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Journal List J Psychiatry Neurosci v.40(3); 2015 May PMC4409431

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J Psychiatry Neurosci. 2015 May; 40(3): 147–150. PMCID: PMC4409431
doi: 10.1503/jpn.150099 PMID: 25903034
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“Mental illness is like any other medical illness”: a critical Add to Favorites
examination of the statement and its impact on patient care
and society
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This view of mental illness is presented for better acceptance of the mentally ill by Exit exceptionalism: mental disease is like any other
medical disease
the public and of treatment by those experiencing mental illness and is indeed based
on accumulated, albeit limited, knowledge in the neurobiology of mental disorders. See all...
However, anything that reaches axiomatic proportions needs a serious examination. In
this editorial we examine the reasons underlying this perspective, its consequences
Links
and the evidence to support or refute its continued justification. We then present a
PubMed
position that we believe best fits the current state of knowledge and is closest to
clinical realities and public perceptions of mental illnesses. Taxonomy

What does the statement actually imply? Go to:

Recent Activity
The statement that “mental illness is like any other medical illness” implies that Turn Off Clear
mental illness has a biological basis just like other medical illnesses and should be “Mental illness is like any other medical illness”: a
treated in the public’s eye in a similar manner. The purpose of this article is not to critical examination of th...
present a philosophical or ideological argument in favour of or against a biological
See more...
basis explaining mental illness, but rather to examine the clinical and public utility of
presenting a dominant neurobiological model of mental illness to patients, their
families and the public at large.

Illness, pathophysiology and the “self’’ Go to:

To understand the justification of equating mental and medical disorders, a

comparison often made between type 2 diabetes and mental disorders, especially
schizophrenia, other psychoses and depression, is worth examining in some detail.
Diabetes, although very complex, is understood as the result of dysfunctional glucose
metabolism related to absolute or relative insufficiency of insulin signalling. This
dysfunctional metabolism is the consequence of endogenous predispositions, such as
hereditary diathesis, and environmental factors, including personal choices, such as
poor diet and sedentary life style. Therefore, by improving glucose metabolism, either
through medication, insulin replacement or changes in lifestyle, positive health
outcomes can be expected. Diabetes is diagnosed by confirming high levels of fasting
glucose and other related biochemical markers of glucose metabolism. Further, the
cascade of its effects on other systems (e.g., cardiovascular, central nervous system)
are, or could be, well explained on the basis of physiologic mechanisms. They can
also be prevented/treated by better and early control of diabetes. All through this,
however, the patient is aware of the nature of his or her problems, including personal
choices, and diabetes generally does not affect his or her day-today thinking,
behaviour or perception. Except for mental health complications due to neurologic
illnesses (e.g., delirium in the context of severe metabolic complications, depression
as a consequence of awareness of the life and death implication of the disorder,
abnormal perceptions in the case of some neurologic conditions), it can be stated that
somatic illnesses, such as diabetes do not usually alter the core self of a person
substantially. More importantly, the model of attribution presented to the patient is
congruent with the scientific “facts,” thereby making it easier for the person as well as
society to accept the condition.

Mental disorders, on the other hand, affect the very core of one’s being through a Review Adult mental health disorders and their age
at onset. [Br J Psychiatry Suppl. 2013]
range of experiences and phenomena of varying severity that alter the individual’s
thinking, perception and consciousness about the self, others and the world. This is
seen to an extreme degree with more serious mental disorders, such as psychoses and
bipolar disorders, but to a lesser albeit significant degree with anxiety, mood, eating
and other psychiatric disorders. Emotion, perception, thought and action are the
essence of human identity and the concept of “self,” and these are the prime domains
altered in mental disorders. The precise definition of what constitutes the self and
whether the location of a state of self is a material reality in the brain, its form and the
brain-related factors that influence it are deeply philosophical issues,6,7 but not the
subject of this editorial. Suffice it to say that factors involved in increasing the risk for
mental disorders are endogenous (genetics is recognized as a major contributor to
most mental disorders) as well as environmental, much like most medical disorders.
Psychological deprivation and trauma, social defeat and isolation, poverty and poor
family environment are but some of the environmental factors that have been reported
to increase the risk for mental disorders. In addition to changes at the physiologic
level, common to somatic and mental disorders the latter encompass changes in one’s
definition of “self,” and are not situated outside the “self.” It can even be argued that
in the absence of any substantiated biological marker for mental disorders (only 1 has
been included in the recent DSM-5: orexin change in narcolepsy),8 the hallmark
defining features of mental disorders, at least for now, remain the changes in how the
patients feel, think and act and how these changes affect their relation to themselves
and to others.

As a first corollary of this definition, contrary to medical conditions where restoring

dysfunctional physiologic mechanisms is the main target of therapeutic interventions,
this is only 1 part of the therapeutic interventions for mental disorders. The primary
focus of therapeutic interventions in mental disorders is helping the patient to feel
better and interact more adaptively with his or her social and physical environments.
Although there is little doubt that all medical conditions require psychological
attention, mental health interventions focus primarily on achieving a positive change
in feeling, self-esteem, mood, perceptions, thoughts and action — all changes in the
“self” that are not primarily targeted in the treatment of medical conditions. Different
models of psychological and social interventions are the main ingredients for these
desired changes in the self.

A second corollary of this definition is the fact that mental health is very laden with
values, not because scientific factors are lacking, but because values become of the
utmost importance — more so than for medical disorders — when we deal with the
self and its restoration. While somatic illnesses such as diabetes are primarily defined
and shaped by biologically discernible facts, values do play a certain role but do not
define the disorder. Societal and personal values are important in the treatment of
most medical disorders, but acquire paramount importance in the case of mental
disorders. Societal and cultural values even define variations in diagnoses over time
and across geographic locations. Compulsory treatments, a particularity in the mental
health field, are a strong testimony of how mental health can interfere with the self
and how the personal values of the patient can clash with the societal values, thus
necessitating legal, value-laden mitigation.

Neurobiology and experience of mental illness Go to:

Advances in neurosciences have surely given us much better biological mechanistic Review The structure of psychiatric science.
[Am J Psychiatry. 2014]
explanations of many of the uniquely human cognitive, emotional and conative
functions, such as memory, thinking, perception, mood and action. This knowledge
has informed us that many mental illnesses derive their vulnerability from underlying
biological variations. However, we are far from being able to explain in
neurobiological terms many of the behaviours and experiences that constitute the core
presentations of mental disorders. Even if neurobiology one day were to provide
better explanations of the workings of the brain, more elaborately explain the role of
genes in increasing the risk for mental illness and the mechanisms behind complex
human behaviour, one would still need to understand the experiences of patients with
different forms of mental illness in psychological terms, as recently described by
Kendler9 so eloquently. By equating mental illness with any medical illness and,
therefore, situating it in an organ within the human biology and not recognizing its
unique nature in the way it affects the “self” cannot be justified on the basis of current
state of knowledge nor may it serve our patients and society well, as we explain in the
rest of this editorial.

Mental illness and the utility of explanatory models Go to:

Indeed, it is envisaged that putting mental illness on the same footing as medical
illness, society will understand it better and not react negatively toward those with
mental illnesses. It is hoped that as a result those with mental illness may face less
social stigma — a major obstacle to people seeking and/or receiving help — and
reducing stigma may help individuals regain eventual acceptance by society as
productive members. Interestingly, the public’s explanatory models of mental illness
do not follow this narrative and, on the contrary, the public have multiple models of
explaining mental illness varying across cultures and times.

One needs to ask the pragmatic question of whether the strategy of using a biogenetic
model of mental illness and equating it with medical illness has actually helped.
There are 2 areas worthy of examination in this regard.

Explanatory models, stigma and society

The first is to examine the effect of the statement, “mental illness is like any other Fighting schizophrenia and its stigma. A new World
[Br J Psychiatry.
Psychiatric Association educational programme. 1997]
medical illness,” on social stigma toward people with mental illness. As indicated
previously, implicit in the axiomatic statement is a primarily biological origin of the Different biogenetic causal explanations and
attitudes towards persons with[Jmajor
Affectdepression,
Disord. 2014]
behaviour and suffering that characterize mental illness. Let us examine the evidence
The relationship of causal beliefs and contact with
in this regard. In the last decade or 2, biogenetic attribution of all mental disorders, [Int J Soc
users of mental health services Psychiatry.
to attitudes 1999]
to the
having acquired a hegemoneous status10 has been used primarily to inform Review Prejudice and schizophrenia: a review of
campaigns for reducing stigma and promoting better acceptance of mental illness and the 'mental illness is an[Acta Psychiatr
illness like any Scand.
other' 2006]
the people with mental illnesses by society.11,12 Several well-conducted studies have Biogenetic models of psychopathology, implicit guilt,
and mental illness stigma. [Psychiatry Res. 2010]
concluded, almost uniformly, that this strategy has not only not worked, but also may
have worsened public attitudes and behaviour toward those with mental illnesses. "A disease like any other"? A decade of change in
[Am Jdepression,
public reactions to schizophrenia, Psychiatry. and
2010]
Investigations of stigma have shown that those who consider mental disorders as
Public attitudes towards people with mental illness
primarily attributable to biological forces, just like other medical disorders, while [Br J Psychiatry. 2009]
in England and Scotland, 1994-2003.
absolving the mentally ill person of responsibility for their behaviour and actions,
tend to feel less optimistic about their ability to get better and function well, are less
accepting of them and feel less positively toward them.13–16 In a review of the
literature related to the concept of mental illness being like any other illness, Read
and colleagues17 reported that biogenetic causal theories and diagnostic labelling as
illness are both positively related to perceptions of dangerousness and
unpredictability and to fear of and desire for social distance. The attitudes
investigated in these studies are reflected in individuals’ responses to whether they
would live next door to, socialize or make friends with or have a close relative get
married to a person described as being mentally ill. There is also evidence to suggest
that biogenetic explanatory models may have negative consequences for those with
mental illness in terms of their implicit self concept and explicit attitudes, such as
fear.18 Further, campaigns to reduce stigma that encourage people to think about
mental illness as simply another form of medical illness have produced results that
show effects to the contrary. For example, a recent study showed that over a 10-year
period of deliberate use of the biogenetic explanatory model for campaigning to
reduce stigma has resulted in worsening of most, if not all, aspects of public attitudes
toward individuals with mental illnesses.19,20 The strength of these perhaps
counterintuitive findings comes from the fact that these studies were adequately
designed, well powered and, most importantly, replicated in several countries (e.g.,
United States, Britain, Germany) with very similar results. It is acknowledged that
these relatively negative attitudes may be particularly stronger in relation to certain
forms of mental illness (e.g., psychosis, manic depressive illness) and addictions.

Explanatory models of mental illness and the mentally ill person

Another domain — perhaps the most important — of examination is the individual
with mental illness. In clinical practice, telling patients that their presenting mental
illness is like any other medical illness may initially reassure some and assist them in
accepting to take medication, especially during the distressing acute phases of a
serious mental disorder. They or their families may welcome a simple explanation for
encouraging them to accept treatment, which in many cases includes medication.
While this strategy can achieve something very important in acute crisis-like
situations, it may become problematic, if persistent over time, in getting individuals
to accept other highly effective psychological and social treatments. These latter
interventions are highly effective and considerably less noxious than often less
effective medications for some forms of mental illness, such as mild to moderate
depression, anxiety and eating disorders, and emotional dysregulation associated with
several long-standing mental illnesses. Even in the most serious mental disorders,
such as psychotic, bipolar and severe major depressive disorders, where medications
are invariably an essential part of treatment, psychological and social therapeutic
interventions are the essential bridge between pharmacological interventions during
the acute crises and the need for their sustained use in the long term while at the same
time achieving the essential goals of relief of internal distress, restoration of self and a
return to productive social and working lives.

Furthermore, presenting mental illness as any other medical illness often implies a
medical treatment (medication in most cases) as the dominant treatment strategy.
Patients’ rejection of the treating clinician’s medical illness model is generally
described as lack of insight and starts the cycle of nonadherence to medication, which
then translates into nonadherence to treatment. In reality, if patients and families are
allowed to articulate their attributional models, given credit for their “experiential
knowledge” and encouraged to enter into a dialogue with the treating clinician, it is
more likely there will be some consensus on acceptance of recommended treatment.
This may prevent the cycle of disengagement and decline in the course that follows.

What needs to be done? Go to:

In clinical practice, if we are to take seriously the multidimensional goals of

providing mental health services, as articulated by those seeking and receiving help
for mental illness, clinicians have to work within an attributional model that makes
sense to the person receiving service, that can be supported by sound argument and
evidence and that provides a framework within which those receiving service and
those providing it can share a common language. Such a framework will need to
include the biogenetic model of attribution of mental illness as 1 of several parallel
and equally authentic social, psychological, environmental and cultural models
offered by service providers and researchers (acquired knowledge) as well as those
who experience mental illness (experiential knowledge). There is a need to create a
common language in order to come to an understanding of the person’s experience
and to promote such an understanding among the public at large. Denying the special
nature of mental illness is unlikely to achieve these important goals.

Some recent developments, such as the promotion of a recovery model21–23 and the Review Beyond the biopsychosocial model:
[Psychiatry. 1995]
early intervention movement,24,25 may hold more promise in improving both the integrating disorder, health, and recovery.
The personal meaning of recovery among
quality of care and possibly involvement of and improvement in public attitudes. The [Psychiatr Serv. 2012]
individuals treated for a first episode of psychosis.
former has emerged from experiential knowledge and advocacy from service users,
Early intervention in psychosis: concepts, evidence
supported later by sound qualitative research, whereas the latter has emerged from a and future directions. [World Psychiatry. 2008]
combination of a shift in philosophy of delivery of care on the part of service Review First-episode psychosis, early intervention,
providers, parallel generation of evidence of its effectiveness26,27 and greater and outcome: what have we[Can J Psychiatry. 2005]
learned?
acceptance by service users and their families, who have now joined the movement as Benefits of enriched intervention compared with
[Can J Psychiatry. 2007]
advocates. A third emerging movement, the concept of positive mental health,28,29 standard care for patients with recent-onset
Review How successful are first episode
may prove to be effective in combating the negative image of mental illness. This [Curr Opin Psychiatry. 2014]
programs? A review of the evidence for specialized
movement promotes and is based on human resilience and positive aspects of the
Positive mental health: a research agenda.
experience of mental illness. There is a burgeoning literature emerging in this field, [World Psychiatry. 2012]
which may balance the rather deterministic, deficit oriented and largely pessimistic The science of well-being: an integrated approach
miasma created by using an exclusively biogenetic model to explain mental disorders. [World Psychiatry. 2006]
to mental health and its disorders.

Conclusion and recommendations Go to:

Simply seeking an axiom of “mental illness is like any other medical illness” is at
best simplifying a complex human problem and at worst doing a major disservice to
patients, their families and the mental health field. Our dialogue should incorporate
the general complexity of human thinking, behaviour, memories and the idea of self
and consciousness, including knowledge emerging from sophisticated biogenetic and
social science research while attending to the specific complexities that each of us as
human beings carry as part of our life stories. That is true for those receiving and
those providing services.

We therefore argue that we should continue to have a social and a professional

conversation where we find a proper place for neurobiology, social, cultural and
environmental forces, personal histories and the uniqueness of each individual when
trying to understand, explain and treat mental disorders while avoiding a simplistic
reductionism that may be perceived at best as patronizing but ultimately harmful,
even though the intentions may be noble. We propose that future antistigma
campaigns should give up the axiom of “mental illness is like any other medical
illness” and instead present the complex and multifaceted explanations of mental
illness as unique along with the positive aspects as discussed here. These campaigns
need to be informed not only by the acquired knowledge of service providers and
scientists but equally by the experiential knowledge from service users and their
families, taking into consideration new knowledge emerging from fields of recovery,
early intervention and positive mental health. For clinicians, it would be equally
important to embrace explanatory models of mental illness that are based on evidence
in science and to include biogenetic, social and cultural models as well as those told
to them by the very people they are trying to serve.

Footnotes Go to:

Editors’ note: The ideas expressed in this editorial are not necessarily those of the journal.
Importantly, JPN continues to focus on publishing “papers at the intersection of psychiatry and
neuroscience that advance our understanding of the neural mechanisms involved in the etiology
and treatment of psychiatric disorders.”

Competing interests: See jpn.ca for R. Joober. None declared by A. Malla or A. Garcia.

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