Practitioner 2011 – 255 (1746): 30

It’s a fine line between health and illness

16 Dec 2011


Professor David Haslam CBE FRCGP
President of the BMA, Past President RCGP, National Clinical Adviser to the Care Quality Commission


I’ve still got it. I’m not by nature a hoarder, but i’ve kept this note for 30 years.

Scribbled in child-like handwriting on a torn-off scrap of lined paper, it came from a middle-aged lady and simply said: ‘Doctor. Please help me. My husband is out of work, and we haven’t got enough to live on. I really can’t cope. It’s freezing and we are all hungry. Could you do me a prescription for some more Valium?’

Of course, this patient’s unhappiness could not be eased by Valium, or these days by an SSRI, though how many people have used non-prescription pharmacology over the generations to make the intolerable seem bearable? A glass of Shiraz might seem comforting, but can’t solve the problems.

The curious borderline between normality and abnormality in mental health is one of the trickiest areas on the primary care map. It isn’t just the complexity of the distinction between justifiable unhappiness and depression.

The more I study depression the less I think I understand it. The fact that someone has massive social problems doesn’t automatically mean that he or she can’t be suffering from a biochemical depression and vice versa.

However, discerning the point at which medication is appropriate can be ludicrously difficult, and full of unintended consequences.

For instance, if a GP offers treatment to someone who is distressed by their living conditions and the intransigence of an unsympathetic council housing department, and as a result of medication he or she feels better, then will those living conditions ever improve? But how can we be certain that the cause of the depression really is the living conditions? Could it not be that the cause is infinitely more complex? When do we become agents of the status quo?

Questions like this rarely have time to impact on our busy day-to-day tasks of helping patients cope with everything that life throws at them, but when such a note appears, this all gets put into sharp relief. The border between mental health and mental health problems gets more blurred by the day.

When does natural shyness become social anxiety? When does low self-esteem become a treatable condition? There are no clear dividing lines between any of these conditions, as they all lie along a spectrum with normality at one end, and insanity, if such a term still has any meaning, at the other.

These aren’t simply the idle thoughts of a doctor with too much time to think. They are the realities that we all face every day.

When a patient asked if I would prescribe medication to help her lose weight, she was asking a hugely complex question. One of the reasons she is overweight is the abuse she suffered as a child which has destroyed her feelings of self-worth. This has not only led

to overeating but a number of overdoses as well. Is she ill?

When another patient told me of his obsession with internet porn, and asked to see a psychologist to help him understand his urges, was he ill? Does the fact that his wife died in her twenties make any difference?

Our role is a complex one. We lurk in the murky waters between health and illness, frequently with little in the way of guidelines that help us. When we do offer help, that act can become part of the justification of the problem. ‘If I wasn’t ill, the doctor wouldn’t have helped, so it must be an illness.’

And when we decide help isn’t appropriate, what prejudices or pragmatism will have driven that decision?