Some interesting observations about the current state of mental health care.

The Paradox of Mental Health: Over-Treatment and Under-Recognition

Among all the conditions in the world of health, mental health occupies a unique and paradoxical place.
On the one hand is over-treatment and over-medicalization of mental health issues, often fueled by a pharmaceutical industry interested in the broadening of the boundaries of “illness” and in the creation of more and wider diagnostic categories and thus markets for “selling sickness.” On the other hand exists profound under-recognition of the suffering and breadth of mental health issues affecting millions of people across geographies, which is a global problem.
As a journal, PLOS Medicine has covered both sides of the mental health “coin,” and we continue to make mental health in general a priority area. We recognize that the whole of the field of mental health research is relatively underdeveloped, and that a particular scarcity of clinical trials exists from outside high-income settings and for non-drug interventions. As a result, we also support efforts to improve capacity in mental health research whilst committing to the publication of the state of the art in research and commentary [1],[2].
Over-treatment, especially when it results from “disease mongering,” is a persistent and troubling issue. The harms of over-treatment arise from situations where normal life experiences (such as menopause, shyness, grief, etc.) are deemed illnesses [3] or when diseases are “created” from mild problems and symptoms (such as restless legs syndrome or female sexual dysfunction) [4],[5]. In both situations, people become patients, and their problems are deemed to need medical treatment when they may not need it or could be harmed by it, or when nonmedical options are available. Over-diagnosis and over-treatment have been shown for a range of human conditions [3], but this phenomenon as it relates to mental health is particularly powerful [6]. For example, the widespread over-diagnosis of conditions such as bipolar disorder, autism spectrum disorder, and attention deficit hyperactivity disorders (ADHD), especially among children, is now being documented—the US Centers for Disease Control recently estimated that 6.4 million children aged 4 to 17 had received an ADHD diagnosis at some point in their lives (amounting to 11% of all US children)—a 41% increase in the last decade that has been met with alarm and concern by many doctors and parents [7]. Two thirds of these children are said to be on medication for the condition. Recent Canadian data [8] reaffirm the concerns with excessive labeling of normal child behavior as pathological. Over-diagnosis in mental health risks unnecessary tests and treatment, the stigma associated with being labeled mentally ill, and the considerable costs of testing, treatment, and wasting resources that could be better utilized elsewhere [3],[5].
The recent DSM-5 process is a lightning rod for these concerns: this month's update of the psychiatric diagnostic manual has been widely criticized for continuing the tradition of broadening diagnostic categories and adding new conditions that redefine more people as having mental illness and in need of pharmaceutical treatment [9],[10]. That decisions about DSM-5 categories are made by experts with financial ties to the industry that benefits most from a widened patient population [11],[12], is particularly worrying.
In perhaps the most dedicated venue for discussions of this topic, the Selling Sickness conferences (http://www.sellingsickness.com), which PLOS Medicine has been instrumental in shaping, have brought together academic researchers, medical reformers, consumer advocates, and health journalists with shared interests in examining the problem of disease mongering and developing strategies and coalitions for change. The inaugural conference in 2006 coincided with our launch of the PLOS Medicine Disease Mongering Collection (http://bit.ly/18i6j6h) that to this day remains astonishingly relevant. In February 2013 we participated again, this time in a roundtable on the role of the medical media where we outlined our responsibility as editors to avoid the spin in published articles and the journal's press releases that can fuel hype about new disease categories and treatment [13]; we also highlighted another important role of journals in fighting disease mongering: to require that all clinical trials be registered and data be reported and shared, so that the full picture of the benefits and harms of tested interventions can be seen (see, for example, http://www.alltrials.net). The conference's Call to Action petition (http://sellingsickness.com/final-stateme​nt/) is available for readers to view and sign. Later in 2013, two comrade conferences, PharmedOut (http://www.pharmedout.org/) and Avoiding Overdiagnosis (http://www.preventingoverdiagnosis.net/), will continue the conversation about both the extent and the prevention of over-diagnosis, and will undoubtedly provide new insights into the problems associated with over-treatment of mental health.
Equally important, however, is the vast under-recognition of mental health conditions, especially in the developing world. This neglect has occurred at multiple levels including at the national level, where many countries have failed to establish adequate mental health policy. At the level of global health agendas, mental health was essentially ignored in the Millennium Development Goal program and failed to elevate to prominence at the recent United Nations special assembly on non-communicable disease.
As many others have noted [14]–[16], this neglect makes little sense: more than 13% of the global burden of disease is attributable to neuropsychiatric disorders, and over 70% of this burden lies in low- and middle-income countries (LMICs). Almost a quarter of the world's disability burden is now attributable to mental and behavioral disorders (including depression, anxiety, Alzheimer disease, and schizophrenia) [17]. And yet mental health has failed thus far to receive the political priority and international funding commensurate with its global toll [14]. There are signs this tide is shifting, and several prominent groups and organizations are working to raise the profile of global mental health. PLOS Medicine has provided a forum for that effort over the last few years, publishing packages of care for mental health disorders in LMICs [18] and an ongoing series on mental health interventions in practice [2]. And this week we conclude a five-part series that sets out an agenda for integrating mental health care into primary care, maternal health, non-communicable disease, and HIV interventions in the developing world [19]. All of these analyses were done by researchers free of financial links to manufacturers with a stake in expanded markets, thus providing the necessary independent opinion.
In addition, we've recently published high-quality research on a range of topics within mental health that contributes to improved clinical practice, policy, and action. This includes definitive evidence on the long-term health consequences of sexual abuse [20] and trafficking [21], a genome-wide analysis establishing the limited ability of genetic data to predict antidepressant response [22], and a meta-analysis reporting the relative benefits and harms of adjunctive antipsychotic medications in depression [23]. These studies add to a growing evidence base, and signal a growing recognition of the importance of mental health.
Still, our understanding of all aspects of mental health is relatively underdeveloped. As others have acknowledged [3],[24], the research base for over-diagnosis and harm from over-treatment remains limited, and so the new initiatives and calls for action are welcomed. So too is growing recognition and research on genuine mental health issues and the best ways to address and prevent mental health problems, especially in terms of policy and human rights action and in a global context. To the extent that these two areas (over-treatment on one hand, under-recognition on the other hand) represent the paradox of mental health, where's the balance point? We don't have all the answers, but as a journal we reaffirm our commitment to publishing rigorous, insightful research and commentary on the breadth of issues around global mental health, and we welcome continued debate on the challenges this paradox represents. The largest challenge may be to recognize and prioritize mental health globally—with the requisite political visibility, funding, research, and attention—without reducing it to an object for disease mongering, pathologizing, and harmful over-treatment.

Author Contributions

Wrote the first draft of the manuscript: JC. Contributed to the writing of the manuscript: JC PS MW LC AR. ICMJE criteria for authorship read and met: JC PS MW LC AR. Agree with manuscript results and conclusions: JC PS MW LC AR.

Citation: The PLOS Medicine Editors (2013) The Paradox of Mental Health: Over-Treatment and Under-Recognition. PLoS Med 10(5): e1001456. doi:10.1371/journal.pmed.1001456
Published: May 28, 2013
Copyright: © 2013 PLoS Medicine Editors. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The authors are each paid a salary by the Public Library of Science, and they wrote this editorial during their salaried time.
Competing interests: The authors' individual competing interests are at http://www.plosmedicine.org/static/edito​rsInterests.action. PLOS is funded partly through manuscript publication charges, but the PLOS Medicine Editors are paid a fixed salary (their salary is not linked to the number of papers published in the journal).
Abbreviations: ADHD, attention deficit hyperactivity disorders; LMIC, low- and middle-income country
Provenance: Written by editorial staff; not externally peer reviewed.

John Cacioppo makes some simple,pragmatic points about how lonely people can get their needs for community and intimacy met

Another piece by John Cacioppo dealing with the physiological effects of feeling lonely

This Guardian piece warns of the dangers of the current attitudes towards groups in our society

Benefit claimants are now seen as other – less than fully human

Research suggests many of us regard people on benefits as part of an 'outgroup' who don't feel the same emotions. This is scary

'There are only a few groups considered to be both threatening and incompetent. These include poor people, homeless people, drug addicts and (you’ve guessed it) welfare claimants.' Photograph: Mark Richardson/Alamy

The government's cuts to welfare benefits are causing real harm to a lot of innocent people. Nevertheless, remarkable numbers seem willing to support them, and all too ready to justify them with extreme aberrations. You can probably put some of this down to our straitened times. People struggling to get by in their own lives will find it hard to sympathise with those they feel are getting a free ride. However, at bottom, a lot of the bad feeling towards people on benefits comes from the way we now see them as a distinct, separate social group. Different from the rest of us. Worse than.
On the face of it this doesn't make a lot of sense. People move on and off benefits throughout their lives (with most claiming only for short periods), and lots of us will have claimed at one point or another. Yet we still have this idea of benefit claimants as a separate, special sort of person.
This is crucial if we want to understand people's antipathy towards the benefits system. Decades of findings in sociology and psychology tell us that as soon as a group can be defined as separate, as an "outgroup", people will start to view them differently. We're all familiar with the negative characteristics people seem to identify with benefit claimants. They're lazy, dishonest, stupid, "scroungers", and so on. But there are also deeper, largely unconscious beliefs that likely have even more profound and insidious effects. These have to do with whether benefit claimants are even felt to be truly, properly human in the same way that "we" are.
This idea comes from a relatively new body of work in psychology on something called "infrahumanisation". The infra just stands for "below", as in below or less than fully human. The term was coined by a researcher at the University of Louvain called Jacque-Philippe Leyens to distinguish this milder form of everyday dehumanisation from more extreme kind associated with genocide.
This is a fascinating (and quite scary) process whereby certain groups are not felt to have the same range of emotional experiences as everybody else. Specifically, while people are fine imagining them feeling basic emotions like anger, pleasure or sadness, they have trouble picturing them experiencing more complex feelings like awe, hope, mournfulness or admiration. The subtle sentiments that make us uniquely human.
There has been plenty of work with ethnic groups that shows this to be a real phenomenon. But crucially this tendency to deny people the full range of human emotions is strongest for low social status groups; particularly those groups that are both disliked and disrespected.
Not all low status groups are in this invidious position. Some – for example disabled people and the elderly – tend to be disrespected, but are also felt to be warm and unthreatening. There are only a few groups that have the dubious honour of being considered to be both threatening and incompetent. These include poor people, homeless people, drug addicts and (you've guessed it) welfare claimants. It is these most stigmatised groups that people have the most trouble imagining having the same uniquely human qualities as the rest of us.
You can try it for yourself. Imagine the most stereotypical "chav" you can. Imagine their clothes, their surroundings, their posture, their attitude. Now imagine them feeling surprise, anger, or fear. Easy right? Well now imagine them experiencing reverence, melancholy, or fascination. If you found that just as easy, congratulations. But I'd bet for a few of you it was just that bit harder. I'm ashamed to admit it was for me.
The reason this is scary is that it takes the "infrahumanised" group out of the warm circle of our moral community. If we don't think of them as experiencing the same rich inner life that we do; don't imagine them feeling things in the same way that we do, then we lose some measure of our empathy for them, and consequently our sense of ethical obligation. This would explain why people are so tolerant of the cuts – on an unconscious level, the people being hurt aren't real, full people. If this is true then fighting the cuts is going to be much, much harder than just fighting myths and misapprehensions.

This article about loneliness, depression and the quality of human contacts is very resonant from an HG point of view.

Dreaming Takes the Sting out of Painful Memories, Research Shows

ScienceDaily (Nov. 23, 2011) — They say time heals all wounds, and new research from the University of California, Berkeley, indicates that time spent in dream sleep can help us overcome painful ordeals.

UC Berkeley researchers have found that during the dream phase of sleep, also known as REM sleep, our stress chemistry shuts down and the brain processes emotional experiences and takes the edge off difficult memories.
The findings offer a compelling explanation for why people with post-traumatic stress disorder (PTSD), such as war veterans, have a hard time recovering from distressing experiences and suffer reoccurring nightmares. They also offer clues into why we dream.
"The dream stage of sleep, based on its unique neurochemical composition, provides us with a form of overnight therapy, a soothing balm that removes the sharp edges from the prior day's emotional experiences," said Matthew Walker, associate professor of psychology and neuroscience at UC Berkeley and senior author of the study to be published on Nov. 23, in the journal Current Biology.
For people with PTSD, Walker said, this overnight therapy may not be working effectively, so when a "flashback is triggered by, say, a car backfiring, they relive the whole visceral experience once again because the emotion has not been properly stripped away from the memory during sleep."
The results offer some of the first insights into the emotional function of Rapid Eye Movement (REM) sleep, which typically takes up 20 percent of a healthy human's sleeping hours. Previous brain studies indicate that sleep patterns are disrupted in people with mood disorders such as PTSD and depression.
While humans spend one-third of their lives sleeping, there is no scientific consensus on the function of sleep. However, Walker and his research team have unlocked many of these mysteries linking sleep to learning, memory and mood regulation. The latest study shows the importance of the REM dream state.
"During REM sleep, memories are being reactivated, put in perspective and connected and integrated, but in a state where stress neurochemicals are beneficially suppressed," said Els van der Helm, a doctoral student in psychology at UC Berkeley and lead author of the study.
Thirty-five healthy young adults participated in the study. They were divided into two groups, each of whose members viewed 150 emotional images, twice and 12 hours apart, while an MRI scanner measured their brain activity.
Half of the participants viewed the images in the morning and again in the evening, staying awake between the two viewings. The remaining half viewed the images in the evening and again the next morning after a full night of sleep.
Those who slept in between image viewings reported a significant decrease in their emotional reaction to the images. In addition, MRI scans showed a dramatic reduction in reactivity in the amygdala, a part of the brain that processes emotions, allowing the brain's "rational" prefrontal cortex to regain control of the participants' emotional reactions.
In addition, the researchers recorded the electrical brain activity of the participants while they slept, using electroencephalograms. They found that during REM dream sleep, certain electrical activity patterns decreased, showing that reduced levels of stress neurochemicals in the brain soothed emotional reactions to the previous day's experiences.
"We know that during REM sleep there is a sharp decrease in levels of norepinephrine, a brain chemical associated with stress," Walker said. "By reprocessing previous emotional experiences in this neuro-chemically safe environment of low norepinephrine during REM sleep, we wake up the next day, and those experiences have been softened in their emotional strength. We feel better about them, we feel we can cope."
Walker said he was tipped off to the possible beneficial effects of REM sleep on PTSD patients when a physician at a U.S. Department of Veterans Affairs hospital in the Seattle area told him of a blood pressure drug that was inadvertently preventing reoccurring nightmares in PTSD patients.
It turns out that the generic blood pressure drug had a side effect of suppressing norepinephrine in the brain, thereby creating a more stress-free brain during REM, reducing nightmares and promoting a better quality of sleep. This suggested a link between PTSD and REM sleep, Walker said.
"This study can help explain the mysteries of why these medications help some PTSD patients and their symptoms as well as their sleep," Walker said. "It may also unlock new treatment avenues regarding sleep and mental illness."
Other co-authors of the study are UC Berkeley sleep researchers Justin Yao, Shubir Dutt, Vikram Rao and Jared Saletin.

http://www.sciencedaily.com/releases/2011/11/111123133346.htm

'In praise of ...REM'

The Guardian, 25 November 2011 referred to the article in Current Biology

No, not the late-lamented band, whom we praised a few weeks ago. We refer to the state in which the twitch of the closed eye betrays the unshackling of the imagination. REM is something shared with many animals. Humans can't even claim to do more than the rest – a glance at the REM league table suggests armadillos dream far bigger dreams. The unlikely connection between the flittering iris and the unconscious mind's eye was first discerned in the 1950s, and was established fact before long. Ever since, we have known we owe our nightly flights of fancy to this distinctive sleep phase which features a complex chemistry and irregular breathing as well as the rapid eye movement itself. We owe to it, too, the whole cultural story of dreaming which stretches from Sumerian myths to Freudian speculation by way of the Bible itself. Throughout, there's been speculation as to why we dream in the first place, and yet most of the myriad "theories" advanced remain just that. Now a paper in Current Biology sheds a little light on what happens in the dark hours. The researchers showed subjects images that pulled on the heartstrings before allowing half – and depriving the rest – of a proper sleep. The next day they saw the images again, and scans revealed that while the raw emotional centres non-sleepers brains still buzzed in response, the sleepers' reasoning apparatus kicked in. Sleep seems to lay demons to rest, or at least allow them to be approached in a dispassionate spirit. Sweet dreams indeed.

Perhaps an example of the process whereby  an idea which starts off being ignored,  then controversial and rejected  finally becomes mainstream and part of the background with no one quite sure where it came from but just obvious when you think about it. Joe's theory links the mystery of dreaming as the leader article says with a rational EXPLANATION so joining two pars of our conscious lives - wondering and digesting satisfying answers.

But as it’s well past midnight I'd better get some rem in myself

Harold

If you go to The Guardian web site and search 'In praise of rem' there is a  link to the Current Biology

reference:

REM Sleep Depotentiates Amygdala Activity to Previous Emotional Experiences

Authors

Els van der Helm, Justin Yao, Shubir Dutt, Vikram Rao, Jared M. Saletin, Matthew P. Walker

 See Affiliations

Sleep and Neuroimaging Laboratory, Department of Psychology, University of California, Berkeley, Berkeley, CA 94720-1650, USA Helen Wills Neuroscience Institute, University of California, Berkeley, Berkeley, CA 94720-1650, USA Corresponding author

• Highlights

► Sleep decreases amygdala activity to prior waking emotional experiences ►The amygdala decrease is associated with reestablished prefrontal connectivity ►These neural changes are accompanied by overnight reductions in subjective reactivity ►Reductions in both brain and behavioral reactivity are associated with REM physiology

Summary

Clinical evidence suggests a potentially causal interaction between sleep and affective brain function; nearly all mood disorders display co-occurring sleep abnormalities, commonly involving rapid-eye movement (REM) sleep [1,2,3,4]. Building on this clinical evidence, recent neurobiological frameworks have hypothesized a benefit of REM sleep in palliatively decreasing next-day brain reactivity to recent waking emotional experiences [5,6]. Specifically, the marked suppression of central adrenergic neurotransmitters during REM (commonly implicated in arousal and stress), coupled with activation in amygdala-hippocampal networks that encode salient events, is proposed to (re)process and depotentiate previous affective experiences, decreasing their emotional intensity [3]. In contrast, the failure of such adrenergic reduction during REM sleep has been described in anxiety disorders, indexed by persistent high-frequency electroencephalographic (EEG) activity (>30 Hz) [7,8,9,10]; a candidate factor contributing to hyperarousal and exaggerated amygdala reactivity [3,11,12,13]. Despite these neurobiological frameworks, and their predictions, the proposed benefit of REM sleep physiology in depotentiating neural and behavioral responsivity to prior emotional events remains unknown. Here, we demonstrate that REM sleep physiology is associated with an overnight dissipation of amygdala activity in response to previous emotional experiences, altering functional connectivity and reducing next-day subjective emotionality.