Cultural change, and yes, economic and adjacent change, more likely than actual significant increase in severe distress. That said, a cultural change that leads to reframing experiencing X as disorder/disease effectively and very realistically CREATES additional distress, so there's that.
On the young people, I also suspend judgement but I suspect defences, workarounds and adjustments to digital native existence will evolve, and the negative effects (if meaningful now) will abate.
Thank you. Yes, I agree - I did not want to lean on that argument too much, but the trend toward "distress = disorder" is pernicious and likely makes things worse.
Looking at the age-adjusted suicide plot, maybe this is just coincidence but its kind of striking to me how much drops in the suicide rate seem to line up with US wars.
1916-18 and 1942-45, WW1 and WW2 respectively, are clear low points in the chart. The start of the Korean war in 1950 also corresponds to a stark drop. The Vietnam war is less obvious but 1964-1970, when US involvement really ramped up also corresponds with less suicides, with the year of the Tet offensive 1968 being a local minima.
The early aberrantly low early 2000's also corresponds to the war on terror, although this one is a pretty bad match because suicides reached a minimum before 2001. Also the dip around 1976 doesn't match up to the start of a war.
There's a lot of plausible reasons why war might lower the count of suicides. Maybe the services of young people in the military reduces their chance of suicide, maybe a wartime economy where labor is in high demand reduces economic stress that may cause suicide, maybe suicides are undercounted in wartime for some administrative reason, maybe war spurs a greater sense of patriotism and belonging to the nation which reduces suicide. Or maybe its just a coincidence.
War and other "national peril" type situations do correlate with lower suicide, which has usually been explained as a pulling together and social cohesion kind of effect. But hard to say! And thanks!
I think your final argument is most effective against views like those of Jonathan Haidt. That's because the increase in suicide mortality is the most striking evidence that we are in a mental health crisis. That and the rise of hospitalizations due to self harm.
I wonder what the demographics for suicides looked like back in the 1900s? Also whether there's any self harm data...
It is hard to get data farther back, obviously. And hard to know if you can trust it. There are a lot of papers from the 80s-80s discussing social contagion aspects of suicide and self-harm, so you always have to wonder how much that is in play.
Excellent post; such a refreshing take on the increase in mental health utilization and diagnoses. Deep insight that diagnoses are misconstrued if they are deemed goods to be sought. Biopsychosocial perspective indeed, with emphasis on the "social"!
One issue that isn't mentioned here (tho it's kinda tangentially related) is how difficult the US healthcare system makes continuing medications when you move. So I think some of the pressure to lower the gatekeeping role or make it easy to get online prescriptions reflects a genuine need that we don't have a system to deal with besides simply lowering gatekeeping roles generally.
I understand the concerns about the online -- and sometimes outright scammy -- prescription of meds like ADHD meds and other controlled substances (less common medications are even worse). But having moved several times in the 20 years or so I've had the same prescription it's sometimes only been online prescribing that avoided disaster.
Even if you start calling a year ahead of a move you run into the problem that often access to psychiatric care is gatekept by PCPs who won't even look at your record before you show up. If you are willing to pay to see a psychiatrist directly (and you can't even do that everywhere) you can't get any answer ahead of time if that doctor will handle your medications. Good chance you show up at that doctor and they tell you sorry that's not a condition they want to handle and direct you to someone else you can't see for months -- while this is much worse for controlled medications it's present in other psychiatric medications less safe/common than SSRIs.
I'd argue that, in addition to marketing, another factor in the push for convenience online scripts reflects thr fact that the us population is highly mobile and this is the only option people see for stable treatment. More engagement in corresponding with recieving doctors or a policy that enables pre-appointment review of new patient needs could help reduce some of the demand for convenience diagnosis/scripts.
Even thoughtful commentators like Awais Aftab advocate for a diagnosis as a precursor to treatment (if you want help for your distress, you need a diagnosis first/too) unlike the old guard conservatives like Allen Frances who argue that help/psychotherapy shouldn't require a diagnosis and against medicalising expected/ubiquitous human distress.
When my (privileged) teenage nephew died by suicide, labelling the adoring dad who cut the rope and attempted CPR on his by then thoroughly dead son, with depression and cPTSD because he couldn't recover from that experience seems insulting and the pathology resides in our society for considering his distress abnormal. Sure he needs support, but a diagnosis? No.
I'm inclined to think that destigmatisation has failed; here schizophrenia is if anything more stigmatized than it was 50 years ago (evidence said it's more). What I see is the relabelling of human distress as (mild-moderate) mental illness. I was taught in my psych ED placement to differentiate between psychosis (schizophrenia and mania) and "life difficulties" - everything else. Some psychiatrists would die on the hill of being able to differentiate between clinical depression and life difficulties (mostly adjustment disorders and borderline traits), others cheerfully asserted they couldn't tell the difference.
I suspect social contagion is responsible for a lot, it's implicated in diagnostic fads. I grew up in a remote indigenous community, suicide was unknown. Now it's ubiquitous. Back then things were primitive: no houses for the indigenous people, they lived on flour and sugar handouts and hunting, even my first home had no electricity, no TV or phone, and an outside toilet. Yet the irony is that we seemed to be happier back then. Certainly less substance abuse. I'm not convinced that modernity has made humanity happier, at least taking my community as an example. I suspect it's like $$$ - beyond a basic standard of living/technology, money/mod cons don't increase happiness.
I don't blame phones, I blame the perfectionism that continually strives for more, and the fear-driven obsession with motivating people for ever more marginal benefits. Remarkably little bad actually happens to anyone within my social circle (apart from the 4 deaths by suicide and 1 accidental drug overdose) and all the awareness raising campaigns about all the terrible things that could happen to me don't increase my happiness.
Zero suicide campaigns are part of this - it's a misguided mission that is totally unrealistic and ignores the lack of social investment in things like reducing the unemployment rate etc that might actually help. We have the mass roll out of Mental Health First Aid training here, despite the fact that there's no evidence it helps anyone having a crisis. The lack of evidence base in the suicide prevention space is intensely frustrating. It's all vibes. Here, we encourage people who are suicidal to go to ED, but all ED does is an assessment, then offer 5 DBT phone counselling appointments and refer to community resources - oh and if you're lucky you get a 24 hour crisis containment admission (which has no evidence for suicide prevention, but hey it makes people feel validated and like there was a point to all that time in the waiting room).
The reduction in stigma only applies to the mental 'health' diagnoses... Not the serious mental illnesses like psychosis and schizophrenia.. they've only become more stigmatised. But even diagnoses like bipolar have become popular amongst patients and psychiatrists alike and subject to diagnostic inflation.
Bipolar Disorder was a very popular diagnosis 10-15 years ago, it seems to have been somewhat superseded since then. Agree that schizophrenia is still avoided at all costs.
Excellent and novel perspective.
As to the points made:
Cultural change, and yes, economic and adjacent change, more likely than actual significant increase in severe distress. That said, a cultural change that leads to reframing experiencing X as disorder/disease effectively and very realistically CREATES additional distress, so there's that.
On the young people, I also suspend judgement but I suspect defences, workarounds and adjustments to digital native existence will evolve, and the negative effects (if meaningful now) will abate.
Thank you. Yes, I agree - I did not want to lean on that argument too much, but the trend toward "distress = disorder" is pernicious and likely makes things worse.
Looking at the age-adjusted suicide plot, maybe this is just coincidence but its kind of striking to me how much drops in the suicide rate seem to line up with US wars.
1916-18 and 1942-45, WW1 and WW2 respectively, are clear low points in the chart. The start of the Korean war in 1950 also corresponds to a stark drop. The Vietnam war is less obvious but 1964-1970, when US involvement really ramped up also corresponds with less suicides, with the year of the Tet offensive 1968 being a local minima.
The early aberrantly low early 2000's also corresponds to the war on terror, although this one is a pretty bad match because suicides reached a minimum before 2001. Also the dip around 1976 doesn't match up to the start of a war.
There's a lot of plausible reasons why war might lower the count of suicides. Maybe the services of young people in the military reduces their chance of suicide, maybe a wartime economy where labor is in high demand reduces economic stress that may cause suicide, maybe suicides are undercounted in wartime for some administrative reason, maybe war spurs a greater sense of patriotism and belonging to the nation which reduces suicide. Or maybe its just a coincidence.
Also A+ ending to the article!
War and other "national peril" type situations do correlate with lower suicide, which has usually been explained as a pulling together and social cohesion kind of effect. But hard to say! And thanks!
Interesting take and nice read.
I think your final argument is most effective against views like those of Jonathan Haidt. That's because the increase in suicide mortality is the most striking evidence that we are in a mental health crisis. That and the rise of hospitalizations due to self harm.
I wonder what the demographics for suicides looked like back in the 1900s? Also whether there's any self harm data...
It is hard to get data farther back, obviously. And hard to know if you can trust it. There are a lot of papers from the 80s-80s discussing social contagion aspects of suicide and self-harm, so you always have to wonder how much that is in play.
Great discussion!
Excellent post; such a refreshing take on the increase in mental health utilization and diagnoses. Deep insight that diagnoses are misconstrued if they are deemed goods to be sought. Biopsychosocial perspective indeed, with emphasis on the "social"!
One issue that isn't mentioned here (tho it's kinda tangentially related) is how difficult the US healthcare system makes continuing medications when you move. So I think some of the pressure to lower the gatekeeping role or make it easy to get online prescriptions reflects a genuine need that we don't have a system to deal with besides simply lowering gatekeeping roles generally.
I understand the concerns about the online -- and sometimes outright scammy -- prescription of meds like ADHD meds and other controlled substances (less common medications are even worse). But having moved several times in the 20 years or so I've had the same prescription it's sometimes only been online prescribing that avoided disaster.
Even if you start calling a year ahead of a move you run into the problem that often access to psychiatric care is gatekept by PCPs who won't even look at your record before you show up. If you are willing to pay to see a psychiatrist directly (and you can't even do that everywhere) you can't get any answer ahead of time if that doctor will handle your medications. Good chance you show up at that doctor and they tell you sorry that's not a condition they want to handle and direct you to someone else you can't see for months -- while this is much worse for controlled medications it's present in other psychiatric medications less safe/common than SSRIs.
I'd argue that, in addition to marketing, another factor in the push for convenience online scripts reflects thr fact that the us population is highly mobile and this is the only option people see for stable treatment. More engagement in corresponding with recieving doctors or a policy that enables pre-appointment review of new patient needs could help reduce some of the demand for convenience diagnosis/scripts.
Even thoughtful commentators like Awais Aftab advocate for a diagnosis as a precursor to treatment (if you want help for your distress, you need a diagnosis first/too) unlike the old guard conservatives like Allen Frances who argue that help/psychotherapy shouldn't require a diagnosis and against medicalising expected/ubiquitous human distress.
When my (privileged) teenage nephew died by suicide, labelling the adoring dad who cut the rope and attempted CPR on his by then thoroughly dead son, with depression and cPTSD because he couldn't recover from that experience seems insulting and the pathology resides in our society for considering his distress abnormal. Sure he needs support, but a diagnosis? No.
I'm inclined to think that destigmatisation has failed; here schizophrenia is if anything more stigmatized than it was 50 years ago (evidence said it's more). What I see is the relabelling of human distress as (mild-moderate) mental illness. I was taught in my psych ED placement to differentiate between psychosis (schizophrenia and mania) and "life difficulties" - everything else. Some psychiatrists would die on the hill of being able to differentiate between clinical depression and life difficulties (mostly adjustment disorders and borderline traits), others cheerfully asserted they couldn't tell the difference.
I suspect social contagion is responsible for a lot, it's implicated in diagnostic fads. I grew up in a remote indigenous community, suicide was unknown. Now it's ubiquitous. Back then things were primitive: no houses for the indigenous people, they lived on flour and sugar handouts and hunting, even my first home had no electricity, no TV or phone, and an outside toilet. Yet the irony is that we seemed to be happier back then. Certainly less substance abuse. I'm not convinced that modernity has made humanity happier, at least taking my community as an example. I suspect it's like $$$ - beyond a basic standard of living/technology, money/mod cons don't increase happiness.
I don't blame phones, I blame the perfectionism that continually strives for more, and the fear-driven obsession with motivating people for ever more marginal benefits. Remarkably little bad actually happens to anyone within my social circle (apart from the 4 deaths by suicide and 1 accidental drug overdose) and all the awareness raising campaigns about all the terrible things that could happen to me don't increase my happiness.
Zero suicide campaigns are part of this - it's a misguided mission that is totally unrealistic and ignores the lack of social investment in things like reducing the unemployment rate etc that might actually help. We have the mass roll out of Mental Health First Aid training here, despite the fact that there's no evidence it helps anyone having a crisis. The lack of evidence base in the suicide prevention space is intensely frustrating. It's all vibes. Here, we encourage people who are suicidal to go to ED, but all ED does is an assessment, then offer 5 DBT phone counselling appointments and refer to community resources - oh and if you're lucky you get a 24 hour crisis containment admission (which has no evidence for suicide prevention, but hey it makes people feel validated and like there was a point to all that time in the waiting room).
The reduction in stigma only applies to the mental 'health' diagnoses... Not the serious mental illnesses like psychosis and schizophrenia.. they've only become more stigmatised. But even diagnoses like bipolar have become popular amongst patients and psychiatrists alike and subject to diagnostic inflation.
Bipolar Disorder was a very popular diagnosis 10-15 years ago, it seems to have been somewhat superseded since then. Agree that schizophrenia is still avoided at all costs.
Would suggest bipolar diagnoses were driven by BP2 - which is arguably part of the distress reinvented as illness and legitimation thereof process
Definitely agree. There is enough wiggle room in the criteria for hypomania that it can be liberally applied.