A call for mental health illiteracy

The Australian and New Zealand Journal of Psychiatry recently published a commentary by Tully et al. (2019) titled ‘A national child mental health literacy initiative is needed to reduce childhood mental disorders’. It follows a previous research article which highlighted the low rates of mental health literacy around children. This research article declared low rates of mental health literacy defining this as ‘knowledge about childhood mental health disorders, knowledge of evidence-based treatments and how and when to access treatments’. As the authors point out, this interest in mental health literacy in children comes on the back of decades of mental health literacy campaigns aimed at adults, most notably in Australia that conducted by beyondblue. I believe it is important to question the idea that mental health literacy is useful in addressing the mental health needs of our community.

The intentions of beyondblue and the authors of the above article are to reduce the burden of mental health disorders on individuals and our community at large. I am certainly not against this as an overarching aim. They have essentially argued that there are illnesses such as depression and anxiety and that they can be seen as akin to medical illnesses. As such, there should be no shame in presenting for treatment and that there are effective treatments available such that people with these illnesses should not have to suffer. The argument would be that by reducing stigma, it would allow more people to access treatment and thus reduce the associated morbidity.

The beyondblue organisation has had some success in convincing Australians that depression and anxiety are illnesses and there has unquestionably been a much greater take up of treatments for these illnesses. The ongoing rise of psychotropic medication use and enthusiastic take up of the ‘Better Access to Mental Health’ scheme are examples of this. However, this has not achieved a reduction in the prevalence of ‘mental health disorders’ or rates of suicide in Australia. It is important to wonder why.

First, we have to question the efficacy of the treatments being offered. Cuijpers et al. (2014) showed that ‘gold standard psychological interventions’ only enabled an additional 14% of patients to achieve remission over ‘usual care’. Furthermore, Paykel et al. (2005) showed that in the treatment of depression, cognitive behavioural therapy offered no advantages in reducing relapse after 4 years. Psychotropic medications do not fare much better. These disappointing results are in adults. The research on efficacy of treatments in children has been limited, and as such, perhaps even less convincing. As difficult as this might be to acknowledge, the treatments offered by psychiatry and psychology are not very effective when compared with placebo or treatment as usual.

I believe this also questions the usefulness of the medical model of diagnose, treat, and remission. The Royal Australian and New Zealand College of Psychiatrists emphasises working towards a formulation of patients’ difficulties, rather than simply making a diagnosis that these campaigns seem to reflect. Although Tully et al. (2019) argue that ‘it is imperative that any CMHL initiative includes biopsychosocial explanations for child mental health disorders’, in practice this more nuanced argument is likely to be ignored by the targets of such a campaign, leaving only the headline diagnoses as the takeaway message.

Mental health literacy programmes have favoured the use of such terms as ‘mental illness’ and ‘mental health disorder’. These are frequently used in the Tully article. The programmes have the express aim of reducing stigma. These terms may have allowed for increased community discussion and indeed prompted more people to identify with these labels and seek treatment, however they are inherently problematic. What is it to experience a label of ‘disorder’, particularly for a child? Furthermore, they have been adopted with a sense of permanency. People carry around ideas that they ‘have’ depression, anxiety, attention deficit hyperactivity disorder or even oppositional defiant disorder as an appendage or even as a means for self-identification. These are sticky labels that are rarely questioned or removed. In practice, children are now collecting these labels, often in multiples. With them they collect medications and an identity that views themselves as fundamentally ‘disordered’.

In child psychiatry, we need to find a way to keep the nuance of individual experience and the subtleties of understanding a child in context. This is an approach that keeps open possibilities for the future of each child, particularly those who are brought for help. My concern is that already campaigns of mental health literacy work to fix a child to their diagnostic identifications which become difficult to break free from. A childhood mental health literacy initiative can only serve to increase the diagnoses of childhood mental health disorders, while failing to consider the complexities of children in context. It is only an ‘illiteracy’ that allows a child, in conjunction with those they come into contact with, to find their own language to author their own lives.