MHB 03: One in Four - Fact or Fiction
I had not intended to publish this blog so early in the walk, but I am feeling a little lazy today and had completed most of the draft for this blog already. Some people may think this is a strange topic to blog about, considering part of the point of the blog is to spread awareness. But it is something that has interested me for a while and I believe in the future issues surrounding it could become more important.
This figure is quoted by almost all mental health charities, and is normally on the slogan of any mental health campaign. But where does it actually come from? Most of the major UK charities relate this back to the Adult Psychiatric Morbidity Survey (APMS), which is done every 7 years and they normally quote the 2007 survey, but sometimes the 2014 survey which confusingly reported the findings in quite different ways. Though the 1 in 4 figure had been banded around from long before this time, I believe originating in the US.
A matter of confusion is that different campaigns and different charities quote the figure differently, some quote it as the amount of people with it a mental health condition at any given time, others quote it as the amount of people with it over a specific time frame (normally a year) and others quote is as the figure at some time in our lifetimes. As you can see quoting 1 in 4 people having a mental health condition active as of today, is quite different to saying at some point in their lives 1 in 4 people will have a mental health condition.
Why the figure could be wrong
At first the APMS report mentioned above seems to be a fairly comprehensive process. There is a first phase interview survey, essentially a questionnaire, and a long questionnaire at that (140 pages long.) This is then followed by a second phase interview with a specialist if it is suspected that psychotic, attention deficit/hyperactive disorder or autism might be present as for these further information would be needed. About 7,500 completed the first phase interview survey.
But the first phase interview is a survey (questionnaire) which is known not to be reliable measure for diagnosing or assessing most mental health conditions. The report itself actually states that survey assessments are not as reliable as clinical assessments. I fully understand that it may not be possible to carry out full clinical assessments of all 7,500 people, as this would likely take too much time and cost too much money. For this reason the report itself actually states that rather than focusing on the actual prevalence estimate for each disorder, the greater value is by examining how rates vary over different groups from one APMS report to the next.
A secondary reason why the figure could be elevated is due to the actual questions asked and the way the results are interpreted. For certain disorders there is a quite black and white boundary between having the disorder or not and for these the survey appears fairly watertight. But for other disorders the boundary is less clear. One example where it is less clear are anxiety disorders, a certain amount of anxiety is healthy and actually fundamental to living. But with anxiety disorders the anxiety is irrational or causes severe/excessive fear, and has a significant effect on the sufferer’s life. From the questions in the survey it would appear that for an area like anxiety it would pick up relatively minor anxiety as a mental health disorder that a clinician may say wasn’t.
Thirdly there do appear to be a fair few questions in the survey whose wording could affect the boxes ticked, for example:
Almost everyone gets sad, miserable or depressed at times.
Have you had a spell of feeling sad, miserable or depressed in the past month?
The first statement ‘Almost everyone gets sad, miserable or depressed at times’ will almost definitely have an effect on some people answering the question, and I would suggest that more people would tick yes because of it. There is no need in that first statement. I agree it is a bit cheeky just dragging one question out of the report to make this specific point but there does appear to be many questions where the phrasing could affect the box being ticked and most of the time it appears to have a bias towards ticking the box that could lead to a mental health issue being noted.
It appears there are almost 2 definitions of mental health these days. The first being specific recognised/labelled mental health conditions. The second one being more about ‘mental wellbeing’, which is about the reaction and management of general life events (stress, bereavement, physical health issues.) The way the survey is done it may not only encapsulate the first of these but also cover the second category as well. An example of this could be if you had a physical injury (tick box), that causes you to be irritable (tick box), that also affects your sleep (tick box), that bothers you when doing something interesting (tick box) etc. alongside other ticked boxes could end up with you being categorised as having a mental health issue under the survey. This is not necessarily a problem, but this could make the figure higher than some people may expect.
Why some organisations use the figure
I think there are 2 main reasons why organisations and charities use this figure. The first one is to reduce stigma and discrimination against people with mental health. This is a very important point as people with mental health can be stigmatised and discriminated in many ways, whether in the workplace, public, applying for support and many other areas. It is clear that the 1 in 4 figure has definitely raised the profile of mental health disorders and thus had an effect in reducing the stigma, which is a good thing.
The second point is that it normalises mental health issues and shows that people with mental health can function and get by OK. Therefore helping clear the historical myth that people with mental health issues can’t function in the wider world. This could help some people with certain conditions because it makes them realise there are many others going through the same thing.
I think the organisations specifically use the 1 in 4 figure (as opposed to some other figures from research) as it is easily quotable, understandable, and not so high that it is unbelievable. It quickly gets across whichever message they are promoting
Issues with the figure
Firstly regards the normalising effect of this figure, as well as the positives listed above it can also go too far and have negative impacts. It can lead to trivialising certain conditions, both within the general public but also within the people treating conditions. I am struggling to explain this point in writing but will try and give a personal example. During an assessment I had at one point the assessor started going on about 1 in 4 and how I would get through it and that there are many others around going through it as well. In his mind this was probably to try and give me optimism, but considering at that stage my clinical diagnosis was severe depression, possible Asperger’s and in the notes detailed worry about my suicidal thoughts, banding me in with 25% of the population and saying I would be alright seemed to me at the time to very much trivialise the situation.
Regards the stigma point, this is less of an issue regards its success but more a general issue. It shouldn’t matter whether the figure is 1 in 4 or 1 in 100, the sufferers shouldn’t be stigmatised whatever. I fully understand thought that the 1 in 4 figure does have a bigger impact on the general public than a lower number would. The other slightly negative thing that comes out of the stat being published is that it is often twinned with ‘there is nothing to be ashamed off, mental health conditions are common’. This has a fundamental issue as rather than saying you shouldn’t be ashamed of having a mental health issue anyway, it states that you shouldn’t be ashamed because the condition is common.
I believe the figure can further confuse the hazy area between mental health illness and mental wellbeing. This can have a serious effect on those with genuine conditions as it can lead to the misallocation of finite resources, leaving those with serious conditions with even less support. This is a much broader area of what constitutes a mental health condition, and something far beyond my blogging capabilities.
The figure also regularly gets bought up in political debates, and at its worse in one interview I saw the person argued that 1 in 4 people needed treatment , the person then divided the population by 4, then split the overall budget by that amount of people to get the figure the government was spending per person. This is clearly a grossly negligent way of working out the figures as it firstly assumes that the stat is saying 1 in 4 people need treatment (which it doesn’t), but also by its nature treats those with something like severe schizophrenia in the same bracket as mild depression.
It could also be helping support those who want to make money out of wellness as opposed to mental health illness. The worldwide ‘Wellness’ industry which includes things like mindfulness is estimated to be worth almost $4 trillion. Once things become commercial as history shows, the health benefits may not be thought of as important as the profit margins. This may become more of an issue in the years to come, when people feel almost pressured into doing/buying certain things to ensure there ‘wellness’ is maintained.
Does it matter?
I think for me the issue arises because the campaigns and charities use this figure without questioning the veracity of the figure. It works for their campaigns due to its simplicity and impact but the full effects of its use are not always considered. In the right hands and with explanation this figure can be useful, but the figure by the fact that it is not exact in its nature can be spun for political or commercial gains by political parties and commercial entities.
I think the main issue is that is has been repeated so many times now (MIND, Mental Health Foundation, Prince Harry, Theresa May to name a few) that people just take it as fact. This value is not fact and no large scale clinical analysis has ever been done in the UK (unless I have missed some research) and therefore its value should not be treated as definitive fact and in fact many people who work in mental health dispute the figure.
So in conclusion I am not saying the 1 in 4 figure is definitely not correct (though from this blog you may guess I think it is a little bit too high), I am more saying that the figure is open to discussion and at some point I think there will a bigger public debate around this area discussing what constitutes a mental health condition.
This is just an opinion piece and I know some people will not agree with my arguments in relation to the 1 in 4 figure Please do comment below if you have a difference of opinion or whether you agree or even just like the blog.