We are at a point in history where mental health is a prominent and necessary conversation. Despite this, the concept is still poorly understood. A major flaw with current popular conceptualization is the conflation of mental health with mental disorders. They are correlated to a large extent but are exclusive concepts. These terms are even used interchangeably - a problem that persists among academicians and professionals too.
Most people confidently claim what starts with poor mental health gets progressively worse and eventually becomes a mental disorder. This idea seems intuitive and simple – a linear progression with good mental health and severe mental disorder at the extremes of a spectrum with clearly defined clinical thresholds. This might be the case sometimes, but the relationship between mental health and mental disorder is often more complex than that. A person can feel awful for many months without having a diagnosis of a mental disorder – think lousy relationships, unsatisfactory working conditions, and the presence of a physiological illness or even a broken leg. On the other hand, an individual with a mental disorder can lead a full and satisfactory life. Poor mental health does not progress linearly or necessarily into a mental disorder.
Before we get into the crux of the debate, let me quickly provide definitions for the two terms and attempt to list out the differences.
Mental health is defined as a state of well-being in which an individual realizes their own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to their community (1).
Mental, behavioural and neurodevelopmental disorders are syndromes characterized by clinically significant disturbance in an individual's cognition, emotional regulation, or behaviour that reflects a dysfunction in the psychological, biological, or developmental processes that underlie mental and behavioural functioning (2).
Right off the bat, it sounds like mental health is firmly in the realms of day to day functioning whereas mental disorder seems to refer to clinical conditions that may cause significant dysfunction over time. Mental disorders are defined by clinical markers whereas mental health has no such criteria. Mental health seems to mean more than the absence of a mental disorder. Moreover, everyone has mental health, but not everyone has a diagnosable mental disorder.
“Wait! What do you mean everyone has mental health?
I do not. I am completely fine!”
Well, you still have mental health. Claiming everyone has mental health is the same as claiming everyone has health. You can be completely healthy or have complications, but you still exist somewhere along this spectrum. Poor mental health can be due to a disease/disorder but it could also be because you consumed a badly cooked meal that day. Your stomach might ache, you might vomit, but this does not mean you have a deadly disease. You have an acute issue with your health leading you to have a bad health day. Similarly, you can have bad mental health days too! Imagine if your day starts with an angry phone call from your manager because you overslept. You rush into work feeling anxious, skip lunch to compensate for lost time, and are on edge every time you spot your manager out of the corner of your eye. You stay after your shift to make up for your tardiness and end up feeling drained. You feel stressed and cannot relax even when you are home. You question your life and professional competency. You just spent a day with incredible stress and anxiety. However, this does not mean you have an anxiety disorder. You just had a poor mental health day.
To explain mental disorders this way, I will use an example that I absolutely hate but might help with clarity. (Sigh! Here it goes). Mental disorders can be comparable to physiological illnesses or diseases. They are not the same (Clearly illustrated by the word ‘disorder’ rather than ‘disease’ or ‘illness’) but share some similarities. Mental disorders are usually significant in affect and can cause acute or chronic challenges to an individual’s wellbeing. When you have a disease like diabetes, there is a serious threat to your wellbeing. You are forced to make lifestyle changes and might experience fatigue and weight loss. Diabetes is currently incurable, chronic, and affects your overall health unless managed. However, it is possible to have a good quality of life despite having diabetes. This is the case with mental disorders too. Having a mental disorder does not rule out good mental health.
Let us consider the example of a person with schizophrenia. Schizophrenia is a chronic mental disorder characterized by hallucinations (usually auditory), delusions and cognitive impairment. However, it is manageable with a combination of drugs, psychotherapy, and social support. People with adequate support and treatment can go on to lead full lives. In my professional life, I have worked with several individuals who live contently despite having a diagnosis of schizophrenia. With proper care and management, good mental health is possible despite having a diagnosis of a severe mental disorder.
From what I have shared already, a strong case can be made for mental health and mental disorders to exist on separate but interacting dimensions. They are not just two extremities of a single linear spectrum.
Still unconvinced? I have interesting research evidence to back this up.
About a couple of decades ago, Keyes, a prominent psychologist and researcher, sought to examine if mental health was more than the absence of a mental disorder. He interviewed around 3,000 individuals to identify if having a diagnosis of depression strongly correlated with poor mental health (which he termed ‘languishing’). On the flip side, he also investigated if people without a diagnosis of depression usually had good mental health (termed ‘flourishing’). Of the 86% of people without a diagnosis of depression, only 20% were found to be flourishing. About 66% were moderately healthy, while 14% were actually languishing. Conversely, among people with depression, only 33.3% were languishing, whereas 66.7% were flourishing or moderately healthy. This led Keyes to conclude that mental health was more than the lack of mental disorder. He conceptualized that mental health and mental disorders are correlated but exist on separate spectrums. Keyes called this the Dual-Continua model (3).
In this model, mental health and mental disorders are represented along separate axes that exist on the same plane. The mental health spectrum extends between ‘good mental health’ and ‘poor mental health’. The mental disorder spectrum extends from ‘lack of mental disorder’ to ‘severe mental disorder’. Here, the conceptualization of an individual’s mental status becomes slightly more complex but significantly more nuanced and accurate.
If an individual has relatively good mental health with no diagnosis of a mental disorder (or low severity; it is a spectrum after all), they are likely to find themselves in quadrant A. If one has poor mental health usually without a diagnosable mental disorder, they are more likely to be in quadrant B. Such a person is probably finding it hard to cope with the stresses of everyday life. In quadrant C, an individual might be experiencing a moderate to severe mental disorder accompanied by poor mental health. An individual in quadrant D will be experiencing relatively good mental health but still, carry a diagnosis of a mental health disorder. Keyes’s model accounts for the fact that a person with no mental disorder can still be struggling with their mental health and that recovery and thriving are possible despite an individual having a diagnosis of a mental disorder. I find this hopeful when compared with the reductionist, single-spectrum conceptualization that damns you to have poor mental health if you have a mental disorder.
Further benefits of such a conceptualization are that we can break the age-old myth that counselling or treatment is only for someone with a diagnosis of severe mental health disorder. This model normalizes having poor mental health, and an individual languishing is recognized and validated. Mental health struggles are just as valid as the challenges of having a mental disorder. Since they are not competing on the same spectrum, we have different standards for each. The separation also helps us understand that promoting mental health should not just be about awareness and prevention of mental disorders. We need to consider the fact that mental health is more than the lack of a mental disorder and create programs that specifically account for this. This dual-continuum also detaches mental health from a purely psychiatric or psychological phenomenon. This detachment can help unburden the stigma and neglect around mental health and prevent people from seeking help only if they recognize signs of a disorder. We can further emphasize that everyone has mental health and that it is worth paying attention to and nurturing. Mental health should not be ignored till blatant signs of a mental disorder start to emerge.
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