"There is genuine anguish and suffering. But madness can sometimes be a legitimate response to an unjust society." -- Geoffrey Reaume
It's one of those quotes you have to take a pencil out for and underline freehand. By the time I got to the end of the sentence in this month's brilliant piece in The Walrus, I was questioning whether my education would still allow me to believe that.
The idea that social injustice can drive a health gradient is becoming a bigger facet of medical education in Canada. The medical field can accept higher rates of diabetes amongst those with chronic stress or uncertain employment, but how are we trained to embrace the culpability of mental illness? And how will it impact the way physicians engage with mental health as a burgeoning burden of disease for years to come?
The public, media, artists, the legal and medical system all shape how we as a society view mental illness. And it may ultimately be how we are judged as a civilization. Stigma can take on many forms, and it's this shapeshifting quality that makes it such a difficult thing to tackle. The inroads by neuroscientists and researchers have helped put psychiatry on the map (maybe like never before), and it's truly incredible to see Hall of Fame figures such as Bruce Springsteen talk suicide.
Quite simply, if the public's gonna listen to anybody on depression, it's the Boss, not Dr. Oz. When it comes to lecture halls, is it the advances of neuropharmacology that will revitalize psychiatry as a career path amongst students? Are we relying too much on a neuronal pathway, genetic cause or even a drug to legitimize disease? Or could we be better served as a profession with a closer look at the bidirectional relationship between mental health and social environment in tandem? With preliminary findings suggesting yoga as superior to anti-depressants without the added risks, could physicians ever prescribe that first? Or would that be too soft?
It's these sort of questions that I believe the field of medicine will have to answer in order to best treat patients. Some of the discourse will be viewed as blasphemous and have to take place early on in training, but a real re-think about our relationship with the biblical Diagnostic and Statistical Manual of Mental Disorders as learners may be necessary. Certainly, Dr. Marcia Angell's account of American Psychiatry gives the profession just cause for reflection.
Philosopher extradorinaire, Michel Foucault, was piqued by the field of psychiatry and wrote extensively on what he termed the "medical gaze" (La Naissance de la Clinique). The concept remains as a current criticism of modern medicine, the way in which medical professionals separate the condition from the person.
If medical education could cast that gaze inwards, the frightening process of exploring our own personal biases towards mental illness should come to light. Furthermore, physician leadership could do much in exposing the vested interests of industry, and prevent the profession from playing poodle to Big Pharma.
On matters of access, Drs. Joshua Tepper and Jeremy Petch recently highlighted the deficiencies for Ontario's Child and Youth Mental Health services. As opposed to the historic confrontation between the neurosciences and the pyschosocial models, coupling evidence and personal context could be medicine's strong suit in treating mental illness. In this instance, a matter of perspective, and one of professional will.
I call it the Beauty and the Beast. Whenever somebody would call me beautiful, I could never believe it. You flash back to the monster, and the chaos you subject yourself to over a toilet bowl. In hiding, always in private. Nobody can see it, and you can't talk to anybody about it.
I heard this from a dear girlfriend over lunch, naturally enough, in a bustling restaurant that drowned out any care for eavesdropping patrons. She was in the health care field and after many trying years, still afflicted with bulimia nervosa. She was religious in keeping it secret from her family, and wondered why she had ever told me.
She honestly wished she was battling something else. A drug or alcohol addiction, or even cancer, something more noble and palatable when it came to talk of remission. I wanted to reassure her that it wasn't the case, but her tears ashamedly reminded me of all the encounters with medical professionals who got all too frustrated with eating disorders.
It's amazing how we can train our inner dialogue to turn up the correct dosage and suggested meds, and even a working prognosis to round it all out. But what if it didn't work, not for her. I thought of that line by the patient about mental illness and social justice from the magazine, and the unfair ideals and injustices she faced every day as a young woman. I was angry, emotional and felt insufficient.
There's a lot more I wish I would have said, but I'm hopeful for the bigger conversation that Mental Health Awareness Day can bring, and all the other private ones that are starting to take place around us.