‘I’m severely depressed.’
These were the words that Donesha*, a 35 year-old African American woman repeatedly uttered to me. I was a medical student in the psychiatric emergency room of a large County Hospital. She was my patient.
She told me she had felt like this for a week or so. I asked her if she had any other symptoms of depression. Did she feel more tired than usual? Did she experience joy out of life? Did she find it difficult to focus? Did she feel like going to sleep and never waking up? She had few symptoms of depression, was not suicidal, and was able to work and look after her 3 children. Still, she maintained, ‘I’m severely depressed’.
We talked further. She told me that she had turned 35, and thought she would be further along in life. But here she was, still single, still trapped in the same job. It made her unhappy. But this wasn’t the place for her. The psych ER was for the violently psychotic, the despairingly suicidal, the intoxicated aggressive. It was not a place for minor depression, and certainly not common unhappiness.
I discussed the case with the attending psychiatrist. I wanted to know how to fill out the paperwork, confident she had no psychiatric diagnosis.
‘Put mood NOS.’
Mood Disorder, Not Otherwise Specified, I mumbled. How could I diagnose her with a mood disorder when she had none? The answer was it was necessary for reimbursement. Here, in the County’s repository of madness, was a woman who was not mentally ill. Far away from the psychiatric emergency room, in the American community at large was an apparent epidemic of mental illness, unrecognized and untreated, that had been uncovered.
In 2005, amidst the devastation of Hurricane Katrina, the jubilation of the first free elections in Iraq, and the horror of Terrorist attacks in London, the results of a study in mental illness were quietly erupting. The National Comorbidity Survey-Replication, a large nationally representative household survey, including more than 9000 participants had found that Americans, in the course of their lifetime would be as likely as not to experience at least one mental illness. Fully 1 in 2 Americans, the study suggested would have a mental disorder at some point in their lives. This was not the first study of its kind, but it was the most up to date. In 1994, the same investigator, Dr. Ronald Kessler, a Professor of Health Care Policy at Harvard Medical School had published the results of a similar study with almost identical results. The 2005 paper had merely replicated the results using the most recent criteria in the latest edition of the American psychiatric bible, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The story does not end there. Dr. Kessler and his group, in a re-analysis of the data from the National Comorbidity Survey Replication have upwardly estimated the prevalence of mental disorders in America – they estimate 57.4% of Americans can expect to meet the diagnostic threshold for at least one mental illness. Many, 27.7% to be more specific, will have 2 or more mental illnesses.
What do the results of this survey mean, and, does it even matter? To be sure, cancer and heart disease are also common. For a comparison, 1 in 3 Americans can expect to have cancer at least once in their lifetime, 1 in 4 will die of cancer. Similarly, roughly 1 in 3 will develop heart disease in the course of their life. Taken in this context, perhaps there should be nothing unsettling about viewing mental illness as common too. There should be nothing inherently suspicious about these numbers, and yet, the first reaction of many is one of incredulity.
Can mental illness really be that common? If we are more likely than not to experience mental illness, what value does the term even have? Has there really been a dramatic rise in mental illness in America? These are some of the questions that you might begin to ask. They are certainly pertinent questions. Criticisms abound: mental illness is over-diagnosed, we have become to quick to seek a pill for every ill, doctors have become too quick to acquiesce, pharmaceutical companies too greedy. These may all be true, but none of them apply to the results of this study, which looked at distribution of mental illness in the community, many of who had never been diagnosed by a mental health professional.
Others criticisms surface: we keep inventing new mental illnesses, we keep redefining the boundaries between mental health and mental illness, the supposed increase in mental illness represents what would have been seen as minor misery in the past. Those who believe there has been an increase in mental disorder retort that life is more stressful, diagnostic surveys reveal the hidden depths of the epidemic of mental illness, that we are aware of disorders we weren’t before, and minor mental health problems take their toll on the individual and society. These illnesses can and should be treated. These arguments get to the heart of the numbers. They address their significance in a country where more than 50% are believed to suffer from mental illness in their lifetime.
There have been many books that have looked at the creation of mental illness, how psychiatry and the pharmaceutical industry have medicalized and psychologized normal behavior, or problems that are moral, spiritual, even social in nature, for pecuniary gain. These texts tend to begin with the American psychiatric bible – the DSM. They note how the first edition in 1952 had only 106 diagnoses, a relatively slender volume at 130 pages. By the time of DSM-III in 1980, where there was major departure from the original format, the number of included diagnoses proliferated to 265, fleshing out the volume to 494 pages. DSM-5 is about to make its appearance, and with it, many diagnoses also make their debut. With new diagnoses comes new research funding, and new treatments, the most lucrative of which are almost always drugs. But the story doesn’t start there. Other books look at how the explosion of apparent mental illness coincided with the drugs revolution in psychiatry. But the story doesn’t start there either.
The belief that we’re all crazier than we like to think, that the boundaries between mental health and mental illness aren’t as clear cut as is often made out is not a recent phenomenon. Rather, it started over 100 years ago. In 1909 a neurologist by the name of Sigmund Freud stepped foot on American soil to deliver lectures on his theory of human mind and behavior and its associated talking cure, psychoanalysis. Freud’s views and those of his disciples were to dominate American Psychiatry for almost half a century. Among these views were the fluidity of the boundaries between mental health and illness; that we were less aware of our motivations than we realized, and importantly, as the title of one of Freud’s works put it, there is a psychopathology of everyday life. When psychodynamic psychiatry declined and biological psychiatry became the ascendant model in American psychiatry, because it was wedded to making diagnoses in the same way other medical specialties used diagnoses to assert expertise and moral authority, it became necessary to create new diagnoses and revise the threshold for the diagnosis of existing disorders. Biological Psychiatry was enabled by a symbiotic relationship with the pharmaceutical industry, which, from the 1950s onwards had profited handsomely from public interest in the new medicines for their psychic woes.
There is one actor that is frequently ignored, conveniently forgotten, accidentally exonerated. It is ironically the character that has the largest role, the most to answer for. It is American Society itself. Psychiatry, whether psychodynamic or biological, whether using psychotherapy or medication, whether in the 1950s or today, by focusing on the individual, provided deflection from the most difficult questions of all. Was it something about the structure of American Society itself that was causing so much unhappiness? Was psychiatry the solution to most of this unhappiness? What was it that made Americans so eager to turn to the mental health industry for help with their psychic angst, be it on the couch or on repeat prescription? Is our co-option of a psychiatric discourse to explain misery prevalent in America making us ill?
In a century of tremendous social, political, and economic upheaval that would leave American the only legitimate superpower on the world stage, it became more convenient to displace to the source of misery onto the individual than to question the structure of American Society itself. What no one quite imagined was that the mental health industry would become unstoppable, with seemingly no end to the situations that could make us mentally ill, no person too well to benefit from therapy. Eventually the mental health industry became a poisoned chalice, rather than deflecting from society’s failings, it added to them. America became paralyzed by an apparent epidemic of mental illness, an epidemic it had created, but could no longer control.
*Name and Identifying details changed to protect confidentiality.