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The community mental health movement arrived in the 1960s with a conceptual shift away from individual to social factors, with a heavy emphasis on prevention.
Rather than treat the symptoms of mental illness once they occur, the goal was to encourage communities not to foster mental illness in the first place. The social factors seen to contribute to mental illness were the family, interpersonal networks, and the social status quo.
In spite of widespread publicity, the movement petered out in less than 10 years, due largely to the financial interests supporting the individualistic paradigm—psychiatrists, big pharma, insurance carriers; and the DSM (Diagnostic and Statistical Manual of Mental Disorders), with its multiplicity of diagnostic labels. The diagnostic labels, along with the psychotherapies corresponding to the labels (to qualify for insurance), alienated working-class citizens from mental health professionals but also the threat of stigma carried over to the growing number of semi-skilled, unskilled, and under-educated.
A recent article, “When Improving Symptoms is Not Enough” in the Journal of the American Medical Association (JAMA), cites symptom relief of individuals with obsessive-compulsive disorder (OCD) receiving cognitive behavioral therapy (CBT) and serotonin reuptake inhibitors. While difficult to figure the exact number of patients who fail to benefit from this protocol, it is estimated somewhere between 40 percent and 60 percent of patients require additional treatment. Around 5 percent to 10 percent remain highly disabled after multiple treatment attempts.
A long-term Swedish study reported individuals with OCD having an increased risk of metabolic and cardiovascular disorders, including 57 percent having increased risk of obesity, 42 percent having increased risk of circulatory system diseases, and 21 percent having increased risk of type 2 diabetes, compared with the general population. These increases in risk are independent of familial confounders, psychiatric comorbidities, and medical use. The culprits appeared to be poor lifestyle habits (e.g. physical inactivity, unhealthy diets), which fortunately are amenable to modification.
The authors go on to note that those with OCD have adverse nonmedical outcomes, such as poor education attainment and reduced participation in the labor market. Moreover, 44 percent of patients in the Swedish study were either receiving a disability pension or long-term sick leave benefits or long-term unemployment insurance payments. These figures illustrate the effects of the disorder not just on the individual but also on society at large.
CBT, even when it reduces OCD symptoms, is relatively specific and tends not to have a larger effect on secondary measures such as depression and quality of life, including metabolic syndrome, educational attainment, family function, or labor-market participation. The field would benefit from measuring and monitoring functional outcomes that matter to patients: Do they have healthy lifestyles?; is their general health monitored appropriately?; are they in full-time education or employed one year after treatment?; and do they engage in meaningful activities and relationships?
Needless to say, a healthy democracy depends upon a healthy citizenry without profit-making at the core of the mental health delivery system. The semi-skilled, unskilled, and under-educated have the highest health risk and are the lowest users of health information. They may fail to recognize that smoking is bad for them, that their nutritional intake is expensive and ill-directed, that their consumption of alcohol is problematic, that their teeth need attention, that their life expectancy is low, and that their fertility rate is high. But until and unless we change our ineffective individualistic paradigm to that of a community mental health approach, we all are losers.
This blog was co-published with PsychResilience.com.
References
Iscoe, I., Toward a viable community mental health psychology, American Psychologist, 1982
