Mental health is health. As Mental Health Awareness Month comes to a close, this is a refrain you’ve likely heard more than once. It’s a good slogan, conveying succinctly the important idea that mental health conditions deserve to be taken with the same seriousness—and provided with the same degree of access to treatment—as physical health conditions. But, when repeated too often—and without a nuanced grasp of the current state of neuropsychological research—there is also a real danger of misunderstanding.
Depression, anxiety, ADHD, OCD, anorexia, PTSD. These ailments—and others like them—can all be profoundly disabling when uncontrolled. Sometimes, they can be fatal. When we say that mental health is health, we are acknowledging that people living with these conditions are genuinely unwell and often need professional intervention in order to recover. It’s, therefore, essential that we provide a destigmatized pathway for mental health diagnosis and treatment. In all these ways, mental health is like physical health.
But we must not gloss over the ways in which mental illnesses and psychological injuries are unlike physical illnesses and injuries. One of the biggest differences is in the way these conditions are diagnosed. There’s no blood test for depression. No imaging technology to reveal PTSD. No biopsy to detect anxiety. And the way that mental health conditions are defined means this gap will not—can not—be bridged by advancements in diagnostic technology. Mental illnesses are diagnosed according to a checklist of external behaviours and self-reported symptoms, not because we lack the tools to detect them more directly, but because the symptoms are the illness.
What we’ve done with the Diagnostic and Statistical Manual of Mental Disorders is draw lines around various clusters of cognitive symptoms and given them names[1]. And so, by definition, a person has the illness if they have the symptoms we put in that box. But the conditions we’ve named—the boxes we’ve drawn—almost certainly do not correspond one-to-one with neurobiological circumstances. Just as not every cough is caused by influenza and not everyone with the flu develops a cough.
Vast amounts of research have gone into finding identifiable biological and neurodevelopmental similarities between patients with a given mental health diagnosis, and there’s been some success. But the fact that brain imaging has shown statistically lower GABA neurotransmitter concentration in the occipital cortex of patients with panic disorder does not mean that panic disorder is a deficiency of GABA. The fact that a number of genes have been identified that correspond to increased risk for anorexia nervosa does not mean that anorexia is a genetic disease. This research may someday progress to the point where we can diagnose some people with a neurotransmitter anomaly that may cause panic disorder, or with a genetic condition that may predispose them to anorexia. But these biological conditions will necessarily be of a different kind than the mental health conditions they’re correlated with. The influenza virus is not the same category of thing as a cough.
This may seem like splitting hairs, but it’s truly important. It is thankfully no longer acceptable to say that mental health disorders are “just in your head” or that people should “just get over it.” As a society, we’ve largely come to understand that these conditions are genuine health issues that need specialized treatment. Mental health is health. But the public discourse is slipping now towards something arguably just as dangerous on the other side of the pendulum swing. Today, we instead refer to all sorts of mental health disorders as “neurological imbalances.” And we speak of pharmacological interventions for these conditions in the same way we talk about insulin for diabetes.
These ideas represent a gross overestimation of the state of neuropsychological research, and they directly contribute to an epidemic of over-treatment and over-medicalization of symptoms better addressed through non-medical interventions. When patients believe that their depression is serotonin dysregulation or that their anxiety is GABA dysregulation or that their ADHD is a neuronal miswiring, of course they are more likely to believe that a pharmacological solution is required for what’s framed as a biochemical problem. These drugs do work wonders for some people, and the fact that we have developed these medications is a testament to the value of ongoing neuropsychological research. But we also have a responsibility to take a step back and recognize that the scientific connection from drug to neurological model to diagnostic criteria to individual lived experience is tenuous at every link in the chain.
Yes, every mental health disorder must tie back to the body and brain in some way. But so too must every healthy behaviour, response, and thought. If the mind exists through the brain[2], then every aspect of our personality, our cognition, and our being is neurological at its root. But it does not follow from this that every mental health condition is best suited to a neurochemical intervention, even if our scientific understanding of the brain were complete—which it certainly isn’t.
So, this Mental Health Awareness Month, we encourage you to recognize that mental health is indeed health. But also that mental health ailments are meaningfully different from physical injuries and illnesses. If we are careful and compassionate, we can make this distinction without undermining our commitment to dignity, understanding, and equal access to care.
[1] It’s worth noting that the latest version of the Diagnostic and Statistical Manual (DSM-5) has been controversial for the ways in which diagnostic criteria have been expanded to include responses that many consider to be within the realm of healthy cognition. For example, the bereavement exception has been removed from the definitions of depressive disorders, making it possible to diagnose a normal grieving process as depression. Likewise, the diagnostic criteria for conditions like ADHD and the mildest level of autism spectrum disorder are now broad enough that the British Psychological Society formally objected to the DSM-5 on behalf of patients as a “medicalisation of their natural and normal responses to their experiences,” saying that these definitions “do not reflect illnesses so much as normal individual variation.”
[2] Or, if the mind is the brain, depending on your favourite philosophy of mind.