What are the main mental health problems currently being diagnosed?

About 1 in every 8 people in the world live with a mental health disorder according to statistics from the World health Organisation (WHO).  Mental health issues contribute to approximately 16% of the global disease burden.

Depression and anxiety are the most common mental disorders diagnosed. Depression is one of the leading causes of disability worldwide.  The number of people living with depression and anxiety has significantly increased since the COVID 19 pandemic. Post traumatic stress disorder is also on the increase given the growing number of conflicts worldwide where civilians are severely impacted by the violence of warfare and displacement from their homes. 

What are the main challenges facing psychiatric medicine?

There are several challenges facing psychiatric medicine. The most important one is lack of resources. Services are underfunded making it difficult to meet the needs of increasingly complex and needy patients.  Mental health disorders such as schizophrenia and bipolar disorder begin in the late teens or young adult stage of life and require lifelong psychiatric care in the majority of cases. In the absence of professional treatment, young people can resort to substance abuse as a form of self-medication.

Prevention, early diagnosis and treatment can have a positive impact on outcome and quality of life. Large case loads and the increasing administrative burden means that psychiatrists are unable to provide the regularity of follow-up recommended in clinical guidelines. Mental health professionals also have to deal with more violent situations in the course of their work due to the increase in substance abuse. This is also true for colleagues working in the area of physical health.

Psychiatry is facing a major recruitment problem in many countries leading to a shortage of psychiatrists at a time when they are sorely needed. So, one of the main challenges is trying to plug the gap between what is needed and what is available in terms of care. Psychiatry has long been an underfunded area of medicine and could be said to suffer from the same form of stigmatization as the patients it treats. The increase in anxiety and depressive disorders especially in young people since the COVID-19 pandemic has raised awareness and in some countries lead to promises of increased funding. 

More than ever, psychiatrists need to play an active role in education and in raising the profile of mental health problems by lobbying government members. Fondation FondaMentale has shown the way in France. It is a trust devoted to early diagnosis, prevention, psychoeducation and personalized treatment plans which has succeeded in obtaining government and private finance to promote research and raise the public profile of mental illness. We need more dynamic people who do this kind of work.

Another major challenge facing psychiatric medicine and medicine in general is that doctors  are not reduced to diagnostic and prescribing technicians who lose the ability to connect with  patients and their suffering. In an era where the business model is taking over medicine, where goals and efficiency are of paramount importance and technology is advancing at a rapid pace, it is more important than ever for doctors to remember that they are dealing with a feeling, thinking human being. It is important to maintain the “art “ of medical practice.

Mental health and Psychiatry are not the same thing. How are they related? How do they benefit each other?

Mental health as defined by the WHO is a state of mental well-being that enables people to cope with the stresses of life, realise their abilities , learn well and work well, and contribute to their community. It includes our emotional, psychological and social well-being. The emphasis here is on well-being in all domains which enables the individual to function in all areas of his/her life and to establish lasting and meaningful relationships with others.

Once the balance between these domains of wellbeing is affected, the risk of developing a mental health problem with a significant disturbance in cognition, emotional regulation and behaviour is increased and so is the need for psychiatric follow-up. Obviously, these difficulties will exist on a spectrum of mild, moderate and severe and those at the mild end are unlikely to require psychiatric help. 

Psychiatry is the area of medicine which focuses on the diagnosis, treatment and prevention of mental, emotional and behavioural disorders. The ultimate goal of Psychiatry is not just to alleviate symptoms and prescrible medication but to provide a multidisciplinary treatment plan which will enable the patient to recover their mental well-being in all domains. This is not always a straightforward process. In the case of the development of a lifelong chronic illness, the initial starting post of mental well-being and what it means may have to be adjusted through a long process of acceptance of the limitations on personal, social and professional aspirations imposed by the illness. This can also be a difficult process for family members whose mental well-being is also impacted by the patient’s illness. A lot of the work in Psychiatry by mental health professions is oriented towards helping patients find that balance in order to promote well-being and to lead meaningful lives in their communities.

Of course, an individual who meets all the criteria of mental well-being will have more resilience should he/she develop a mental health problem after a traumatic life event and be more likely to make a complete recovery than someone whose mental well-being in one or two domains is fragile from the outset due to an adverse environment in childhood or adolescence. 

Many mental illnesses remain a stigma and a taboo for patients. How can we break down these barriers?

Education, raising the public profile of mental illness, challenging stereotypic views of mental illness and most of all getting rid of the divide “us and them.”

This is perhaps the origin of the stigma, the fear that mental illness may affect us too in the way that people were terrified of the plague in the past. The experiences described by people with mental illness are not alien to the population in general. We all know what it is like to suffer profound, paralyzing sadness following a bereavement, a state of euphoria when we fall in love and otherwise healthy people can experience auditory hallucinations. What is different in a person who suffers from mental illness is not the nature of the experience but the intensity, frequency and suffering generated by these experiences. That is what differentiates someone with a mental health problem from a healthy person. It is also important to remember that none of us is immune to developing a mental health problem.

The media plays an important role and has done so in publishing the stories of celebrities who talk openly about their bipolar disorder, substance abuse or depression. The media needs to be more responsible when reporting violence perpetrated by a psychiatric patient. These incidences, although extremely rare, usually get front headline treatment whereas other violent acts committed by criminals with no psychiatric history are relegated to a small paragraph at the bottom of a page. The reality is that the majority of violent crimes are committed by sane people and not by people with a mental illness.  Usually when they happen, there is also substance abuse involved which increases the risk of violent behavior.

So, stigma needs to be tackled at a societal level and also at an individual level, beginning with the patient who suffers the most from stigma but who also stigmatizes him/herself because of the illness.  This requires a psychotherapeutic approach to enable them to change the way they see themselves and their illness. They can’t control how others see them but they can control how they see themselves. This type of work is often done in a group context with well-established protocols. 

Ensuring people with mental health problems have access to a supportive work environment is also important.

There are increasingly more technological applications being implemented in therapies and diagnoses in the field of psychiatry. How do you evaluate this?

These technological applications will improve access to care especially for geographical areas where there is a penury of psychiatrists and other mental health professionals. Tele psychiatry consultations provides access to mental health professionals and crisis support.  Telehealth and applications providing cognitive behavioral therapy, enable diagnostic and therapeutic approaches which can transcend geographic boundaries. One AI chatbox tool which delivers cognitive behavioral therapy for depression has been shown to be effective in reducing symptoms of depression and anxiety in clinical trials. Other AI chatbox tools helps connect patients with licensed therapists appropriate to their needs.

Symptom tracking, mood monitoring and behavioral changes can be monitored through apps and can signal changes in mental state and an impending relapse. Immersive exposure therapy through Virtual Reality can help people with phobias and social anxiety who have difficulty travelling to see therapists or carrying out the exercises required to treat their phobias.

Technology allows massive amounts of clinical data to be processed in order to predict changes in mental health and also to identify disease subtypes and disease progression. The data collected can potentially lead to a more individualized approach based on a patient’s pattern and profile as opposed to a one suits all approach.

In theory, these approaches have great potential for increasing access to care, monitoring, symptoms, improving treatment compliance, facilitating diagnosis and the implementation of more personalized treatment plans based on big data analysis. 

Some of the approaches seem quite intrusive because of constant monitoring but with a generation who has grown up with smartphones, this may not be a problem. This approach will also give the patient a greater role and more responsibility in the management of their mental health problems which is important.

How does AI impact our mental health?

At one level AI has been described as having a potentially transformative and revolutionary effect on mental health through its capacity to analyze extensive data sets and complex human behaviors. It’s integration into overburdened mental health services could enhance early detection, provide personalized treatment plans, and support offered through innovative platforms could make care more accessible and improve mental well-being. There are also several AI apps to help therapists obtain feedback from patients and better adapt their therapy to patient needs.

So, AI has the potential of having a beneficial effect on mental health. However, there are ethical considerations such as the lack of a comprehensive regulatory framework for the use of AI in mental health, the protection of privacy and the need to preserve the human element. AI should be used as a supplementary tool and not replace the human element in therapy. A recent study from Stanford demonstrated that AI chatbox tools used in mental health failed to pick up on suicide intent. The same study also showed that after exposure to different clinical cases including depression, addiction and schizophrenia, different AI chatboxes showed increased stigma to the cases with schizophrenia.

There have also been recent reports of negative effects of AI on mental health with an increase in psychotic symptoms, increasing dependence on AI, bad decision making based on AI including advice on assisted dying and how to commit suicide when people communicated a feeling of sadness. Although potentially useful in the field of human health, its limitations and dangers need to be recognized.

Technology unites us across distance, breaking down physical and temporal barriers. Is this really beneficial for our minds, or does it merely fuel a fantasy?

Certainly, technology has broken down barriers, facilitated communication and training across time zones and geographical barriers. One out of four adults report being online all of the time. But there are concerns about the effects on our brain structure and function. Evidence from research indicates that technology may have both positive and harmful effects on our brains.

There is evidence that harmful effects of technology may be increased attention deficit symptoms, impaired emotional and social intelligence, social isolation, impaired brain development and a decrease in working memory capacity. The World Health Organisation (WHO) published strict guidelines about children’s screen time use in 2019 based on the results of research.  Intensive use was also linked to depression, anxiety and sleep disturbance. Increased screen time in children under age 3 has been linked to poorer early language development, poorer executive functioning and greater sleep problems.

Older children have shown impairments in the recognition of emotions from photographs of facial expression and social cues by comparison with children whose screen time is restricted. There is also the risk of technology addiction. The global prevalence is around 6% with greater prevalence in some areas. Internet addiction is associated with greater levels of attention deficit  symptoms, impulsivity and hyperactivity in schoolchildren. 

On the positive side it has been shown that certain online tools, programs and videogames can provide mental exercises which activate the brain, improve connectivity between different neural circuits, improve sleep, diminish anxiety and improve memory. One study found that surgeons who played videogames more than three hours per week made fewer surgical errors, had faster responses and better laporoscopic and suturing skills.

Multitasking is one of the consequences of spending a lot of time online and is known to have a negative impact on performance. It is also a skill which declines with age.  However, interestingly enough, certain videogames have been shown to improve attention, working memory and the ability to multitask.

So, in conclusion there are arguments for and against technology. It would appear that when targeted programmes and tools are used in a moderate manner, technology may have a beneficial effect. In children, it needs to be used with caution but may be beneficial when accompanied by parent interaction. In other words, technology can be beneficial or harmful depending on how it is used and the particular vulnerability, in terms of age or emotional fragility of the person using it.

What environmental factors have the greatest impact on our mental health?

The social and natural environment both have an impact on our mental health.

In the social environment, different forms of abuse (sexual, physical and emotional) have all been shown to have a negative impact on mental health in adult life and are associated with psychosis, mood disorders and substance abuse. Social isolation, loneliness and lack of a support network have been shown to contribute to depression and poorer physical health in general. On a larger scale, major conflicts affecting civilian populations contribute to the development of post-traumatic stress disorder (PTSD), an incapacitating disorder which can lead to substance abuse and chronic depression.

Major natural disasters such as earthquakes or flooding are also a cause of PTSD. Studies have also shown an association between dense urbanization and the prevalence of mental illness. High population density can lead to chronic stress due to stressors like noise, pollution, crime and incivilities. The number of green spaces and walkable areas would appear to be a protective factor against the development of mental illness. 

How does a lack of communication influence our behaviour?

Lack of communication can have an adverse impact on the quality of our relationships with others. Maintaining healthy relationships with others is important for our physical and mental health. Studies have shown that the absence of social relationships has been shown to predict mortality from every cause. Low levels of social support are associated with higher levels of cardiovascular disease. 

Lack of communication can be due to physical impairments such as deafness, neurological disorders, psychiatric disorders as in severe forms of schizophrenia and poor social skills.

Lack of communication can impact our behaviour through increased frustration, stress , anger and resentment. Outwardly this can manifest itself as irritability, impatience, perhaps even violent behaviour and social withdrawal.  A vicious circle is installed whereby family, friends and acquaintances also withdraw as a protective measure or through exhaustion. This reinforces the feelings of incomprehension, anger and frustration and results in further social isolation and a loss of network. This leads to increased stress and a greater risk of physical and mental illness.

How does psychiatric medicine evaluate optimism?

Dr Rick Hanson, a psychologist, states that human brains are like scotch for negative experiences and Teflon for positive experiences. From an evolutionary perspective, our brains are primed for negative biases in order to counteract potentially dangerous situations.  Learned helplessness is a psychological theory of depression based on animal experiments where the animal was deprived of all control over an external stressor. Applied to humans, learned helplessness is a state of mind where an individual after repeated exposure to uncontrollable negative events, believes they are powerless to change the situation even if opportunities exist to do so. The result is passivity, lack of motivation and a sense of hopelessness. Learned helplessness is associated with depression and PTSD.  Optimism is the antithesis of hopelessness. Psychiatric medicine is more accustomed to assessing pessimism than optimism.

Rating scales exist to assess dysfunctional attitudes, ruminations, learned helplessness and hopelessness. Few exist to assess optimism. Pessimism is also explored in clinical interviews through exploration of the negative triad in depression-negative attitudes about oneself, the future and one’s relationship with the world. Excessive optimism can also be a problem as in mania where the individual concerned believes everything is possible, to the point of endangering his/her own life.

However studies using the Life Orientation Questionnaire have looked at the relationship between Mental Disorders and optimism and concluded that maintaining an optimistic view reduced the risk of mood disorders, anxiety disorders and alcohol abuse. Optimism contributes to mental health and overall sense of wellbeing. Cognitive behavioural therapy focuses on negative thoughts  and helps the individual challenge the validity of these thoughts through reasoning and beahvioural experiments in order to develop a more balanced mental attitude to life. Gratitude journals are encouraged in order to enable patients to note the multitude of minuscule positive situations encountered each day.

The idea is to tilt the brain from a negative towards a more balanced mindset where positive experiences whether they are thoughts, emotions or real life situations have equal salience to negative events.

Social media is a means of communication, but what challenges do they pose for mental health? What would you recommend for healthy use of it?

Addiction, paradoxically social isolation and worsening of conditions such as social anxiety.

Social skills may also be impaired especially in children who depend on an early age on social media for communication. There are also other well mediatized challenges such as on-line bullying which has tragically lead to suicide in schoolchildren. 

For healthy use, I would recommend restricted use in children and adolescents and moderate use in adults. 

Success and failure: how do they affect mental health?

“Success is not final, failure is not fatal: It is the courage to continue that counts.”(Winston Churchill). 

Failure can engender emotional distress and cause depression and anxiety.  Not everyone who experiences failure collapses. Protective factors according to studies appear to be higher self-esteem, a more positive attribution style for the cause of failure, and a tendency to be less perfectionistic in order to meet societal values.

Success can have a positive impact on mental health creating a sense of well-being  unless the need for success is driven by poor self- esteem and a fear of failure and humiliation. In this case, the drive for success can create chronic stress which in turn can lead to substance abuse, anxiety depression and physical health problems.

You are an expert in mindfulness, among other areas. What does this therapy consist of, and how can it benefit mental health?

Mindfulness is a way of paying attention in a particular way on purpose, in the present moment and nonjudgementally” Jon Kabat Zinn.

Mindfulness is the practice of being fully present and aware of your experiences as they arise, without overreacting or being swept away by thoughts and emotions.

Mindfulness incorporates several practices which include meditation, mindful body movement, mindful walking,  mindful eating or being mindful during other daily activities.

The opposite to mindfulness is being on automatic pilot where we are so lost in our thoughts or daydreaming that we are no longer connected to the here and now. All of us have had the experience of driving on a familiar route and arriving at our destination with no recollection of the journey because we were so absorbed in our thoughts. This in itself is not a problem except when automatic pilot takes us down alleyways of dark brooding thoughts and feelings that can eventually spiral into a depressive illness. We are living our lives through the prism of the stories in our mind and not the real experience as it is unfolding.

Jon Kabat Zinn,  integrated mindfulness into medical practice through his mindfulness based stress reduction programme (MBSR)  for chronically  ill patients with intractable pain or cardiovascular problems. The success of his programme has lead to a mushrooming of mindfulness based approaches for physical and mental health problems such as depression, anxiety and substances abuse. It has been shown to reduce relapse rates in addiction and depression and to improve the overall quality of life. Mindfulnnes has been  incorporated into psychotherapeutic approaches such as acceptance and commitment therapy, dialectical behavioural therapy and compassionate focused therapy.

Mindfulness practices have also been introduced into the workplace, schools and prisons in order to promote mental well-being and help cope with stress. It improves attention, mood, decreases anxiety and through its non-judgemental approach, encourages a more compassionate attitude towards oneself and others. In a world where constant doing is highly valued, mindfulness reminds us of the value and benefits of non-doing.

Can we talk about a mentally healthy person? What conditions must be met?

We can talk about a mentally healthy person in the same way that we talk about a physically healthy person. A mentally healthy person has good coping strategies to manage stress, is not overwhelmed by negative thoughts and emotions to the point of being paralysed physically and mentally and is capable of  maintaining satisfying healthy relationships with others. This does not mean that a healthy person will not traverse periods of sadness, negative thoughts, anxiety and frustration in response to difficult situations such as bereavement, professional and sentimental disappointments but these are appropriate reactions in given situations. We can work at reinforcing our mental health in the same way that we work at improving our physical health through physical activity , time spent in nature and good nutrition. Physical activity has shown to be beneficial for anxiety and depressive symptoms and over the past decade, there has been increasing interest in psychonutrition and the impact food has on our mental health.

A good social network and support is very important. Acts of kindness to others has also been shown to have a beneficial effect on mental health. Loneliness has a deleterious effect on mental and physical health so the importance of social contacts cannot be sufficiently underlined. Having fun whether that be through leisure activities or precious moments with friends and family plays an important part in maintaining our mental health. We should never forget the child in ourselves and the importance of having fun. 

What value does art have have in the well-being and recovery of patients?

For thousands of years, people have used art as a means of self-expression, healing and communication.

Art can play an important role in the recovery of patients. It enables  patients to express themselves more freely, to connect with their emotions, improve self-esteem and interpersonal relationships. Various art forms have been used as treatment options- theatre, dance movement psychotherapy, music therapy, painting and drawing. Art therapy has been shown to decrease anxiety and promote better regulation of emotions though a better acceptance of emotions. A recent study in the British Journal of Psychiatry showed that women suffering from post-partum depression recovered d sooner if in a singing group as opposed to the control group.  Studies have shown greater emotional awareness scores in patients with schizophrenia who were assigned to an art therapy group. 

Art therapy can help people cope with stress and despair and diminish the burden of chronic illness. It can contribute to the healing of emotional trauma, enhance awareness of oneself and others, help cultivate the capacity for self-reflection, help generate more appropriate responses to difficult situations and transform behaviours and thinking.  Art therapy can be a way for a deeply traumatized patient to express the unthinkable.

Art therapy answers the social, spiritual, emotional as well as the clinical needs of the patient. Let us not forget that the word psychiatry literally means  ”medical treatment of the soul.”

The Catalan cardiologist Josep Brugada onces said that happiness is one of the best medicines for cardiovascular health. Does the same hold true for mental health?

Happiness is a state of well-being that contributes to better mental health. Happiness is associated with a reduced risk of chronic illness, better immune function and lower levels of stress. Happiness is often associated with material success,  external approbation  and validation which can lead to a fleeting sense of joy and pleasure. The happiness that leads to good mental health is related to a more stable core feeling of wellbeing that comes from living a life that has meaning and is in harmony with one’s own values. This may not always be easy but ultimately will be rewarding and provide peace of mind and increase resilience in the face of adversity. Viktor Frankl, a survivor of a Nazi concentration camp illustrated this point in his book ”Man’s Search for Meaning.”

A core feeling of well-being comes from reflecting on what is fundamentally important in one’s life, reflecting through mindfulness or other contemplative approaches on the way the mind functions and one relationship with thoughts and emotions. This not only changes one’s relationship with oneself for the better but also one’s relationship with others. In the society in which we live, people rarely take time to stop and reflect yet as Jon Kabat Zinn, once said of meditation, our life depends on it. Knowledge of ourselves can lead to greater acceptance of our distressing emotions and thoughts as well as the impermanence of things both negative and positive. It enables us to understand what is truly important for us in our lives and live according to those values. Carl Jung, the Swiss psychiatrist talked about the process of individuation as being the ultimate goal of the psychic journey of man. This was viewed by him as not only a service rendered to onself but also to society.

The more we integrated the different facets of our psyche, the healthier and more honest our relationship with ourselves and others become. Cultivating a sense of wellbeing is important as it helps sustain people through difficult situations and promotes physical and mental health. In meditation, there is a practice that uses the mountain as a metaphor. The mountain remains present and true to itself whether it be summer of winter, night or day, lightning and thunder or snow and scorching sun.