Offline: The reflection of ourselves we choose to ignore

Abstract

Can medicine for the body and mind ever be united? The slogan “No health without mental health” was supposed to signify some kind of marriage (or truce might be a better word). But the physical and the mental still seem to occupy separate worlds, light years apart. In strategies to defeat non-communicable diseases (NCDs), the emphasis has been on four priorities—cardiovascular disease, cancer, diabetes, and chronic respiratory disease. These pathologies are important killers. They certainly deserve our attention. But they exclude anything that might have a mental dimension, such as self-harm or depression. Thanks to a determined few, great efforts have been made to raise the profile of mental health. In almost every discussion about chronic diseases, someone will argue the importance of mental health. Due lip service is paid. But the focus on four diseases never wavers. The “comprehensive global monitoring framework” that governs the assessment of progress against NCDs makes no mention of mental health. Additional indicators are specified—eg, fruit and vegetable intake, hepatitis B vaccination, and palliative care—but mental health is invisible. So invisible, in fact, that one almost wonders if there is a conspiracy of silence about mental health. David Cavan (Director of Policy and Programmes at the International Diabetes Federation) and John Yudkin (Emeritus Professor of Medicine at University College London) last week reviewed the present predicament of diabetes in our Lancet–London School of Hygiene & Tropical Medicine Global Health Lab, co-chaired by Martin McKee. David called diabetes a global emergency, pointing out that, in 2015, 415 million people lived with diabetes, a figure that would soar to 642 million by 2040. In the early 1960s, diabetes was “relatively rare”. Not now. One in 11 adults lives with diabetes. He noted a sinister shift—to expand the population who are at risk of diabetes. From the 1970s onwards, the idea of impaired glucose tolerance evolved—first, to impaired fasting glucose, and then to prediabetes. Prediabetes has pathologised millions of people. For example, in China WHO estimates 81·8 million people with impaired glucose tolerance. The American Diabetes Association definition of prediabetes catches 493·4 million people, or one in two adults. John Yudkin had an explanation for the trend towards prediabetes: corporate capture, a “beanfest for the drug industry”. Compare diabetes with suicide. At Manchester Medical Society's annual meeting last week, Louis Appleby (Chair of England's National Suicide Prevention Strategy) described the global burden of suicide: 800 000 suicides each year (one every 40 s), the second leading cause of death among 15–29 year olds. In England, there are 4800 suicides annually, a figure that is rising since a record low in 2006–07 (likely due to the recession). He explained the geographical variation of suicide, and how simple actions, such as removing ligature points, can be effective. We know many of the risk factors associated with suicide, which offer opportunities for intervention. His description of suicide was rigorously epidemiological and clinical—setting out the facts as if he was discussing any other NCD. And yet the contrast with diabetes was striking. One commands widespread societal action. The other is shrouded with stigma. Suicide was once classed as a crime against God, and until 1961 was illegal in England. What can explain the global community's aversion to addressing mental ill health? With diabetes, we understand and empathise with the social conditions we share together which enhance the risks of disease. Although our choices shape those risks, we live in the same environment and understand the common pressures that influence those choices. But suicide is perplexing because it instils a sense of dread among us. This existential fear paralyses us. We seem unable to comprehend the conditions that lead to mental illness. We seem to lack a sense of solidarity with those who live with mental distress, perhaps because we cannot understand (or confront) how our societies affect our minds to the point of self-harm. The task, not only for psychiatry but also for all those concerned with health, must be to defeat the dread that turns us away from mental illness. The disdain the NCD community displays towards mental health is the same anxiety we feel when we hold a mirror up to ourselves. Until we look deep into our reflection and accept that a disordered mind is within us all, suicide and mental illness will remain the reality we prefer to avoid.