Abstract
If all mankind minus one, were of one opinion, and only one person were of the contrary opinion, mankind would be no more justified in silencing that one opinion, than he, if he had the power, would be justified in silencing mankind.
This issue carries a number of opinions. An opinion is a ‘judgement resting on grounds insufficient for complete demonstration’ (Shorter Oxford English Dictionary). Suppose it were indeed possible to find the truth about abortion and the mother’s subsequent mental health? And suppose the answer was that it does confer a beneficial effect, as intended? For better or for worse, ethical and religious resistance to the procedure would remain. In this issue of the Journal, Fergusson et al. (2013) reappraise evidence that abortions reduce the risk of women having subsequent mental health problems. They conclude that there is unlikely to be a therapeutic effect, but that there may be a small to moderate increase in the risk of some mental health problems. Alongside this, we also publish two Viewpoints arguing that Fergusson et al.’s data are unsuitable to test the central hypothesis, and that such data can never be obtained. Steinberg (2013) carefully considers what the target population should be, advocating that it should include women who have an unwanted pregnancy but do not seek an abortion. Romans (2013) points to the impossibility of finding an adequate control group. Her final Tacitean sentence captures the core of the matter. A randomised control trial is not practicable in a civilised society, for obvious reasons. But we can add yet another deficiency in the studies used, surprisingly overlooked by all our contributors: none of the samples of women can be confidently assumed to be representative of the true denominator. This should be all women in any large population who are pregnant, who seek an abortion and who then either have, or do not have an abortion. The samples are unlikely to have included women whose abortions were never formally recorded, probably a non-trivial number, but powerfully germane to the question in hand because, as in drug trials, they may be systematically different from those included in the study. In the end, we shall never know if there are benefits or hazards to mental health from having an abortion, over what time period either outcome might hold, or if some women may benefit while others have adverse consequences. One of the most precious attributes that our species has acquired is the capacity for choice, but there is apparently disagreement about whether this should apply to a woman having a baby. Here, we have to live with different opinions.
In a deeply thoughtful essay, Kecmanovic’s (2013), a psychiatrist, sets out his opinion on how the general population deal with ‘mad’ people.They look upon them with stigma and rejections because of their deviance, but at the same time provide care through mental health services. He sees psychiatrists as agents of social control but argues that control of the socially unsettling aspects of psychotic people and psychiatric treatment are not at odds. The discipline of psychiatry, he thinks, brings about this syncretism. Pilgrim (2013), a professor of Health and Social Policy at Liverpool in the UK, presents a very different approach. Unlike him, few of us in psychiatry have the cognitive equipment plus erudition to traverse the borderlands of sociology and philosophy, while also having a sound grasp of the history of ideas in relation to mental illness. Pilgrim expects that some of Kecmanovic’s article could offend some readers, and asks why only psychotic people should be selected for consideration. In his ‘pilgrimage’ he points out that psychiatry is frequently far from benign in its routine practices.
Berk et al. (2013) draw attention to a grave anomaly in mental health services: the discordance between the burden caused by serious mood disorders and their current pattern of care. In Australia, severe mental illness is taken to be mainly the responsibility of the states, while the high prevalence disorders, so frequent in general practice, are handled largely through federal resources. The authors recommend a strengthening of collaborative care, whereby there is translation direct from the clinic to education and to the community. A possible cause for alarm is that they propose this would be done using ‘specialised managers’ (sic). The opinions of our colleagues are likely to have a significant impact on policy, so their argument deserves close attention.
For close to two decades, Anthony Jorm and his colleagues have been measuring the opinions, beliefs and attitudes of the general public and health professionals about mental disorders and their treatment. Now Morgan et al. (2013) report the beliefs of general practitioners, psychiatrists and clinical psychologists about the helpfulness of different interventions for mental disorders. The value of their study is that it tells us something of what is happening within our professions in knowledge and attitudes. This in turn should lead us to ask what the significance is for their further education, for patients and for the general community. Linked to this theme, Makhija and Karunakaran (2013) bring to our attention the need for practitioners to maintain their literacy in medicine and neuroscience and, in a carefully constructed review of the literature, they inform us about the role of inflammation in the development of depression, whereby inflammatory cytokines contribute to depression.
Lucas et al. (2013) show that children with impaired mental health incur substantial healthcare costs, apart from being a group of concern for their well-being now and in their later lives. Of particular significance for policy is that, unlike adults, treatment through Medicare is rarely reaching children. Two papers provide useful information about morbidity from drugs and alcohol in relation to mortality (Dekker et al., 2013) and in persons with psychoses with comorbid obsessive–compulsive symptoms (Lloyd et al., 2013). Finally, the Correspondence columns amply confirm John Stuart Mill’s own opinion.