Attitudes to Mental Illness

Ever wondered what the British public think about mental illness?

Well, the British government has, and the results of the 2010 Attitudes to Mental Illness Survey are out. I'm never sure how much faith to put in such data because what people are willing to say they think, and what they really feel, are not the same.

So while it's encouraging that only 20% of people say they agree with the statement that "Anyone with a history of mental illness should be excluded from taking public office", it would be naive to think that the other 80% would really be equally likely to vote for someone with a psychiatric history when push came to shove. We've moved on since McGovern, but maybe not all that much.

Worse, a lot of the questions are dubious. One asks whether you agree that "Mental hospitals are an outdated means of treating people with mental illness", the 'right' answer, that gets counted as a nice positive attitude, being to agree. I disagree, not least because inpatient treatment for depression helped my grandfather hugely when he was a young man. If that means I have a bad attitude to the mentally ill, so be it. I don't think it does.

*

Another item asks "What proportion of people in the UK do you think might have a mental health problem at some point in their lives?" The approved answer, as Neuroskeptic readers may have guessed, was 1 in 4. But only 16% of the British public picked that option from the multiple-choice quiz. Most thought it was much lower:

How silly of them...or maybe not. There has in fact never been a study of the lifetime prevalence of mental illness in Britain. Studies in other English-speaking countries, such as the US and New Zealand, have repeatedly shown lifetime prevalence rates of 50%, or higher, for mental illness according to DSM-IV criteria. But these figures and these criteria have been credibly accused of overstating the proportion of people with a genuine psychiatric illness, maybe greatly so. There's a lot to say on both sides of this debate, but the point is that the question is open. Expecting the public to know the answer, when the experts don't, is rather unfair.

However, interestingly enough, this very survey asked whether respondents had ever suffered mental illness themselves. How many had? There's a 4 in it, but it's not 1 in 4, it's 4%.

I strongly suspect this is an underestimate. Some people are ill and don't know it or don't admit it. People with mental illness might be less likely to participate in the study. There'll be people will get ill at some point in their lives after they fill in the survey. And the format of the question was a bit odd (see page 64 and see what you make of it). But still, this is another point of data for the great prevalence debate.

The proportion of people with mental illness ultimately depends on how you define "mental illness". I don't think anyone has an entirely satisfactory definition, so any attempt to pin down the lifetime prevalence is problematic until we sort that out, but if I had to put it a number on it, it would be about 1 in 10 in Western countries.

I'm no expert on this topic so take this with a big pinch of salt. Still, I'd find it very hard to accept a figure much lower than this, from personal experience if nothing else. I'd be open to the idea that the true figure is much higher, but this would mean that tens of millions of British people are going around getting mentally ill and never receiving treatment, and it would take some very strong evidence to convince me of that.

Attitudes to Mental Illness

Ever wondered what the British public think about mental illness?

Well, the British government has, and the results of the 2010 Attitudes to Mental Illness Survey are out. I'm never sure how much faith to put in such data because what people are willing to say they think, and what they really feel, are not the same.

So while it's encouraging that only 20% of people say they agree with the statement that "Anyone with a history of mental illness should be excluded from taking public office", it would be naive to think that the other 80% would really be equally likely to vote for someone with a psychiatric history when push came to shove. We've moved on since McGovern, but maybe not all that much.

Worse, a lot of the questions are dubious. One asks whether you agree that "Mental hospitals are an outdated means of treating people with mental illness", the 'right' answer, that gets counted as a nice positive attitude, being to agree. I disagree, not least because inpatient treatment for depression helped my grandfather hugely when he was a young man. If that means I have a bad attitude to the mentally ill, so be it. I don't think it does.

*

Another item asks "What proportion of people in the UK do you think might have a mental health problem at some point in their lives?" The approved answer, as Neuroskeptic readers may have guessed, was 1 in 4. But only 16% of the British public picked that option from the multiple-choice quiz. Most thought it was much lower:

How silly of them...or maybe not. There has in fact never been a study of the lifetime prevalence of mental illness in Britain. Studies in other English-speaking countries, such as the US and New Zealand, have repeatedly shown lifetime prevalence rates of 50%, or higher, for mental illness according to DSM-IV criteria. But these figures and these criteria have been credibly accused of overstating the proportion of people with a genuine psychiatric illness, maybe greatly so. There's a lot to say on both sides of this debate, but the point is that the question is open. Expecting the public to know the answer, when the experts don't, is rather unfair.

However, interestingly enough, this very survey asked whether respondents had ever suffered mental illness themselves. How many had? There's a 4 in it, but it's not 1 in 4, it's 4%.

I strongly suspect this is an underestimate. Some people are ill and don't know it or don't admit it. People with mental illness might be less likely to participate in the study. There'll be people will get ill at some point in their lives after they fill in the survey. And the format of the question was a bit odd (see page 64 and see what you make of it). But still, this is another point of data for the great prevalence debate.

The proportion of people with mental illness ultimately depends on how you define "mental illness". I don't think anyone has an entirely satisfactory definition, so any attempt to pin down the lifetime prevalence is problematic until we sort that out, but if I had to put it a number on it, it would be about 1 in 10 in Western countries.

I'm no expert on this topic so take this with a big pinch of salt. Still, I'd find it very hard to accept a figure much lower than this, from personal experience if nothing else. I'd be open to the idea that the true figure is much higher, but this would mean that tens of millions of British people are going around getting mentally ill and never receiving treatment, and it would take some very strong evidence to convince me of that.

How to Stop Smoking

1. Don't smoke.
2. See 1.

This is essentially what Simon Chapman and Ross MacKenzie suggest in a provocative PloS Medicine paper, The Global Research Neglect of Unassisted Smoking Cessation: Causes and Consequences.

Their point is deceptively simple: there is lots of research looking at drugs and other treatments to help people quit smoking tobacco, but little attention is paid to people who quit without any help, despite the fact that the majority (up to 75%) of quitters do just that. This is good news for the pharmaceutical industry and others who sell smoking-cessation aids, but it's not clear that it's good for public health.

As they put it,

despite the pharmaceutical industry’s efforts to promote pharmacologically mediated cessation and numerous clinical trials demonstrating the efficacy of pharmacotherapy, the most common method used by most people who have successfully topped smoking remains unassisted cessation ... Tobacco use, like other substance use, has become increasingly pathologised as a treatable condition as knowledge about the neurobiology, genetics, and pharmacology of addiction develops. Meanwhile, the massive decline in smoking that occurred before the advent of cessation treatment is often forgotten.

Debates over drugs, or other treatments, tend to revolve around the question of whether they work: is this drug better than placebo for this disorder? Chapman and MacKenzie point out that even to frame an issue in these terms is to concede a lot to the medical or pathological approach, which may not be a good idea. Before asking, do the drugs work? We should ask, what have drugs got to do with this?

Their argument is not that drugs never help people to quit; nor are they saying that tobacco isn't addictive, or that there is no neurobiology of addiction. Rather, they are saying that the biology is only one aspect of the story. The importance of drugs (and other stop-smoking aids like CBT), and the difficulty of quitting, is systematically exaggerated by the medical literature...

Of the 662 papers [about "smoking cessation" published in 2007 or 2008], 511 were studies of cessation interventions. The other 118 were mainly studies of the prevalence of smoking cessation in whole or special populations. Of the intervention papers, 467 (91.4%) reported the effects of assisted cessation and 44 (8.6%) described the impact of unassisted cessation (Figure 1).... Of the papers describing cessation trends, correlates, and predictors in populations, only 13 (11%) contained any data on unassisted cessation.

And although pharmaceutical industry funding of research plays a part in this, the fact that medical science tends to focus on treatments rather than on untreated individuals is unsurprising since this is fundamentally how science works:

Most tobacco control research is undertaken by individuals trained in positivist scientific traditions. Hierarchies of evidence give experimental evidence more importance than observational evidence; meta-analyses of randomized controlled trials are given the most weight. Cessation studies that focus on discrete proximal variables such as specific cessation interventions provide ‘‘harder’’ causal evidence than those that focus on distal, complex, and interactive influences that coalesce across a smoker’s lifetime to end in cessation.

Overall, it's an excellent paper and well worth a read in full (it's short and it's open access). Of course, it is itself only one side of the story and many in the tobacco control community will find it controversial. But I think Chapman and MacKenzie's is a point that needs to be made, and point applies to other areas of medicine, especially, although not exclusively, to mental health. This week, British social care charity Together told us that

Six out of ten of people have had at least one time in their life where they have found it difficult to cope mentally... stress (70%), anxiety (59%) and depression (55%) were the three most common difficulties encountered by the public

Which was not still not quite as good as rivals Turning Point who last month said

Three quarters of people in the UK experience depression occasionally or regularly yet only a third seek help

These were opinion surveys, not real peer-reviewed science, but they might as well have been: the best available science says that if you go and ask people, 50-70% of the population report suffering at least one diagnosable DSM-IV mental disorder in their lifetime, and that the majority receive no treatment at all. This leads to papers in major journals such as this one warning that "Depression Care in the United States" is "Too Little for Too Few."

But we don't know whether these tens of millions of cases of untreated "mental illness" should be treated, because there is basically no research looking at what happens to such people without treatment. On the other hand, the very fact that they aren't treated, and yet manage to hold down jobs, relationships and so forth, suggests that the situation is not so bad.

Of course we must never forget that depression and anxiety can be crippling diseases, but fortunately, such cases are at least comparatively rare. By using the word "depression" to cover everything from waking-up-at-4-am-in-a-suicidal-panic-melancholia to feeling-a-bit-miserable-because-something-bad-just-happened, it's easy to forget that while clinical depression is a serious matter, feeling a bit miserable is normal and resolves without any help 99% of the time. Even though there are no published scientific studies proving this, because it's not the kind of thing scientists study.

Incidentally, this issue is a good reminder that there's no one big bad conspiracy behind everything. With smoking, Big Tobacco find themselves in direct opposition to Big Pharma, like in From Dusk Till Dawn when the psychopaths fight the vampires. With depression, the people who are quickest to decry the widespread use of antidepressants often seem to be the ones who are most keen on the idea that depression is common and under-treated, perhaps because it allows them to recommend their own favorite psychotherapy. Big Pharma hands the baton to Big Couch in the race to medicalize life.

Chapman S, & MacKenzie R (2010). The global research neglect of unassisted smoking cessation: causes and consequences. PLoS medicine, 7 (2) PMID: 20161722

How to Stop Smoking

1. Don't smoke.
2. See 1.

This is essentially what Simon Chapman and Ross MacKenzie suggest in a provocative PloS Medicine paper, The Global Research Neglect of Unassisted Smoking Cessation: Causes and Consequences.

Their point is deceptively simple: there is lots of research looking at drugs and other treatments to help people quit smoking tobacco, but little attention is paid to people who quit without any help, despite the fact that the majority (up to 75%) of quitters do just that. This is good news for the pharmaceutical industry and others who sell smoking-cessation aids, but it's not clear that it's good for public health.

As they put it,

despite the pharmaceutical industry’s efforts to promote pharmacologically mediated cessation and numerous clinical trials demonstrating the efficacy of pharmacotherapy, the most common method used by most people who have successfully topped smoking remains unassisted cessation ... Tobacco use, like other substance use, has become increasingly pathologised as a treatable condition as knowledge about the neurobiology, genetics, and pharmacology of addiction develops. Meanwhile, the massive decline in smoking that occurred before the advent of cessation treatment is often forgotten.

Debates over drugs, or other treatments, tend to revolve around the question of whether they work: is this drug better than placebo for this disorder? Chapman and MacKenzie point out that even to frame an issue in these terms is to concede a lot to the medical or pathological approach, which may not be a good idea. Before asking, do the drugs work? We should ask, what have drugs got to do with this?

Their argument is not that drugs never help people to quit; nor are they saying that tobacco isn't addictive, or that there is no neurobiology of addiction. Rather, they are saying that the biology is only one aspect of the story. The importance of drugs (and other stop-smoking aids like CBT), and the difficulty of quitting, is systematically exaggerated by the medical literature...

Of the 662 papers [about "smoking cessation" published in 2007 or 2008], 511 were studies of cessation interventions. The other 118 were mainly studies of the prevalence of smoking cessation in whole or special populations. Of the intervention papers, 467 (91.4%) reported the effects of assisted cessation and 44 (8.6%) described the impact of unassisted cessation (Figure 1).... Of the papers describing cessation trends, correlates, and predictors in populations, only 13 (11%) contained any data on unassisted cessation.

And although pharmaceutical industry funding of research plays a part in this, the fact that medical science tends to focus on treatments rather than on untreated individuals is unsurprising since this is fundamentally how science works:

Most tobacco control research is undertaken by individuals trained in positivist scientific traditions. Hierarchies of evidence give experimental evidence more importance than observational evidence; meta-analyses of randomized controlled trials are given the most weight. Cessation studies that focus on discrete proximal variables such as specific cessation interventions provide ‘‘harder’’ causal evidence than those that focus on distal, complex, and interactive influences that coalesce across a smoker’s lifetime to end in cessation.

Overall, it's an excellent paper and well worth a read in full (it's short and it's open access). Of course, it is itself only one side of the story and many in the tobacco control community will find it controversial. But I think Chapman and MacKenzie's is a point that needs to be made, and point applies to other areas of medicine, especially, although not exclusively, to mental health. This week, British social care charity Together told us that

Six out of ten of people have had at least one time in their life where they have found it difficult to cope mentally... stress (70%), anxiety (59%) and depression (55%) were the three most common difficulties encountered by the public

Which was not still not quite as good as rivals Turning Point who last month said

Three quarters of people in the UK experience depression occasionally or regularly yet only a third seek help

These were opinion surveys, not real peer-reviewed science, but they might as well have been: the best available science says that if you go and ask people, 50-70% of the population report suffering at least one diagnosable DSM-IV mental disorder in their lifetime, and that the majority receive no treatment at all. This leads to papers in major journals such as this one warning that "Depression Care in the United States" is "Too Little for Too Few."

But we don't know whether these tens of millions of cases of untreated "mental illness" should be treated, because there is basically no research looking at what happens to such people without treatment. On the other hand, the very fact that they aren't treated, and yet manage to hold down jobs, relationships and so forth, suggests that the situation is not so bad.

Of course we must never forget that depression and anxiety can be crippling diseases, but fortunately, such cases are at least comparatively rare. By using the word "depression" to cover everything from waking-up-at-4-am-in-a-suicidal-panic-melancholia to feeling-a-bit-miserable-because-something-bad-just-happened, it's easy to forget that while clinical depression is a serious matter, feeling a bit miserable is normal and resolves without any help 99% of the time. Even though there are no published scientific studies proving this, because it's not the kind of thing scientists study.

Incidentally, this issue is a good reminder that there's no one big bad conspiracy behind everything. With smoking, Big Tobacco find themselves in direct opposition to Big Pharma, like in From Dusk Till Dawn when the psychopaths fight the vampires. With depression, the people who are quickest to decry the widespread use of antidepressants often seem to be the ones who are most keen on the idea that depression is common and under-treated, perhaps because it allows them to recommend their own favorite psychotherapy. Big Pharma hands the baton to Big Couch in the race to medicalize life.

Chapman S, & MacKenzie R (2010). The global research neglect of unassisted smoking cessation: causes and consequences. PLoS medicine, 7 (2) PMID: 20161722

Crazy Like Us

You've probably heard about Crazy Like Us, the new book by Urban Tribes author Ethan Watters. But you probably haven't bought it yet. You really should.

Crazy Like Us is a vivid, humane, and thought-provoking examination of "the globalization of the American psyche" - the process by which, slowly but surely, the world has adopted America's way of thinking about mental illness.

*

The key to the American approach is the 844-page Diagnostic and Statistical Manual of the American Psychiatric Association - the DSM, or as the saying goes, the Bible of psychiatry. The heart of the DSM is a long list of disorders, each with a code number, and each with an accompanying list of symptoms: Major Depressive Disorder (296.2), Post-Traumatic Stress Disorder (309.81), Schizophrenia (295.90), etc. The DSM is more than just a catalogue of names and numbers, however; it's part a conceptual system, a way of deciding what kind of feelings and behaviours are normal, and which are pathological; it's almost a philosophy of life.

On the most straightforward level, Crazy Like Us is the story of how, over the past 20 years, this system has gone from being American to international, displacing the ways of thinking found in other countries and cultures. In four chapters, Watters describes the rise of anorexia in Hong Kong, PTSD in Sri Lanka following the 2004 tsunami, schizophrenia in Madagascar, and major depressive disorder in Japan.

This much is plain fact. The DSM is now the internationally-recognized standard for psychiatric diagnosis; almost all academic papers in psychiatry make use of the American criteria, or the extremely similar ICD-10. What's interesting, however, is Watters' account of how the DSM spread so quickly to other countries, displacing what were - in many cases - equally rich and complex local vocabularies of distress and disorder.

In the case of Japan, Watters' answer is simple: the big drug companies, in the hopes of opening a new market for SSRI antidepressants, promoted the concept of clinical depression as a common ailment, through campaigns in the Japanese media. (Japan did have an "indigenous" concept of depression, utsubyo, but it was seen as a rare, serious disease, like schizophrenia.)

But in "developing" countries, such as Sri Lanka, the picture is rather more complex. Sri Lankans were eager to learn from the West about mental illness because of their respect for Western science and technology. Americans can put people into space - surely, they know a lot about everything, including medicine, including psychiatry.

*

Yet there's another level to the story of Crazy Like Us, a more interesting and more controversial one. Watters' argues that the globalization of the American way of thinking has actually changed the nature of "mental illness" around the world. As he puts it:

In the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments but also the expression of mental illness in other cultures.

Essentially, mental illness - or at least, much of it - is a way of unconsciously expressing emotional or social distress and tension. Our culture, which includes of course our psychiatric textbooks, tells us various ways in which distress can manifest, provides us with explanations and narratives to make our distress understandable. And so it happens. The symptoms are not acted or "faked" - they're as real to the sufferer as they are to anyone else. But they are culturally shaped.


The historian of psychiatry, Edward Shorter, has written of how, in late 19th century Europe, people (mostly women) were said to be especially prone to suffering from "hysterical paralysis", but every time and place has its own shared "symptom repertoire". Culture does not just create symptoms out of thin air - there has to be some kind of underlying stress. As Watters puts it

We can become psychologically unhinged for many reasons that are common to all, like personal traumas, social upheavals or biochemical imbalances in our brains. ... Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening.

Watters links anorexia in 1990s Hong Kong to the anxiety caused by the impending transfer of control from Britain to China, a geopolitical event which caused personal worry and social disruption as people or families emigrated. But it was the high-profile 1994 case of a young girl's death from self-starvation, and the subsequent media attention paid to the Western concept of Anorexia Nervosa (DSM code 307.1), that put self-starvation into the symptom repertoire for distressed young women and led to the rise in cases.

The idea that America has exported not just concepts of illness, but illnesses themselves, is a provocative one. Is it true? Commentators have pointed out that Watters' explanation of the rise of anorexia in Hong Kong is rather simplistic. There were many social and cultural changes going on during the 1990s, most of which had nothing to do with the DSM. How do we know that increasing media promotion of dieting, and the fashion for thinness, wasn't also important? In truth, we don't, but I do not think that Watters' argument requires psychiatry to be the only force at work.

*

Overall, Crazy Like Us is a fascinating book about transcultural psychiatry and medical anthropology. But it's more than that, and it would be a mistake - and deeply ironic - if we were to see it as a book all about foreigners, "them". It's really about us, Americans and by extension Europeans (although there are some interesting transatlantic contrasts in psychiatry, they're relatively minor.)

If our way of thinking about mental illness is as culturally bound as any other, then our own "psychiatric disorders" are no more eternal and objectively real than those Malaysian syndromes like amok, episodes of anger followed by amnesia, or koro, the fear the that ones genitals are shrinking away.

In other words, maybe patients with "anorexia", "PTSD" and perhaps "schizophrenia" don't "really" have those things at all - at least not if these are thought of as objectively-existing diseases. In which case, what do they have? Do they have anything? And what are we doing to them by diagnosing and treating them as if they did?

Watters' does not discuss such questions; I think this was the right choice, because a full exploration of these issues would fill at least one book in itself. But here are a few thoughts:

First, the most damaging thing about the globalization of Western psychiatric concepts is not so much the concepts themselves, but their tendency to displace and dissolve other ways of thinking about suffering - whether they be religious, philosophical, or just plain everyday talk about desires and feelings. The corollary of this, in terms of the individual Western consumer of the DSM, i.e. you and me, is the tendency to see everything through the lens of the DSM, without realizing that it's a lens, like a pair of glasses that you've forgotten you're even wearing. So long as you keep in mind that it's just one system amongst others, a product of a particular time and place, the DSM is still useful.

Second, if it's true that how we conceptualize illness and suffering affects how we actually feel and behave, then diagnosing or narrativizing mental illness is an act of great importance, and potentially, great harm. We currently spend billions of dollars researching major depressive disorder and schizophrenia, but very little on investigating "major depressive disorder" and "schizophrenia" as diagnoses. Maybe this is an oversight.

Finally, if much "mental illness" is an expression of fundamental distress shaped by the symptom pool of a particular culture, then we need to first map out and understand the symptom pool, and the various kinds of distress, in order to have any hope of making sense of what's going on in any individual on a psychological, social or neurobiological level. To put it another way, you need to understand people before you can understand psychiatry. After reading Crazy Like Us, I think I understand both a little bit better, and I strongly recommend it.

Links:

• Ethan Watters' Crazy Like Us blog.
  
• The Americanization of Mental Illness, Watters' much-read NYT article which is a fine summary of the book's argument, but being so short, misses much of the human detail which make Crazy Like Us so interesting, in particular when Watters is writing about the response of PTSD experts to the 2004 tsunami, and the life of a Madagascan woman with schizophrenia and her family.
  
• Exporting American Mental Illness, an excellent discussion of the article over at Neuroanthropology.
• Did Antidepressants Depress Japan? A 2004 article on the Japanese antidepressants and depression story.

Crazy Like Us

You've probably heard about Crazy Like Us, the new book by Urban Tribes author Ethan Watters. But you probably haven't bought it yet. You really should.

Crazy Like Us is a vivid, humane, and thought-provoking examination of "the globalization of the American psyche" - the process by which, slowly but surely, the world has adopted America's way of thinking about mental illness.

*

The key to the American approach is the 844-page Diagnostic and Statistical Manual of the American Psychiatric Association - the DSM, or as the saying goes, the Bible of psychiatry. The heart of the DSM is a long list of disorders, each with a code number, and each with an accompanying list of symptoms: Major Depressive Disorder (296.2), Post-Traumatic Stress Disorder (309.81), Schizophrenia (295.90), etc. The DSM is more than just a catalogue of names and numbers, however; it's part a conceptual system, a way of deciding what kind of feelings and behaviours are normal, and which are pathological; it's almost a philosophy of life.

On the most straightforward level, Crazy Like Us is the story of how, over the past 20 years, this system has gone from being American to international, displacing the ways of thinking found in other countries and cultures. In four chapters, Watters describes the rise of anorexia in Hong Kong, PTSD in Sri Lanka following the 2004 tsunami, schizophrenia in Madagascar, and major depressive disorder in Japan.

This much is plain fact. The DSM is now the internationally-recognized standard for psychiatric diagnosis; almost all academic papers in psychiatry make use of the American criteria, or the extremely similar ICD-10. What's interesting, however, is Watters' account of how the DSM spread so quickly to other countries, displacing what were - in many cases - equally rich and complex local vocabularies of distress and disorder.

In the case of Japan, Watters' answer is simple: the big drug companies, in the hopes of opening a new market for SSRI antidepressants, promoted the concept of clinical depression as a common ailment, through campaigns in the Japanese media. (Japan did have an "indigenous" concept of depression, utsubyo, but it was seen as a rare, serious disease, like schizophrenia.)

But in "developing" countries, such as Sri Lanka, the picture is rather more complex. Sri Lankans were eager to learn from the West about mental illness because of their respect for Western science and technology. Americans can put people into space - surely, they know a lot about everything, including medicine, including psychiatry.

*

Yet there's another level to the story of Crazy Like Us, a more interesting and more controversial one. Watters' argues that the globalization of the American way of thinking has actually changed the nature of "mental illness" around the world. As he puts it:

In the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments but also the expression of mental illness in other cultures.

Essentially, mental illness - or at least, much of it - is a way of unconsciously expressing emotional or social distress and tension. Our culture, which includes of course our psychiatric textbooks, tells us various ways in which distress can manifest, provides us with explanations and narratives to make our distress understandable. And so it happens. The symptoms are not acted or "faked" - they're as real to the sufferer as they are to anyone else. But they are culturally shaped.


The historian of psychiatry, Edward Shorter, has written of how, in late 19th century Europe, people (mostly women) were said to be especially prone to suffering from "hysterical paralysis", but every time and place has its own shared "symptom repertoire". Culture does not just create symptoms out of thin air - there has to be some kind of underlying stress. As Watters puts it

We can become psychologically unhinged for many reasons that are common to all, like personal traumas, social upheavals or biochemical imbalances in our brains. ... Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening.

Watters links anorexia in 1990s Hong Kong to the anxiety caused by the impending transfer of control from Britain to China, a geopolitical event which caused personal worry and social disruption as people or families emigrated. But it was the high-profile 1994 case of a young girl's death from self-starvation, and the subsequent media attention paid to the Western concept of Anorexia Nervosa (DSM code 307.1), that put self-starvation into the symptom repertoire for distressed young women and led to the rise in cases.

The idea that America has exported not just concepts of illness, but illnesses themselves, is a provocative one. Is it true? Commentators have pointed out that Watters' explanation of the rise of anorexia in Hong Kong is rather simplistic. There were many social and cultural changes going on during the 1990s, most of which had nothing to do with the DSM. How do we know that increasing media promotion of dieting, and the fashion for thinness, wasn't also important? In truth, we don't, but I do not think that Watters' argument requires psychiatry to be the only force at work.

*

Overall, Crazy Like Us is a fascinating book about transcultural psychiatry and medical anthropology. But it's more than that, and it would be a mistake - and deeply ironic - if we were to see it as a book all about foreigners, "them". It's really about us, Americans and by extension Europeans (although there are some interesting transatlantic contrasts in psychiatry, they're relatively minor.)

If our way of thinking about mental illness is as culturally bound as any other, then our own "psychiatric disorders" are no more eternal and objectively real than those Malaysian syndromes like amok, episodes of anger followed by amnesia, or koro, the fear the that ones genitals are shrinking away.

In other words, maybe patients with "anorexia", "PTSD" and perhaps "schizophrenia" don't "really" have those things at all - at least not if these are thought of as objectively-existing diseases. In which case, what do they have? Do they have anything? And what are we doing to them by diagnosing and treating them as if they did?

Watters' does not discuss such questions; I think this was the right choice, because a full exploration of these issues would fill at least one book in itself. But here are a few thoughts:

First, the most damaging thing about the globalization of Western psychiatric concepts is not so much the concepts themselves, but their tendency to displace and dissolve other ways of thinking about suffering - whether they be religious, philosophical, or just plain everyday talk about desires and feelings. The corollary of this, in terms of the individual Western consumer of the DSM, i.e. you and me, is the tendency to see everything through the lens of the DSM, without realizing that it's a lens, like a pair of glasses that you've forgotten you're even wearing. So long as you keep in mind that it's just one system amongst others, a product of a particular time and place, the DSM is still useful.

Second, if it's true that how we conceptualize illness and suffering affects how we actually feel and behave, then diagnosing or narrativizing mental illness is an act of great importance, and potentially, great harm. We currently spend billions of dollars researching major depressive disorder and schizophrenia, but very little on investigating "major depressive disorder" and "schizophrenia" as diagnoses. Maybe this is an oversight.

Finally, if much "mental illness" is an expression of fundamental distress shaped by the symptom pool of a particular culture, then we need to first map out and understand the symptom pool, and the various kinds of distress, in order to have any hope of making sense of what's going on in any individual on a psychological, social or neurobiological level. To put it another way, you need to understand people before you can understand psychiatry. After reading Crazy Like Us, I think I understand both a little bit better, and I strongly recommend it.

Links:

• Ethan Watters' Crazy Like Us blog.
  
• The Americanization of Mental Illness, Watters' much-read NYT article which is a fine summary of the book's argument, but being so short, misses much of the human detail which make Crazy Like Us so interesting, in particular when Watters is writing about the response of PTSD experts to the 2004 tsunami, and the life of a Madagascan woman with schizophrenia and her family.
  
• Exporting American Mental Illness, an excellent discussion of the article over at Neuroanthropology.
• Did Antidepressants Depress Japan? A 2004 article on the Japanese antidepressants and depression story.

Is Depression Undertreated?

Neuroskeptic readers will be familiar with the idea that too many people are being treated for mental illness. But not everyone agrees. Many people argue that common mental illnesses, such as depression, are undertreated. Take, for example, a paper just out in the esteemed Archives of General Psychiatry: Depression Care in the United States: Too Little for Too Few.

The authors looked at the results of three large (total N=15,762) surveys designed to measure the prevalence of mental illness in American adults. I've described how these surveys are conducted before: they took a randomly selected representative sample of Americans, and asked them a standardized series of questions (the CIDI interview) about their mood and emotions, in order to try to diagnose mental illness. The interviewers, while trained, were not clinicians.

What did they find? The rate of people experiencing Major Depressive Disorder (MDD), as defined in DSM-IV, in the past year, was 8.3%. When they examined ethnicity, this ranged from 6.7% in African Americans to 11.8% in Puerto Ricans. The average severity of the depression was roughly the same in all ethnic groups.

Of those with MDD, 51% reported that they'd had treatment in the past year, either antidepressants, psychotherapy, or both. This ranged from 53% for Whites down to just 29% of Caribbean Blacks and 33% of Mexican Americans. Therapy was somewhat more popular than drugs in all ethnic groups, although a lot of people used both. However, few of the treatments were classed as "guideline-concordant", i.e. long enough to do any good, which they defined as

use of an antidepressant for at least 60 days with supervision by a psychiatrist, or other prescribing clinician, for at least 4 visits in the past year. For psychotherapy...having at least 4 visits to a mental health professional in the past year lasting on average for at least 30 minutes each.

Only 21% of depressed people were getting such treatment, even though these strike me as very lenient guidelines, especially in the case of psychotherapy - how much good is 2 hours per year doing to do?

*

So depression's undertreated, especially in minorities. Too little, for too few. But this rests on an assumption: that we should treat Major Depressive Disorder.

That might not seem like an assumption, but assumptions generally don't. It seems like common sense, almost a tautology - it's a disorder, of course we should treat it! Yet it's not so simple. DSM-IV criteria for MDD require you to have 5 or more out of a list of 9 symptoms, including either depressed mood or a loss of interest in activities, lasting at least 2 weeks, and causing significant distress or impairment in social, occupational, or other important areas of functioning.

Fair enough. That's quite useful as a way of ensuring that psychiatrists in different countries are talking about the same thing when they talk about depression. But to think that depression is undertreated because only half of people meeting DSM-IV criteria for Major Depressive Disorder are being treated, is to put absolute faith in DSM-IV as a guide to who to treat. This is not what the DSM was meant to be, and there's no evidence it works for that purpose.

Is it really true that people with 5 symptoms need help, and those with 4 don't? Why not 6, or all 9? Why 2 weeks - why not 3 weeks, or 3 months? It's not as if there are loads of studies showing that treating people who have 5 symptoms for 2 weeks, and not treating people who don't, is the best strategy. I'm not aware of any such research. In particular, there's no evidence that people from the general population who meet these criteria when interviewed, but don't seek treatment, would all benefit from treatment as opposed to being left alone. Certainly some would, but they may be a minority.

This is not to say that any other criteria would be better than DSM-IV as guides to treatment, or that there is anything identifiably wrong with the DSM-IV criteria (although there is evidence that antidepressants are not useful in people with relatively "mild" MDD). The point is that doctors don't strictly apply textbook criteria when diagnosing and treating mental illness; they also use clinical judgement.

I don't know any psychiatrist who would prescribe treatment for someone solely on the basis that they met DSM-IV criteria for MDD. They would also want to know about the severity of the symptoms, whether they're related to any stresses or life events, how far they're "out of character" for that individual, etc. In general, they would deploy their training and experience to try to judge whether this person would benefit from treatment. This is why the DSM-IV carries a cautionary statement that "The proper use of these criteria requires specialized clinical training that provides both a body of knowledge and clinical skills."

So, it's far from clear that we should be treating everyone who answers interview questions in such a way that they meet DSM-IV criteria for Major Depressive Disorder. That's an assumption.

This isn't to say that everyone who needs depression treatment gets it. Sadly, there are many sufferers who would benefit from help and don't get any, or don't get it as early as they should. We need to do more to help such people. In this respect, depression is undertreated, although it's hard to know the extent of the problem. Yet it's quite possible that depression is also overtreated at the same time.

H/T Thanks to The Neurocritic for drawing my attention to this paper.

Gonzalez, H., Vega, W., Williams, D., Tarraf, W., West, B., & Neighbors, H. (2010). Depression Care in the United States: Too Little for Too Few Archives of General Psychiatry, 67 (1), 37-46 DOI: 10.1001/archgenpsychiatry.2009.168

Is Depression Undertreated?

Neuroskeptic readers will be familiar with the idea that too many people are being treated for mental illness. But not everyone agrees. Many people argue that common mental illnesses, such as depression, are undertreated. Take, for example, a paper just out in the esteemed Archives of General Psychiatry: Depression Care in the United States: Too Little for Too Few.

The authors looked at the results of three large (total N=15,762) surveys designed to measure the prevalence of mental illness in American adults. I've described how these surveys are conducted before: they took a randomly selected representative sample of Americans, and asked them a standardized series of questions (the CIDI interview) about their mood and emotions, in order to try to diagnose mental illness. The interviewers, while trained, were not clinicians.

What did they find? The rate of people experiencing Major Depressive Disorder (MDD), as defined in DSM-IV, in the past year, was 8.3%. When they examined ethnicity, this ranged from 6.7% in African Americans to 11.8% in Puerto Ricans. The average severity of the depression was roughly the same in all ethnic groups.

Of those with MDD, 51% reported that they'd had treatment in the past year, either antidepressants, psychotherapy, or both. This ranged from 53% for Whites down to just 29% of Caribbean Blacks and 33% of Mexican Americans. Therapy was somewhat more popular than drugs in all ethnic groups, although a lot of people used both. However, few of the treatments were classed as "guideline-concordant", i.e. long enough to do any good, which they defined as

use of an antidepressant for at least 60 days with supervision by a psychiatrist, or other prescribing clinician, for at least 4 visits in the past year. For psychotherapy...having at least 4 visits to a mental health professional in the past year lasting on average for at least 30 minutes each.

Only 21% of depressed people were getting such treatment, even though these strike me as very lenient guidelines, especially in the case of psychotherapy - how much good is 2 hours per year doing to do?

*

So depression's undertreated, especially in minorities. Too little, for too few. But this rests on an assumption: that we should treat Major Depressive Disorder.

That might not seem like an assumption, but assumptions generally don't. It seems like common sense, almost a tautology - it's a disorder, of course we should treat it! Yet it's not so simple. DSM-IV criteria for MDD require you to have 5 or more out of a list of 9 symptoms, including either depressed mood or a loss of interest in activities, lasting at least 2 weeks, and causing significant distress or impairment in social, occupational, or other important areas of functioning.

Fair enough. That's quite useful as a way of ensuring that psychiatrists in different countries are talking about the same thing when they talk about depression. But to think that depression is undertreated because only half of people meeting DSM-IV criteria for Major Depressive Disorder are being treated, is to put absolute faith in DSM-IV as a guide to who to treat. This is not what the DSM was meant to be, and there's no evidence it works for that purpose.

Is it really true that people with 5 symptoms need help, and those with 4 don't? Why not 6, or all 9? Why 2 weeks - why not 3 weeks, or 3 months? It's not as if there are loads of studies showing that treating people who have 5 symptoms for 2 weeks, and not treating people who don't, is the best strategy. I'm not aware of any such research. In particular, there's no evidence that people from the general population who meet these criteria when interviewed, but don't seek treatment, would all benefit from treatment as opposed to being left alone. Certainly some would, but they may be a minority.

This is not to say that any other criteria would be better than DSM-IV as guides to treatment, or that there is anything identifiably wrong with the DSM-IV criteria (although there is evidence that antidepressants are not useful in people with relatively "mild" MDD). The point is that doctors don't strictly apply textbook criteria when diagnosing and treating mental illness; they also use clinical judgement.

I don't know any psychiatrist who would prescribe treatment for someone solely on the basis that they met DSM-IV criteria for MDD. They would also want to know about the severity of the symptoms, whether they're related to any stresses or life events, how far they're "out of character" for that individual, etc. In general, they would deploy their training and experience to try to judge whether this person would benefit from treatment. This is why the DSM-IV carries a cautionary statement that "The proper use of these criteria requires specialized clinical training that provides both a body of knowledge and clinical skills."

So, it's far from clear that we should be treating everyone who answers interview questions in such a way that they meet DSM-IV criteria for Major Depressive Disorder. That's an assumption.

This isn't to say that everyone who needs depression treatment gets it. Sadly, there are many sufferers who would benefit from help and don't get any, or don't get it as early as they should. We need to do more to help such people. In this respect, depression is undertreated, although it's hard to know the extent of the problem. Yet it's quite possible that depression is also overtreated at the same time.

H/T Thanks to The Neurocritic for drawing my attention to this paper.

Gonzalez, H., Vega, W., Williams, D., Tarraf, W., West, B., & Neighbors, H. (2010). Depression Care in the United States: Too Little for Too Few Archives of General Psychiatry, 67 (1), 37-46 DOI: 10.1001/archgenpsychiatry.2009.168

A "Severe" Warning for Psychiatry

Imagine there was a nasty disease that affected 1 in 100 people. And imagine that someone invented a drug which treated it reasonably well. Good work, surely.

Now imagine that, for some reason, people decided that 10% of the population need to be taking this drug, instead of 1%. So sales of the drug sky-rocket. Eventually some clever person comes along and asks "This is one of the biggest selling drugs in the world - but does it work?" They look into it, and find that it doesn't work very well at all. For about 9 out of 10 people, it's completely useless! What a crap drug.

Of course the drug hasn't changed, and what's crap was the decision to prescribe it to so many people.

*

Back to reality. According to accepted DSM-IV diagnostic criteria, close to 50% of people suffer from a mental illness at some point; a large fraction of this being depression. 10% of Americans took antidepressants last year according to the best estimates.

Guess what? Clever people have started asking "Antidepressants are amongst the biggest selling drugs in the world - but do they work?" And their answer is - not very well. The latest such claim came from Fournier et al and appeared in JAMA a couple of weeks ago: Antidepressant Drug Effects and Depression Severity.

These researchers re-analysed the data from six clinical trials testing antidepressants against placebo pills. The drugs were the tricyclic imipramine and the newer SSRI paroxetine. The total sample size was a respectable 718, and most trials lasted 8 weeks, which is longer than average for this kind of study. Here's what they found -

Grey circles are people on antidepressants, white circles people on placebo. What this shows is that the more severe the patient's depression, the more they get better - when they're given either drugs or placebos. However, because the improvement on antidepressants rises more steeply, the benefit of antidepressants versus placebos correlates with severity. The thin blue line marks the minimum severity for which the average effect of the drugs over placebo was "clinically significant" according to NICE criteria (although these are arbitrary).

*

So, this study says that antidepressants work better in more severe depression. This is not a new claim - Kirsch et al (2008) famously found the same thing, and long before that so did Khan et al (2002). However this new analysis has some advantages over previous ones. First, Fournier et al looked at what happened to each patient individually, whereas the previous studies found that in trials where the patients were more severely depressed, on average, antidepressants worked better.

Second, the patients in this analysis spanned a wide range of severity scores, from 10 points on the Hamilton Scale to nearly 40. In Kirsch et al almost all the trials had average severities in the narrow range of 22 to 29. Finally, none of the trials in the new paper used a placebo run-in period. These are meant to exclude people from the trial if they improve "too well" during an initial week or so of placebo pills. In theory, they bias trials against finding large placebo effects; it's not clear they actually work, but either way, it's good to know it wasn't a factor.

*

Overall, the evidence all seems to point to the idea that people with more serious clinical depression respond better to antidepressants vs. placebos in clinical trials. The exact details are debatable, there's the issue of whether antidepressant clinical trials are realistic, and the question of how clinically effective antidepressants are is also controversial, but I'm not aware of any studies which have contradicted this central claim.

But when you start to think about it, this is a very odd result. Fournier et al say that

The general pattern of results reported in this work is not surprising. As early as the 1950s, researchers conducting controlled investigations of treatments for a wide variety of medical and psychiatric conditions described a phenomenon whereby patients with higher levels of severity showed greater differential (i.e., specific) benefit from the active treatments.

and refer to a couple of papers from the 1960s. But I must admit that I do find this very surprising. We don't wait until someone's nearly dead from a bacterial infection before we give them antibiotics, we give them early, when the disease is still mild. Doctors unfortunately don't tell people "Good news! You've got advanced-stage cancer - just the kind where drugs work best." Why is depression so different?

Look a little closer, and a possible answer emerges. Severity, in all of these studies, was measured using the Hamilton Rating Scale for Depression (HAMD). The HAMD has 17 items, and each asks whether you're suffering from certain symptoms; the more symptoms you have, and the more pronounced they are, the higher your total score. You get 1 point if you have "occasional difficulty falling asleep", 2 points for "nightly difficulty falling asleep", 4 points for "Hand wringing, nail biting, hair-pulling, biting of lips". Here's the whole thing.

The HAMD was designed in 1960 by a psychiatrist, Max Hamilton, and it was originally intended for use by staff at psychiatric hospitals for use on depressed inpatients. So it's not a measure of severity per se: it's a measure of how well your symptoms match those considered to be characteristic of severe depression in 1960.

Psychiatry's concept of depression - not to mention the wider culture's - has changed greatly since then. 1960 was a full 20 years before the DSM-III criteria of depression were published, which form the basis for today's DSM-IV criteria. A quick comparison of the DSM-IV alongside the HAMD reveals a lot of differences. It's quite possible to meet DSM-IV criteria for "Major Depressive Disorder" yet score low on the HAMD.

Which brings us back to the imaginary scenario at the start of this post. My personal interpretation of results like those of Fournier et al is this: antidepressants treat classical clinical depression, of the kind that psychiatrists in 1960 would have recognized. This is the kind of depression that they were originally used for, after all, because the first antidepressants arrived in 1953, and modern antidepressants like Prozac target the same neurotransmitter systems.

Yet in recent years "clinical depression" has become a much broader term. Many people attribute this to marketing on the part of pharmaceutical companies. Whatever the cause, it's almost certain that many people are now being prescribed antidepressants for emotional and personal issues which wouldn't have been considered medical illnesses until quite recently. (Antidepressants also have a long history of use for other conditions, like OCD, but this is a separate issue.)

My imaginary story used made up numbers: I'm not saying that only 10% of the people on antidepressants have "classic" depression. I don't know what the % is. But apart from that, in my opinion (and I don't think I'm alone), it's far from fantasy.

Fournier, J., DeRubeis, R., Hollon, S., Dimidjian, S., Amsterdam, J., Shelton, R., & Fawcett, J. (2010). Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-analysis JAMA: The Journal of the American Medical Association, 303 (1), 47-53 DOI: 10.1001/jama.2009.1943

A "Severe" Warning for Psychiatry

Imagine there was a nasty disease that affected 1 in 100 people. And imagine that someone invented a drug which treated it reasonably well. Good work, surely.

Now imagine that, for some reason, people decided that 10% of the population need to be taking this drug, instead of 1%. So sales of the drug sky-rocket. Eventually some clever person comes along and asks "This is one of the biggest selling drugs in the world - but does it work?" They look into it, and find that it doesn't work very well at all. For about 9 out of 10 people, it's completely useless! What a crap drug.

Of course the drug hasn't changed, and what's crap was the decision to prescribe it to so many people.

*

Back to reality. According to accepted DSM-IV diagnostic criteria, close to 50% of people suffer from a mental illness at some point; a large fraction of this being depression. 10% of Americans took antidepressants last year according to the best estimates.

Guess what? Clever people have started asking "Antidepressants are amongst the biggest selling drugs in the world - but do they work?" And their answer is - not very well. The latest such claim came from Fournier et al and appeared in JAMA a couple of weeks ago: Antidepressant Drug Effects and Depression Severity.

These researchers re-analysed the data from six clinical trials testing antidepressants against placebo pills. The drugs were the tricyclic imipramine and the newer SSRI paroxetine. The total sample size was a respectable 718, and most trials lasted 8 weeks, which is longer than average for this kind of study. Here's what they found -

Grey circles are people on antidepressants, white circles people on placebo. What this shows is that the more severe the patient's depression, the more they get better - when they're given either drugs or placebos. However, because the improvement on antidepressants rises more steeply, the benefit of antidepressants versus placebos correlates with severity. The thin blue line marks the minimum severity for which the average effect of the drugs over placebo was "clinically significant" according to NICE criteria (although these are arbitrary).

*

So, this study says that antidepressants work better in more severe depression. This is not a new claim - Kirsch et al (2008) famously found the same thing, and long before that so did Khan et al (2002). However this new analysis has some advantages over previous ones. First, Fournier et al looked at what happened to each patient individually, whereas the previous studies found that in trials where the patients were more severely depressed, on average, antidepressants worked better.

Second, the patients in this analysis spanned a wide range of severity scores, from 10 points on the Hamilton Scale to nearly 40. In Kirsch et al almost all the trials had average severities in the narrow range of 22 to 29. Finally, none of the trials in the new paper used a placebo run-in period. These are meant to exclude people from the trial if they improve "too well" during an initial week or so of placebo pills. In theory, they bias trials against finding large placebo effects; it's not clear they actually work, but either way, it's good to know it wasn't a factor.

*

Overall, the evidence all seems to point to the idea that people with more serious clinical depression respond better to antidepressants vs. placebos in clinical trials. The exact details are debatable, there's the issue of whether antidepressant clinical trials are realistic, and the question of how clinically effective antidepressants are is also controversial, but I'm not aware of any studies which have contradicted this central claim.

But when you start to think about it, this is a very odd result. Fournier et al say that

The general pattern of results reported in this work is not surprising. As early as the 1950s, researchers conducting controlled investigations of treatments for a wide variety of medical and psychiatric conditions described a phenomenon whereby patients with higher levels of severity showed greater differential (i.e., specific) benefit from the active treatments.

and refer to a couple of papers from the 1960s. But I must admit that I do find this very surprising. We don't wait until someone's nearly dead from a bacterial infection before we give them antibiotics, we give them early, when the disease is still mild. Doctors unfortunately don't tell people "Good news! You've got advanced-stage cancer - just the kind where drugs work best." Why is depression so different?

Look a little closer, and a possible answer emerges. Severity, in all of these studies, was measured using the Hamilton Rating Scale for Depression (HAMD). The HAMD has 17 items, and each asks whether you're suffering from certain symptoms; the more symptoms you have, and the more pronounced they are, the higher your total score. You get 1 point if you have "occasional difficulty falling asleep", 2 points for "nightly difficulty falling asleep", 4 points for "Hand wringing, nail biting, hair-pulling, biting of lips". Here's the whole thing.

The HAMD was designed in 1960 by a psychiatrist, Max Hamilton, and it was originally intended for use by staff at psychiatric hospitals for use on depressed inpatients. So it's not a measure of severity per se: it's a measure of how well your symptoms match those considered to be characteristic of severe depression in 1960.

Psychiatry's concept of depression - not to mention the wider culture's - has changed greatly since then. 1960 was a full 20 years before the DSM-III criteria of depression were published, which form the basis for today's DSM-IV criteria. A quick comparison of the DSM-IV alongside the HAMD reveals a lot of differences. It's quite possible to meet DSM-IV criteria for "Major Depressive Disorder" yet score low on the HAMD.

Which brings us back to the imaginary scenario at the start of this post. My personal interpretation of results like those of Fournier et al is this: antidepressants treat classical clinical depression, of the kind that psychiatrists in 1960 would have recognized. This is the kind of depression that they were originally used for, after all, because the first antidepressants arrived in 1953, and modern antidepressants like Prozac target the same neurotransmitter systems.

Yet in recent years "clinical depression" has become a much broader term. Many people attribute this to marketing on the part of pharmaceutical companies. Whatever the cause, it's almost certain that many people are now being prescribed antidepressants for emotional and personal issues which wouldn't have been considered medical illnesses until quite recently. (Antidepressants also have a long history of use for other conditions, like OCD, but this is a separate issue.)

My imaginary story used made up numbers: I'm not saying that only 10% of the people on antidepressants have "classic" depression. I don't know what the % is. But apart from that, in my opinion (and I don't think I'm alone), it's far from fantasy.

Fournier, J., DeRubeis, R., Hollon, S., Dimidjian, S., Amsterdam, J., Shelton, R., & Fawcett, J. (2010). Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-analysis JAMA: The Journal of the American Medical Association, 303 (1), 47-53 DOI: 10.1001/jama.2009.1943

That Sinking Feeling?

Sinking and Swimming is a paper just out from the Young Foundation, a British think-tank. It "explores how psychological and material needs are being met and unmet in Britain." I'm not sure how useful their broad concept of "unmet needs" is, but there's some rather interesting data in this report.

On page 238, and prominently in the executive summary, we find the following terrifying graph, which comes with warnings like "anxiety and depression looks set to double during the course of a single generation..."

The % of the population self-reporting suffering from depression or anxiety seems to have been consistently rising since 1990, from less than 6% to almost 10% today. And the line continues ever upwards. Eeek!

Is Britain really becoming more depressed and anxious? No, and that's what makes this graph terrifying. According to the large government Adult Psychiatric Morbidity Survey, the prevalence of self-reported depression and anxiety symptoms rose slightly from 1993 to 2000 (15.5% to 17.5%) and then stayed level up to 2007 (17.6%). Not very scary. Even the Young Foundation note (on page 80) that when you look at "well-being"

analysis of the English health survey that uses a variation of GHQ [General Health Questionnaire] suggested that the proportion of the working age population with poor psychological well-being decreased from 17% in 1997 to 13% in 2006.

On that measure, we're getting happier. And the rate of new diagnoses of clinical depression fell over the past decade.

So what about that ominous line? Well, that graph was based on "self-reported anxiety or depression", but in a specific sense. People were not reporting feeling scared or unhappy (see above for the data on that), but rather, reporting having anxiety or depression as medical disorders. Curiously the % of people reporting having every other sort of health problems (except with vision) increased from 1991 to 2007 as well:


What seems to be happening is that British people are becoming more willing to label our problems as medical illnesses, although in fact our mental health has not changed much over the past two decades, and may even have improved slightly. This is what's terrifying, because medicalizing emotional issues is a bad idea.

Mental illness does exist, and medicine can help treat it, but medicine can't resolve non-medical problems even if they're labelled as illnesses. Antidepressants, for example, are (imperfectly) effective for severe clinical depression but probably not for "mild depression"; much of what is labelled "mild depression" is probably not, in any meaningful sense, an illness.

Why does this matter? Drugs have side effects, and psychotherapy is expensive. The cost-benefit profile of any treatment is obviously negative when there are no benefits because the treatment is being used inappropriately. My biggest concern, though, is that if someone is unhappy because of tensions in their marriage or because they're in the wrong job, they don't need treatment, they need to do something about it. Labelling a problem as an illness and treating it medically may, in itself, make that problem harder to overcome.

[BPSDB]