1. What is an illness? What is health?

What is an illness? An illness happens when under the harm due to certain causes, the organs inside a body are impaired in structure and function, resulting in symptoms and disability. For example in ischemic heart disease, due to a lack of blood supply from a blocked blood vessel in the heart muscle, some muscle of heart was damaged, resulting in symptoms like chest pain upon exertion and impaired fitness of the person.

However, the absence of an illness does not mean possession of health. In 1948, the World Health Organization defined health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

2. What is a mental illness?

When the heart is the organ involved in a heart disease, brain is the organ involved in a mental illness. In the mental illness, certain parts of brain are damaged, resulting in symptoms involving cognitive function, content of thought, perception, emotion, behaviour and biological function (e.g. sleep and appetite), and impaired overall functioning of the person. Like many illnesses in other organs, there are effective evidence-based treatments for mental illness. With advent of neuroscience, the treatment of mental illness has been advancing over the past decades, particularly in pharmacological treatment.

There are two most important concepts related to our understanding about mental illness is the relationship between brain and mind, and the relationship between brain and other parts of body.

As for brain versus mind, what we call “mind” is the expression of the activity of the brain. “Mind” is the term that refers to brain functions such as memory or mood, while “brain” is the organ that produces those functions.

The brain, as an organ in our body, is closely related to other organs of body. Normal brain function requires normal function of other organs. For example, if the heart fails and the brain does not get enough oxygen, the brain cannot function, giving the mental symptoms such as clouding of consciousness. Likewise, brain can affect function of other organs. For example, thinking about a scary event immediately leads to rapid heart rate and raised blood pressure. So, we can see mental and physical health are inter-dependent.

3. How common is mental illness?

Mental illness is more common than most people expect. Everyone can suffer from mental illness at any time point of his life. A large survey in the UK found 1 in 6 people of working age suffer from a mental illness; mental illness is as common as asthma. Among those above 65 years old, one out of twenty suffers from dementia. Depression affects about 5% of men and 10% of women in developed countries. In 2000, the World Health Organization predicted that 20 years later, depression will become the second biggest burden of disease, second to ischemic heart disease.

The stigma and misunderstanding on mental illness in society discourage patients to seek help and receive treatment. Even if the patients have plucked up courage to seek treatment, they often conceal their illness from their family and peers. This made a general misconception that mental illnesses are rare. Therefore, when we understand that the fact that mental illnesses are common and treatable, we are more able to combat mental illnesses.

4. What are the common types of mental illness?

Common types of mental illnesses include: dementia, disorder due to psychoactive drug use (e.g. alcohol, opiate, stimulant etc), psychotic disorder, mood disorder (including depressive disorder, bipolar affective disorder), neurotic disorder (including anxiety disorder, phobic disorder, obsessive compulsive disorder), eating disorder, disorder in childhood and adolescence (including autism, attention deficit hyperactivity disorder, conduct disorder).

5. What are causes of mental illness?

The “stress-vulnerability” model best articulates the causes of mental illness. (In fact, this model also well applies to most illnesses involving all other organs.). Both “external stressor” and “internal tendency towards the illness” contribute to the onset of mental illness.

For mental illness, the vulnerability mainly refers to the genetic predisposition to the illness. Major environmental stressors are “social stressors” which refer to all events we perceive stressful or heart-breaking in daily life, e.g. being abused in childhood, break-down of relationship or setback in career, burden from child care at home or work at office. Too much experience of stress results in too much “stress hormones” (one of them is cortisol) which is toxic to the brain, causing brain damage. Other external stressors to brain can be chemical substances, e.g. alcohol, illicit drugs, or a physical insult to the brain (e.g. stroke, head injury).

When a person who is born with a biological vulnerability in the brain is hit by an external stressor (e.g. loss of relationship or consumption of illicit drug), the brain fails to cope and breaks down, giving rise to the onset of a mental illness. Depending on which part of the brain is being damaged and the direction of vulnerability, the core mental symptom differs, for example, it is mood in a depressive illness, perception and thought content in a psychotic disorder, or cognitive function in dementia. However, due to the highly complicated connection among different parts of the brain, the core symptoms are associated with symptoms in other domain, e.g. impaired concentration is also present in a person with depression.

6. How does a psychiatrist diagnose mental illness?

Everyone has fluctuation of mood and might have some extreme thinking at some moment of life. How to define a mood or a thinking to be abnormal and to be an illness? How depressed is an illness?

Generally speaking, a mental illness has two parts – 1. a collection of symptoms and signs, 2. disturbance of functioning and suffering to the person. For each symptom, a psychiatrist see how persistent and prominent it is and how it is accompanied by other symptoms. For example, in a depressive illness, the mood is markedly depressed for most of the time of the day, lasting for more than 2 weeks and accompanied by other symptoms like loss of energy and interest. These symptoms impair the functioning of the person, e.g. lower his performance at work. All in all, defining abnormality in a mental activity demands clinical experience and skills of a doctor, and therefore, assessment by a doctor is indicated when a mental illness is suspected.

A psychiatrist assesses the patient by the experiences recounted by the patient as well as the behaviour observed by the psychiatrist. The psychiatrist also collects relevant personal background and social information of the patient, and observation reported by the patient’s significant others, to complete the assessment. Based on information collected, the psychiatrist matches the person’s condition against the internationally agreed diagnostic criteria to make it a judgment of illness, and formulate how various problems in the person’s life contribute to the illness. The psychiatrist performs blood tests or imaging examination to rule out diseases in other parts of the body which might cause the presenting mental symptoms. Therefore, both the clinical skills of the psychiatrist and the willingness of the patient to disclose his symptoms are essential in making a correct diagnosis and formulating the management plan.

Unlike illness involving other parts of body, e.g. heart disease or cancer, the diagnosis of mental illness does not rely heavily on laboratory tests, e.g. blood test and imaging. The reason is that a mental illness is a disease of the brain which is far more complicated than all other organs. The current technology in brain imaging can only demonstrate the very gross lesion of brain, e.g. a tumour or a bleeding. Most mental illnesses are due to very subtle pathology in brain which cannot be shown by the current imaging technology. So, a “normal” computed tomography scan of brain in a patient with, say a psychotic disorder, only means that the mental illness is not caused by a tumour or a bleeding inside the skull. There is certainly some subtle pathology in the brain leading to the symptoms of mental illness, and the pathology is amendable to treatment. All in all, all mental illnesses are due to pathology in brain.

7. How does treatment of mental illness work?

Treatment of mental illness can be mainly divided into pharmacological and non-pharmacological one. For pharmacological treatment, they work by restoring balance of chemicals in brain. For example, an antipsychotic normalizes the transmission of a chemical known as dopamine, and therefore, makes delusion subside. Some medication might even promote the healing of brain. For example, an antidepressant works by restoring the normal transmission of a chemical called serotonin among the brain cells, as well as promoting the healing of damaged part of brain through a growth factor called brain-derived neurotrophic factor (BNDF).

Non-pharmacology treatment includes various forms of psychotherapy and psychiatric rehabilitation training. Psychotherapy helps patients to change their way of thinking and behavior. For example, in cognitive behavioral therapy for depression, under the guidance of a therapist, the patient learns to change the way of thinking and acting, and subsequently improve mood and get rid of undesirable thought and maladaptive behaviour.

There are two important concepts about psychological treatment. First, although it is called “psychological” treatment, the ultimate effect of these treatments is to bring some changes in the very delicate change in the structure and function of neurons by changing the way a person habitually think and behave. They also promote the healing of the brain by reducing the stress experienced by the patients in daily life.

Second, unlike receiving a surgical treatment, (e.g. a resection of a tumour) in which you sleep on the surgical table and let the surgeon to cut away an unwanted part from your body, receiving psychological treatment is not a passive process. Receiving psychological treatment is more like working in a gym with a fitness coach; the coach instructs and motivates you to complete various programmes of training. All in all, it is you giving the strength and sweat to lift up weights and running on treadmill, to build up muscles in your body and fitness of heart and lung. In psychological treatment, all treatment effect comes from your effort to take new behaviour and adopt new way of thinking. Nobody can replace yourself.

Psychiatric rehabilitation training maintains the motivation, work skills and interpersonal skills of the patients by engaging them to tasks which match their ability.

8. How to manage side-effects of psychiatric medications?

Patient should pay attention to side-effects of medications. Every medication has numerous possible side-effects among which a few are common (i.e. in more than 10% of patients). For psychiatric medications, in recent decades, the new generation of psychiatric medications has already improved significantly in side-effect profile. Also, many side-effects subside as the body starts to adapt to the medications. Doctors can minimize the medication side-effects by adjusting the dosage and frequency of taking medications. It is important for patients to report to their doctor any discomfort after taking the prescribed medications. The doctor will judge whether the discomfort is a medication side-effect, a symptom of the mental illness or the symptoms of another illness. Sometimes, the side-effects can be completely relieved. The doctor will discuss with the patient to decide on the plan of medication treatment, after balancing the risk of relapse and the harm of side-effect. It is unwise to totally refuse medication treatment for fear of side-effects, because the doctors can always adjust the dosage and types of medication, or to stop medications, in response to patient’s experienced side-effect.

9. How to overcome the avoidance attitude to mental illness?

Facing a mental illness might be more difficult than many other illnesses involving other parts of body, for the stigma on mental illness in the society. Stigma makes patients reluctant to seek help and to receive appropriate treatment. Seeking help early and adhering to appropriate treatment are the two most important steps in combating a mental illness. These steps take a lot of courage. Most of those who refuse to seek help or fail to adhere to treatment are actually aware of something wrong with their mind, but they just cannot take the wise move. How can a patient motivate himself to seek treatment? How can a person motivate a family member or a friend to seek treatment?

The two key actions are: A correct knowledge of mental illness, and a correct attitude to mental illness.

Everyone has his own health belief, i.e. a belief about what is good and bad for his health and what can treat or prevent illnesses. Our health belief is much shaped by the culture (e.g. about what a healthy diet is, people in Hong Kong are more influenced by traditional Chinese medicine than those in the West, and therefore we local Chinese avoid certain food most Westerners would not, such as avoiding cold drinks when having a common cold). Health belief based on traditional idea might not be always true, as advance in scientific knowledge unearth more and more true about health. This is particularly so for knowledge about the most complicated organ of the body which was still a total myth to people one century ago.

There is wide-spread misunderstanding about mental illness, for example that mental illness is feigned or self inflicted, that mental illness reflects a weakness of character, or that mental illnesses are incurable. As mentioned before, mental illness is due to damage to certain parts of brain, and there is effective treatment which helps to heal the damaged part.

For attitude, a denial attitude to problems which are perceived as too difficult to overcome is not a good attitude but is understandable. Have you ever chosen to deny a problem (e.g. a relationship problem with your spouse) as if it had not happened (e.g. delaying discussion with your spouse about what you feel unhappy about), rather than solving it rationally and immediately? Although the patient has been troubled by the symptoms of a mental illness for some time already, the fear of having a mental illness and the subsequent perceived “unbearable catastrophic consequence” (e.g. incurable, losing all friends, being locked up in mental hospital for life) forbids him from seeking treatment. He might tell himself that as long as I have not seen a doctor and I have not yet been diagnosed a mental illness, I am still not mentally ill. This might sound ridiculous. However, this denial to illness is not limited to mental illness. Have you known any friend who is obviously overweight and is having an unhealthy lifestyle, but refuses body check? He might believe that as long as he has not been diagnosed diabetes or high blood cholesterol, he is still healthy and can continue the lifestyle without consequence. To overcome the denial and avoidance attitude to mental illness, we should tell ourselves that most patients can recover from their mental illness; the earlier the treatment, the earlier the recovery. Support from family and peers are important, but all in all, it is the patient himself giving the courage to seek treatment. Only after overcoming the denial attitude, a patient can seek assessment and treatment for an illness.

10. How to combat mental illness by myself and by my will power?

Some people firmly refuse psychiatric treatment despite all the suffering from the mental illness. One reason is misunderstanding on the notion of “relying on myself and my will power”. It is not uncommon for people to wrongly think that receiving treatment equals depending on medication, or that refusing treatment is an act of relying on myself, or that people can only either choose to receive treatment or to use their own will power, not both.

The truth is that the recovery of any illness, e.g. diabetes, or osteoarthritis of knee, relies on the patients themselves; they choose to see the doctor, to take the prescribed medication or other treatment programme, e.g. physiotherapy, and to make the necessary change in lifestyle, e.g. dieting for body weight reduction. Treatments provided by doctors and other health professionals are tools which facilitate the healing of the damaged body part. In mental illness, psychiatric medications are like shoes which help us to walk on the road of recovery. They are not trains which can take us to the place we want to go, sparing all the efforts in our legs. Receiving psychiatric treatment takes a lot of will power, as the treatment requires the patients to persistently take medication, to persistently take new way of thinking and interacting with people, to persistently change some aspects of lifestyle. So, a patient receiving psychiatric treatment is like a top athlete receiving his training programme which requires him to keep doing what he is advised, with discipline and persistence.

11. What is recovery in mental illness?

Recovery in mental illness means that the patient regains control on his own life and has the opportunities in relationship, vocation and education an ordinary person has in society. To achieve all these tasks in recovery, symptoms in mental illness should be eliminated or attenuated by putting disturbed brain activities back to order. Psychiatric medications are particularly useful in this aspect. With symptoms under control, rehabilitation programme, together with support from peers and family, helps the patient to regain his role in family, among peers and in workplace.

It is best to compare the process of recovery to a marathon. The patient is the marathon runner who runs towards the goal of recovery. People around him, including family, friends, health professionals, boost the strength of the patients by giving emotional support, professional advice, equipment (e.g. medication). All in all, it is the patient who takes the advice, takes the equipment provided and participates in all treatment activities, i.e. he runs his own recovery marathon.

This takes much courage and perseverance to complete the marathon of recovery. Having hope is single most important element to sustain the run. In fact, there are enough reasons to support this piece of hope, because the advance of medical science has been making treatment more and more effective (i.e. the equipment is more advanced), so this is not a false hope.

How can family and friends support the patient in his recovery process? They love the patient, feel hurt by his illness and genuinely want him to recover. However, there are some pitfalls which prevent family and friends from translating their genuine concern to actions which genuinely helps the patient’s recovery. First, it is easy to overlook other strengths of the patient. The mental illness is only part of the patient who still has strengths in many other aspects, e.g. conscientiousness in personality, respect to parents, talents in art, sports or cookery etc. Second, the patient might feel embarrassed or shameful when family and friends encourage him to receive treatment. Third, family and friends wrongly adopt some methods which do not help the patient’s recovery. It is true that a mother scolds a child because she loves him, cares about his well-being and wants him to lead a good life. Blaming or scolding seldom works if the undesirable behavior is an expression of brain dysfunction.

Family and friends should pay attention to the strengths of the patients and help them to develop their strengths. Doing well in a hobby can boost the self-confidence of a person very much. Family and friends should attend to the patient’s feeling when they remind or advise the patient on treatment-related issues. Family might get some ideas on how to communicate with patient on the mental illness by just imaging what they do not want to hear if they had mental illness. Family should listen to the patients more, and to facilitate the patient to tell what he thinks to be good for him. A decision coming from the patient himself is more likely to be implemented than that being told to the patient.

12. Why do patients continue medications after recovery?

One common misconception about recovery in mental illness is about the role of maintenance in medication treatment. This misconception is common because in many other illnesses, e.g. pneumonia, the patient stops taking the antibiotics after the infection has been cleared, and the patient continues the antibiotics until the infection is cleared. The recovery of the pneumonia is apparently defined by the stop of medication.

For mental illness, even after the patient has all the symptoms subsided and has fully resumed his work and normal family life, in many cases, the psychiatrists advise the patients to continue the medication for a period which can be months or even years.

Why does a patient continue medication after he has recovered? In fact, the use of medication to consolidate recovery is not unique to psychiatric treatment. In some cancer disease, even the cancer is at early stage and it has not spread, after a complete resection of the tumour, the doctor might let the patient to take a few months of chemotherapy to consolidate the recovery.

Most mental illnesses are due to stress-induced damage to certain vulnerable parts of the brain. Psychiatric medication promotes the healing of the damaged brain region or normalized the disordered chemical transmission in the damaged brain cells. After the brain function is normalized and the symptoms have all subsided, the underlying vulnerability which is largely due to genetic makeup still exists and poses risks of a relapse. Medication cannot eradicate this underlying vulnerability. Furthermore, the stressor which causes the last episode of mental illness would probably happen again and might trigger a relapse. Therefore, the role of maintenance treatment in mental illness is to consolidate the recovery by offering protection to the brain.

In fact, many of us have been doing some extra protective measures in daily life to maintain health and to prevent another episode of illness. For example, some people are more easily to get sunburn so they choose to apply sunscreen lotion to avoid sunburn whenever they have outdoor activities. Some people are more easily to get a common cold, so they choose to wear a jacket whenever they go to a shopping mall or a cinema. The rationale of these measures is that of continuing medication for maintaining mental health.

13. How to prevent mental illness and maintain mental health?

Although genetic factors are relevant in most mental illness, we can do much to promote our own mental health and minimize the risk of mental illness. All these are not difficult to understand, but they are quite easily forgotten and omitted in our life, particularly when life is busy.

• Keeping physically fit. Mental health and physical health are inter-dependent. Healthy diet, adequate sleep and regular exercises bring you good physical health and mental health.
• Physical exercise. Physical exercise is an effective means of coping with mental stress. Mental stress is the most common trigger of mental illness.
• Be socially connected. Keep contact with people, and share both your joy and burdens in life with friends and family.
• Be active. Keep taking hobbies and learning. Keep your limbs and brain active.
• Be positive in thinking. You might not always able to change what happen to you every day, but you can change the way you see what happen to you. Positive psychology has good evidence on mental well-being.
• Learn to manage stress.
• Seek help early when there is a mental health problem
• Say no to illicit drugs and excessive use of alcohol.