LESSON 4 - MENTAL HEALTH ACROSS THE LIFESPAN

INTRODUCTION

Our understanding of the development of mental health across the lifespan is based
largely on our knowledge of the development of mental illness; unfortunately, we know much
less about the etiology of mental health. However, the recent, and growing, emphasis on mental
health promotion and the consequent development and evaluation of mental health programs
and indicators will facilitate advancing knowledge in this area.

In contrast, our understanding of mental health problems and mental disorders is

increasingly well developed. Most mental health problems and mental disorders develop along a
pathway, or trajectory, with gradually increasing frequency and severity of symptoms, and there
are often no clear-cut stages where a disorder is not present at one moment and present at the
next. Some disorders develop slowly over time, such as some drug use disorders, while others
can be episodic in nature, such as schizophrenia and depression. Other disorders may develop
very quickly following a major trigger event. A severely traumatic event may trigger anxiety,
depression or post-traumatic stress reactions in people who would otherwise not experience a
mental health problem.

A whole-of-lifespan approach informs our understanding of the development of mental

health problems and mental disorders and thereby informs our understanding of appropriate
interventions. The earliest signs and symptoms of a disorder may occur at any time throughout
the lifespan, but there are periods when the occurrence of particular mental health problems or
mental disorders is more likely. The nature and timing of prevention and early intervention
depends not just on the individual’s age, but on the identified pathways to mental health
problems and mental disorders, and the risk factors and critical transition points that
characterize those pathways.

LEARNING OUTCOMES: At the end of this lesson, you should be able to:

1. Understand the diversity of mental health between children and youth and adults
2. Compare the coping mechanisms across different age groups

COURSE MATERIALS

Mental Disorders Start Early and Vary Across the Lifespan

Most of us will have at least one diagnosable mental disorder before we’re 45 years old.
And most of us think that if we’re diagnosed with a disorder today, our future (and past) mental
health concerns will be related to that disorder. But will they? New evidence is challenging the
wisdom of focusing too much on the diagnosis, given that several recent studies demonstrate

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transdiagnostic etiology (Antilla et al., Goodkind 2015; Sprooten 2017), and that transdiagnostic
treatments are increasing in popularity (Meier & Meier 2017).

What if most people met the criteria, over time, for a succession of different disorders?
One two-decade study with over two million Danish participants showed just that (Plana-Ripoll
et al, 2019): every mental disorder that was diagnosed carried an increased risk that the patient
would be diagnosed at another time with other disorders, both within and across internalizing,
externalizing, and thought disorder diagnostic families. This study was conducted on patients on
inpatient and outpatient clinical registers, thus excluding those being treated in the community
and going untreated, and therefore increasing the likelihood that the research participants
experienced more complex comorbidities and lengthier treatments than usual.

In this study, Caspi and colleagues (2020) report on replication and extension of the
Danish research, using a birth cohort that was representative of the entire population of New
Zealand, a cohort whose mental health has been repeatedly and systematically assessed for
four decades. The investigators were interested in the stability of mental health diagnoses over
time. If you’ve been diagnosed with depression, for example, what are the chances you’ll be
diagnosed later with schizophrenia, anxiety, alcoholism, or one of the myriad other diagnostic
labels?

Methods

The Dunedin Study is an ongoing longitudinal cohort study of 1,037 participants, all born
in New Zealand in 1972 and 1973. When the participants were eleven (1983/84), it was the first
cohort where mental health disorders were measured in children using standardized diagnostic
interviews (Anderson et al, 1987). Subsequent diagnoses were made on 9 occasions with
strong participant retention until participants turned age 45 years. This diagnostic time-series
allowed the researchers to describe mental disorder life histories in terms of 3 developmental
parameters: age of onset, duration, and comorbid diversity.

The research group applied confirmatory factor analysis to participants’ symptoms in

order to summarize mental disorder life histories by means of a general factor of
psychopathology, the p-factor (Caspi & Moffitt, 2018; Lahey et al, 2017). They tested the
hypothesis that mental disorder life histories (p-factors), reflect compromised brain function, by
examining associations with neurocognitive deficits at age 3, a subsequent cognitive decline
from childhood to adulthood, and advanced brain age in midlife, as derived from neuroimaging.

Results

Approximately one-third (346 of 1,013) of the cohort experienced an initial onset of a

disorder by age 15 years, and nearly two-thirds (600 of 1,013) experienced an initial onset of a
disorder by age 18 years.

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 Early onset was associated with more years with a disorder and more comorbid
disorders. Participants with early-onset disorders subsequently met diagnostic criteria for more
diverse disorder types (r = 0.64; 95% CI, 0.60 to 0.67; P < .001).

A large majority of the participants eventually experienced a disorder: by age 45,

86% of the cohort met the criteria for at least one disorder. Although these findings suggest
that a majority of the population has a mental health disorder at one or more points, it’s a
relatively small minority who sustain enduring mental health disorders (14% in this cohort).

Participants characterized by only one pure disorder were atypical. For example, among
participants ever diagnosed with an internalizing disorder, most (503/712) also experienced
externalizing or thought disorders and another 16% (113/712) had multiple kinds of internalizing
disorders.

Longitudinal analyses showed that participants with extensive mental disorder life
histories had poor neurocognitive functioning at age 3 years, experienced childhood-to-
adulthood cognitive decline, and older brain age at midlife.

Conclusions

Most participants had one or more mental disorders by the time they are 45, and most of
those who later had chronic or severe mental disorders showed evidence of problems at the
age of three.

The authors concluded:

“Mental disorder life histories are better described by age of onset, duration, and
diversity of disorder than by any particular diagnosis. The finding that most mental disorder life
histories involve different successive disorders helps to account for genetic and neuroimaging
findings pointing to transdiagnostic causes and cautions against over-reliance on diagnosis-
specific research and clinical protocols”.

Applying a life-course framework to mental health problems orients research and

practice away from looking for the cause of a single disorder at one point in time toward
considering the dynamics of an individual’s mental disorder life history. This means encouraging
researchers to design tools to assess an individual’s life-course vulnerability to
psychopathology, identify causes of this vulnerability, explain why this vulnerability manifests in
different diagnoses at different points in the life course, and develop transdiagnostic prevention.

Strengths and limitations

This is a report on a complex analysis of longitudinal data, part of an enormous multi-

decade project involving over a thousand participants and hundreds of professionals conducting
cognitive, physical, financial, psychological, and mental health assessments on these
participants every few years. The data analysis was carefully considered and reconsidered from
different angles, meeting a high standard of evolving best practice in psychological assessment
techniques and statistical methods.

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 One of the strengths (as well as limitations) of this report is that the participants
comprise a complete cohort of people born in a single place (Dunedin, New Zealand) in a single
year, 1972/73. They were not chosen because of a propensity to mental disorders, an important
strength, but they all come from the same city in the same year, a limitation. They are
predominantly White, and lived through the same historic period. The fact that the findings
replicate a very large Danish study (Plana-Ripoll, et al, 2019) mitigates the geographic
homogeneity of the participants, although, in both studies, the participants were predominantly
White.

This is a compelling and fascinating report. This report revealed that mental health
disorders are as prevalent as they are, or that diagnoses vary so dramatically across time within
a single individual. The biggest strength of this research may be its importance in informing
professional practice, research, and public health education. The biggest limitation is the ethnic
homogeneity of the research participants. It is important to investigate whether or not the same
findings apply to people from other cultures and races.

Implications for practice

Currently, most research programs, treatment protocols, specialist clinics, and specialist
journals are oriented to presenting diagnoses, on the assumption that a person’s diagnosis
provides information about causes and prognosis. This study indicates, however, that a current
diagnosis should be seen as a starting place for understanding a dynamic and temporary
situation; one that will probably change over time. Instead of focusing on the current diagnosis
as a static label of a person’s permanent mental health status, then, mental health practitioners
and others would do well to focus on the current symptoms and the complexities of the
individual’s personal life situation and journey.

This study’s findings argue against too much reliance on diagnostic labels, and for
considering each person’s mental health as dynamic, changing over time with changing
situations, experiences, and support. We should pay attention to alleviating troublesome
symptoms as they show up, and avoid categorizing people as mentally ill, or not. The authors
write:

“Therapy cannot just mitigate the presenting symptoms, but must also build skills for
maintaining enduring mental health. The life-course approach makes transdiagnostic
interventions a high priority”.

Perhaps the most urgent implication is the fact that all of those who go on to have
serious or chronic mental disorders show up as needing help as children and teens, many as
early as age three. These findings underline the importance of investing in children’s and
adolescents’ mental health, both prevention and treatment, especially because too few children
receive effective treatment in a timely fashion.

The results of this investigation encourage researchers to design tools to assess an

individual’s life-course vulnerability to psychopathology, identify causes of this vulnerability,

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explain why this vulnerability manifests in different diagnoses at different points in the life
course, and develop transdiagnostic prevention.

Finally, this study highlights the prevalence of mental illness in the population and the
importance of public health education concerning this. Knowing that 86% of us will have at least
one mental disorder by the time we’re 45 and that 85% of this group (73% of the population) will
have at least one other (different) diagnosis should go a long way toward removing the cultural
stigma against mental illness.

SUGGESTED READINGS/REFERENCES:

Matthews, D. (2021, April 27). Mental Disorders Start Early and Vary Across the Lifespan: It’s

time to pay attention to the whole person and less to the diagnosis. The Mental Elf.
https://www.nationalelfservice.net/treatment/mental-illness-prevention/mental-disorders-
early-onset/

ACTIVITIES/ASSESSMENT:

Stop and Think:

How can you know if you are mentally ill or not?

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