Political and ethical dilemmas for psychiatrists in the media

Digital, social and print media, as well as radio and television have transformed the reach of health professionals to inform the public about self-care and health promotion, as well as about the signs and symptoms of a range of illnesses including cancer, heart disease and mental illnesses. The information provided is usually based on the latest research or a synthesis of previous research offering particular new recommendations or reinforcing old messages, especially around lifestyle management. Knowledge is shared about when help-seeking is appropriate and who might be able to provide appropriate care. These schema or scripts have been described as illness perceptions or explanatory models when focused narrowly on health services, and could be useful to consider in population approaches where the range of potential pathways is greater, more variable and closely linked to social and cultural assets. Media is also used now in anti-stigma campaigns, involving leading and well-known sports personalities, actors or political leaders acknowledging and sharing their personal stories with the wider public in the hope that others will not hesitate to seek help.

There are also media reporting guidelines encouraging sensitive and careful reporting of incidents of self-harm or suicide, or of violence and riots, and even of terrorism as behaviours and ideas spread and lead to epidemics. Television programmes in particular, but theatre and performance generally, also depict the harrowing dilemmas and suffering faced by many with mental illnesses, to share this with the wider public but also to foster empathy and intrigue when placed within a good plotline. Television dramas frequently depict simplified and somewhat sharper characterisations of specific mental illnesses and their consequences, making good use of dramatic licence, yet risk stereotypical or stigmatising portrayals that may do more harm for public mental health. The language used, whether descriptive, behavioural or diagnostic, also needs care so as to not overly emphasise psychiatric diagnoses as totally discrete and mutually exclusive, or that each is allied to unique care pathways and interventions to promote recovery. Mental health experts inform, advise and even take part in campaigns to improve mental health and to encourage self-awareness and appropriate help-seeking, demystifying much of medical practice for the public so shared decision-making is the norm rather than an exception.

An area less well explored is whether psychiatric experts have a role to play in political discourse, leadership and decision-making. It is well established that top negotiators must have emotional intelligence and know how to escalate and de-escalate tension to avoid impasse. This expertise is not dissimilar to that needed resolving political violence in Northern Ireland, or what is being applied now within the Brexit negotiations. The ease with which negotiations become polemical, personalised and politically polarised is not difficult to see in everyday political discourse around the world.

Should psychiatrists, and mental health professions more generally, have a privileged voice or status when concern is expressed about the mental health of public figures, especially those in positions of power and authority? The American Psychiatric Association supports the Goldwater principle that it is unethical for psychiatrists to comment on the mental health of public figures, unless there is proper authorisation including consent from the person and there is a comprehensive assessment.^{1, 2} The Royal College of Psychiatrists endorses this position, yet there is much heated debate given what is at stake, especially when considering the current political crisis facing the US President. This is not the first time a political leader who adopts strong opinions that promotes nationalism and isolation attracts criticism for fear of not learning historical lessons about atrocities that can be committed in a political climate that oppresses freedom of speech or criminalises the opposing political parties, neither of these being directly relevant to the USA.³ There is concern that professional narcissism or hubris must be mitigated or guarded against.^{4, 5} The debate in this month's BJPsych makes for a riveting read. Experts from the USA and from the UK thoughtfully and robustly rehearse arguments and counterarguments on what is acceptable and what is actually necessary on the basis of what is at stake or ‘a duty to warn’ (see Gartner, Langford and O'Brien, pp. 633–637).

Returning to more conventional scenarios facing clinicians, Adshead et al emphasise ethical and legal dilemmas around consent to treatment, where dialogue is needed before shared decision-making is possible (pp. 630–632). The principle of shared decision-making is not optional and is not sufficiently well applied they argue. Shared decision-making should be an ethical imperative for high-quality care and professional practice, so that patients’ interests and perspectives are not neglected. Although not framed in terms of ethics, how do advances in the diagnostic practice for bipolar disorders and mood disorders influence tools used to assess symptoms and procedures for diagnoses, and ultimately care pathways (see Scott & Murray, pp. 627–629)?

Premature mortality of those with serious mental illness is a well-recognised challenge for prevention, public health and care services. Hosang et al show that childhood neglect, abuse or any sort of maltreatment are associated with greater medical morbidity among patients with bipolar mood states when compared with unipolar mood states or no mood state; there was a dose–response relationship showing the highest risks among those experiencing at least two forms of maltreatment (pp. 645–653). The findings argue for more assertive prevention and care interventions for medical illness among people experiencing maltreatment in childhood, especially if they are at high risk of developing bipolar illnesses.

Dementia presents a major public health challenge with significant neuropsychiatric and medical morbidity. Two studies show that those with depressive symptoms and anxiety are at higher risk of cognitive impairment and vascular dementia, respectively (Zheng et al, pp. 638–644 and Becker et al, pp. 654–660). The social and relational isolation faced by people with dementia is known to be associated with more disabilities. There is some evidence that cognitive stimulation, through mentally engaging interventions that are enjoyable and help socialisation, reduce cognitive decline. An analysis of data including those aged 50 or more from the English Longitudinal Study of Ageing shows a lower incidence rate of dementia at 10-year follow-up among those visiting museums (Fancourt et al, pp. 661–663). The association was independent of demographics, socioeconomic conditions, sensory impairment and depression, as well as vascular conditions and other form of community connections. We need to better understand the mechanisms that may mediate these effects before promoting museum attendance per se or closely related influences as preventive interventions.