Where to draw the line between mental health and illness?

Schizophrenia is considered an illness by nearly all Finns, while grief and homosexuality are not. On the other hand, opinions vary greatly on whether alcoholism, work exhaustion, drug addiction and gambling addiction are illnesses.

Defining mental disorders and illnesses is not straightforward. Notions of whether a certain phenomenon should be classified as an illness or disorder, or something falling within the category of normal emotional fluctuations or personality traits, have changed significantly over the years, and continue to do so.

“It’s difficult to draw a definite line between normal and abnormal behaviour, or to know when mental symptoms should be called a disease. For instance, grief and anxiety can be normal reactions to a difficult stage in life, but they may also underlie severe depression or an anxiety disorder,” says Kari Tikkinen, the principal author of a research article on this topic who is an Academy of Finland clinical researcher and adjunct professor at the University of Helsinki.

In a study carried out with a Finnish dataset, an international group of researchers looked into which mental conditions from a group of 20 were considered illnesses and which were not by five different groups of people. The questionnaire was distributed to 6,200 individuals, of whom 3,000 were Finns chosen randomly from the Population Register. The rest included 1,500 physicians – a number of psychiatrists and other specialists – 1,500 nurses and, in addition, all of the 200 members of the Finnish Parliament. The researchers received 3,259 responses (53%).

The respondents were asked whether they would define the following conditions as diseases: ADHD, alcoholism, anorexia, autism, bulimia, premature ejaculation, homosexuality, drug addiction, depression, panic disorder, gambling addiction, personality disorder, absence of sexual desire, schizophrenia, social anxiety disorder, grief, transsexualism, work exhaustion, insomnia and generalised anxiety disorder.

At least 75% of respondents in all groups considered schizophrenia and autism illnesses, while a corresponding share did not consider homosexuality and grief illnesses.

In all groups, ADHD, anorexia, bulimia, depression, panic disorder, personality disorder and generalised anxiety disorder were classified as diseases by 50–75% of respondents. The same number of respondents did not classify premature ejaculation, absence of sexual desire and transsexualism as diseases.

The widest range of views concerned alcoholism, drug and gambling addiction, social anxiety disorder, insomnia and work exhaustion.

Psychiatrists were most inclined to classify the conditions included in the questionnaire as diseases, followed by other physicians, nurses, members of parliament and laypeople.

“In other words, the more psychiatric training you had, the more likely you were to consider the conditions diseases. The difference between psychiatrists and laypeople was substantial,” Tikkinen says.

People’s notions of what is and is not a disease is very important in the discourse on mental health and human behaviour. These notions also influence the allocation of society's resources and the stigmatisation of various groups of people.

“Society's attitude towards alcoholics and drug addicts largely depends on whether substance abuse is considered an illness or a life choice,” Tikkinen points out.

“The medicalisation of various problems is not a positive trend either; it may result in non-medical causes being overlooked, solving problems with an approach that is too reliant on pharmaceuticals.”

Further information:

Kari Tikkinen, Academy of Finland clinical researcher and adjunct professor, University of Helsinki and Helsinki University Hospital

Email kari.tikkinen@gmail.com

Reference: Kari AO Tikkinen, Jarno Rutanen, Allen Frances, et al. Public, health professional, and legislator perspectives on the concept of psychiatric disease: population-based survey. BMJ Open 2019