About Mental Health

  • Mental Health Basics
  • Types of Mental Illness

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What is mental health?

Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make healthy choices. 1 Mental health is important at every stage of life, from childhood and adolescence through adulthood.

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Why is mental health important for overall health?

Mental and physical health are equally important components of overall health.  For example, depression increases the risk for many types of physical health problems, particularly long-lasting conditions like diabetes , heart disease , and stroke. Similarly, the presence of chronic conditions can increase the risk for mental illness. 2

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Can your mental health change over time?

Yes, it’s important to remember that a person’s mental health can change over time, depending on many factors.  When the demands placed on a person exceed their resources and coping abilities, their mental health could be impacted. For example, if someone is working long hours, caring for a relative, or experiencing economic hardship, they may experience poor mental health.

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How common are mental illnesses?

Mental illnesses are among the most common health conditions in the United States.

  • More than 1 in 5 US adults live with a mental illness.
  • Over 1 in 5 youth (ages 13-18) either currently or at some point during their life, have had a seriously debilitating mental illness. 5
  • About 1 in 25 U.S. adults lives with a serious mental illness, such as schizophrenia, bipolar disorder, or major depression. 6

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What causes mental illness?

There is no single cause for mental illness. A number of factors can contribute to risk for mental illness, such as

  • Adverse Childhood Experiences , such as trauma or a history of abuse (for example, child abuse, sexual assault, witnessing violence, etc.)
  • Experiences related to other ongoing (chronic) medical conditions, such as cancer or diabetes
  • Biological factors or chemical imbalances in the brain
  • Use of alcohol or drugs
  • Having feelings of loneliness or isolation

People can experience different types of mental illnesses or disorders, and they can often occur at the same time. Mental illnesses can occur over a short period of time or be episodic. This means that the mental illness comes and goes with discrete beginnings and ends. Mental illness can also be ongoing or long-lasting.

There are more than 200 types of mental illness. Some of the main types of mental illness and disorders are listed here .

  • Strengthening Mental Health Promotion . Fact sheet no. 220. Geneva, Switzerland: World Health Organization.
  • Chronic Illness & Mental Health . Bethesda, MD: National Institutes of Health, National Institute of Mental Health. 2015.
  • Kessler RC, Angermeyer M, Anthony JC, et al. Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry. 2007;6(3):168-176.
  • Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health. Rockville, MD: Center for Behavioral Health Statistics and Quality. Substance Abuse and Mental Health Services Administration. 2016.
  • Merikangas KR, He J, Burstein M, et al. Lifetime Prevalence of Mental Disorders in US Adolescents: Results from the National Comorbidity Study-Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry. 2010;49(10):980-989. doi:10.1016/j.jaac.2010.05.017.
  • Health & Education Statistics . Bethesda, MD: National Institute of Mental Health. National Institutes of Health. 2016.
  • Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, Severity, and Comorbidity of Twelve-month DSM-IV Disorders in the National Comorbidity Survey Replication (NCS-R). Archives of general psychiatry. 2005;62(6):617-627. doi:10.1001/archpsyc.62.6.617.Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health. Rockville, MD.
  • Rui P, Hing E, Okeyode T.  National Ambulatory Medical Care Survey: 2014 State and National Summary Tables. Atlanta, GA: National Center for Health Statistics. Centers for Disease Control and Prevention. 2014.
  • Web-based Injury Statistics Query and Reporting System (WISQARS) . Atlanta, GA: National Center for Injury Prevention and Control. Centers for Disease Control and Prevention. 2015.
  • Insel, T.R. Assessing the Economic Costs of Serious Mental Illness. Am J Psychiatry. 2008 Jun;165(6):663-5. doi: 10.1176/appi.ajp.2008.08030366.
  • HCUP Facts and Figures: Statistics on Hospital-based Care in the United States, 2009. Rockville, MD: Agency for Healthcare Research and Quality. 2009.
  • Reeves, WC et al. CDC Report: Mental Illness Surveillance Among Adults in the United States. MMWR Morb Mortal Wkly Rep 2011;60(03);1-32.
  • Parks, J., et al. Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA: National Association of State Mental Health Program Directors Council. 2006.

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What is mental health.

Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act, and helps determine how we handle stress, relate to others, and make choices.

Mental health is important at every stage of life, from childhood and adolescence through adulthood. Over the course of your life, if you experience mental health problems , your thinking, mood, and behavior could be affected.

Mental Health Conditions

Mental illnesses are disorders, ranging from mild to severe, that affect a person’s thinking, mood, and/or behavior. According to the National Institute of Mental Health, nearly one-in-five adults live with a mental illness.

Many factors contribute to mental health conditions, including:

  • Biological factors, such as genes or brain chemistry
  • Life experiences, such as trauma or abuse
  • Family history of mental health problems

Some mental health topics include:

  • Antisocial personality disorder
  • Anxiety disorders (including generalized anxiety, panic disorders, obsessive-compulsive disorder (OCD), phobias, and social anxiety)
  • Attention-deficit hyperactivity disorder (ADHD)
  • Bipolar disorder
  • Borderline Personality Disorder (BPD)
  • Eating disorders (including Anorexia Nervosa, binge eating Disorder, and Bulimia Nervosa)
  • Post-traumatic Stress Disorder (PTSD)
  • Schizophrenia
  • Seasonal affective disorder (SAD)
  • Suicide and suicidal behavior

A Serious Mental Illness (SMI) is a mental illness that interferes with a person’s life and ability to function. Despite common misperceptions, having an SMI is not a choice, a weakness, or a character flaw. It is not something that just “passes” or can be “snapped out of” with willpower.

View SAMHSA's Public Message about Serious Mental Illnesses .

Early Warning Signs & Symptoms

Not sure if you or someone you know is living with mental health problems? Experiencing one or more of the following feelings or behaviors can be an early warning sign of a problem:

  • Eating or sleeping too much or too little
  • Pulling away from people and usual activities
  • Having low or no energy
  • Feeling numb or like nothing matters
  • Having unexplained aches and pains
  • Feeling helpless or hopeless
  • Smoking, drinking, or using drugs more than usual
  • Feeling unusually confused, forgetful, on edge, angry, upset, worried, or scared
  • Yelling or fighting with family and friends
  • Experiencing severe mood swings that cause problems in relationships
  • Having persistent thoughts and memories you can't get out of your head
  • Hearing voices or believing things that are not true
  • Thinking of harming yourself or others
  • Inability to perform daily tasks like taking care of your kids or getting to work or school

Do you think someone you know may have a mental health problem? Talking about mental health can be difficult. Learn about common mental health myths and facts and read about ways to help you get the conversation started.

Tips for Living Well with a Mental Health Condition

Having a mental health condition can make it a struggle to work, keep up with school, stick to a regular schedule, have healthy relationships, socialize, maintain hygiene, and more.

However, with early and consistent treatment—often a combination of medication and psychotherapy—it is possible to manage these conditions, overcome challenges, and lead a meaningful, productive life.

Today, there are new tools, evidence-based treatments, and social support systems that help people feel better and pursue their goals. Some of these tips, tools and strategies include:

  • Stick to a treatment plan. Even if you feel better, don’t stop going to therapy or taking medication without a doctor’s guidance. Work with a doctor to safely adjust doses or medication if needed to continue a treatment plan.
  • Keep your primary care physician updated. Primary care physicians are an important part of long-term management, even if you also see a psychiatrist.
  • Learn about the condition. Being educated can help you stick to your treatment plan. Education can also help your loved ones be more supportive and compassionate.
  • Practice good self-care. Control stress with activities such as meditation or tai-chi; eat healthy and exercise; and get enough sleep.
  • Reach out to family and friends. Maintaining relationships with others is important. In times of crisis or rough spells, reach out to them for support and help.
  • Develop coping skills. Establishing healthy coping skills can help people deal with stress easier.
  • Get enough sleep. Good sleep improves your brain performance, mood and overall health. Consistently poor sleep is associated with anxiety, depression, and other mental health conditions.
  • If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org .
  • To learn how to get support for mental health, drug, and alcohol issues, visit FindSupport.gov .
  • To locate treatment facilities or providers, visit FindTreatment.gov or call SAMHSA’s National Helpline at 800-662-HELP (4357) .

Mental Health Resources Landing Page

  • National Helpline
  • SAMHSA's 2021 National Survey on Drug Use and Health
  • Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC)
  • SMI Adviser | American Psychiatric Association (APA) and SAMHSA
  • Technology Transfer Centers (TTC) Program
  • Centers for Disease Control and Prevention: Stress and Coping
  • NIMH: Caring for Your Mental Health

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If you are in an emergency, in crisis or need someone to talk to, there is help.

Mental Health 101

It all starts with knowledge. Use this series of free online tutorials as a starting point for learning about mental health.​

Turning Knowledge Into Action

Knowing that knowledge is power, our hope for these tutorials is twofold. One, that you come away with a greater understanding of the core concepts presented. And two, that they help you and those around you begin to break down barriers and dispel the stigma associated with mental illness and addiction, and help bring these issues into the daylight where they belong. We have several topics for you to explore below.   And of course, we encourage you to share these tutorials with friends,  family, and colleagues!  Please note: to view the tutorials below, you may need to turn off your browser's pop-up blocker.

Introducing our Mental Health 101 site

We are pleased to introduce our course site featuring tutorials on:

  • Mental Health

The site offers an opportunity to create a private user account so that you can get the most out of your online learning experience. You will be able to self-enroll in course that interest you, view your activity and quiz results, track your course completions and earn course completion badges. Read more about how these tutorials work.

Find the Mental Health 101 topic you’re looking for:

Refine alphabetically, addiction 101 – updated.

This updated self-directed tutorial is meant to introduce you to the topic of addiction, a disorder characterized by out-of-control behaviours, such as gambling or alcohol and other drug use.

Anxiety Disorders

This module provides basic information about anxiety disorders.

Bipolar Disorder

This module provides basic information about bipolar disorder.

Concurrent Disorders

This module provides basic information about concurrent disorders.

Depression 101

Depression 101 – updated.

This updated self-directed tutorial is meant to introduce you to the topic of depression, a common but serious mood disorder that can affect people’s day-to-day functioning and is much more than unhappiness.

Diversity and Health Equity

This module provides basic information about diversity and health equity.

Harm Reduction

This module provides basic information about harm reduction.

Mental Health 101 – Updated

This self-directed tutorial is meant to introduce you to the concepts of mental health and mental health problems (and mental illnesses). Mental health problems are conditions in which people’s thinking, mood and behaviours negatively impact their day-to-day functioning. Someone with a diagnosed mental illness can experience good mental health, while someone without a diagnosed mental illness can experience difficulties at certain times of stress. Mental health is more than the absence of a mental illness.

Older Adults

This module provides basic information about the health issues of older adults.

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The Importance of Mental Health

Elizabeth is a freelance health and wellness writer. She helps brands craft factual, yet relatable content that resonates with diverse audiences.

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Akeem Marsh, MD, is a board-certified child, adolescent, and adult psychiatrist who has dedicated his career to working with medically underserved communities.

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Risk Factors for Poor Mental Health

Signs of mental health problems, benefits of good mental health, how to maintain mental health and well-being.

Your mental health is an important part of your well-being. This aspect of your welfare determines how you’re able to operate psychologically, emotionally, and socially among others.

Considering how much of a role your mental health plays in each aspect of your life, it's important to guard and improve psychological wellness using appropriate measures.

Because different circumstances can affect your mental health, we’ll be highlighting risk factors and signs that may indicate mental distress. But most importantly, we’ll dive into all of the benefits of having your mental health in its best shape.

Mental health is described as a state of well-being where a person is able to cope with the normal stresses of life. This state permits productive work output and allows for meaningful contributions to society.

However, different circumstances exist that may affect the ability to handle life’s curveballs. These factors may also disrupt daily activities, and the capacity to manage these changes. 

The following factors, listed below, may affect mental well-being and could increase the risk of developing psychological disorders .

Childhood Abuse

When a child is subjected to physical assault, sexual violence, emotional abuse, or neglect while growing up, it can lead to severe mental and emotional distress.

Abuse increases the risk of developing mental disorders like depression, anxiety, post-traumatic stress disorder, or personality disorders.

Children who have been abused may eventually deal with alcohol and substance use issues. But beyond mental health challenges, child abuse may also lead to medical complications such as diabetes, stroke, and other forms of heart disease.

The Environment

A strong contributor to mental well-being is the state of a person’s usual environment . Adverse environmental circumstances can cause negative effects on psychological wellness.

For instance, weather conditions may influence an increase in suicide cases. Likewise, experiencing natural disasters firsthand can increase the chances of developing PTSD. In certain cases, air pollution may produce negative effects on depression symptoms.  

In contrast, living in a positive social environment can provide protection against mental challenges.

Your biological makeup could determine the state of your well-being. A number of mental health disorders have been found to run in families and may be passed down to members.

These include conditions such as autism , attention deficit hyperactivity disorder , bipolar disorder , depression , and schizophrenia .

Your lifestyle can also impact your mental health. Smoking, a poor diet , alcohol consumption , substance use , and risky sexual behavior may cause psychological harm. These behaviors have been linked to depression.

When mental health is compromised, it isn’t always apparent to the individual or those around them. However, there are certain warning signs to look out for, that may signify negative changes for the well-being. These include:

  • A switch in eating habits, whether over or undereating
  • A noticeable reduction in energy levels
  • Being more reclusive and shying away from others
  • Feeling persistent despair
  • Indulging in alcohol, tobacco, or other substances more than usual
  • Experiencing unexplained confusion, anger, guilt, or worry
  • Severe mood swings
  • Picking fights with family and friends
  • Hearing voices with no identifiable source
  • Thinking of self-harm or causing harm to others
  • Being unable to perform daily tasks with ease

Whether young or old, the importance of mental health for total well-being cannot be overstated. When psychological wellness is affected, it can cause negative behaviors that may not only affect personal health but can also compromise relationships with others. 

Below are some of the benefits of good mental health.

A Stronger Ability to Cope With Life’s Stressors

When mental and emotional states are at peak levels, the challenges of life can be easier to overcome.

Where alcohol/drugs, isolation, tantrums, or fighting may have been adopted to manage relationship disputes, financial woes, work challenges, and other life issues—a stable mental state can encourage healthier coping mechanisms.

A Positive Self-Image

Mental health greatly correlates with personal feelings about oneself. Overall mental wellness plays a part in your self-esteem . Confidence can often be a good indicator of a healthy mental state.

A person whose mental health is flourishing is more likely to focus on the good in themselves. They will hone in on these qualities, and will generally have ambitions that strive for a healthy, happy life.

Healthier Relationships

If your mental health is in good standing, you might be more capable of providing your friends and family with quality time , affection , and support. When you're not in emotional distress, it can be easier to show up and support the people you care about.

Better Productivity

Dealing with depression or other mental health disorders can impact your productivity levels. If you feel mentally strong , it's more likely that you will be able to work more efficiently and provide higher quality work.

Higher Quality of Life

When mental well-being thrives, your quality of life may improve. This can give room for greater participation in community building. For example, you may begin volunteering in soup kitchens, at food drives, shelters, etc.

You might also pick up new hobbies , and make new acquaintances , and travel to new cities.

Because mental health is so important to general wellness, it’s important that you take care of your mental health.

To keep mental health in shape, a few introductions to and changes to lifestyle practices may be required. These include:

  • Taking up regular exercise
  • Prioritizing rest and sleep on a daily basis
  • Trying meditation
  • Learning coping skills for life challenges
  • Keeping in touch with loved ones
  • Maintaining a positive outlook on life

Another proven way to improve and maintain mental well-being is through the guidance of a professional. Talk therapy can teach you healthier ways to interact with others and coping mechanisms to try during difficult times.

Therapy can also help you address some of your own negative behaviors and provide you with the tools to make some changes in your own life.

A Word From Verywell

Your mental health state can have a profound impact on all areas of your life. If you're finding it difficult to address mental health concerns on your own, don't hesitate to seek help from a licensed therapist .

World Health Organization. Mental Health: Strengthening our Response .

Lippard ETC, Nemeroff CB. The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease Vulnerability and Poor Treatment Response in Mood Disorders . Am J Psychiatry . 2020;177(1):20-36. doi:10.1176/appi.ajp.2019.19010020

 Helbich M. Mental Health and Environmental Exposures: An Editorial. Int J Environ Res Public Health . 2018;15(10):2207. Published 2018 Oct 10. doi:10.3390/ijerph15102207

Helbich M. Mental Health and Environmental Exposures: An Editorial. Int J Environ Res Public Health . 2018;15(10):2207. Published 2018 Oct 10. doi:10.3390/ijerph15102207

National Institutes of Health. Common Genetic Factors Found in 5 Mental Disorders .

Zaman R, Hankir A, Jemni M. Lifestyle Factors and Mental Health . Psychiatr Danub . 2019;31(Suppl 3):217-220.

Medline Plus. What Is mental health? .

National Alliance on Mental Health. Why Self-Esteem Is Important for Mental Health .

By Elizabeth Plumptre Elizabeth is a freelance health and wellness writer. She helps brands craft factual, yet relatable content that resonates with diverse audiences.

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  • Volume 5, Issue 6
  • What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey
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  • Laurie A Manwell 1 , 2 ,
  • Skye P Barbic 1 , 3 ,
  • Karen Roberts 1 ,
  • Zachary Durisko 1 ,
  • Cheolsoon Lee 1 , 4 ,
  • Emma Ware 1 ,
  • Kwame McKenzie 1
  • 1 Social Aetiology of Mental Illness Training Program , Centre for Addiction and Mental Health, University of Toronto , Toronto, Ontario , Canada
  • 2 Department of Anatomy and Cell Biology , Schulich School of Medicine & Dentistry, University of Western , London, Ontario , Canada
  • 3 Department of Psychiatry , University of British Columbia , Vancouver, British Columbia , Canada
  • 4 Department of Psychiatry , Gyeongsang National University Hospital, School of Medicine, Gyeongsang National University , Jinju , Republic of Korea
  • Correspondence to Dr Laurie A Manwell; lauriemanwell{at}gmail.com

Objective Lack of consensus on the definition of mental health has implications for research, policy and practice. This study aims to start an international, interdisciplinary and inclusive dialogue to answer the question: What are the core concepts of mental health?

Design and participants 50 people with expertise in the field of mental health from 8 countries completed an online survey. They identified the extent to which 4 current definitions were adequate and what the core concepts of mental health were. A qualitative thematic analysis was conducted of their responses. The results were validated at a consensus meeting of 58 clinicians, researchers and people with lived experience.

Results 46% of respondents rated the Public Health Agency of Canada (PHAC, 2006) definition as the most preferred, 30% stated that none of the 4 definitions were satisfactory and only 20% said the WHO (2001) definition was their preferred choice. The least preferred definition of mental health was the general definition of health adapted from Huber et al (2011). The core concepts of mental health were highly varied and reflected different processes people used to answer the question. These processes included the overarching perspective or point of reference of respondents (positionality), the frameworks used to describe the core concepts (paradigms, theories and models), and the way social and environmental factors were considered to act . The core concepts of mental health identified were mainly individual and functional, in that they related to the ability or capacity of a person to effectively deal with or change his/her environment. A preliminary model for the processes used to conceptualise mental health is presented.

Conclusions Answers to the question, ‘ What are the core concepts of mental health ?’ are highly dependent on the empirical frame used. Understanding these empirical frames is key to developing a useful consensus definition for diverse populations.

  • MENTAL HEALTH
  • mental illness
  • social determinants of health
  • human rights
  • primary health care

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjopen-2014-007079

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Strengths and limitations of this study

Our study identifies a major obstacle for integrating mental health initiatives into global health programmes and health service delivery, which is a lack of consensus on a definition, and initiates a global, interdisciplinary and inclusive dialogue towards a consensus definition of mental health .

Despite the limitations of a small sample size and response saturation, our sample of global experts was able to demonstrate dissatisfaction with current definitions of mental health and significant agreement among subcomponents, specifically factors beyond the ‘ability to adapt and self-manage’, such as ‘diversity and community identity’ and creating distinct definitions, ‘one for individual and a parallel for community and society’.

This research demonstrates how experts in the field of mental health determine the core concepts of mental health, presenting a model of how empirical discourses shape definitions of mental health.

We propose a transdomain model of health to inform the development of a comprehensive definition capturing all of the subcomponents of health: physical, mental and social health.

Our study discusses the implications of the findings for research, policy and practice in meeting the needs of diverse populations.

Introduction

A major obstacle for integrating mental health initiatives into global health programmes and primary healthcare services is lack of consensus on a definition of mental health. 1–3 There is little agreement on a general definition of ‘mental health’ 4 and currently there is widespread use of the term ‘mental health’ as a euphemism for ‘mental illness’. 5 Mental health can be defined as the absence of mental disease or it can be defined as a state of being that also includes the biological, psychological or social factors which contribute to an individual’s mental state and ability to function within the environment. 4 , 6–11 For example, the WHO 12 includes realising one's potential, the ability to cope with normal life stresses and community contributions as core components of mental health. Other definitions extend beyond this to also include intellectual, emotional and spiritual development, 13 positive self-perception, feelings of self-worth and physical health, 11 , 14 and intrapersonal harmony. 8 Prevention strategies may aim to decrease the rates of mental illness but promotion strategies aim at improving mental health. The possible scope of promotion initiatives depends on the definition of mental health.

The purpose of this paper is to begin a global, interdisciplinary, interactive and inclusive series of dialogues leading to a consensus definition of mental health. It has been stimulated and informed by a recent debate about the need to redefine the term health . Huber et al 15 emphasised that health should encompass an individual's “ability to adapt and to self-manage” in response to challenges, rather than achieving “a state of complete wellbeing” as stated in current WHO 6 , 12 definitions. They also argued that a new definition must consider the demographics of stakeholders involved and future advances in science. 15 Responses to the article suggested the process of reconceptualising health be extended “beyond the esoteric world of academia and the pragmatic world of policy” 16 to include a “much wider lens to the aetiology of health” 17 along with patients and lay members of the public. Huber et al's 15 definition of health could include mental health but it is not clear that this would be satisfactory to patients, practitioners or researchers. We aimed to compare the satisfaction of mental health specialists, patients and the public with Huber et al ’s definition and other currently used definitions of mental health. We also asked them what they considered to be the core components of mental health.

Participants and procedures

A pool of 25 researchers in mental health was identified through literature/internet searches to capture expertise in (1) ‘community mental health’ and ‘public mental health’, (2) ‘human rights’ and ‘global mental health’, (3) ‘positive mental health’ and ‘resilience’, (4) ‘recovery’ and ‘mental health’, and (5) ‘natural selection’ and ‘evolutionary origins’ of ‘mental health’. Each of these five areas was assigned to an author with expertise in that area who then conducted a series of literature/internet searches using the key terms listed above. Proposed participants were identified based on their expert contributions, such as published papers, presentations, community outreach, and other evidence of work in their field that had implications for mental health. Each author presented their list to the research team which then narrowed the number to 5 per category for a total of 25 initial participants. An additional 31 individuals were added, which included people with lived experience of mental illness as well as the mentors of the Social Aetiology of Mental Illness (SAMI) Training Programme (funded by the Canadian Institutes of Health Research and includes a multidisciplinary group of experts with diverse interests, including biological, social and psychological sciences); all of these participants were identified through the SAMI/Centre for Addiction and Mental Health network. Fifty-six participants were sent the survey in the first round. Two subsequent rounds were completed using a snowballing technique: each person in round 1 was asked to indicate up to three other people they thought should receive the survey, which was then distributed to those identified individuals. This was repeated in round 2.

The ‘What is Mental Health?’ survey was created and distributed electronically using the SurveyMonkey platform. Respondents were asked to describe their areas of expertise, and list or describe the core concepts of mental health. Respondents ranked four definitions (without citations) of mental health 12 , 15 , 18 (McKenzie K. Community definition of Mental Health. What Is Mental Health Survey. Centre for Addiction and Mental Health, personal communication, 15 January 2014) and a fifth choice of ‘None of the existing definitions are satisfactory’ in order of preference (1=most preferred, 5=least preferred), and could rate multiple definitions as most and/or least preferred (see table 1 ). Respondents were asked to state, ‘What was missing and why?’ from these definitions.

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Current definitions of mental health and participant rank ordering from most to least preferred

Data analysis

Thematic analysis 19 was used to evaluate the core concepts of mental health, followed by triangulation (ie, multiple methods, analysts or theory/perspectives) to verify and validate the qualitative data analysis. 20

First, multiple analysts with knowledge from different disciplines reviewed the data. 20 Our collective areas of expertise encompass the following: animal models of human behaviour; arts; clinical, cognitive, political and social psychology; ecology; education; epidemiology; evolutionary theory; humanities; knowledge translation; measurement; molecular biology; neuroscience; occupational therapy; psychiatry; qualitative and quantitative research; social aetiology of mental illness; toxicology and transcultural health. All transcripts were reviewed by each coder first independently, then collectively, to become familiar with the data and create a mutually agreed on code book using NVivo 10. Codes were organised into themes, and compared and contrasted manually and through NVivo10 coding queries within each major theme and across response items. Initial models derived from the data were created and validated by the multidisciplinary research team.

Second, method triangulation was used to assess the consistency of our findings. 20 Preliminary results from the survey were presented and discussed at the 4th Annual Social Aetiology of Mental Illness Conference (20 May 2014) at the Centre for Addiction and Mental Health, University of Toronto (Toronto, Ontario, Canada). Attendees were divided into five focus groups of 10–12 people facilitated by a project leader and 2 trained note takers. The two consecutive 1 h focused discussions used the ORID method (Objective, Reflective, Interpretive and Decisional) 21 in order to elicit feedback on the methods and results of the survey. All responses from each of the five groups were transcribed by two recorders and disseminated to the research team for individual and collaborative review.

A second round of data analysis was conducted to validate the results according to key areas of interest and critique reported by the conference participants.

Survey respondents

Fifty-six surveys were distributed in the first round, 28 in the second and 38 in the third. Fifty people completed the survey (rounds 1, 2 and 3 had 32, 12 and 6 respondents, respectively) with a total response rate of 41%. Two-thirds of respondents (66%) were male and one-third were female (34%). Respondents’ current country of residence/employment included Canada (52%), UK (20%), USA (14%), Australia (6%), New Zealand (2%), Brazil (2%), South Africa (2%) and Togo (2%). The majority of respondents (72%) held academic positions at postsecondary institutions and were conducting research in the broad field of mental health. Sixty per cent were also involved in giving advice to mental health services or managing them. Thirty-four per cent of respondents were clinicians.

Survey items

Respondents had diverse expertise (see table 2 ). Forty-six per cent of respondents rated the Public Health Agency of Canada (PHAC) 18 definition as their most preferred. However, 30% stated that none were satisfactory. The WHO definition 12 was preferred by 20%. The least preferred definition of mental health was the general definition of health adapted from Huber et al 15 (see table 1 ).

Self-reported areas of expertise

Analysis of the three open-ended items established four major themes— Positionality, Social/Environmental Factors, Paradigms/Theories/Models and the Core Concepts of Mental Health —and five-directional relationships between them ( figure 1 ). Positionality represented the overarching perspective or point-of-reference from which the Core Concepts were derived; whereas Paradigms/Theories/Models represented the theoretical framework within which the Core Concepts were described. Core Concepts represented factors related to the individual; these were distinguishable from the Social/Environmental Factors related to society. Five significant relationships between these themes were established ( figure 1 ). First, respondents’ theoretical framework (Direction A) influenced the overarching point-of-reference they used to describe the core concepts and vice versa (Direction B). Positionality and Paradigms/Theories/Models significantly influenced the core concepts respondents provided and the corresponding descriptions (Direction C). Respondents described how social and environmental factors impacted the core concepts (Direction D) and reciprocally, how the core concepts could influence society (Direction E) ( tables 3 and 4 ). Feedback from the conference focus groups showed support for these five-directional relationships but questioned whether there was evidence for other direct relationships, specifically the impact of Social/Environmental Factors on both Paradigms/Theories/Models and Positionality . A second round of data analysis confirmed these relationships were not explicitly reported by respondents in the survey. Respondents did not discuss how social factors (ie, education or employment) would impact the adoption of a particular paradigm, theory or model (ie, quality of life, evolutionary theory or biomedical model).

Theme—Positionality

Theme—Core Concepts

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Themes of Positionality, Core Concepts, Social/Environmental Factors, and Paradigms/Theories/Models. *Indicates answers specifically from the third open-ended question asking respondents to state “what is missing” from the definitions provided for ranking.

The theme of Positionality demonstrated how respondents positioned their conceptualisations of mental health within an explicit or implicit framework of understanding ( table 3 , figures 2 and 3 ). Several respondents described the core concepts in terms of binary or conflicting dynamics or as categorical or continuous . Some respondents pointed to the mutual exclusivity of ‘mental health’ and ‘mental illness’ while others described these concepts as distinct points separated on a continuum or as overlapping. Respondents specified the complexity of mental health, for example, positioning mental health explicitly outside of, and specifically in between, the individual and society. Several respondents framed the core concepts of mental health as descriptive versus prescriptive , arguing that these must be empirically determined and defined (ie, describing what is ) rather than prescribed according to values and morals (ie, describing what should be ). In accordance with Hume's Law (ie, an ‘ought’ cannot be derived from an ‘is’), 22 several respondents cautioned that problems of living, such as ‘poverty, vices, social injustices and stupidity’, should not be defined ‘as medical problems’. Many respondents described mental health in relation to hierarchical levels , and/or temporal trajectories , and/or context ( table 3 , figure 3 ). Respondents articulated the multiple levels at which mental health can be understood (ie, from the basic unit of the gene, through the individual and up to the globe) and how meaning changes across time (ie, mental health described as functioning in line with our evolutionary ancestors, to current developmental mechanisms and including expectations of a peaceful death and spiritual existence) and across context (ie, from region, to race, to culture, to epistemology). In the second round of data analysis, we searched for bias in participants’ reporting of evidence-based models and bias against other sources of information; there was support for objective and subjective sources in conceptualising mental health.

Positionality. The overarching perspective or point-of-reference used to describe the constructs of mental health and illness.

Complexity. Descriptions of mental health in relation to hierarchical levels, and/or spatial directions, and/or temporal trajectories.

A second theme of Paradigms/Theories/Models developed as respondents discussed the need to perceive health through various frameworks (eg, recovery, resilience, human flourishing, quality of life, developmental and evolutionary theories, cultural psychiatry and ecology). Some respondents noted that current definitions of mental health treat problems of living as medical problems, rather than adaptive responses to the conditions that people experience, and that alternative explanations should be considered: “An evolutionary approach to these conditions suggests that anxiety and depression (as responses to social stressors) evolved to help the individual take corrective action that could ameliorate the negative effects of these stressors”. Some respondents emphasised that ‘low’ mental health did not equate to mental illness, but rather a state of hopelessness and lack of personal autonomy, whereas ‘high’ mental health was demonstrated by ‘meaningful participation, community citizenship, and life satisfaction’. Others referenced Westerhof and Keyes's 23 two-continuum model describing mental illness and mental health as related by two distinct dimensions.

The Core Concepts of mental health ( figure 1 , table 4 ) largely described factors relating to the individual—as opposed to society—that are observed in correlation with mental health and which are necessary, to some degree or another, but not normally sufficient on their own to achieve mental health. Concepts related to agency, autonomy and control appeared frequently in relation to an individual's ability or capacity to effectively deal with and/or create change in his or her environment (Directions D–E). Agency/autonomy/control reappeared as an essential component of other core concepts: agency may be required in order to engage in meaningful participation (eg, ‘sense of being part of a vibrant society, with agency to make change for you and others, and supportive relationships and governance’) and in dignity (eg, ‘a state of mind that allows one to lead one's life knowing that one’s dignity and integrity as a human being is respected by others’). A cluster of concepts describing the self signified (1) the subjective experience of the individual as fundamental to well-being and (2) the importance of one's ability, confidence and desire to live in accordance with one's own values and beliefs in moving towards the fulfilment of one's goals and ambitions ( figure 1 ).

Social and Environmental Factors reflected the societal factors external to the individual that affect mental health. Although many respondents listed the basic necessities for general health/mental health (eg, housing, food security, access to health services, equitable access to public resources, childcare, education, transportation, support for families, respect for diversity, opportunities for building resilience, self-esteem, personal and social efficacy, growth, meaning and purpose, and sense of safety and belonging, and employment), some also recommended approaches to achieving social equity (eg, “mental health needs to be protected by applying antiracism, antioppression, antidiscrimination lens to prevention and treatment”) ( figure 1 , Direction D). A distinct category of human rights developed from responses to the third open-ended question (eg, “What is missing?”) ( figure 1 ). Several respondents suggested that a basic standard, analogous to a legal definition, is required ( table 3 ) and/or that “a human rights, political, economic and ecosystem perspective” should be included.

The international exploratory ‘What is Mental Health?’ survey sought the opinions of individuals, across multiple modes of inquiry, on what they perceived to be the core concepts of mental health. The survey found dissatisfaction with current definitions of mental health. There was no consensus among this group on a common definition. However, there was significant agreement among subcomponents of the definitions, specifically factors beyond the ‘ability to adapt and self-manage’, such as ‘diversity and community identity’ and creating distinct definitions, “one for individual and a parallel for community and society.” The Core Concepts of mental health that participants identified were predominantly centred on factors relating to the individual, and one's capacity and ability for choice in interacting with society. The concepts of agency, autonomy and control were commonly mentioned throughout the responses, specifically in regard to the individual's ability or capacity to effectively deal with and/or create change in his or her environment. Similarly, respondents pointed to the self as an essential component of mental health, signifying the subjective experience of the individual as fundamental to well-being, particularly in relationship to achieving one's valued goals. Respondents suggested that mentally healthy individuals are socially connected through meaningful participation in valued roles (ie, in family, work, worship, etc), but that mental health may involve being able to disconnect by choice, as opposed to being excluded (eg, having the capacity and ability to reject social, legal and theological practices). In contrast, Social and Environmental Factors reflected respondents’ emphasis on factors that are external to the individual and which can influence the core concepts of mental health. Many respondents reiterated the basic necessities for general health/mental health, similar to the foundations of Maslow's hierarchy of needs, 24 and their recommendations for achieving social equity.

Descriptions of the core concepts of mental health were highly influenced by respondents’ Positionality and Paradigms/Theories/Models of reference, which often propelled the discourse of “What is mental health?” in opposing directions. The debate as to whether mental health and illness are distinct constructs, or points of reference on a continuum of being, was a common theme. Respondents were either, adamant in asserting the distinction between the descriptive or prescriptive nature of the core concepts, or, ardent in integrating them, producing ideas such as describing mental health as a life free of poverty, discrimination, oppression, human rights violations and war. Respondents’ made repeated references to human rights, suggesting that a basic standard, analogous to a legal definition, is required, and that ‘a human rights, political, economic and ecosystem perspective’ should be included. Again, in the tradition of Hume's ‘ought–is’ distinction, several respondents cautioned that problems of living, such as ‘poverty, vices and social injustices…’ should not be defined ‘as medical problems’. The significance of this issue cannot be understated: while we asked respondents what the core concepts of mental health are , overwhelmingly they answered in terms of what they should be. This finding is similar to other issues in public health policy that address instances of ‘conflating scientific evidence with moral argument’. 15 , 22 Indeed, a primary criticism of the WHO definition of health is that its declaration of “complete physical, mental, and social wellbeing” 6 is prescriptive rather than descriptive. 15 Such a definition “contributes to the medicalization of society” and excludes most people, most of the time, and has little practical value “because ‘complete’ is neither operational nor measurable.” 15

Accordingly, we propose a transdomain model of health ( figure 4 ) to inform the development of a comprehensive definition for all aspects of health. This model builds on the three domains of health as described by WHO 6 , 12 and Huber et al, 15 and expands these definitions to include four specific overlapping areas and the empirical, moral and legal considerations discussed in the current study. First, all three domains of health should have a basic legal standard of functioning and adaptation. Our findings suggest that for physical health, a standard level of biological functioning and adaptation would include allostasis (ie, homeostatic maintenance in response to stress), whereas for mental health, a standard level of cognitive–emotional functioning and adaptation would include sense of coherence (ie, subjective experience of understanding and managing stressors), similar to Huber et al 's 15 proposal. However, for social health, a standard level of interpersonal functioning and adaptation would include interdependence (ie, mutual reliance on, and responsibility to, others within society), rather than Huber et al 's 15 focus on social participation (ie, balancing social and environmental challenges). Our results provide further insight into how these domains interact to affect overall quality of life. Integration of mental and physical health can be defined by level of autonomy (ie, the capacity for control over one's self), whereas integration of mental and social health can be defined by a sense of ‘us’ (ie, capacity for relating to others); the integration of mental and physical health can be defined by control (ie, capacity for navigating social spaces). The highest degree of integration would be defined by agency , the ability to choose one's level of social participation (eg, to accept, reject or change social, legal or theological practices). Such a transdomain model of health could be useful in developing cross-cultural definitions of physical, social and mental health that are both inclusive and empirically valid. For example, Valliant's 25 seven models for conceptualizing mental health across cultures are all represented, to varying degrees, within the proposed transdomain model of health . The basic standard of functioning across domains which is proposed here is congruent with Valliant's 25 criteria for mental health to be ‘conceptualised as above normal’ and defined in terms of ‘multiple human strengths rather than the absence of weaknesses’, including maturity, resilience, positive emotionality and subjective well-being. In addition, Valliant's 25 conceptualisation of mental health as ‘high socio-emotional intelligence’ is also represented in the transdomain model's highest level of integration of the three areas for full individual autonomy. Finally, Valliant's 25 cautions for defining positive mental health—being culturally sensitive, recognising that population averages do not equate to individual normalcy and that state and trait functioning may overlap, and contextualising mental health in terms of overall health—are all addressed within the transdomain model .

Transdomain Model of Health. This model builds on the three domains of health as described by WHO 6 , 12 and Huber et al 15 and expands these definitions to include four specific overlapping areas and the empirical, moral, and legal considerations discussed in the current study. There are three domains of health (ie, physical, mental, and social), each of which would be defined in terms of a basic (human rights) standard of functioning and adaptation . There are four dynamic areas of integration or synergy between domains and examples of how the core concepts of mental health could be used to define them.

Strengths and limitations of the current study

We are unaware of any study to date that has asked this research question to a group of international experts in the broad field of mental health. Although our survey sample was small (N=50), it was diverse with regard to place of origin and expertise; it was also further validated by participants (N=58) at a day-long conference on mental health through discussion, debate and written responses. The current study included global experts who dedicate their research and professional lives to advancing the standards of mental health. Of particular note was that little to no consensus among the selected group of experts on any particular definition was found. In fact, this was simultaneously a limitation and strength of the study: the small sample size limited the scope of the core concepts of mental health, but indicated that it was sufficient to demonstrate that there are highly divergent definitions that are largely dependent on the respondents’ frame of reference. It is possible that saturation was not achieved in regards to the diversity of responses. Further, more than half of the survey respondents were from Canada, which may have influenced the preference towards the PHAC definition of mental health. Although there were advantages to using a snowball sampling method, another type of sampling method (eg, cluster sampling, stratified sampling) may have resulted in more varied responses to the survey items. The next logical step would be to survey experts in countries currently not represented and then ultimately survey members of the general public with regard to their conceptual and pragmatic understanding of mental health. One of the a priori objectives for the survey was to eventually create a consensus definition of mental health that could be used in public policy; this objective was not communicated in the survey, nor did we actually ask this question. Our results indicate that finding consensus on a definition of mental health will require much more convergence in the frame of reference and common language describing components of mental health. Even we, as authors, have been challenged by consensus. For example, some of us wish to emphasise that future work should focus on developing an operational definition that can be applied across disciplines and cultures. Others among us suggest further exploring what purpose a definition of mental health would or should serve, and why. In contrast, others among us wish to emphasise the process of conceptualising mental health versus the outcome or application of such a definition. What we hoped would be a straightforward, simple question, designed to create consensus for a definition of mental health, ultimately demonstrated the nuanced but crucial epistemological and empirical influences on the understanding of mental health. Based on the results of the survey and conference, we present a preliminary model for conceptualising mental health. Our study provides evidence that if we are to try to come to a common consensus on a definition of mental health, we will need to understand the frame of reference of those involved and try to parse out the paradigms, positionality and the social/environmental factors that are offered from the core concepts we make seek to describe. Future work may also need to distinguish between the scientific evidence of mental health and the arguments for mental health . Similar debates in bioethics 22 , 26–28 demonstrate the theoretical and practical limitations of science for proscribing human behaviour, especially with regard to individual freedom and social justice.

Conclusions

Our results suggest that any practical use of a definition of health will depend on the epistemological and moral framework through which it was developed, and that the mental and social domains may be differentially influenced than the physical domain. A definition of health, grounded solely in biology, may be more applicable across diverse populations. A definition of health encompassing the mental and social domains may vary more in application, particularly across systems, cultures or clinical practices that differ in values (eg, spiritual, religious) and ways of understanding and being (eg, epistemology). A universal (global) definition based on the physical domain could be parsed out separately from several unique (local) definitions based on the mental and social domains. Understanding the history and evolution of the concept of mental health is essential to understanding the problems it was intended to solve, and what it may be used for in the future.

Acknowledgments

The authors wish to extend their gratitude to their colleagues for their generous feedback, constructive critiques and recommendations for the project, and to the many volunteers who organised the conference. Special thanks to Nina Flora, Helen Thang, Andrew Tuck, Athena Madan, David Wiljer, Alex Jadad, Sean Kidd, Andrea Cortinois, Heather Bullock, Mehek Chaudhry and Anika Maraj.

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Contributors All the authors contributed to the conceptualisation of the project. LAM wrote the manuscript. SB, KR, ZD, CL and KM contributed to the content and editing of the manuscript. LAM, SB, KR, ZD, CL and EW created the survey and conducted data analyses. SB, KR and LAM presented findings at the conference. LAM, SB, KR, ZD and EW led the focused discussion groups. KM supervised the project. LM is the guarantor.

Funding This work was performed with grants from the Canadian Institutes of Health Research (CIHR) for the Social Aetiology of Mental Illness Training Program at the Centre for Addiction and Mental Health.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional are data available.

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  • Patient Care & Health Information
  • Diseases & Conditions
  • Mental illness

Mental illness, also called mental health disorders, refers to a wide range of mental health conditions — disorders that affect your mood, thinking and behavior. Examples of mental illness include depression, anxiety disorders, schizophrenia, eating disorders and addictive behaviors.

Many people have mental health concerns from time to time. But a mental health concern becomes a mental illness when ongoing signs and symptoms cause frequent stress and affect your ability to function.

A mental illness can make you miserable and can cause problems in your daily life, such as at school or work or in relationships. In most cases, symptoms can be managed with a combination of medications and talk therapy (psychotherapy).

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Signs and symptoms of mental illness can vary, depending on the disorder, circumstances and other factors. Mental illness symptoms can affect emotions, thoughts and behaviors.

Examples of signs and symptoms include:

  • Feeling sad or down
  • Confused thinking or reduced ability to concentrate
  • Excessive fears or worries, or extreme feelings of guilt
  • Extreme mood changes of highs and lows
  • Withdrawal from friends and activities
  • Significant tiredness, low energy or problems sleeping
  • Detachment from reality (delusions), paranoia or hallucinations
  • Inability to cope with daily problems or stress
  • Trouble understanding and relating to situations and to people
  • Problems with alcohol or drug use
  • Major changes in eating habits
  • Sex drive changes
  • Excessive anger, hostility or violence
  • Suicidal thinking

Sometimes symptoms of a mental health disorder appear as physical problems, such as stomach pain, back pain, headaches, or other unexplained aches and pains.

When to see a doctor

If you have any signs or symptoms of a mental illness, see your primary care provider or a mental health professional. Most mental illnesses don't improve on their own, and if untreated, a mental illness may get worse over time and cause serious problems.

If you have suicidal thoughts

Suicidal thoughts and behavior are common with some mental illnesses. If you think you may hurt yourself or attempt suicide, get help right away:

  • Call 911 or your local emergency number immediately.
  • Call your mental health specialist.
  • Contact a suicide hotline. In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline , available 24 hours a day, seven days a week. Or use the Lifeline Chat . Services are free and confidential.
  • Seek help from your primary care provider.
  • Reach out to a close friend or loved one.
  • Contact a minister, spiritual leader or someone else in your faith community.

Suicidal thinking doesn't get better on its own — so get help.

Helping a loved one

If your loved one shows signs of mental illness, have an open and honest discussion with him or her about your concerns. You may not be able to force someone to get professional care, but you can offer encouragement and support. You can also help your loved one find a qualified mental health professional and make an appointment. You may even be able to go along to the appointment.

If your loved one has done self-harm or is considering doing so, take the person to the hospital or call for emergency help.

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Mental illnesses, in general, are thought to be caused by a variety of genetic and environmental factors:

  • Inherited traits. Mental illness is more common in people whose blood relatives also have a mental illness. Certain genes may increase your risk of developing a mental illness, and your life situation may trigger it.
  • Environmental exposures before birth. Exposure to environmental stressors, inflammatory conditions, toxins, alcohol or drugs while in the womb can sometimes be linked to mental illness.
  • Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that carry signals to other parts of your brain and body. When the neural networks involving these chemicals are impaired, the function of nerve receptors and nerve systems change, leading to depression and other emotional disorders.

Risk factors

Certain factors may increase your risk of developing a mental illness, including:

  • A history of mental illness in a blood relative, such as a parent or sibling
  • Stressful life situations, such as financial problems, a loved one's death or a divorce
  • An ongoing (chronic) medical condition, such as diabetes
  • Brain damage as a result of a serious injury (traumatic brain injury), such as a violent blow to the head
  • Traumatic experiences, such as military combat or assault
  • Use of alcohol or recreational drugs
  • A childhood history of abuse or neglect
  • Few friends or few healthy relationships
  • A previous mental illness

Mental illness is common. About 1 in 5 adults has a mental illness in any given year. Mental illness can begin at any age, from childhood through later adult years, but most cases begin earlier in life.

The effects of mental illness can be temporary or long lasting. You also can have more than one mental health disorder at the same time. For example, you may have depression and a substance use disorder.

Complications

Mental illness is a leading cause of disability. Untreated mental illness can cause severe emotional, behavioral and physical health problems. Complications sometimes linked to mental illness include:

  • Unhappiness and decreased enjoyment of life
  • Family conflicts
  • Relationship difficulties
  • Social isolation
  • Problems with tobacco, alcohol and other drugs
  • Missed work or school, or other problems related to work or school
  • Legal and financial problems
  • Poverty and homelessness
  • Self-harm and harm to others, including suicide or homicide
  • Weakened immune system, so your body has a hard time resisting infections
  • Heart disease and other medical conditions

There's no sure way to prevent mental illness. However, if you have a mental illness, taking steps to control stress, to increase your resilience and to boost low self-esteem may help keep your symptoms under control. Follow these steps:

  • Pay attention to warning signs. Work with your doctor or therapist to learn what might trigger your symptoms. Make a plan so that you know what to do if symptoms return. Contact your doctor or therapist if you notice any changes in symptoms or how you feel. Consider involving family members or friends to watch for warning signs.
  • Get routine medical care. Don't neglect checkups or skip visits to your primary care provider, especially if you aren't feeling well. You may have a new health problem that needs to be treated, or you may be experiencing side effects of medication.
  • Get help when you need it. Mental health conditions can be harder to treat if you wait until symptoms get bad. Long-term maintenance treatment also may help prevent a relapse of symptoms.
  • Take good care of yourself. Sufficient sleep, healthy eating and regular physical activity are important. Try to maintain a regular schedule. Talk to your primary care provider if you have trouble sleeping or if you have questions about diet and physical activity.
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  • Dual diagnosis. National Alliance on Mental Illness. https://www.nami.org/Learn-More/Mental-Health-Conditions/Related-Conditions/Dual-Diagnosis. Accessed April 8, 2019.
  • Practice Guidelines for the Psychiatric Evaluation of Adults. 3rd ed. Arlington, Va.: American Psychiatric Association; 2013. http://psychiatryonline.org. Accessed April 1, 2019.
  • Understanding psychotherapy and how it works. American Psychological Association. https://www.apa.org/helpcenter/understanding-psychotherapy. Accessed April 1, 2019.
  • Asher GN, et al. Complementary therapies for mental health disorders. Medical Clinics of North America. 2017;101:847.
  • Complementary health approaches. National Alliance on Mental Illness. https://www.nami.org/Learn-More/Treatment/Complementary-Health-Approaches. Accessed April 4, 2019.
  • Warning signs of mental illness. American Psychiatric Association. https://www.psychiatry.org/patients-families/warning-signs-of-mental-illness. Accessed April 4, 2019.
  • Helping a loved one cope with mental illness. American Psychiatric Association. https://www.psychiatry.org/patients-families/helping-a-loved-one-cope-with-a-mental-illness. Accessed April 4, 2019.
  • What is mental illness? American Psychiatric Association. https://www.psychiatry.org/patients-families/what-is-mental-illness. Accessed April 4, 2019.
  • For friends and family members. MentalHealth.gov. https://www.mentalhealth.gov/talk/friends-family-members. Accessed April 4, 2019.
  • For people with mental health problems. MentalHealth.gov. https://www.mentalhealth.gov/talk/people-mental-health-problems. Accessed April 4, 2019.
  • Brain stimulation therapies. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml. Accessed April 4, 2019.
  • Mental health medications. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml. Accessed April 4, 2019.
  • Psychotherapies. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/psychotherapies/index.shtml. Accessed April 4, 2019.
  • Muesham D, et al. The embodied mind: A review on functional genomic and neurological correlates of mind-body therapies. Neuroscience and Biobehavioral Reviews. 2017;73:165.
  • Suicide in America: Frequently asked questions. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/suicide-faq/index.shtml. Accessed April 10, 2019.
  • Types of mental health professionals. National Alliance on Mental Illness. https://www.nami.org/Learn-More/Treatment/Types-of-Mental-Health-Professionals. Accessed April 8, 2019.
  • Risk and protective factors. Substance Abuse and Mental Health Services Administration. Accessed April 8, 2019.
  • Newman L, et al. Early origins of mental disorder — Risk factors in the perinatal and infant period. BMC Psychiatry. 2016;16:270.
  • Treatment settings. National Alliance on Mental Illness. https://www.nami.org/Learn-More/Treatment/Treatment-Settings. Accessed April 10, 2019.
  • Hall-Flavin DK (expert opinion). Mayo Clinic, Rochester, Minn. May 18, 2019.
  • Intervention: Help a loved one overcome addiction
  • Mental health providers: Tips on finding one
  • Mental health: Overcoming the stigma of mental illness

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Matter over mind: How mental health symptom presentations shape diagnostic outcomes

Mental health disorders face less stigma today than in the past, yet they continue to be misdiagnosed and at times improperly treated. One account for this problem is that physicians rely exclusively on a verbal interview of patients for diagnosis. Because this diagnostic method is likely to be shaped by the way patients present their symptoms, it is critical that we examine whether and how patients’ communication practices shape diagnostic and treatment outcomes. This study examines a sample of 14 encounters involving mental health-related symptoms from a dataset of adult primary care visits. Using conversation analytic methods, I show that when patients present mental health symptoms by simply describing the symptoms, primary care physicians exhibit a preference for providing a physical health diagnosis. Conversely, when patients provide a concrete link between their symptoms and the way the symptoms are disrupting their everyday lives, primary care physicians typically provide a mental health diagnosis.

Introduction

Studies have focused on the stigmatization of mental illness since the mid-twentieth century ( Goffman, 1963 ; Link and Phelan, 2001 ; Martin et al., 2007 ). The stigma associated with mental illness has remained largely unchanged despite its increasing awareness due to more research, public campaigns, and mental health education ( Phelan and Link, 1998 ). Attitudes toward mental illness continue to engender negative stereotypes and discrimination ( Phelan, 2005 ). However, evidence points to some improvement in perceptions of mental illness. The public’s orientation to mental illness has become more tolerant ( Phelan et al., 2000 ). Furthermore, those with mental health symptoms are seeking treatment more frequently ( Kessler et al., 1999 ). Research has reported that when patients seek care for mental health issues, they do so largely from their primary care provider (PCP) ( Wang et al., 2006 ).

Despite this increase in help-seeking for mental health concerns, there still appears to be bias against diagnosing mental health disorders as current estimates suggest that the majority of those with mental health issues remain untreated ( Boyer and Lutfey, 2010 ). Conversely, there is another complication to the treatment of mental health disorders which is a concern that they are actually over-pathologized and over-diagnosed ( Kutchins and Kirk, 1997 ). Why are these medical issues the subject of such fraught treatment perspectives? This article suggests that the answer to this question lies in the moment-to-moment interaction between PCPs and patients. Specifically, the way patients characterize their mental health symptoms to their PCPs can condition how PCPs take up and treat those symptoms as indicative of a mental health disorder or not. At the same time, the way that patients talk about their symptoms with their PCP will likely be complicated by the stigma associated with mental health disorders.

This pilot study investigates the ways patients present their mental health-related symptoms and the relationship between patient symptom presentations and physician orientation to those symptoms in diagnosis. I show that PCPs are biased against mental health diagnoses and treat mental health symptoms only in contexts where patients go beyond a basic presentation of symptoms to show that their lifeworld ( Mishler, 1984 ) has been disrupted. This is true even when the symptoms being presented are essentially the same.

Diagnosing mental health problems in primary care

Longitudinal data suggest that most people experiencing mental health issues are not receiving treatment for their symptoms despite an increase in help-seeking for such problems ( Kessler et al., 2005 ). Most individuals in the USA who pursue help do so in primary care rather than seeking out a specialist for treatment. This is thought to be because patients feel more comfortable communicating to a provider with whom they have a relationship ( Glazier et al., 2015 ). However, there may also be structural bases for this, such as insurance requirements that primary care physicians serve as gatekeepers to specialty care including mental healthcare ( Forrest, 2003 ). Overall, the literature suggests that mental illness remains undertreated despite increased visits for related symptoms, which demonstrates evidence for an institutional bias against diagnosing and treating mental illness.

Yet, studies document both underdiagnosis and overdiagnosis of mental illnesses. Kutchins and Kirk (1997) argue that changing requirements of treatments reimbursable by health insurance companies have caused physicians to inappropriately diagnose their patients with a mental illness for compensation. Others argue that mental health diagnosis categories are too broad, therefore physicians too frequently diagnose mental illness and overprescribe ( Dowrick and Frances, 2013 ). Many critics blame the drug industry for promoting the medicalization of emotions and thus the overdiagnosis of mental illness ( Horwitz and Wakefield, 2007 ; Karp, 2009 ). Overdiagnosis is particularly problematic because medications indicated for treatment of mental health problems can have adverse consequences including drug dependency, more severe mental health symptoms, and suicide ( Bezchlibnyk-Butler et al., 2013 ; Karp, 2009 ).

However, underdiagnosis is also problematic leading to improper treatment of depressive and anxiety disorders ( Bet et al., 2013 ). Researchers have called for interventions to improve detection and treatment in specific medical settings ( Gilbody et al., 2003 ), and underscore that while major depression is often properly diagnosed and treated, moderate depression or anxiety are underdiagnosed and under treated ( Kroenke et al., 2007 ; Thompson et al., 2001 ).

The complexity of diagnosing mental health problems

One account for how mental health symptoms can be both over and under-diagnosed is that the mental health diagnostic process is particularly multifaceted with opaque boundaries and contingencies. This complexity contradicts the straightforward guidelines for primary care treatment of problems like depression, which follow a biomedical treatment model comprised of psychotropic drug prescription and referral to a mental health specialist ( Gelenberg, 2010 ). Some have argued that this “one size fits all” approach is inappropriate for primary care patients in particular, who present with an array of symptoms that do not necessarily fit within the biomedical treatment model ( Nutting et al., 2002 ). Different from other medical issues which include clear signs that physicians can see, hear, or feel, the detection and treatment of mental health problems are entirely reliant on information patients provide, and this information is conditioned by the physicians’ diagnostic interview. This context may make for a ripe environment for doctor–patient inter- action in shaping diagnostic outcomes.

Previous research suggests that patients’ behavior in the medical encounter can shape both the diagnosis and treatment of medical issues. In studying pediatric acute care, Stivers (2002) found that the ways parents presented their children’s symptoms had direct implications for physician uptake of those symptoms—what Stivers terms symptoms-only and candidate diagnosis presentations. While the former lists just the symptoms (e.g. “She has a scratchy throat”), the latter includes a suspected diagnosis (e.g. “We think she has strep because she has a fever and a scratchy throat”). When examining physician uptake of each presentation type, Stivers established that following a symptoms-only presentation, physicians simply moved to investigate the problem further, while following a candidate diagnosis presentation, physicians moved to either confirm—or disconfirm—the existence of the diagnosis proposed by the family.

Other research also suggests that how patients communicate can shape outcomes. A randomized controlled trial conducted by Kravitz et al. (2005) using standardized patients found that the ways in which patients with mental health symptoms requested psychotropic drugs (no request for medication vs general request for medication vs specific brand request) shaped how physicians treated their symptoms. Patients who made either a general request or a brand-specific request for medication received a psychotropic drug prescription and/or referral to a mental health specialist significantly more frequently than those who provided just their symptoms but no medication request. An exploratory investigation into decision-making for depression treatment in primary care found that patients who presented their symptoms in line with diagnostic criteria received prescriptions for antidepressants, while patients who presented their symptoms as the result of a situational problem were unlikely to receive such a remedy ( Karasz et al., 2012 )

Studies point to several reasons why presented symptoms may not be properly addressed in the physician-patient encounter. Some findings demonstrate that in contrast with a clear symptom presentation at the outset of the primary care visit, failure to topicalize all symptoms related to all medical concerns early in the visit is associated with the symptoms being less likely to be properly taken up (see Robinson, 2003 ). This has implications for proper diagnosis and treatment of the problem. Moreover, some believe that primary care physicians are over diagnosing mental health problems while others believe there is an underdiagnosis problem. Others point to constraining diagnostic guidelines which shift PCP’s orientations toward diagnosing and treating depressive disorders involving a particular set of symptoms ( Karasz et al., 2012 ). Despite work thus far, it is still unclear what in the interactional machinery of these visits leads some studies to arrive at different conclusions about the outcome of primary care visits that treat mental health-related symptoms. I propose a conversation analytic (CA) pilot investigation of the moment-to-moment interactional practices of US patients and their PCPs, specifically exploring how patients present mental health-related symptoms and whether this impacts subsequent diagnoses.

The data used for this investigation are video-recorded US adult acute primary care visits from clinics in Southern California collected from 1997 to 2004. Study procedures were approved by the institutional review board (IRB). All participants provided written informed consent. A corpus of 240 encounters was examined for inclusion of mental health-related symptoms in the encounter. Surprisingly, just fourteen cases were identified in which the patient discussed mental health-related symptoms. Thus, this study acts as a pilot investigation of the phenomenon. Inclusion criteria were determined based on the symptoms indicated in the Mental Health Inventory ( Hays, 1994 ). The Mental Health Inventory (MHI) is a 38-item survey from core measures of emotional well-being from the Medical Outcomes Study. Patients who mentioned one or more of the adverse symptoms as indicated on the MHI during their visit met inclusion criteria.

Each visit was manually transcribed by the author using standard CA conventions and notations as detailed in Hepburn and Bolden (2012) . These notations are crucial for understanding not only what participants said, but how they said it. Data analysis was guided by CA practices (see Heritage, 1984 ; Sidnell and Stivers, 2012 ). The CA approach to studying medical interaction hinges on the idea that the medical encounter involves commonsense reasoning (see Garfinkel, 1967 ) and a distinct interaction order (see Goffman, 1983 ). CA offers a novel and important lens through which the interaction order plays out in medicine and how physicians and patients work to co-construct a medical visit ( Heritage and Maynard, 2006 ). Through CA’s implementation, patterns in clinical interactions are evaluated turn-by-turn which can then be shown to be ordered and systematic in usage within and across medical contexts, known as a conversational practice. Such conversational practices are meaningful on an institutional level because interactions are couched in larger activities and end-goals to which the institutional figures are oriented ( Drew and Heritage, 1992 ).

Patient presentations of mental health concerns

I am concerned with the ways in which patients characterize symptoms that may indicate a mental health disorder. Drawing on Stivers’ aforementioned work on problem presentations, I reviewed data for any consistent pattern in symptom presentation. What emerged was a two-way distinction between “symptoms-only” presentations as Stivers identified and presentations that provided an additional causal link between mental health-related symptoms and an everyday life disruption (e.g. “I can’t do household chores because I’m so anxious”). I identify the latter as “Lifeworld Disruption” presentations. Although the actual symptoms presented are nearly identical in both presentation types, the different presentation formats lead to distinct diagnostic outcomes. I examine how these different problem presentations affect the way physicians diagnose and treat this information in clinical interactions.

Symptoms-only problem presentations

In 57% (n = 8) of cases in the sample, patients presented symptoms related to a mental health concern and nothing more. An instance of this is shown in Extract 1. At the beginning of the visit, this patient believes something is not right with him. At the outset of his turn in Extract 1a, it is unclear whether he is moving into the territory of mental health as he speaks about his family’s diabetic history and his own symptoms, which he thinks may be related. He discusses family members who have had complications with diabetes and that he feels like “something is going do:wn” on him (line 04). He analogizes this feeling to how he feels on an empty stomach (line 06):

After more narrative about a feeling that he cannot quite describe, the patient becomes more concrete in Extract 1b by referencing a feeling similar to tension or nerves (lines 01–02):

The patient equates his feelings with tension or nervousness in lines 01–02, “It’s it’s: (.) kind of uhm like uh (0.2) when you’re tense or ner- nerv- in my nerves” which signals a relationship to a mental health issue. The patient’s first mention of depression in lines 03–04 seems to be related to the weather outside, as the patient points to the window when saying “ days like this de press me.” Next the patient mitigates his prior assertion of depression by questioning his feelings in lines 04–05, “ why do I feel de pression if I gotta nice family,.” He continues to provide evidence of discomfort (lines 05–06): “I feel uncomfortable mayn it’s something weird that I’ve never felt befo:re.” which is a nebulous description of his symptoms. In this presentation, he outlines symptoms of nervousness, tension, discomfort, and depression on certain days. However, he does not link these symptoms to disrupting his everyday life.

In this example, we see that one way patients present mental health problems is to describe just symptoms. These symptoms-only presentations allow for the possibility that there could be a physical health diagnosis or that the symptoms are not in need of immediate treatment. This problem presentation type contrasts with one that includes the provision of a causal link between mental health symptoms and a disruption to the patient’s lifeworld.

Lifeworld disruption problem presentations

Here, I examine problem presentations involving mental health symptoms that are causally linked to concrete lifeworld disruptions. When patients do this, they treat the problem as in need of immediate treatment. In Extract 2, the interaction begins with an understanding by both physician and patient that something bad happened the day before. What that is, however, we do not initially see. Instead, the patient discusses stress and provides situational evidence as causation in Extract 2a:

The mutual understanding between physician and patient that something has happened is indicated in the first exchange. When the physician walks in and asks, “How are you doing?” (line 01) he indexes knowledge of some already known medical issue ( Coupland et al., 1994 ). It is clear from the patient’s response, “I’m much better toda:y than yesterday,” (line 02) that she orients to this question as a reference to medical business to be covered ( Heritage and Robinson, 2006 ). Next the physician asks, “Wha- .hh what happened yesterday” (line 05). Rather than responding to this, the patient indicates that she has difficulty falling asleep, attributes this to her experiencing stress, and discusses situational instances– her mother’s health– that she interprets as causing her stress. At this point, the presentation is a symptoms-only presentation.

Subsequently, the physician asks whether this occasioned her recent visit to the emergency room (line 01), thus requesting confirmation of an implicit causal link between the mental health symptoms and emergency room visit. The patient does not provide this link initially:

In lines 04–05, the patient offers a pre-announcement ( Terasaki, 2004 ) to the doctor about the nature of her high blood pressure, and in lines 09–10 this is expanded, specifically that the blood pressure continued to increase which caused her to panic. So far, this patient has described her mental health-related symptoms and indicated that she visited the emergency room but she has not made an explicit link between her symptoms and the lifeworld disruption. This comes in Extract 2c:

In lines 03, 08, and 10, the patient causally links her symptoms to a lifeworld disruption, that she called her physician’s emergency number because she was “just too afraid” about her increasing blood pressure.

While symptoms-only presentations include symptoms of feeling unusual, depressed, or down without provision of a causal link to a lifeworld disruption, these problem presentation types contrast with those that do provide the addition of a causal link between mental health symptoms and a disruption to the patient’s lifeworld. These latter presentations reflect a patient orientation toward a problem in need of treatment, which contrasts with how symptoms only presentations are made even though actual symptoms are effectively the same. The question to which I now turn is whether the design of the problem presentation conditions physician response.

Physician uptake of mental health concerns

The two presentation practices employed by patients–symptoms-only and lifeworld disruption— have consequences for physician response. In this section, I show that questions pursued by physicians are implicitly biased and move toward different diagnostic trajectories depending on the problem presentation. Specifically, following symptoms-only presentations physicians primarily pursue physical health diagnoses, while in the context of lifeworld disruption presentations physicians primarily pursue mental health diagnoses. This result suggests that amid nearly identical symptoms, physicians generally show bias toward physical health diagnoses when only mental health symptoms are presented, but once patients provide the addition of a causal link between their symptoms and a lifeworld disruption, physicians orient to the symptoms as indicative of a mental health problem.

The symptoms-only context: setting aside a mental health diagnosis

A primary way that physicians show a bias toward a physical health diagnosis in the symptoms-only context is to directly acknowledge a patient’s mental health issue but then set it aside in favor of the physical health issue. This is illustrated in Extract 3. The patient presents with cold symptoms and then suggests that there may be a connection between depression and the colds she has been getting (lines 01–02). This presentation is symptoms-only:

Following a question that receives no uptake by the physician in lines 01–02, the patient provides an account for her question (lines 04–07). Here, she collateralizes her suspicion of depression symptoms with situational evidence. The core of this interaction unfolds in line 09, where the physician makes an assessment about the patient’s appearance, “= You don’t look depressed but you feel sad all the time or,=.” In telling the patient that she does not physically look depressed, this physician counters the patient’s implied diagnosis. However, in the same turn, this physician asks a polar question which is biased toward a mental health problem (see Heritage, 2010 ): “but d’you feel sad all the time or,=“ (line 09). Yet, because the physician in his professional opinion has communicated a clear stance that the patient does not look depressed prior to asking about her feeling sad, based on his assessment we might assume that she would minimize any response about feeling sad moving forward in her symptom narrative.

Following this sequence, the patient continues with opaque symptoms of feeling “blue” and tired in the mornings, which get no uptake. After the patient has completed her narrative, the physician offers a still stronger counter-diagnosis of no depression:

In this extract, the physician shuts down potentially more discussion about the patient’s symptoms as related to depression. In lines 01–02, his diagnosis that the patient is not depressed is done under the guise of answering the patient’s question from (3a): whether depression can cause colds. In the next few lines of talk, he states that should she present with sadness, no desire to have fun, the inability to sleep, and frequent crying— in that case, he would consider a depression diagnosis. When, in lines 13–14, she says “Okay no I’m pretty much up for doing anything .hh if something comes up,” he responds with an assessment, “Good” in line 17 and then discusses treatment of her fatigue and cold symptoms.

This physician sets aside the issue of depression because he briefly inquires about the depression in line 09 of Extract 3a following her initial suggestion that depression may be the cause of her colds, “= You don’t look depr e ssed but d’you feel sad all the time or,=,” yet pursues a physical health diagnosis in line 17 when he recommends more exercise. The patient could have further pushed the issue of her symptoms or been prompted to be clearer had the physician moved toward a mental health concern. Instead, she did not orient to her mental health concerns as problematic because her physician dismissed those concerns. This physician moves toward a physical health diagnosis, yet here he acknowledges and sets the potential mental health diagnosis aside in favor of a physical health one. Like in Extract 1 of the previous section, we see depression symptoms being described but without a concrete provision linking these symptoms to disrupting the patient’s lifeworld. Notably, the patient provides information about her lifeworld as a potential cause for these symptoms but does not causally link these symptoms to a disruption in her lifeworld.

In this case shown, the patient uses a symptoms-only mental health problem presentation. In this type of presentation, once patients provide mental health-related symptoms that could be taken up by physicians as indicative of a mental health issue, physicians in these data instead move toward physical health diagnoses by setting aside mental health- related diagnoses. This is done via tilting questions to a physical health diagnosis by being problem-attentive ( Stivers, 2007 ) toward a physical ailment. Although this is a small dataset, this pattern is consistent.

The lifeworld disruption context: physician uptake of mental health symptoms

When patients include a causal link to a lifeworld disruption, physicians are more likely to orient to the problem as a mental health one. Specifically, in the context of lifeworld disruption problem presentations, physicians pursue a mental health diagnosis instead of a physical health one. In Extract 4, the patient presents with situational depression due to stress from her job and personal issues. She has noted that she went to urgent care because she was likely having a panic attack. She continues to indicate that her symptoms are due to stress and includes a concrete link between her symptoms and an everyday life disruption in lines 05–06:

The physician responds to the patient’s example of a disruption with the question, “are you crying easily? °Or-°” (line 09). The problem-attentive nature of this question is in marked contrast to the prior cases insofar as it is biased in favor of a mental health problem. Here, the physician orients to this disruption as problematic and provides an opportunity for the patient to further expand her symptoms. Notably, it is only when the patient makes the causal connection between symptoms of sleeplessness, headaches, tension, and the inability to do jobs around the house (a lifeworld disruption) that the physician actively pursues additional mental health-related symptoms. As a result of the physician’s active search for additional symptoms, the patient’s illness presentation becomes more granular ( Schegloff, 2000 ).

A pattern in these data is apparent: physicians pursue questioning biased toward a physical diagnosis when patients present symptoms-only mental health concerns and physicians pursue questioning biased toward a mental health-related diagnosis when patients provide a causal connection between a concrete lifeworld disruption and their symptoms. This pattern holds for 12 out of the 14 total cases. However, two cases do not fit this pattern. In what follows, I show that the ways in which a departure from the pattern nonetheless supports the broader analysis.

A deviant case

How do we account for a symptoms-only mental health presentation that results in the pursuit of a mental health diagnosis? Such an instance arose in the dataset as shown in Extract 5. The patient in this case presents with persistent fatigue. Her problem presentation begins below:

The patient explains that she had visited this office twice before with the same complaint and was given a pregnancy test during one visit and a thyroid test during another. Next, the physician reassures her about her thyroid and continues with diagnosis:

The physician in this case also references these past visits and the physical tests conducted in lines 01–03 and again in lines 08–09. At these past visits where this patient initially presented with the same symptoms, the physician did as the analysis in this article would predict: pursued a physical health diagnosis. During this visit, however, the physician pursues a mental health-related diagnosis, a “neurochemical imbalance,” in line 10.

On the surface, this visit does not fit with the rest: the patient used a symptoms-only presentation yet a mental health diagnosis follows. Note, however, that the physician makes clear that he is only pursuing this diagnosis in the context of previous physical diagnoses that he is now able to rule out: “When you’ve been in fatigue as long as you can remember (.) and your blood counts are all right (.) and your thyroid’s all right you’re not pregnant it makes think (.) that you have a neurochemical imbalance” (lines 07–10). Purely because the two physical health diagnoses did not solve the symptoms of fatigue does this physician now move toward a mental health diagnosis. This provides further support that physicians are biased against a mental health diagnosis initially. The physician continues:

This physician’s account further demonstrates that he is arriving at this mental health-related diagnosis in the context of physical diagnoses that have still left the patient with the complaint (lines 01–05). He labels the neurochemical imbalance diagnosis a “diagnosis of exclusion” (line 03), which effectively concludes how he arrived at this particular diagnosis without a concrete lifeworld disruption. This outcome therefore can be explained because it was a diagnosis made following two failed physical-health diagnoses. Furthermore, we have evidence for the physician’s behavior on two prior visits that the default orientation was to a physical health diagnosis before a mental health one. It took extra work—a third visit from the patient—in order to secure a mental health diagnosis.

Why does the addition of causal link make the difference for physicians’ treatment orientations? One explanation for this could be how we understand biographical disruption in chronic illness ( Bury, 1982 ). In studying patients with rheumatoid arthritis, Bury investigates the way chronic illness is conceptualized—as a disruptive event. He writes,

… illness, and especially chronic illness, is precisely that kind of experience where the structures of everyday life and the forms of knowledge which underpin them are disrupted … it brings individuals, their families, and wider social networks face to face with the character of their relationships in stark form, disrupting normal rules of reciprocity and mutual support. (169)

Chronic illness, therefore, represents a disruption of our taken-for-granted lifeworld (see Schutz, 1967 ). Barker (2009) argues that because our sense of self is rooted in our bodies’ daily functioning, an interruption of that functioning which restricts our everyday life performances threatens our fundamental selves. It is perhaps our orientation to this threat of our selves before illness which makes lifeworld disruption salient to us– and consequently to physicians– who take up these issues as indicators of an issue beyond a physical ailment. Once symptoms are presented, the addition of a lifeworld disruption tips the scales.

This article outlines two approaches patients take to present their mental health– related symptoms in the primary care setting. Taken one step further, this dichotomy is matched to two distinct physician responses and thus holds consequences for diagnosis. When patients use a symptoms-only problem presentation to articulate their mental health symptoms, physicians orient to such complaints as indicative of a physical health problem and therefore pursue questioning biased in favor of a physical health diagnosis. In contrast, when patients provide the addition of a causal link between their mental health symptoms and a lifeworld disruption in their problem presentation, termed lifeworld disruption presentations, physicians align to the symptoms as indicating a mental health issue and subsequently pursue questioning biased in favor of a mental health diagnosis. This pattern holds in the majority of cases in the sample. While two of the cases in the sample deviated from this initial pattern, they still provided evidence for the pattern: that without the addition of a causal link between mental health symptoms and an everyday life disruption, physicians will demonstrate bias toward a physical health problem even when they initially topicalize a potential mental health problem.

In the medical encounter, physicians typically initiate actions while patients typically respond, resulting in an interactional asymmetry ( Robinson, 2003 ). What underlies a medical diagnosis is not just information that patients provide to their physicians; it is also the ways in which physicians can shape patients’ symptoms through the interactional sequence. This can affect how patients explain their illness and whether physicians adequately hear patients’ experience of illness ( Gill and Maynard, 2006 ). While this analysis primarily examines how patients’ descriptions of symptoms conditions physicians’ diagnoses, it is important to also note that the ways in which physicians guide patients through the symptom presentation conditions how those symptoms get explained in the first place.

Mental illness continues to be a fundamental problem in society today. It is estimated that approximately half of American adults will experience at least one mental health disorder in their lifetime and 25% will have an ongoing mental health disorder at any given time ( Kessler et al., 2005 ). When compared with other illness categories including cancer and heart disease, the World Health Organization (WHO) concludes that mental health disorders account for the highest incidence of disability in developed nations ( WHO, 2004 ). Moreover, mental health disorders are associated with a reduction in quality of life, social functioning ( Saarni et al., 2007 ), and impairment in carrying out daily tasks ( Knudsen et al., 2013 ). These disorders also play a significant role in morbidity and mortality in the United States and are positively associated with the incidence of other chronic health problems ( Chapman et al., 2005 ).

As Parsons (1951) theorized, illness is a form of social deviance, and by nature this deviance disrupts the normal, everyday functioning of those who are sick. Furthermore, the responsibility of remediating this deviance lies in the physician’s domain. As far as the data presented in this article is concerned, we can see evidence for today’s physicians closely following a Parsonian script in the pursuit of mental health diagnoses. If patients are not showing functional incapacity, their physicians are not taking their symptoms up as indicative of a mental health issue and instead are orienting the diagnosis to a physical problem, echoing prior work which suggests that PCPs frequently address medically ambiguous and/or complex symptoms with somatic interventions ( Ring et al., 2005 ). These data further show that patients must not only strongly assert their mental health symptoms but assert them as unquestionably tied to the inability to carry out everyday life tasks. If patients query, mitigate, or collateralize these symptoms, they are consistently treated as insufficient evidence to indicate a potential mental health problem and instead get taken up as indicative of a physical health issue.

The concern from many in the medical community regarding the misdiagnosis of mental health issues is unsurprising given what this pilot study suggests. Current literature is split on whether this problem of misdiagnosis could be one of underdiagnosis or over diagnosis. A possible explanation for these diagnostic errors can be deduced from the data presented. Potentially, problems of underdiagnosis can be associated with patients who provide a symptoms-only problem presentation but who also have underlying mental health issues. Based on the data in this article, such patients will not get treatment for those underlying mental health issues because they have not demonstrated a disruption to their lifeworld. Importantly, when mental health symptoms are provided as just symptoms, there appears to be bias in the medical community toward providing a physical health before a mental health one.

This preliminary analysis may also help account for the problems of overdiagnosis. Overdiagnosis of mental health problems could be correlated with patients who do not actually have underlying mental health issues, but who over-catastrophize their symptoms by indexing their symptoms as causally linked to a lifeworld disruption. As is shown by the data analyzed, when patients do the extra work to provide a causal link between mental health symptoms and a lifeworld disruption, whether it is indicative of a mental health issue, a mental health diagnosis is often the result. Thus, there is suggestive evidence of an association between the way patients present their mental health symptoms and the misdiagnosis of underlying mental health problems in primary care.

Limitations and future research

Related studies have found that patients who include situational problems in their symptom narrative are actually less likely to receive a psychotropic drug prescription ( Chew-Graham et al., 2002 ; Karasz et al., 2012 ). Yet in these studies, patients causally linked their lifeworld to their symptoms, rather than causally linking their symptoms to disrupting their life- world, as this study has found. An overlapping concern among these investigations is what happens to patients with these complex symptom narratives, who go improperly diagnosed or leave without a diagnosis, after they exit the clinic. Further research on a larger scale could follow patients with mental health symptoms longitudinally from diagnosis to follow-up. This could help us begin to uncover the medically complicated root cause of their symptoms through following treatment outcomes over time.

Patient and physician self-reported demographic variables, such as gender, race/ethnicity, socioeconomic status, and education level are not available for analysis in this study. This is a limitation of the study and would undoubtedly offer an important level of explanatory power for the findings. As we know, patients from underrepresented groups receive inadequate treatment for mental healthcare ( Alegría et al., 2008 ) which can be attributed to a variety of interrelated social forces ( Link and Phelan, 1995 ). For instance, research has shown that ethnicity and gender both impact how pain gets perceived by clinicians ( Al-Hashimi et al., 2015 ; Norman, 2018 ). This study hopes to lay groundwork on which health disparities research can be built, where patterns in physician uptake of patient-presented mental health symptoms could be explored for diagnostic biases and differential treatment of patients from marginalized groups.

Acknowledgments

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This article was supported by the National Research Service Award under grant award 5TL1TR002388 (PI: David Meltzer, MD, PhD). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of NCATS/NIH.

Author biography

Alexandra Tate is a Postdoctoral Fellow in the Department of Medicine at The University of Chicago. She received her MA and PhD in Sociology from the University of California, Los Angeles, and her BA in Sociology from the Northwestern University. Her research explores the US healthcare system and engages theories of ethnography and conversation analysis to inform her findings. Her interests lie in the complexities of doctor–patient interaction and implications for patient care, focusing primarily on the physician-patient relationship in oncology, primary care, and palliative care settings.

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Volume 30, Number 3—March 2024

About the Cover

Mental health and tuberculosis—holding our breath in isolation.

Suggested citation for this article

Paulina Siniatkina (1989–), Don’t speak! Tempera on canvas (2016), 37.4 in × 41.3 in/100 cm × 105 cm. http://www.paulinasiniatkina.com

Paulina Siniatkina (1989–), Don’t speak! Tempera on canvas (2016), 37.4 in × 41.3 in/100 cm × 105 cm. http://www.paulinasiniatkina.com

Paulina Siniatkina, an artist and activist, is a survivor of tuberculosis (TB). In 2015, in a TB hospital on the outskirts of Moscow, the treating physician advised her to never talk about her TB diagnosis to anyone—further reinforcing the longstanding stigma associated with the disease. During her 7 months of treatment in isolation, Paulina experienced firsthand the suffering and loss associated with TB and turned to art to express her emotions and frustrations. She now uses her artistic talent and personal experience to advocate in the global fight against TB, and her work has drawn international recognition by the American Medical Association and World Health Organization. This month’s cover image, Don’t speak! , by Ms. Siniatkina, exemplifies the poignant psychology associated with TB. At the center, a young woman with sullen eyes draws your attention with her gaze, using a silent expression of longing to tell her story from behind the mask. Her unspoken feelings of hopelessness and depression appear to be subtly calmed by her nervous plucking of white petals from the single daisy protected by her hand, as the surrounding community dissolves into the background with looks of fear and judgement.

TB remains one of the leading causes of death by an infectious disease agent. Each year, more than 10 million people suffer from TB, and 1.5 million die as a result. Although curable, TB is a chronic multisystem infectious disease with well-documented, and often life-changing, disability and reduced quality of life. Treatment requires a multidrug, multimonth course of antibiotics; drug-resistant forms of TB extend the duration of treatment and in many communities require the patient to spend months in hospital or respiratory isolation. Not surprisingly, an estimated 40%–70% of persons treated for TB experience clinical anxiety or depression.

Beyond stigma and social isolation, mental illness persists as a silent driver of the global TB epidemic. Mental illness is associated with acquired drug resistance, TB transmission, disease recurrence, and TB-related death. Mental illness and TB are often exacerbated by homelessness and HIV co-infection. Integrated services for persons with TB and concurrent psychiatric conditions such as addiction, anxiety, or depression are now considered an essential component of global TB elimination efforts. However, in many countries with high burdens of TB, access to psychiatric services, including routine mental health screening and treatments, remain extremely limited.

Each year on March 24, we commemorate World TB Day in honor of the day Robert Koch announced to the Berlin Physiologic Society that he had discovered the cause of tuberculosis. World TB Day is a time to remember the millions of persons who suffer from TB, often in silence. It is also a time to break the silence, raise greater awareness, take specific actions to reduce the impact of mental health on our ambitions for global TB elimination, and not hold our breath in isolation.

Acknowledgment

We thank Paulina Siniatkina, the artist discussed in this article, for her review of the manuscript and for permission to republish her work. More of her work can be viewed at http://www.paulinasiniatkina.com .

Bibliography

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  • World Health Organization . Hold your breath, paintings made by Russian artist while in a TB clinic [ cited 2023 Dec 21 ]. https://www.who.int/news-room/feature-stories/detail/hold-your-breath-paintings-made-by-russian-artist-while-in-a-tb-clinic
  • World Health Organization . Global tuberculosis report, 2022. Geneva: The Organization; 2022 .

Suggested citation for this article : Fukunaga R, Moonan PK. Mental health and tuberculosis—holding our breath in isolation. Emerg Infect Dis. 2024 Mar [ date cited ]. https://doi.org/10.3201/eid3003.AC3003

DOI: 10.3201/eid3003.ac3003

Original Publication Date: February 15, 2024

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Table of Contents – Volume 30, Number 3—March 2024

Please use the form below to submit correspondence to the authors or contact them at the following address:

Patrick K. Moonan, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Mailstop H21-6, Atlanta, GA 30329-4018, USA; email [email protected]

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COMMENTS

  1. About Mental Health

    Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make healthy choices. 1 Mental health is important at every stage of life, from childhood and adolescence through adulthood.

  2. PDF MENTAL HEALTH 101.ppt

    Mental Disorders are common in the United States and internationally. An estimated 26.2 percent of Americans ages. 18 and older, about 1 in 4 adults, suffer from a diagnosable mental disorder in a given year. Mental disorders are the leading cause of disability in the U.S. and Canada for ages 15-44.

  3. What is Mental Health?

    Mental illnesses are disorders, ranging from mild to severe, that affect a person's thinking, mood, and/or behavior. According to the National Institute of Mental Health, nearly one-in-five adults live with a mental illness. Many factors contribute to mental health conditions, including: Biological factors, such as genes or brain chemistry

  4. PDF Mental health awareness in the workplaces slides

    Today's presentation may bring up strong feelings. Feel free to take steps to care for yourself. If you need to step out of the room or take a break, please do so. If someone shares a personal experience, please keep that information private. Mental health statistics

  5. Mental health

    It is an integral component of health and well-being that underpins our individual and collective abilities to make decisions, build relationships and shape the world we live in. Mental health is a basic human right. And it is crucial to personal, community and socio-economic development. Mental health is more than the absence of mental disorders.

  6. Mental health: Definition, common disorders, early signs, and more

    "Mental health is a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community." The...

  7. PDF Understanding mental health problems

    Good mental health means being generally able to think, feel and react in the ways that you need and want to live your life. But if you go through a period of poor mental health you might find the ways you're frequently thinking, feeling or reacting become difficult, or even impossible, to cope with.

  8. Mental Health: Meaning, Characteristics, Management

    Mental health is a term used to describe emotional, psychological, and social well-being. The quality of a person's mental health is often measured by how adaptively they can cope with everyday stressors. Mental health allows people to use their abilities, be productive, make decisions, and play an active role in their communities.

  9. Mental health

    Mental health is a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community. It has intrinsic and instrumental value and is integral to our well-being.

  10. Mental Health 101

    Introducing our Mental Health 101 site. We are pleased to introduce our course site featuring tutorials on: Mental Health. Addiction. Depression. The site offers an opportunity to create a private user account so that you can get the most out of your online learning experience. You will be able to self-enroll in course that interest you, view ...

  11. PDF Introduction to mental health awareness presentation cover note

    Improve awareness of mental health, including what good mental health looks like, basic understanding of mental health problems and give an introduction to the mental health continuum. Introduce the concept of mental health at work and how the mental health of emergency services personnel can be affected.

  12. The Importance of Mental Health

    Mental health is described as a state of well-being where a person is able to cope with the normal stresses of life. This state permits productive work output and allows for meaningful contributions to society. However, different circumstances exist that may affect the ability to handle life's curveballs.

  13. PPTX Home

    How to talk about mental health in the classroom? This interactive lesson plan from Mind, a leading mental health charity, provides guidance and activities for teachers and students to explore the topic of mental health and wellbeing. Download the PowerPoint file and learn how to create a safe and supportive environment for discussion.

  14. PPTX PowerPoint Presentation

    Mental health practitioners and others may sometimes have a very limited view or perception of people with psychosocial, intellectual or cognitive disabilities. For instance, they see people with psychosocial disabilities only at a very specific time in their life (e.g. when they are experiencing distress or in a crisis). ... Presentation: The ...

  15. What is mental health? Evidence towards a new definition from a mixed

    Introduction. A major obstacle for integrating mental health initiatives into global health programmes and primary healthcare services is lack of consensus on a definition of mental health.1-3 There is little agreement on a general definition of 'mental health'4 and currently there is widespread use of the term 'mental health' as a euphemism for 'mental illness'.5 Mental health ...

  16. Ideas about Mental health

    Mental health advocate Sahaj Kaur Kohli provides you with 8 dos and 8 don'ts. Posted May 2021. Caring for a loved one is hard work — 6 ways you can fight burnout. Many people are caregivers for their sick parents, partners, friends or others, with an unfortunate consequence: They end up suffering. TED speakers share steps that caregivers can ...

  17. Mental disorders

    A mental disorder is characterized by a clinically significant disturbance in an individual's cognition, emotional regulation, or behaviour. It is usually associated with distress or impairment in important areas of functioning. There are many different types of mental disorders. Mental disorders may also be referred to as mental health ...

  18. Mental Health Disorders: Types, Diagnosis & Treatment Options

    A healthcare provider will carefully review your symptoms to evaluate your mental health. Be sure to tell your healthcare provider: If there are any specific triggers that make your mental health worse. If your mental health problems are chronic (ongoing) or if they come and go. When you first noticed changes in your mental health.

  19. Mental illness

    Mental illness, also called mental health disorders, refers to a wide range of mental health conditions — disorders that affect your mood, thinking and behavior. Examples of mental illness include depression, anxiety disorders, schizophrenia, eating disorders and addictive behaviors. Many people have mental health concerns from time to time.

  20. PowerPoint Slides

    The Mental Health Foundation runs two national campaigns every year: Mental Health Awareness Week and Pink Shirt Day. More. Library Info Hub. The Library Info Hub provides Kiwis with access to the latest resources about mental health and wellbeing. More. In My Kete. This feature includes reviews of books and stories from experts in the mental ...

  21. Matter over mind: How mental health symptom presentations shape

    Patient presentations of mental health concerns. I am concerned with the ways in which patients characterize symptoms that may indicate a mental health disorder. Drawing on Stivers' aforementioned work on problem presentations, I reviewed data for any consistent pattern in symptom presentation. What emerged was a two-way distinction between ...

  22. Free templates on Mental Health for Google Slides & PPT

    Google Slides PowerPoint Mental Health and Well-being - Health - 10th Grade Mental health and well-being are crucial for leading a fulfilling life. In today's fast-paced world, it is all too easy to sideline our mental health, leading to various issues such as anxiety, depression, and burnout. But it doesn't have to be that way.

  23. Mental Health

    Mental Health. February 9, 2024 / Mental Health. Self-Love: Why It's Important and What You Can Do To Love Yourself. Like being your own best friend in times of trouble, self-love is an act of ...

  24. ACF Releases New Resources on Behavioral Health for Young Adults

    They shared their own experiences and provided insights on what parents and caregivers should say and do when discussing mental health. This practical tool is designed to help parents and caregivers start conversations about mental health with children and teens. The enhanced ACF behavioral health webpage also includes audience-specific pages ...

  25. National Alliance on Mental Illness presentation set for Feb. 22

    All are welcome to attend a National Alliance on Mental Illness (NAMI) In Our Own Voice presentation Thursday, Feb. 22 from 6:30-8 p.m. on the McNichols Campus.. The presentation, hosted by the College of Health Professions and made possible by the Mission Micro-Grant, will take place in the Chemistry Building, Room 114.

  26. Stress is a key factor driving some teens to drugs and alcohol, CDC

    Supporting and improving mental health could have a direct impact on substance use among teens in the United States, according to a new study from the US Centers for Disease Control and Prevention.

  27. Mental Health and Tuberculosis—Holding Our Breath in Isolation

    Mental illness is associated with acquired drug resistance, TB transmission, disease recurrence, and TB-related death. Mental illness and TB are often exacerbated by homelessness and HIV co-infection. Integrated services for persons with TB and concurrent psychiatric conditions such as addiction, anxiety, or depression are now considered an ...

  28. Crow Wing Energized offers free Make It OK presentation

    Kathy Cottew, Essentia Health workforce development specialist, will be the presenter. The event will focus on removing the stigma surrounding mental illness.

  29. Employees think mental health is OK to discuss at work. But not ...

    Mercer found that two-thirds (67%) of employers have said they consider depression and anxiety a concern at work, with 21% citing it as a serious concern, in its most recent health benefits survey ...