Half of Us Are Mentally Ill (and the Other Half Are Undiagnosed)

In a New York Review of Books essay, Marcia Angell, former editor of The New England Journal of Medicine, considers three books that take skeptical looks at "the epidemic of mental illness" sweeping the country:

The tally of those who are so disabled by mental disorders that they qualify for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) increased nearly two and a half times between 1987 and 2007—from one in 184 Americans to one in seventy-six. For children, the rise is even more startling—a thirty-five-fold increase in the same two decades....

A large survey of randomly selected adults, sponsored by the National Institute of Mental Health (NIMH) and conducted between 2001 and 2003, found that an astonishing 46 percent met criteria established by the American Psychiatric Association (APA) for having had at least one mental illness within four broad categories at some time in their lives. 

Angell poses some questions about this epidemic:

Is the prevalence of mental illness really that high and still climbing? Particularly if these disorders are biologically determined and not a result of environmental influences, is it plausible to suppose that such an increase is real? Or are we learning to recognize and diagnose mental disorders that were always there? On the other hand, are we simply expanding the criteria for mental illness so that nearly everyone has one? And what about the drugs that are now the mainstay of treatment? Do they work? If they do, shouldn't we expect the prevalence of mental illness to be declining, not rising?

As those questions suggest, Angell seems to share the skepticism of the authors whose books she reviews: University of Hull psychologist Irving Kirsch, who in The Emperor's New Drugs shows that antidepressants are only slightly more effective than placebos, so slightly that the difference may be attributable to stronger expectations of improvement primed by the drugs' side effects; the journalist Robert Whitaker, who in Anatomy of an Epidemic argues that the "astonishing rise of mental illness in America" can be understood largely as an outgrowth of the desire to sell psychiatric drugs; and Daniel Carlat, a Boston psychiatrist who confesses his profession's shortcomings in Unhinged: The Trouble With Psychiatry. Angell notes that "none of the three authors subscribes to the popular theory that mental illness is caused by a chemical imbalance in the brain." She adds that "the main problem with the theory is that after decades of trying to prove it, researchers have still come up empty-handed."

That may come as a surprise to uncritical viewers of pharmaceutical commercials or credulous readers of the APA's Diagnostic and Statistical Manual of Mental Disorders. But it is a truth acknowledged even by many psychiatrists, including the chief editor of the current DSM, who recently despaired that the attempt to define mental disorders is "bullshit." Despite psychiatry's medical pretensions, the equation of mental illnesses with brain diseases remains little more than an assumption. In fact, as Thomas Szasz observes in the preface to the 50th anniversary edition of The Myth of Mental Illness, once a particular pattern of behavior can be confidently ascribed to a physical defect, such as the brain damage caused by advanced syphilis or Alzheimer's disease, it is no longer considered a psychiatric issue. "Contemporary 'biological' psychiatrists tacitly recognized that mental illnesses are not, and cannot be, brain diseases," Szasz writes. "Once a putative disease becomes a proven disease, it ceases to be classified as a mental disorder and is reclassified as bodily disease."

Angell does not mention Szasz in the first installment of her essay, and I suspect he will be absent from the second part as well. It is OK to agree with Szasz about psychiatry's lack of scientific rigor as long as you do not acknowledge that you are agreeing with him. In an upcoming book review for Reason, I note that the renegade psychiatrist's ideas are routinely dismissed as obsolete at a time when they seem more relevant than ever.

[via Stanton Peele, who comments on Angell's review here]

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  • ||

    So how do you explain Warty, then?

    On topic, any psychologist who is honest will tell you that the reason they went into psychology was first and foremost to fix/understand themselves.

  • ld||

    Or because psych was a fun major and they just wanted to spend their life getting paid for chatting with people.

    That's why my friend is in it.

    I almost went into psychology (-> on path to psychiatry or maybe EM currently), but I was mainly interested in purely research. Research sucks, however.

  • ||

    Not all of them, but quite a lot of them.

  • hlm||

    What libertarian activist, who used to call himself the Italian Stallion, used to collect SSI on the basis of being mentally disabled?

  • Restoras||

    Rocky Balboa was a libertarian activisist? Who knew?

  • ||

    ADRIAN

  • Scruffy Nerfherder||

    My friend Harvey disagrees with this diagnosis.

  • tote-road||

    Interesting. Half? I thought only 21% identify themselves as liberals.

  • Zeb||

    And 29% identify as conservatives, so it all adds up.

  • Michael Savage||

    Liberalism is a mental disorder.

  • Sparky||

    Well if the Bible is to be believed then all of humanity sprang from a handful of inbred families. That must be where all the mental defects come from. Thankfully our great government has disallowed incestuous relations thus saving us from further mental degradation.

    THANKS GOVERNMENT!

  • Thick-headed||

    So, you want to bang your sister?

  • Sparky||

    Not my sister. My mom on the other hand...

  • James McMurtry||

    Ruth Ann and Linda are second cousins to me. Man, I don't care I want to get between 'em.

  • H man||

    If we weren't all crazy we would go insane.

  • ||

    Do she really want to prove Tom Cruise and his crazy cult right?

  • ||

    THIS IS WHAT SCIENTOLOGISTS ACTUALLY BELIEVE

  • ||

    Thank you Trey Parker

  • Sparky||

  • Mensan||

    Jonathan Coulton is awesome.

  • X||

    So mental illness has grown since a diagnosis became a paycheck instead instead of institutionalization? Thank science correlation isn't causation.

  • ld||

    I would imagine some of the "mental illness" that are included in the 50% lifetime ratio are things like adjustment disorders and other diagnostic categories that are used mainly to help clinicians to avoid diagnosing individuals with actual mental illnesses.

    Otherwise, that is indeed very high. There are quite a few parts of the DSM that I personally (current medical student, planning on entering psych) consider actual mental disorders. Rather, I think they are actually closer to what Szasz calls "of the soul". Quite a few can still benefit from psychiatric or (moreso, since medication has less use in most of these cases, although it can still be helpful) psychologist interventions. This is not to say that I am a dualist like Szasz and Sullum, but rather that they aren't disorders so much as variations in the normal spectrum of personality. In most cases.

    On the other hand, I think many things, including major depression, bipolar affective disorder, schizophrenia, PTSD, and quite a few others are pretty clearly specific problems with brain functioning. I also think all of them (including schizophrenia) exist on a spectrum from normal to worst case. That does not make them less physical in some way. Quite a few clearly physical medical problems are judged on a spectrum (most, really, when you get down to it, except trauma).

    And, as I say every time I respond to a Sullum thread doubting the actuality of mental illness, the very fact that there are verifiable psychiatric symptoms that diagnose non-psychiatric problems would seem to make it likely that the psychiatric symptoms that are a bit more complex to pinpoint might also be related to something not entirely immaterial.

  • ld||

    TL;DR, there are plenty of things to criticize about psychiatry. Still not a good idea to throw the baby out with the bath water.

    Also, dualism is so passe. Functionalism4lyfe. Or at least reductive materialism.

  • Hugh Akston||

    Or at least reductive materialism

    That just leads (inevitably, don'tchaknow) to being a massive dick like Sam Harris.

  • ld||

    I've always thought that too. I

  • ||

    So what is wrong with Charlie Sheen then?

  • ||

    Charlie is on a drug, it's called Charlie Sheen. It's not available because if you try it you will die. Your face will melt off and your children will weep over your exploded body.

  • ld||

    Nothing. Charlie Sheen is just being a boss.

  • BOOM||

    Winning.

  • Sparky||

    IOW, sometimes an asshole is just an asshole?

  • ld||

    Most assholes are just assholes.

    Although, a related story:

    When I was working in the psych part of our ER, we had this guy come in repeatedly for being an asshole (fights, threatening people, etc) and getting injured for it, and he always made it over to our side of the ER from the main section after claiming suicidal thoughts. Pretty sure he never had them, but who can say. He was also consistently a dick

    However, we finally convinced him to go to a partial program (like an inpatient psych program but instead you go home at night). He came back about 2 months later with a thank you card and cookies for our section of the ER. He was in successful treatment for bipolar affective disorder, and he was no longer a dick. My attending pointed out to me that sometimes people are actually not just an asshole, but only an asshole when not in treatment. She also then pointed out that there were quite a few people who were never assholes, no matter how much bad they were. So on the grand scale of things, still kinda an asshole.

  • Sparky||

    So he was an asshole AND a dick but then you turned him into a pussy (but still an asshole sometimes). Sounds like that guy is fucked.

  • Dark Helmet ||

    I knew it! I'm surrounded by assholes! Well, keep firing assholes!

  • Barely Suppressed Rage||

    It's assholes all the way down, sir.

  • Joe M||

    I think bipolar might be one of the few conditions that is legitimate. I have a friend that has it all together, but about five years ago he started acting really strangely at work, with this creepy twinkle in his eyes, talking about how some people were just pure evil. I thought he was dropping acid on the job or something.

    Turns out he had been taking medicine for manic depression for years, and had recently changed his exercise regime, screwed up his drug dosage, and stopped taking his medicine (I think it was Lithium) completely.

    He had to be temporarily committed, but he got back on his meds and has been totally fine since. He apparently once took a rowboat out into the middle of a lake during high school while babbling about meeting god or somesuch, which got him the initial prescription. Purely anecdotal, but still.

  • ld||

    I think BPAD and schizophrenia are the two biggies that people do not doubt once they've interacted with someone who has a severe form of them.

    Depression and PTSD (and many other disorders), it's just so easy for people to say that the people should just suck it up. I think people have a harder time understanding it is a real problem because they have a better idea of what the people are feeling. I mean we've all been sad. And most of us can imagine being extra jumpy if we've seen our parents hacked to death in front of us. It's the extremes that really grab our attention as "whoa, something is really different here" whereas, there is actual differences in the other areas as well.

  • ld||

    I think BPAD and schizophrenia are the two biggies that people do not doubt once they've interacted with someone who has a severe form of them.

    Depression and PTSD (and many other disorders), it's just so easy for people to say that the people should just suck it up. I think people have a harder time understanding it is a real problem because they have a better idea of what the people are feeling. I mean we've all been sad. And most of us can imagine being extra jumpy if we've seen our parents hacked to death in front of us. It's the extremes that really grab our attention as "whoa, something is really different here" whereas, there is actual differences in the other areas as well.

  • Sparky||

    Posted once from each personality???

  • Some Sock Puppet||

    It's hard to get others to understand that in order to "Suck it up" you need an off-switch.

    People with PTSD don't have control over that. That's the whole damn problem.

    Flesh is willing, Mind is weak or somesuch.

  • Sy||

    I had an LCSW diagnose me with PTSD several years ago.
    It's not that some people LACK an off-switch, but it takes some serious work to find it.
    I think the medications that they use to treat the condition just exacerbate the condition and delay any real work being done to engage that 'off-switch'

  • Some Sock Puppet||

    Certainly. I've got it as well. Just putting my perception of it.

    Feels like my instincts are in overdrive and overstimulated and I don't know how to make them stop.

    At one point in my life I was very good at sucking it up. I dealt with every day with a grim determination, but something broke.

    I do agree with your second statement.

    To me, it almost feels like the more I try to supress or deny the reactions I'm having, the worse it's getting. Similar, to me, to having a good cry being better than bottling it all up.

  • ld||

    Also, it may be my selective experience, but I've never heard any of the psychiatrists I worked with in the ER, research, and now in medical school describe things as a chemical imbalance.

    That was, however, a very popular explanation in the past. I'm not sure if that was what psychiatrists actually believed, or if it was just a very simplified way of saying things. But not one psychiatrist or resident I've worked with has ever used that explanation when I've been around.

    The closest I've heard is that there is a correlation between decreased (some neurotransmitter) and/or increased (some neurotransmitter) and symptoms.

  • ||

    What about "hormone imbalance"? That was big when I was a teen.

  • ld||

    Hormone overproduction or underproduction has all sorts of effects. They can have psychiatric effects but I don't think that most classical psychiatric disease are generally caused by them.

    But yeah, sex hormones have a big effect on affect. PMS for example (which is, incidentally, a much smaller phenomenon than most people think it is).

  • s||

    "On the other hand, I think many things, including major depression, bipolar affective disorder, schizophrenia, PTSD, and quite a few others are pretty clearly specific problems with brain functioning."

    Of course you do you fucking quack. And you're prepared to remove the liberty of anyone you so label.

  • Restoras||

    Well I self-medicate with as much weed/booze/exercise/sex/golf/photography/obsessing-over-my-favorite-baseball-team/(insert other hobby here) that I can and still function somewhat normally, so I'm fine, just fine.

  • ||

    This is admittedly an unscientific opinion, but right after it was announced that Mr. Weiner Tweeter was going to some sort of "rehab" I noticed that his defenders started responding to demands for his resignation with whining about "he's addicted, he needs help, etc." So I wonder if sometimes "mental illness" is just a way of avoiding responsibility for one's actions.

  • ||

    ..and how!!

  • Restoras||

    Well, we all know no one in the Potomac Swamp wants to be held accountable for anything, so does that make them all mentally ill?

  • Zeb||

    Only when it is convenient for them.

  • Joe M||

    That's the whole problem with the "addiction is a disease" nonsense that is commonly accepted.

  • Zeb||

    There can be little doubt that that is sometimes the case. How often, I am not sure.

    The South Park episode on sex addiction was pretty great.

  • ld||

    I think this almost all the time with politicians.

    There are people who have problems with sexual behavior (and I think there is a range of reasons for this, some more a "disorder" some more about poor inhibitory control). I think it's almost never the case with politicians, just a nice way to hide after getting caught.

  • Restoras||

    Yep. It's just another, umm, extension of power for them...at least for the boys.

  • Some Sock Puppet||

    Like anything else that human hands touch, it's corrupted and abused.

  • Namon||

    Randy be snitchin

  • Zeb||

    The way I look at mental illness and treatment for mental illness is more or less "if it works for you, go for it".

    I personally think that most of it is bullshit, but most of the people I know who see a psychologist are pretty realistic about it and recognize that most of the value of it is having someone to talk to who is getting paid to listen to whatever you have to say and who will not tell anyone else or do anything to make you feel worse about it. I can see that there is some value in that for many people.

  • Sparky||

    I'm with you. I think some people just want to be special in some way when really they're just ordinary folk like everyone else.

  • ||

    There's a big difference between psychology, and psychiatry. The first being mostly normal people that have normal problems but want professional help. Zeb's example. I wouldn't necessarily call them mentally ill. The later is for people that have a real biochemical problem which pharma can help. Bipolar, Schzio, ect.

    I think the increases we are seeing is a product of a few things. 1. Better diagnosis 2. Expansion of definitions 3. Pharma advertisements. Too many people see a commercial with a list of symptoms and a cure presented in a pill, and think they need that pill. I had a chat with my doctor once and I asked how often he sees people coming in that self diagnosed themselves from the Internet. He replied, before the Internet it was magazines.

    I don't think we have more mental illness, we've just changed how we go about handling it.

  • ld||

    I disagree about most being bullshit.

    However, I do think that the majority of people who see a therapist do not have what I consider a real psychiatric problem. I think some did, at one point, but liked continuing on. I think others never did, but either felt some sort of benefit from it or felt like it was the thing to do (I think this is rare, but I've met at least one person who actually started seeing a therapist because their friends liked it. I don't think they particularly enjoyed it at all though).

    I know people who went into psychology, hoping to mostly work with people that did not have major psychiatric illnesses, because it's easier, and often pays far far better.

  • jtuf||

    I'm also pro-choice when it comes to the psychiatric industry, but too many people enter the psychiatric industry through coercion. All to often, people are forcibly committed to psychiatric wards in hospitals or sent to a shrink's office as a child by a government school.

  • ld||

    I don't mind kids in public education being sent to see a psychiatrist or psychologist (generally a better choice, IMO) to evaluate learning or behavioral problems. It should be up to the parent whether to act on them though. (Or, rather, whether to even see them, but I think few parents would mind their kid being interviewed compared to being forced on medication). I do think evaluations can have an important educational role, and so long as their are public schools, it doesn't bother me that they do something that can help.

    Not a big fan of forced anything, however.

  • jtuf||

    Great post, Sullum. I'm glad to see Reason tackle the psychiatric industry.

  • Jeff P||

    I get hungry every 4 to 6 hours.
    I get erections I cannot control.
    I feel relief when shitting.

    My god what's wrong with me?

  • ||

    I get erections I cannot control.

    STEVE SMITH?

  • A Serious Man||

    "It is OK to agree with Szasz about psychiatry's lack of scientific rigor as long as you do not acknowledge that you are agreeing with him."

    Well would you want to agree with a guy that inspired a Batman villain?

  • ld||

    "It is OK to agree with Szasz about psychiatry's lack of scientific rigor as long as you do not acknowledge that you are agreeing with him. "

    I find this an interesting statement. I always think Sullum does his best when he ignores Szasz, but this is just blatantly advertising Szasz.

    There are quite a few reasons these individuals might not mention Szasz.

    1. He has a bad association. But they agree with his ideas. (What Sullum seems to be suggesting).

    2. They disagree with one (or likely, more) of many of his ideas, and as such do not mention him.

    There are so many ways. I, for one, am quite critical of a few aspects of psychiatry, not even counting theoretical aspects that I haven't seen (in my admittedly more "cutting edge" experience) that I would disagree with, such as the chemical imbalance explanation.

    I wouldn't mention Szasz if I wrote a critical piece about most of them, because I flat out disagree with his fundamental views. However, if (and only if) I was writing about problems with medico-legal issues and forced treatment, then I would acknowledge Szasz, because while I disagree with most of his critique of psychiatry in general, I think his contribution from a libertarian point of view is valid and worthy of noting.

  • ld||

    "It is OK to agree with Szasz about psychiatry's lack of scientific rigor as long as you do not acknowledge that you are agreeing with him. "

    I find this an interesting statement. I always think Sullum does his best when he ignores Szasz, but this is just blatantly advertising Szasz.

    There are quite a few reasons these individuals might not mention Szasz.

    1. He has a bad association. But they agree with his ideas. (What Sullum seems to be suggesting).

    2. They disagree with one (or likely, more) of many of his ideas, and as such do not mention him.

    There are so many ways. I, for one, am quite critical of a few aspects of psychiatry, not even counting theoretical aspects that I haven't seen (in my admittedly more "cutting edge" experience) that I would disagree with, such as the chemical imbalance explanation.

    I wouldn't mention Szasz if I wrote a critical piece about most of them, because I flat out disagree with his fundamental views. However, if (and only if) I was writing about problems with medico-legal issues and forced treatment, then I would acknowledge Szasz, because while I disagree with most of his critique of psychiatry in general, I think his contribution from a libertarian point of view is valid and worthy of noting.

  • ||

    Is the prevalence of mental illness really that high and still climbing?

    Perhaps the Iron Law can provide some guidance:

    You get more of what you reward . . .

  • William Shakespeare||

    I am not mad; I would to heaven I were! For then, ’tis like I should forget myself; O, if I could, what grief should I forget!

  • Albert Einstein||

    Insanity: doing the same thing over and over again and expecting different results.

  • Albert Einstein||

    Insanity: doing the same thing over and over again and expecting different results.

  • Barely Suppressed Rage||

    Again?

  • Joe M||

    C-c-c-c-combo breaker!

  • Barely Suppressed Rage||

    Interesting - I was just reading this piece last night - opining that most people are depressed simply because their lives suck, not because there's something wrong within their brains. Seems apropos here.

  • Some Sock Puppet||

    Good piece.

  • CE||

    Yeah, it sucks to be us, living in an age of comfort and plenty, with riches unknown to most of mankind throughout recorded history and unrecorded pre-history.

  • Some Sock Puppet||

    It's all in perspective. Debt is just as mentally taxing as wondering where your next meal is coming from, just not as simple in concept.

  • cbmclean||

    comfort != happiness

    of course,

    discomfort != happiness

    and I am beginning to suspect that

    happiness = {}

  • Robert||

    It's not clear to me what portion of the depressed are so because their lives suck, and what portion because they think their lives suck for false reasons that cognitive therapy can't shake. For instance, what if you're depressed because of the invisible Nazis under your bed who are keeping you prisoner there? Or because you died in an accident nobody ever witnessed and are now a zombie controlled by Raoul Castro?

  • JD the Elder||

    That's not a bad essay, although my take is slightly different: it's not that people's lives suck so much as that they think things should be better. There is, IMO, a strong tendency in the American psyche to believe that you should be rich AND have passionate true love AND a fulfilling career AND be in excellent shape AND travel AND have hobbies, and, and, and. We also tend to believe that all these things are achievable, and if you don't have them, it's your own fault.

    By way of comparison, if you were raised in a time and place where you believed that the good life consisted of being a goat farmer just like your father was before you, and having a spouse and a few children and not seeing too many of either your family or your livestock die before their time - well, that's probably pretty achievable. So we've created, unintentionally, a culture that's going to produce a lot of unsatisfied, unhappy people.

  • Some Sock Puppet||

    End result of all the forced medicating of our children for ADD?

  • CE||

    The really interesting question is why placebos are so effective for such a wide range of ailments.

  • Invisible Finger||

    If Congress is any indication, maybe mental illness IS contagious.

  • Invisible Finger||

    The first paragraph of the NYT review alone explains the problem - mental illness is essentially a government-enabled scam. People are encouraged to be mentally ill so they can get some free government money.

  • Neu Mejican||

    On the epidemiology of mental illness:

    The 50% lifetime occurrence sounds bad until you put it into perspective. Lifetime occurrence of disease is 100%. Everyone gets sick in some way at sometime during their lifetime. For half of people, that can include a mental issue (typically short lived) that is significant enough to count. What people do with "mental illness," however, is conflate "chronic mental illness" with "mental illness." And they also conflate "mental illness" with "seriously disturbed." But just as most people don't end up with chronic physical issues, most don't suffer from chronic mental illness. And, indeed, as most instances of disease don't require intervention from a professional, most instances of mental illness are mild and don't require professional intervention.

  • Neu Mejican||

    And if you want an example of someone conflating "mental illness" with "chronic mental illness" you need go no further than the headline of this here article ("are mentally ill" implying "chronically" - although, I guess, it could be misinterpreting the 50% lifetime occurrence to mean that half of people are mentally ill in any given time frame - an even worse misunderstanding of the epidemiology - but not on that I would put past JS)

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