mental well being? Are these different - surely they must be. But they are so often used interchangeably – often to avoid the stigma that still accompanied mental illness/disorder. Whilst that is understandable, it is not always helpful.
So let me start with mental disorder. The most recent iteration of the Adult Psychiatric Morbidity Survey (https://www.gov.uk/government/statistics/adult-psychiatric-morbidity-sur... ) , the gold standard when it comes to knowing what is happening in population terms, now reports that most people who fulfil criteria for mental disorders are aware that they have a mental health problem. If true, this represents progress, but also is I think occasion to reflect. If that is so, then raising awareness in the admittedly narrow sense that I was using the term, may no longer be the most pressing priority. As Isabella Goldie correctly observes, most people still don’t seek help for the commonest mental health disorders. But I suggest that this is no longer due to lack of awareness in its simplest sense, but issues such as shame, guilt, stigma, beliefs about untreatability, lack of access to acceptable services and so on, may now be playing a major role. I agree with Isabella Goldie that “raising awareness of any health issue is the crucial first step towards ensuring that people take action to improve their health”, but if we are getting close to achieving that goal, then it is time to think about the second and third steps. Randomised controlled trials of mental health screening, such as the one we have just concluded with the UK Armed Forces, did not fail because of lack of awareness, but for many other reasons 1
I accept the point made by several commentators that increasing awareness campaigns are also about reducing stigma. The problem may be as Dr Martino wryly observes, “awareness” has become something of a “bingo term” these days. Certainly in my interview, research and in much of my writings as President, stigma and the need to reduce it raises its ugly head on a regular basis. Recent research such as Time to Change and our own in the Armed Forces is starting to show small, but hence believable, reductions, but there is a long way to go. And if “raising awareness” is a short hand for “raising awareness and reducing stigma”, then all well and good.
My second point is simple, and I doubt many would disagree.. If we encourage more people to seek professional help, either by raising awareness or decreasing stigma, this has to accompanied by increasing resource. In the context of mental disorder that largely means more staff, since in 90% of our work no longer takes place in expensive hospitals, we have very little reliance on costly kit, and the drugs that we use when we have to are very cheap compared to other areas. Although there have been some welcome investments (lAPTS, liaison and perinatal come to mind) I am afraid that this is a case of the facts speaking for themselves. Services are increasingly over stretched, investment has yet to reach where it is most needed, patients with the severest illnesses continue to be bussed around the country, and so on. And we are indeed seeing increased sick absence, early retirement, burnout etc, just as we are in general practice. Indeed, when Emma Richardson talks about the rising level of sick leave amongst NHS staff, and the problems of falling recruitment across the board in those who work in mental health, I think this is supporting my case. Improving recruitment was one of the main objectives of my three years as President, and ways to achieve this was probably the longest part of my conservation with Sophie Arie.
But note that I am being very specific when I say “encouraging people to seek professional health”, whether it by from psychiatrists (my obsession for the last three years), psychologists, social workers, nurses and so on. And that seems to be right when the goal is to able to deliver interventions and treatments of proven benefit for those with defined mental health disorders. But of course, that is not the goal for most of the population most of the time, Just as services get overstretched by increased demand, we also need to make sure that we do not over stretch ourselves by either extending the boundaries of mental disorder into the realm of normal emotional reactions and/or variations in personality. In the world of psychological trauma we know that there is a long historical tradition that shows that people are more resilient than professionals, politicians and planners give them credit for 2. We also know that if people like me get involved too early in the aftermath of trauma (by which I mean hours and days), we can actually make things worse. Instead the best resource remains a person’s own social network – their family, friends and colleagues, and it is something of a relief to have shown that this is exactly who people do turn to in adversity as we showed in the aftermath of the 2005 London Bombs 3. One of the most important things we can do to improve population mental health after such tragedies (note I am now not talking about mental disorder) of people is to assist in mobilising social networks. This might mean ensuring that mobile phone networks continue to function after disasters, or that relief centres have an adequate supply of power leads and landlines, or alternatively combating loneliness or homesickness in students by promoting volunteering, sports, drama, peer support or whatever.
And this can be facilitated by programmes such as Mental Health First Aid, which do not seek to create more mental health professionals, but just giving some very basic knowledge to the kind of people you already meet in your normal life – teachers, colleagues etc. We helped pioneer exactly such a system in the Armed Forces 4. I sometimes think that the training is not just about imparting information, but more about saying it’s OK to talk to people in distress, and no, you won’t make things worse as some seem to think. And I read Isabella Goldie as saying much the same. And if encouraging peer support and its variants also comes under the broad heading of awareness, then yes, I am in favour.
I could not help a wry smile when Dr Browker talks about the new alienism which he links to the the rise of “counselling services”, simply because I used almost the same title in an essay in the BMJ 21 years ago 5. And this has indeed come to pass – with psychiatry becoming increasingly seen as dealing only with the severest of mental illness. My prediction that this would lead to a slow but steady shift of resources away from the most severely ill, has also been fulfilled. As the Chief Executive of our largest mental health trust recently observed, mental health funding is like a soufflé which is gradually expanding, but leaving the core weaker and weaker until it suddenly collapses.
One final point that has been picked up by Twitter and also by the BMJ’s own star columnist, Margaret McCartney, is the issue of unintended consequences. I teach medical students that anything that works, no matter what it is, will always have side effects. If something genuinely has no downside, then there is probably no upside either. The question is simply the balance between the two. And I would argue strongly that this must be true of raising awareness, just as it is true of any other public health intervention. Here I am talking about the dangers of professionalisation or medicalisation of normal emotional reactions and/or personality variations. I expect that the benefits will outnumber the risks, but I am certain that risks there will be, and that all of us should know about them

1. Rona R, Burdett H, Khondoker M, Chesnikov M, Green K, Pernet D, Jones N, Greenberg N, Wessely S, Fear N. Post deployment screening for mental disorder and tailored advice about help seeking in the UK military: a cluster randomized controlled trial. Lancet 2017: 389: 1410-1423
2. Jones E, Woolven R, Durodie W, Wessely S. Civilian Morale During the Second World War: Responses to Air Raids Re-examined. J Social History 2004: 17: 463-479
3. Rubin J, Brewin C, Greenberg N, Simpson J, Wessely S. Psychological and behavioural reactions to the bombings in London on 7 July 2005: cross sectional survey of a representative sample of Londoners. British Medical Journal 2005. 311: 606-610
4. Greenberg N, Langston V, Iversen A, Wessely. S. The acceptability of a peer group support system “Trauma Risk Management (TRiM)” within the UK Armed Forces. Occupational Medicine 2011: 61: 184-189
5. Wessely S. The rise of counselling and the return of alienism. Br Med J 1996;313:158-160