“You will know very few happy moments in life, so make the most of them.” Those are words I often heard from my late mother, leading me to believe that life was going to be a painful affair. In retrospect, I wonder whether she was dealing with chronic depression or whether she was “merely” dogged by unhappiness. In fact, is unhappiness so different from depression? The World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease” from which it is logical to deduce that if you are unhappy, then you are ill.
I am annoyed to see the umpteenth book published on how to cure your depression through mindfulness, sports, or improved diet. Someone with major depressive disorder or psychosis is not going to get better simply by meditating or going for a brisk walk. The problem here may well be semantics. Given that, in the quasi-absence of biological markers, we speak of mental illness rather than disease is part of the reason for confusing sadness (a normal reaction to negative stressors) with depression (a pathological state). The development of scales for mental symptoms have allowed us to progress in measuring degrees of distress, but have not in themselves made clear for most people (including non-specialised healthcare professionals) that mental illness is not a state of mind.
Let me illustrate my point by a metaphor. You may experience elevated levels of blood sugar such that you need to watch your diet; but then one day you go on to develop diabetes for which you must still watch your diet but also take insulin. The same is true of mental illness in all its forms and it is to this transition from exposure (worries, for example) to outright disease (major anxiety disorder, for example) that I refer. So how do we know when to draw the line between existential hardship and overt mental illness? I will risk stating that even a suffering individual is mentally healthy if he/she adapts correspondingly to his/her surroundings and circumstances, and if objective reality is not distorted by his/her perceptions. Reality is, of course, nearly impossible to define, but… take the example of someone suffering from acute anxiety who feels the walls of her flat are going to cave in on her: in terms of “objective” reality, this is unlikely to happen, therefore she has an skewed perception of her surroundings. The same is true of an anorexic who perceives herself in the mirror as overweight.
Since most people must deal occasionally with psychological distress, many seek counselling; however, it is unlikely that most of these individuals are actually mentally ill – rather, they are dealing with existential hardship. And here it may be useful to understand the limits of psychotherapy: I do not believe that bipolar depression or psychosis can be substantially alleviated by words or behavioral advice, however wise and true these may be. Quite obviously, grief can lead to depression, unrelenting stress to anxiety, and rape to a range of post-traumatic disorders, but this occurs as part of a pathological process in which there is clearly a before and after even if we cannot pinpoint the moment at which this occurs.
Why am I so adamant? Because I feel that many people who are truly mentally ill suffer not only from their symptoms and associated stigma, but also from the patronizing attitudes of those who believe they should just “get on with their lives”.
Competing interests: None declared
Marta Balinska works in the medical department of Médecins Sans Frontières, Switzerland. While not herself a psychiatrist or psychologist, she was prompted to write this piece owing to her intimate experiences with people with mental illness, and her own reflections on the topic.