Do Psychiatry and Mental Illness Need Rebranding?

Would promoting the whole-body effects of mental illness improve the way psychiatry is perceived? 

A few months ago, the American Heart Association published a position paper concluding that depression should be officially recognized as a risk factor for adverse outcomes in patients hospitalized with acute coronary syndrome. [1] 

From my vantage point as a psychiatry resident, it seems like both medicine and the public still characterize the mind’s illnesses as separate from the body’s. So I was glad to see the AHA paper draw attention to the well-established relationship between “mental” illnesses and “physical” ones. 

In the case of depression and cardiac disease, for example, we know there is a strong bidirectional connection.  Approximately 20% of persons who have recently suffered a myocardial infarction meet criteria for major depressive disorder (MDD) [2], and persons with major depression are 1.6 times as likely to suffer their first heart attack [3]. 

A variety of potential explanations have been proposed to explain this relationship. [4] Behaviorally, persons who are depressed are less likely to engage in pro-health activities such as exercise and healthy eating, and they are more likely to smoke, abuse substances, and have difficulty adhering to medication regimens.  

Depression has physiologic effects that may also contribute to the evolution of cardiac disease. Depression has been associated with increased platelet aggregation, increased levels of clotting factors, and endothelial dysfunction—all of which could hypothetically promote plaque formation and disruption in the pathophysiology of heart attack.  

People with depression often have dysregulated stress-cortisol systems. Because they are physiologically experiencing chronic stress, their bodies (HPA axis) may lose the ability to respond appropriately to acute stressors.   

Chronic activation of cortisol may also lead to insulin resistance —itself an independent risk factor for heart disease.  Hyperactivity of the sympathetic nervous system may contribute to insulin resistance or high blood pressure.  Finally, elevated inflammatory markers in both depression and heart disease may possibly be clues to a common pathway or a causal relationship between these two conditions.   

The implications of a hard-wired, physiologic connection between the mind and the body are far-reaching, and extend beyond improving patient risk factors.  In what other ways might this information be relevant to our psychiatry patients, and our profession? 

In the psychiatry clinic, describing the physical consequences of a mental illness might be helpful in persuading otherwise-hesitant patients to begin or adhere to psychiatric treatment.  Perhaps they think their depression or anxiety “isn’t that bad” and they’d rather “suffer through it”.  Pointing out how psychiatric symptoms might increase their risk of medical illnesses or aggravate an existing one might really tip the scales in favor of treatment. 

On a larger scale, drawing more attention to the “physical” ramifications of “mental” illnesses might help decrease stigma and lend more legitimacy to psychiatric illnesses, both in the sphere of medicine and the public perception. 

This movement may already be underway.  The American Psychiatric Association chose as its theme for the 2015 Annual Meeting: “Psychiatry:  Integrating Body and Mind, Heart and Soul.” [5] At the 2014 meeting, outgoing President Jeffrey Lieberman said that two of his goals for psychiatry were that “[p]sychiatry will return to its rightful place in the house of medicine” and that “[g]overnments, health care policy makers, and nonpsychiatric medical colleagues will finally understand that ‘there is no health without mental health.’” [6] Indeed! 

What are your thoughts on the topic?  Do you think that promoting the physical dimension of mental illness would contribute positively to the way psychiatry is perceived? 

References:

1. Licthman JH, Froelicher ES, Blumenthal JA et al. Depression as a risk factor for poor prognosis among patients with acute coronary syndrome:  systematic review and recommendations: A scientific statement from the American Heart Association. Circulation. 2014; 129(12):1350-1369.

2. Thombs BD, Bass EB, Ford DE et al. Prevalence of depression in survivors of acute myocardial infarction. J Gen Int Med, 2006; 21:30-38.

3. Van der Kooy K, van Hout H, Marwijk H, et al.  Depression and the risk of cardiovascular diseases: systematic review and meta-analysis. Int J Geriatr Psychiatry. 2007; 22:613-626.

4. Katon WJ. Epidemiology and treatment of depression in patients with chronic medical illnesses. Dialogues Clin Neurosci. 2011; 13:7-23.

5. https://annualmeeting.psychiatry.org/scientific-program/2015-call-for-abstracts.  Accessed July 17, 2014.

6. https://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1877665.  Accessed September 5, 2014. 

Leigh Jennings, MD, is a senior psychiatry resident in the Department of Neurology and Psychiatry at Saint Louis University School of Medicine.