Biopsychosocial diversity

How about changing the term ‘neurodiversity’ to ‘biopsychosocial diversity’? As I said in a previous post, neurodiversity is an umbrella term. It actually means different things to different people. Fundamentally, it is about recognising personal differences and the need for society to adapt to those differences.

There are also disadvantages with the term ‘neurodiversity’ (see eg. previous post). It tends to imply that people’s brains are different. Of course people’s brains are not the same. They are different people. But that doesn’t necessarily mean that their differences are just due to their brains. Don’t get me wrong! Of course the brain constructs people. But so do their development and experiences, maybe particularly in the family situation but also outside.

It’s wrong to think that people are their brains (see eg. previous post). All sorts of myths are being promulgated about who we are. People need to  be understood as wholes, as their brains are only part of them. Whelpley et al (2023) note the distinction between the social and medical models of neurodiversity and the need for a more person-centred approach to neurodiversity. Maybe switching the term ‘neurodiversity’ to ‘biopsychosocial diversity’ would help to create this more personal focus.

Rethinking mental health practice

As I said, for example in my 2002 article, there is an overemphasis on psychiatric diagnosis. Nonetheless, the current diagnostic system still needs to be referenced when discussing mental health system reform, if only to avoid confusion. Over the longer term language can change. Certainly it has done so in the past, for example reflected in repeated revision of the DSM manual (see eg. previous post). 

As I have also said, the UK mental health system has become too dysfunctional and fragmented (see eg. previous post and another previous post). The problem is not just insufficient funding. Throwing more money at the problem is not going to solve it and hasn’t worked anyway. For example, waiting lists for assessment for neurodiversity are out of control (see eg. previous post). An excellent report from the N8 Research partnership (2024) on autism in children and young people makes 3 recommendations (see last post). These can be summarised more generally as (1) More integrated working within mental health services and between different services, not just health services. (2) Improve training co-produced with people with lived experience to provide and deliver holistic support which is not overmedicalised and focuses on people’s needs rather than being diagnosis-led. (3) Integrated care including both statutory and non-statutory services at local levels should be overseen by a prioritised governmental approach to addressing the crisis. 

The UK is not in the position to be able to put a large amount of money into health services and public services generally. The next UK government needs to act at pace though. Failure to provide appropriate mental health support results in poor long term outcome and high rates of associated health conditions. A major barrier in our existing systems is the perceived need for a medical diagnosis of mental health problems before people can receive support. Overmedicalisation of mental health problems also means the health system simply cannot meet the demand for all such assessments (see eg. previous post). Giving support on the basis of mental health need is required nonetheless, even if people don’t have a mental health diagnosis. Services need to be developed on the basis of this principle, co-ordinated by NHS England and implemented locally. Such a plan should be prioritised by the next government.

Rethinking neurodiversity

I very much like the definition of neurodiversity used at the spotlight conference in Bradford last year:-

Neurodiversity is the term used to describe the wide variety [of] different ways human beings think, learn, communicate and exist in the world. It is an umbrella term - a word that sums up lots of different things and helps us reframe conditions such as autism, ADHD, dyslexia as differences rather than deficits.

As I mentioned in my last post, a recent report on autism in children and young people, one of the main components of said neurodiversity (see previous post), by the N8 Research Partnership talks about the need for a radical rethink on autism. It was the result of a collaborative programme of work between Child of the North and the Centre for Young Lives. Three helpful evidenced-based recommendations are made:-

(1) Build effective partnerships between education and health professionals for assessing and supporting autistic children. This should include delivering assessments in education settings and making a holistic offer of support in schools and nurseries before and after a formal diagnosis is made. 

(2) Provide and extend access to mandatory Continuing Professional Development (CPD) courses for health, education, and social care professionals that improve understanding and awareness of autism (and related issues). These courses should include information on how to create “neurodiverse friendly” environments, and particularly raise awareness of autism in girls and ethnic minority groups. Additional training should be co-produced by individuals with lived experience, delivered to professionals, and integrated into undergraduate health and education professional training, to improve the identification of autistic girls.  

(3) Create formal partnerships at a local authority level comprising sector leaders (including schools, health, voluntary services, faith, universities, educational psychologists, and businesses) to oversee a prioritised governmental ward-level approach to addressing the autism crisis. The partnership should focus on its most disadvantaged wards and provide leadership in trialling data-driven, community and family co-produced, “whole system” approaches to improve autism support with and through education settings.

As the report says, these recommendations have resource implications but offer the potential for decreasing long-term costs by acting now. They should actually benefit the economy by increasing the employment of autistic people. Throwing money at the problem doesn’t solve it. To quote from the report:-

The time has come for everyone to cross organisational and geographical boundaries and commit to working together in the best interests of autistic CYP [children and young people] and their families.

A major barrier to progress is the overemphasis on psychiatric diagnosis (see eg. my article). This relates to the overmedicalisation of developmental and mental health problems (see eg. previous post). I very much agree with the essence of the report that support should be given on the basis of need regardless of the diagnosis of autism.

The industrialisation of neurodiversity

Nuffield Health has highlighted the need for a radical rethink on neurodiversity services (see eg. Sky news report) by its publication of data on waiting lists for assessment for ADHD and autism (see blog post). Increased public awareness of autism, ADHD and other neurodivergent conditions has led to more people seeking support and, as a Guardian report says, the “NHS faces [an] ‘avalanche’ of demand for autism and ADHD”. What’s required is a needs-based rather than diagnosis-led service, as has been argued for autism in children by a report resulting from a collaborative programme of work between Child of the North and the Centre for Young Lives. 

Neurodiversity has become an industry, often more motivated by profit than patient interest. Biomedical myths that suggest emotional problems are due to brain disorder support this development, although the neurodiversity movement itself promotes neurodiversity as not being a mental health problem. Neurodiversity in this sense means intrinsic diversity of brain function (see previous post). Society does need to adapt to individual differences but to suggest these personal differences are due to brain problems is also a biomedical myth.

The internet does seem to have made it relatively easy to sell all sorts of mental health treatments online, including psychological, medication and other physical treatments (see eg. previous post). People talk about COVID causing an increase in demand for mental health treatments, but maybe that’s just because the pandemic was associated with more widespread use of the internet. In another previous post, I expressed scepticism that COVID really increased depression and anxiety, not to minimise the emotional impact of the pandemic, and of course long COVID. Certainly, as I said in my last post, the marketing of digital apps online is out of control.  And it’s particularly the diagnosis-led basis of such interventions than can lead to their exploitation, even to corrupt business practices (see eg. yet another previous post). 

As I keep saying, the cultural process of seeking to create panaceas for emotional and other mental health problems doesn’t always work and may create more problems than it is worth (see previous post). The limitation of treatment to help people cope with their differences from others does need to be recognised, but such people should be able to obtain support if they ask for it. They don’t necessarily require a label of neurodiversity or any other mental health diagnosis to be able to make the most of that support.

Digital apps in mental health

Charlotte Blease (2023) points out that the digital health economy is out of control. There are tens of thousands of apps for people to download. The motivation for these apps may not necessarily be to improve patient care but to make profit (see eg. previous post). 

What's needed is better evidence that these apps are of any benefit to people. Placebo effects need to be controlled in research studies. As Charlotte says, many studies lack a clear description of the nature of the control. Robust placebo design is required in randomised controlled studies. As with psychotherapy trials there will always be a question in assessing the efficacy of mental health apps about the adequacy of control groups (see my BMJ letter). There is enough questioning even of the effectiveness of psychotropic medication (see eg. another previous post) and psychotherapy (see eg. yet another previous post) to reinforce the need to ensure that these apps are not really exploiting people. 

There is concern, of course, in general about misinformation on the internet (see eg. previous post). But medication and other physical treatments for mental health problems and psychological therapy are being oversold on the internet (see eg. another previous post). How are we supposed to decide which is the best app to use? Does it matter? Are they just panaceas (see yet another previous post)? I'm not saying using a digital app may not help. But we do need to recognise their limitations and potential costs and side effects.