In “The Epidemic of Mental Illness: Why?” (New York Review of Books, 2011), Marcia Angell, former editor-in-chief of the New England Journal of Medicine, discusses over-diagnosis of psychiatric disorders, pathologizing of normal behaviors, Big Pharma corruption of psychiatry, and the adverse effects of psychiatric medications. While diagnostic expansionism and Big Pharma certainly deserve a large share of the blame for this epidemic, there is another reason.
A June 2013 Gallup poll revealed that 70% of Americans hate their jobs or have “checked out” of them. Life may or may not suck any more than it did a generation ago, but our belief in “progress” has increased expectations that life should be more satisfying, resulting in mass disappointment. For many of us, society has become increasingly alienating, isolating, and insane, and earning a buck means more degrees, compliance, ass-kissing, shit-eating, and inauthenticity. So, we want to rebel. However, many of us feel hopeless about the possibility of either our own escape from societal oppression or that political activism can create societal change. So, many of us, especially young Americans, rebel by what is commonly called mental illness.
While historically some Americans have consciously faked mental illness to rebel from oppressive societal demands — e.g., a young Malcolm X acted crazy to successfully avoid military service — today, the vast majority of Americans who are diagnosed and treated for mental illness are in no way proud malingerers in the fashion of Malcolm X. Many of us, sadly, are ashamed of our inefficiency and nonproductivity and desperately try to fit in. However, try as we might to pay attention, adapt, adjust, and comply with our alienating jobs, boring schools, and sterile society, our humanity gets in the way, and we become anxious, depressed, and dysfunctional.
The Mental Illness Epidemic
Severe, disabling mental illness has dramatically increased in the Untied States. Marcia Angell, in her 2011 New York Review of Books piece, summarizes: “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 1 in 184 Americans to 1 in 76. For children, the rise is even more startling—a thirty-five-fold increase in the same two decades.”
Angell also reports that a large survey of adults conducted between 2001 and 2003 sponsored by the National Institute of Mental Health found that at some point in their lives, 46% of Americans met the criteria established by the American Psychiatric Association for at least one mental illness.
In 1998, Martin Seligman, then president of the American Psychological Association, spoke to the National Press Club about an American depression epidemic: “We discovered two astonishing things about the rate of depression across the century. The first was there is now between ten and twenty times as much of it as there was fifty years ago. And the second is that it has become a young person’s problem. When I first started working in depression thirty years ago… the average age at which the first onset of depression occurred was 29.5… Now the average age is between 14 and 15.”
In 2011, the U.S. Centers for Disease Control and Prevention (CDC) reported that antidepressant use in the United States has increased nearly 400% in the last two decades, making antidepressants the most frequently-used class of medications by Americans ages 18-44 years. By 2008, 23% of women ages 40–59 years were taking antidepressants.
The CDC, on May 3, 2013, reported that the suicide rate among Americans ages 35–64 years increased 28.4% between 1999 and 2010 (from 13.7 suicides per 100,000 population in 1999 to 17.6 per 100,000 in 2010).
The New York Times reported in 2007 that the number of American children and adolescents treated for bipolar disorder had increased 40-fold between 1994 and 2003. In May 2013, CDC reported in “Mental Health Surveillance Among Children—United States, 2005–2011,” the following: “A total of 13%–20% of children living in the United States experience a mental disorder in a given year, and surveillance during 1994–2011 has shown the prevalence of these conditions to be increasing.”
Over-Diagnosis, Pathologizing the Normal, and Psychiatric Drug Adverse Effects
Even within mainstream psychiatry, few continue to argue that the increase in mental illness is due to previous under-diagnosis of mental disorders. The most common explanations for the mental illness epidemic include recent over-diagnosis of psychiatric disorders, diagnostic expansionism, and psychiatry’s pathologizing normal behavior.
The first DSM (short for Diagnostic and Statistical Manual of Mental Disorders), psychiatry’s diagnostic “bible,” was published by the American Psychiatric Association in 1952 and listed 106 disorders (initially called “reactions”). DSM-2 was published in 1968, and the number of disorders increased to 182. DSM-3 was published in 1980, and though homosexuality was dropped from it, diagnoses were expanded to 265, with several child disorders added that would soon become popular, including oppositional defiant disorder (ODD). DSM-4, published in 1994, contained 365 diagnoses.
DSM-5 was published in May, 2013. The journal PLOS Medicine reported in 2012, “69% of the DSM-5 task force members report having ties to the pharmaceutical industry.” DSM-5 did not add as many new diagnoses as had previous revisions. However, DSM-5 has been criticized even by some mainstream psychiatrists such as Allen Frances, the former chair of the DSM-4 taskforce, for creating more mental patients by making it easier to qualify for a mental illness, especially for depression (see Frances’s (“Last Plea To DSM-5: Save Grief From the Drug Companies”).
In the last two decades, there have been a slew of books written by journalists and mental health professionals about the lack of science behind the DSM, the over-diagnosis of psychiatric disorders, and the pathologizing of normal behaviors. A sample of these books includes: Paula Caplan’s They Say You’re Crazy (1995); Herb Kutchins and Stuart Kirk’s Making Us Crazy 1997); Allan Horwitz and Jerome Wakefield’s The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder (2007); Christopher Lane’s Shyness: How Normal Behavior Became a Sickness (2008); Stuart Kirk, Tomi Gomory, and David Cohen’s Mad Science: Psychiatric Coercion, Diagnosis, and Drugs (2013); Gary Greenberg’s The Book of Woe: The DSM and the Unmaking of Psychiatry (2013); and Allen Frances’s, Saving Normal (2013).
Even more remarkable than former chair of the DSM-4 taskforce, Allen Frances, jumping on the DSM-trashing bandwagon has been the harsh critique of DSM-5 by Thomas Insel, director of the National Institute of Mental Health (NIMH). Insel recently announced that the DSM’s diagnostic categories lack validity, and that “NIMH will be re-orienting its research away from DSM categories.” And psychiatrist Robert Spitzer, former chair of the DSM-3 task force, wrote the foreword to Horwitz and Wakefield’s The Loss of Sadness and is now critical of DSM’s inattention to context in which the symptoms occur which, he points out, can medicalize normal experiences.
So, in just two decades, pointing out the pseudoscience of the DSM has gone from being an “extremist slur of radical anti-psychiatrists” to a mainstream proposition from the former chairs of both the DSM-3 and DSM-4 taskforces and the director of NIMH.
Yet another explanation for the epidemic may also be evolving from radical to mainstream, thanks primarily to the efforts of investigative journalist Robert Whitaker and his book Anatomy of an Epidemic (2010). Whitaker argues that the adverse effects of psychiatric medications are the primary cause of the epidemic. He reports that these drugs, for many patients, cause episodic and moderate emotional and behavioral problems to become severe, chronic, and disabling ones.
Examining the scientific literature that now extends over 50 years, Whitaker discovered that while some psychiatric medications for some people may be effective over the short term, these drugs increase the likelihood that a person will become chronically ill over the long term. Whitaker reports, “The scientific literature shows that many patients treated for a milder problem will worsen in response to a drug — say have a manic episode after taking an antidepressant — and that can lead to a new and more severe diagnosis like bipolar disorder.”
With respect to the dramatic increase of pediatric bipolar disorder, Whitaker points out that, “Once psychiatrists started putting ‘hyperactive’ children on Ritalin, they started to see prepubertal children with manic symptoms. Same thing happened when psychiatrists started prescribing antidepressants to children and teenagers. A significant percentage had manic or hypomanic reactions to the antidepressants.” And then these children and teenagers are put on heavier-duty drugs, including drug cocktails, often do not respond favorably to treatment, and deteriorate. And that, for Whitaker, is a major reason for the thirty-five-fold increase between 1987 and 2007 of children classified as being disabled by mental disorders (see my 2010 interview with him, “Are Prozac and Other Psychiatric Drugs Causing the Astonishing Rise of Mental Illness in America?”).
Whitaker’s explanation for the epidemic has now, even within mainstream psychiatric institutions, entered into the debate; for example, Whitaker was invited by the National Alliance for the Mentally Ill (NAMI) to speak at their 2013 annual convention that took place last June. While Whitaker concludes that psychiatry’s drug-based paradigm of care is the primary cause of the epidemic, he does not rule out the possibility that various cultural factors may also be contributing to the increase in the number of mentally ill.
Mental Illness as Rebellion Against Society
The most deadly criticism one could make of modern civilization is that apart from its man-made crises and catastrophes, is not humanly interesting… In the end, such a civilization can produce only a mass man: incapable of spontaneous, self-directed activities: at best patient, docile, disciplined to monotonous work to an almost pathetic degree… Ultimately such a society produces only two groups of men: the conditioners and the conditioned, the active and passive barbarians.
— Lewis Mumford, 1951
Once it was routine for many respected social critics such as Lewis Mumford and Erich Fromm to express concern about the impact of modern civilization on our mental health. But today the idea that the mental illness epidemic is also being caused by a peculiar rebellion against a dehumanizing society has been, for the most part, removed from the mainstream map. When a societal problem grows to become all-encompassing, we often no longer even notice it.
We are today disengaged from our jobs and our schooling. Young people are pressured to accrue increasingly large student-loan debt so as to acquire the credentials to get a job, often one which they will have little enthusiasm about. And increasing numbers of us are completely socially isolated, having nobody who cares about us.
Returning to that June, 2013 Gallup survey, “The State of the American Workplace: Employee Engagement”, only 30% of workers “were engaged or involved in, enthusiastic about, and committed to their workplace.” In contrast to this “actively engaged group,” 50% were “not engaged”, simply going through the motions to get a paycheck, while 20% were classified as “actively disengaged”, hating going to work, and putting energy into undermining their workplace. Those with higher education levels reported more discontent with their workplace.
How engaged are we with our schooling? Another Gallup poll “The School Cliff: Student Engagement Drops With Each School Year” (released in January, 2013), reported that the longer students stay in school, the less engaged they become. The poll surveyed nearly 500,000 students in 37 states in 2012, and found nearly 80% of elementary students reported being engaged with school, but by high school, only 40% reported being engaged. As the pollsters point out, “If we were doing right by our students and our future, these numbers would be the absolute opposite. For each year a student progresses in school, they should be more engaged, not less.”
Life clearly sucks more than it did a generation ago when it comes to student loan debt. According to American Student Assistance’s “Student Debt Loan Statistics,” approximately 37 million Americans have student loan debt. The majority of borrowers still paying back their loans are in their 30s or older. Approximately two-thirds of students graduate college with some education debt. Nearly 30% of college students who take out loans drop out of school, and students who drop out of college before earning a degree struggle most with student loans. As of October 2012, the average amount of student loan debt for the Class of 2011 was $26,600, a 5% increase from 2010. Only about 37% of federal student-loan borrowers between 2004 and 2009 managed to make timely payments without postponing payments or becoming delinquent.
In addition to the pain of jobs, school, and debt, there is increasingly more pain of social isolation. A major study reported in the American Sociological Review in 2006, “Social Isolation in America: Changes in Core Discussion Networks Over Two Decades,” examined Americans’ core network of confidants (those people in our lives we consider close enough to trust with personal information and whom we rely on as a sounding board). Authors reported that in 1985, 10% of Americans said that they had no confidants in their lives; but by 2004, 25% of Americans stated they had no confidants in their lives. This study confirmed the continuation of trends that came to public attention in sociologist Robert Putnam’s 2000 book Bowling Alone.
Underlying many of psychiatry’s nearly 400 diagnoses is the experience of helplessness, hopelessness, passivity, boredom, fear, isolation, and dehumanization — culminating in a loss of autonomy and community-connectedness. Do our societal institutions promote:
Enthusiasm — or passivity?
Respectful personal relationships — or manipulative impersonal ones?
Community, trust, and confidence — or isolation, fear and paranoia?
Empowerment — or helplessness?
Autonomy (self-direction) — or heteronomy (institutional-direction)?
Participatory democracy — or authoritarian hierarchies?
Diversity and stimulation — or homogeneity and boredom?
Research (that I documented in Commonsense Rebellion) shows that those labeled with attention deficit hyperactivity disorder (ADHD) do worst in environments that are boring, repetitive, and externally controlled; and that ADHD-labeled children are indistinguishable from “normals” when they have chosen their learning activities and are interested in them. Thus, the standard classroom could not be more imperfectly designed to meet the learning needs of young people who are labeled with ADHD.
As I discussed last year in AlterNet, in “Would We Have Drugged Up Einstein? How Anti-Authoritarianism Is Deemed a Mental Health Problem,” there is a fundamental bias in mental health professionals for interpreting inattention and noncompliance as a mental disorder. Those with extended schooling have lived for many years in a world where all pay attention to much that is unstimulating. In this world, one routinely complies with the demands of authorities. Thus for many M.D.s and Ph.D.s, people who rebel against this attentional and behavioral compliance appear to be from another world — a diagnosable one.
The reality is that with enough helplessness, hopelessness, passivity, boredom, fear, isolation, and dehumanization, we rebel and refuse to comply. Some of us rebel by becoming inattentive. Others become aggressive. In large numbers we eat, drink, and gamble too much. Still others become addicted to drugs — illicit and prescription. Millions work slavishly at dissatisfying jobs, become depressed and passive-aggressive, while no small number of us can’t cut it and become homeless and appear crazy. Feeling misunderstood and uncared about, millions of us ultimately rebel against societal demands, however; given our wherewithal, our rebellions are often passive and disorganized, and routinely futile and self-destructive.
When we have hope, energy, and friends, we can choose to rebel against societal oppression with, for example, a wildcat strike or a back-to-the-land commune. But when we lack hope, energy, and friends, we routinely rebel without consciousness of rebellion and in a manner in which we today commonly call mental illness.
For some Americans, no doubt, the conscious goal is to get classified as mentally disabled so as to receive disability payments (averaging $700 to 1,400 per month). But isn’t that, too, a withdrawal of cooperation from society and a rebellion of sorts, based on the judgment that this is the best-paying and least miserable financial option?
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.