It is, as ever, the stigmatisation of mental illness and the underfunding of mental health services. The two are clearly related, and despite some improvements in recent years, there remains a long way to go.
The stigma is attached to both the treatment and those who provide it, creating a dangerous narrative that mental illness is somehow imaginary or “all in the mind”, and – at the same time – hopelessly incurable. At worst, the latter-day anti-psychiatrists argue that diagnoses are of no value, and treatments are of no use.
Antidepressants are seen by some as glorified placebos, while others argue they are terribly addictive and harmful. However, clinical trials have established beyond reasonable doubt that antidepressants for depression, lithium for bipolar disorder and antipsychotic drugs for schizophrenia are all just as effective as any other treatment in medicine.
For example, continuing antidepressant treatment for a year reduces relapse rates from around 41 per cent to 18 per cent. Moreover, the combination of drug and talking treatments works better than either alone.
Randomised controlled trials and systemic reviews in patients with schizophrenia yield similar results – that antipsychotic drugs have a large effect on psychotic symptoms and improve quality of life compared with placebo.
Studies show that taking antipsychotics for a year reduces chance of relapse to 27 per cent, compared to 64 per cent on placebo. That 37 percentage-point absolute reduction in risk is one of the largest treatment effects in all of medicine.
Sadly, the majority of people with a diagnosable mental illness do not present the symptoms for the treatment that could help them, or worse, they struggle to access treatment at all.
This is yet another manifestation of stigma, and so is the underfunding of mental health services. If everyone suffering from mental health conditions asked for help, the services would be completely overwhelmed.
The language we use to discuss mental health can also contribute to its stigmatisation. When we talk about physical health and illness, we refer to specific conditions: diabetes, stroke, cancer.
By using the umbrella term “mental health”, we are reinforcing the mystery around it. Only when individuals can talk openly about their specific mental health conditions and their effects, will the stigmatisation be dispelled.
The question remains, however, what is the underlying cause of stigmatisation and under-funding?
It is fundamentally down to the fact that our minds feel different from our bodies. The separation of mind and brain, and seeing them as under voluntary control or not, has a very long cultural tradition.
Indeed, it is this view that underpins the criticism of the experience, diagnosis and treatment of mental illness. We need to become more aware of the stigma attached to mental health, and encourage those who wish to discuss the illness to do so openly. Only then will we be able to destigmatise mental illness.
Stephen Lawrie is a fellow of the Royal Society of Edinburgh, and a professor of psychiatry at the University of Edinburgh. The RSE is Scotland's National Academy, which brings great minds together to contribute to the social, cultural and economic well-being of Scotland.