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Understanding Biology in Adult Mental Health

Written by Steven Coles on . Posted in Clinical Psychology Bite-Size

Understanding Biology in Adult Mental Health

Issue 47 – April 2016

Author: Steven Coles (steven.coles@nottshc.nhs.uk)

Key points

  • There are differing views as to the importance of biology in causing mental health issues
  • Staff tend to favour biologically based models, the public psychosocial
  • There is no firm evidence base for biology being the primary cause of mental health issues
  • Biology’s importance is in enabling what we do, rather than necessarily causing what we do.

Implications for practice

  • We need to be honest and transparent about the contested nature of mental health
  • More emphasis needs to be placed on psychosocial factors
  • We need to develop shared understandings, rather than impose diagnostic categories
A common belief held within mental health services is that some kind of malfunction in a person’s biology is the main cause of someone’s problems, particularly for experiences labelled as schizophrenia. Is this belief supported by evidence? Is there an alternative way to think about biology in mental health?

Who believes what?

Staff, family members and service users hold a range of different beliefs about what causes distress or unusual experiences. Some of these models and ideas emphasise biology significantly more than others. Currently mental health services are dominated by a model of biology as a primary cause, whilst psychosocial factors have been given less significance and often seen as a trigger of an underlying biological problem. Interestingly the general public tend to favour psychosocial factors as causes1, whereas mental health staff (though with diversity within and between staff groups) tend towards biological explanations. For example, a study of British Psychiatrists found that only 0.4% thought the causes of schizophrenia are ‘primarily social’, whereas 46.1% said ‘primarily biological’ 2. This suggests that there is a potentially large mismatch in beliefs between those delivering and people receiving mental health services. Staff members have more power in these interactions and so their biologically leaning views may side-line alternative perspectives. Do services need to be more flexible in their views and give more emphasis to psychosocial factors?

Is the evidence of biological causation robust and consistent?

It is rather common for research to hit the headlines claiming to have found the biological cause of schizophrenia. There is then usually a study which fails to replicate this research, though given far less media attention 3,4. There is no firm evidence that mental distress in adult mental health is primarily caused by biochemical imbalances, genes, or something going wrong in the brain 3, 4, 5, 6.  If we focus on the evidence for schizophrenia, there has been a very well-funded research programme on biological causation for many years (vastly more than on psychosocial causation), the “problem, however, is that the overall pattern of this evidence is neither compelling nor clear” (p.785). Furthermore, the evidence has numerous issues: methodological problems, lack of replication and alternative explanations for results3, 4, 5, 6. One key issue is that the biological research base is built on a diagnosis (“schizophrenia”) which has poor scientific credibility, so any research based on such a diagnosis will be limited 5, 7. This was acknowledged by the director National Institute for Mental Health in the US8. With the diagnosis of schizophrenia, behavioural genetic research (twin and adoption studies) appear to vastly inflate the role of genetics, due to methodological weaknesses and unsustainable assumptions3,4,5,. Molecular genetics, which look at gene sequences, should be based on sound behavioural genetics which is not the case in this area. Due to the vast number of gene sequences considered in molecular genetic research, there is a significant risk of finding a ‘result’  by chance (i.e. a false positive result), which helps explains the failure of replication of research that hit headlines 3,4,5. At best molecular research would only suggest very small effects of multiple genes, and none specific to a diagnosis of schizophrenia. Also these genes do not necessarily indicate a deficit or problem but will be dependent on the environment for their expression. A simplistic model of biological causation is not sustainable as biology and environment interact and fundamentally alter each other5. 

Is there an alternative way to view biology?9

Despite the inconsistent evidence for biological causation, biology is still important. Biology enables all that we do, but it does not necessarily cause what we do. In typing this bite-size, my fingers are essential, though they are not the cause of my words and my grammatical errors stem from a complex range of current circumstances, educational background and so forth! Distress is not just in the mind, it is felt through our bodies. In all our activities we experience and feel the world through our bodies 9. Even though our bodies and brains are essential to writing poetry, dancing, singing, walking and so forth we do not class these as symptoms of an illness. So why class distress and attempts to survive difficult circumstances as an illness?  When terrible things happen to people this will alter their biology such as systems in the brain that deal with threat – this is survival. For many people the threat is ongoing and live precarious and marginalised lives which continue to shape them – such as racism, abuse, poor housing and cuts to finances. However, even if the actual threat has decreased, a person’s threat response will remain on high alert. This will influence how the person responds to the world around them – perhaps to avoid, or become aggressive quickly, which will increase the likelihood of a negative response from the social environment. This will then heighten or maintain their threat response.

What does this mean in practice?

If we accept that biology is not the primary cause of mental health issues, it means we need to rethink a significant amount of our assumptions in adult mental health and what we tell clients about their experiences. Professional training would need to be more balanced to give greater weight to psychosocial causation and alter the biological dominance in services. We have based the whole classification of distress and unusual experiences on models of physical health, and it needs to change. We cannot assume service users lack insight for not accepting their diagnosis as our insight might be called into question for our adherence to psychiatric diagnosis and beliefs in biological causation. We need to devote more time to psychosocial factors that are detrimental to people’s well-being (abusive relationships, access to education, child abuse, lack of community resources, housing). Ultimately a social-psychological model requires new social policies.  If the above critique of the role of biological causation is not accepted, it is still a fact that the role of biology in mental health is contested by a significant number of academics, professionals, people with lived experience and supporters. Ethically in the name of honesty and transparency, we should make services users aware of the contested nature of mental health and so fully informed. This will also allow more space for people to make sense of their experiences. Opening up space for a diversity of understanding is also likely to decrease conflict between service users and staff.

REFERENCES  

  1. Read, J., Magliano, L., & Beavan, V. (2013). Public beliefs about the causes of ‘schizophrenia’. In J. Read & J. Dillon (Eds.) Models of Madness (2nd) Hove: Routledge.
  2. Kingdon, D. et al. (2004). What attitudes do psychiatrist hold towards people with mental illness? Psychiatric Bulletin, 28, 401-406.
  3. Joseph, J. (2013). ‘Schizophrenia and heredity’. In J. Read & J. Dillon (Eds.) Models of Madness (2nd) Hove: Routledge.
  4. Joseph, J. (2006). The Missing Gene. New York: Algora
  5. Cromby, J., Harper, D. & Reavey, P. (2013). Psychology, mental health and distress. Hampshire: Palgrave Macmillan
  6. Read, J. (2013). Biological psychiatry’s lost cause: The ‘schizophrenic’ brain. In J. Read & J. Dillon (Eds.) Models of Madness (2nd Ed.) Hove: Routledge.
  7. Bentall, R. (2010). Doctoring the mind. London: Penguin
  8. Insel, T. (2013). Dirctor’s blog: Transforming diangosis. http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml
  9. Cromby, J. (2015). Feeling bodies: Embodying psychology. London: Palgrave

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