What We’re Doing Isn’t Working
The World Health Organization estimated that in 2017, almost 800 million people on our planet suffered from mental health disorders. This represents a bit over 10 percent of the world’s population, or one in every ten people. When substance use disorders are included in the count, the number climbs to 970 million people, or 13 percent of the global population. Anxiety disorders were the most common, affecting about 3.8 percent of people around the world, followed by depression, affecting about 3.4 percent.1 Rates of these disorders are higher in the United States, with approximately 20 percent, or one in five people, diagnosed with a mental or substance use disorder.
These numbers give us a snapshot of the prevalence of mental disorders over a specific one-year period. But lifetime prevalence rates are much higher. In the United States, data now suggest that about 50 percent of the population will meet the criteria for a mental disorder at some point in their lives.2 Yes—half of all people.
Estimating the rates of mental illness is difficult. People often deny their mental health problems to others or even to themselves. Having a mental illness is stigmatized pretty much everywhere in the world. While societies have made important strides in recognizing things like depression and anxiety disorders as “real” illnesses, this progress is relatively recent, and it is far from universal. There are still people who see those suffering from these disorders as simply “whiny” or “lazy.” On the other hand, while people with psychotic disorders are usually believed to have “real” illnesses, they face a different kind of stigma. Many people are afraid of them or dismiss them as “crazy.” Then there are those with substance use disorders—not only do many see them as self-centered or morally weak, in some countries, such as some Middle Eastern ones, they are classified as criminals and can be incarcerated for using even alcohol. The effects of stigma can range from shame to outright discrimination, but stigma of any kind can motivate people to minimize or lie about symptoms. As such, prevalence statistics are most likely underestimates of the true scope of these disorders.
And as dire as these statistics are, the problem seems to be getting worse.
A Growing Epidemic
We have the best data for this in the United States, where researchers have been tracking mental health statistics for decades now. Rates of mental illness are on the rise. According to the CDC (Centers for Disease Control), US adults over the age of eighteen had higher rates of mental illness in 2017 than in all but three of the years between 2008 and 2015. Of note, the youngest group (those aged eighteen through twenty-five) had the largest increase—rising 40 percent between 2008 and 2017.
The rate of ADHD (attention deficit/hyperactivity disorder) is rising in children and adolescents, increasing 41 percent in children four through seventeen between 2003 and 2012. This particular diagnosis and its reported upward trend attract considerable controversy. Some suggest that we are simply getting better at recognizing this disorder and providing treatment to children who need it to thrive. Others suggest that we are medicating normal behavior—that society and schools have come to expect too much from children, and that our expectations are unrealistic for what they are capable of at certain ages. Still others argue that the attention span of the American population has decreased across the board, likely due to increased time spent in front of screens, and this is being mistaken for ADHD. Is the rate of this disorder truly increasing, or are these other factors responsible for what we see in the data? We’ll further consider questions like this shortly. But ADHD isn’t the only diagnosis on the rise.
Depression in children, adolescents, and young adults is increasing as well. From 2006 to 2017, rates of depression in the US increased by 68 percent in children ages twelve to seventeen. In people ages eighteen to twenty-five, there was an increase of 49 percent. For adults over the age of twenty-five, the rate of depression supposedly stayed stable.
However, much of this information is gleaned from surveys, and both the questions we ask and the way we ask them matters. Although surveys suggest that the rates of depression in adults are not increasing, many reports suggest that burnout is on the rise. Burnout is not an official psychiatric diagnosis in DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), but the World Health Organization recently added it to its list of mental disorders—the ICD-11 (International Classification of Diseases, Eleventh Revision). The criteria are similar to those for depression, but focus primarily on the stress of work and the work environment. There has been a lot of debate about whether burnout is simply a work-related form of depression, and for good reason: In one study looking at physician burnout, they found that those with mild burnout were three times more likely to meet criteria for major depression. Those with severe burnout were forty-six times more likely,3 suggesting little, if any, difference between these diagnostic labels. Like depression, burnout is also associated with much higher rates of suicide. Because burnout is not yet an official diagnosis in the DSM-5, US agencies don’t track its prevalence. However, a 2018 Gallup poll found that 23 percent of employees reported feeling burned out at work often or always, while another 44 percent felt burned out sometimes.4 These rates are much higher than those of depression.
Suicide rates are increasing across most age groups. In 2016, nearly 45,000 people died by suicide in the United States alone. In general, for every person who dies by suicide, approximately thirty others attempt to kill themselves—putting the rate of suicide attempts at well over one million people per year. From 1999 to 2016, suicide rates increased in most US states, with twenty-five states seeing an increase of 30 percent or more. Another statistic, deaths of despair, tracks combined deaths in the United States from alcohol, drugs, and suicide. This statistic more than doubled between 1999 and 2017.
Anxiety disorders are the most common mental disorders, but the criteria for diagnosing them continue to evolve. This makes it difficult to assess changes over time. Some have argued that the rates have not changed in recent years.5 However, an annual household survey of approximately forty thousand US adults suggests that anxiety is increasing. Survey participants were asked, “How often did you feel nervous during the past 30 days?” with five response options ranging from “all of the time” to “none of the time.” From 2008 to 2018, rates of anxiety increased by 30 percent. In the youngest group, ages eighteen to twenty-five, there was an 84 percent increase.6
Sometimes the more “common” diagnoses like depression and anxiety are thought of separately from mental disorders like schizophrenia—the term “serious mental illness” is often used by mental health professionals to talk about disorders that involve significant impairment and disability, such as those with psychotic symptoms. While this category includes some severe forms of depression and anxiety, it mostly refers to diagnoses like schizophrenia, bipolar disorder, autism, and the like. So what about these disorders? What’s happening with them? They’re increasing, too. Between 2008 and 2017, there was a 21 percent increase in serious mental disorders in those over the age of eighteen in the United States. For the younger group, those aged eighteen to twenty-five, the rate of serious mental illness doubled during that same period—less than a decade.7
The diagnosis of autism is increasing at an alarming rate.8 In 2000, autism affected about 1 in 150 children in the US; by 2014, it was about 1 in 59.
The statistics for bipolar disorder are also concerning. From the mid-1970s to 2000, the prevalence of bipolar disorder was somewhere in the range of 0.4 to 1.6 percent. By the early 2000s, it had increased to 4 to 7 percent.9 In children and adolescents, this diagnosis was almost nonexistent prior to 1994, but it’s increasingly common now.
These statistics are difficult to comprehend. Diagnoses like autism and bipolar disorder aren’t supposed to increase exponentially over such a short period of time. While anxiety and depression can be situational, these other disorders are generally regarded as firmly “biological,” and many researchers believe they are determined in large part by genetics. Clearly, the human species didn’t have an epidemic of genetic mutations.
Researchers, clinicians, and society at large are struggling to understand what to make of the sharp increase in mental illness. While there is no consensus explanation, plenty of people have theories—and generally speaking, these theories can be divided into two categories.
The first category relies on the belief that the statistics are wrong, or that they don’t mean what we think they do. Many people think it’s impossible that the rates of mental disorders could increase so rapidly; they believe that these statistics are the result of doctors and/or patients seeing “disorders” that are not there. Here are three of the most prominent theories in this category:
1.It’s the pharmaceutical companies! They are looking to sell pills to as many people as possible, and to sell pills, they have to convince both doctors and the public that they need them. They spend billions of dollars every year on marketing, sending samples to doctors to keep the name of their product top of mind. They run television ads that ask if the viewer has any of a variety of vague symptoms, like “decreased enjoyment.” If you do, you are instructed to “talk to your doctor and see if ‘drug X’ is right for you.” These types of advertisements feed into people’s tendencies to be hypochondriacs. These worried people then go to doctors and emerge with a new diagnosis, and of course, the pills to treat it.
2.It’s laziness! People today don’t want to work at things. They also don’t want to experience any discomfort or think that they should have to. They increasingly categorize run-of-the-mill human emotions or experiences as “symptoms.” They flock to therapists to relieve these “symptoms.” Sometimes, they even go to the doctor to complain about them. People want quick and easy fixes; doctors are overworked and busy, and the easiest thing for them to do is write a prescription.
3.It’s this new generation of kids! Given that the rates are increasing most dramatically in children and young adults, it is clear that the blame lies with them—or their parents. Parents have pampered and spoiled this younger generation—catering to their every whim. These children and young adults have never been disciplined and also don’t have much willpower or perseverance. They get easily frustrated and overwhelmed. When their parents are no longer there to fix things, or when anyone tells them “no,” they go into a crisis. These meltdowns get them diagnosed with some mental disorder. Or, unable to handle life in the real world, they look for a “mental illness” to blame.
As appealing as these types of theories may be, they are likely not the answers. If you do not suffer from a mental health issue yourself, or have a child who does, or have daily contact with patients who do, it’s easy to assume that these people are simply whiners and complainers, and that doctors, patients, and parents are looking for quick fixes. It’s easy to dismiss a problem when that problem is far removed from you. However, when you are confronted with the real people behind these statistics and witness their suffering, these blanket assumptions become impossible to sustain. When someone you know to be a “good parent” has a seven-year-old who suffers from fits of rage, who is not sleeping, who is threatening to kill himself or other people, the problem begins to look like a real one. These behaviors are not normal. When a woman has such severe panic attacks that she stops leaving the house, this is not normal. When a person is so depressed that they sometimes cannot get out of bed in the morning, this is not normal.
So, the second category of theories about the increasing rates of mental disorders accepts the statistics as real. These are people who believe that these illnesses are truly on the rise. They offer a variety of perspectives and possible explanations:
1.It’s a good thing! These statistics are positive—they reflect a broader understanding of mental disorders and more awareness of how to identify them. There are many programs in schools and work environments on recognizing the symptoms of mental and substance use disorders. There are public service campaigns focused on suicide prevention. Celebrities are speaking out about their own mental health struggles, and there is more coverage of mental health in the media that is explicitly aimed at raising awareness and reducing stigma. People are increasingly getting the help they need, being diagnosed, and treated.
2.It’s society! We have become increasingly dependent on technology and screens. As we sit and look at our phones, computers, or televisions, we have become both more sedentary and more isolated. We interact with each other less in “real life,” connecting through social media instead of spending time together or talking on the phone. People only post the parts of their lives that “look good,” so social media fosters unrealistic expectations and shame, not real connection. The pace of life is faster, too. Everyone is busy and over-scheduled—even children. Families aren’t having dinner together like they did in “the old days.” No wonder people feel burned out. No wonder so many people are developing mental disorders.
3.It’s toxins, chemicals, and fake food! It is not just the behavior of society that has changed, it is the physical world we live in. We are exposing ourselves to toxins every day. The foods we eat are filled with artificial ingredients. New chemicals are everywhere—on our lawns, in our water supply, in personal hygiene products that we use morning and night. We create and surround ourselves with compounds we’d never encounter in nature, the effects of which—especially in combination with so many other compounds—we do not fully understand. These are leading to increases in all sorts of illnesses, including cancer, obesity, and mental disorders, too, even if we don’t yet know precisely how.
There are many more of these “second category” theories for the rise of mental health problems, but these are some of the most commonly discussed ones. None of these three are far-fetched. They might well play a role with at least some people, or at least some of the time. As I will explain later in this book, some of them almost certainly do.
But as for number one on the list above—rationalizing the statistics as simply the result of improved recognition and diagnosis—the evidence shows that it isn’t just recognition that is increasing. The surveys comparing year-after-year data include samples of the entire population, regardless of whether people get diagnosed or not. These disorders are truly on the rise.
Perhaps the most important point to note is that the rates of very different mental disorders—autism, bipolar disorder, depression, and ADHD, to name a few—are all increasing at the same time. Why would that be? We think of bipolar disorder, ADHD, and depression as very distinct from one another, with distinct contributing causes. If these disorders are genetic, what happened to our genes? Is there a toxin causing numerous mutations? If the culprit is the stress of our fast-paced modern society, why are all of the disorders increasing? Wouldn’t more stress simply lead to more depression and anxiety? Certainly, stress doesn’t cause autism and bipolar disorder. Or does it? These statistics raise more questions than they answer.
To add insult to injury, the COVID-19 pandemic has taken an additional toll. In June 2020, an estimated 40 percent of all US adults reported struggling with mental health or substance use issues. Eleven percent of the adults surveyed said they had considered suicide in the past thirty days.10
The Price We Pay
Mental disorders are costly to society. The financial toll worldwide was $2.5 trillion in 2010 and is expected to reach $6 trillion by 2030.11 These figures include the costs of direct mental healthcare services (hospitalizations, doctor and therapist visits) and prescription medications. But there are also other financial costs that are more difficult to measure, including lost productivity due to employees becoming less focused or taking sick leave. These losses affect employers and employees, societies and individual sufferers. Depression is now the diagnosis that tops the list of disabling illnesses—above all other illnesses, including cardiovascular disease, cancer, and infections. Mental and substance use disorders are the leading cause of “years lost to disability” and “overall disease burden” in the US.12
Much more important than the financial costs of mental disorders is the suffering they cause to individuals and their families. They cause untold misery and despair. Mental illnesses can ruin people’s lives. They may lead to social isolation, disrupt school and career plans, and limit what people can expect for themselves in heartbreaking ways. The suffering almost always extends beyond the person with the disorder. Family life can be thrown into chaos. Divorce is a common consequence. Those closest to the sufferer can themselves develop mental disorders like anxiety or PTSD (posttraumatic stress disorder); they can simply burn out and abandon their suffering friend or family member to preserve their own health. At least half of the people in homeless shelters suffer from mental or substance use disorders.13 The same is true of prisons.14 Mental disorders can contribute to violence—not just the school shooters who make it into the headlines, but also domestic violence. Mental disorders can result in such extreme hopelessness that people take their own lives.
For the majority of people, however, mental disorders don’t show themselves in dramatic and easily visible ways. Instead, people suffer alone in silence. They are ashamed. They don’t know what to do about their symptoms. Oftentimes, they don’t even know they have an illness. They don’t think of their symptoms as “symptoms”; they think their suffering is just a natural part of existence. They might believe that they are weak or inferior to others. They may think that they just need to make the most of the life they were given. They experience their distress, their symptoms, as an integral part of themselves or their life experiences.
For example, imagine a woman we’ll call Mary. Her father was an alcoholic and verbally and physically abusive. He found fault with seemingly everything that she did, and she grew to believe that she was stupid and had few redeeming qualities. She didn’t talk to people about her father’s rages; she assumed this would only cause more trouble and incite further punishment from him. By high school, she was depressed, isolated, and saw little hope for her future. This continued into her adulthood. Mary had trouble sleeping, had flashbacks of her father yelling at her, and startled easily at loud noises. It did not occur to her that any of this might constitute a “disorder,” much less be treatable. I see patients like Mary who have suffered like this for years before something brings them to treatment. Many, many people like Mary never seek treatment at all.
What About Treatment?
Treatment for mental disorders is vitally important. It can reduce suffering. It can prevent disability. It can restore people’s dreams and potential. Treatment can save lives. In fact, it does. Many people benefit tremendously from present-day mental health treatments. Patients overcome addiction, find relief from psychotic episodes, learn to manage anxiety, recover from eating disorders—these victories are real and significant. The treatments we have work. Unfortunately, they just don’t work all the time or for everyone.
Let’s look at a success story first.
John was a thirty-six-year-old engineer, married with two young children. Life had been pretty good for him . . . until he discovered his wife was having an affair. John wanted to save his marriage, but his wife wanted a different life, and she had decided to leave him. John was devastated and became severely depressed. He was unable to sleep more than two hours at a time. He couldn’t stop obsessing about how his life was now ruined. He couldn’t focus at work. He felt the only solution was to get his wife to return, but she wasn’t interested. He was tormented with guilt about all the ways he thought he’d failed as a husband, as a father, as a person. This went on for three months and showed no signs of improving—if anything, it was getting worse. Finally, John’s family encouraged him to see a psychiatrist. He came away with a prescription for an antidepressant and a sleep medication, and he started weekly psychotherapy.
Within days, John was getting more sleep. This helped him to feel less disoriented and overwhelmed, but he was still distraught. Within a month, however, things started to turn around. His mood began to improve. He was able to stop the sleep medication and sleep normally on his own. He was managing to focus less on tortured ruminations and more on things that he could control. He focused on projects at work and around the house, and he made the decision to get into better shape. He started spending more quality time with his two children. He took the steps he’d been avoiding to finalize the divorce. After a few months, he was able to stop psychotherapy. After a year, he tapered off the antidepressant and continued to feel well. He started dating again.
John’s story demonstrates the success of modern psychiatry. The combination of medications and psychotherapy alleviated his depression and anxiety and helped him cope with an extraordinarily stressful time in his life. John’s was not the only suffering lessened, either. Divorce is difficult for children—in fact, it increases their risk of experiencing mental health challenges of their own. Having a parent with severe depression also increases this risk. Treatment allowed John to be a better, more engaged father. So, helping John feel better was also beneficial to his children. John’s workplace benefited, too. While depressed, John still showed up at work every day, but he wasn’t able to focus, and he got less done. Successful treatment helped John be a more productive employee.
There are countless stories like John’s, and it is easy to understand why researchers and clinicians in the mental health field like to tell them. It’s important to highlight that treatments can work. It’s important to encourage people to seek help, to let them know their suffering can end. And professionals in any field want to focus on their successes. They don’t tend to advertise what’s not working. Unfortunately, in the mental health field, there is a lot that isn’t working. Not everyone gets a positive outcome like John. In fact, most don’t.
Depression is one of the most commonly diagnosed and treated mental disorders in the United States. In 2020, an estimated 21 million adults experienced at least one depressive episode, representing 8.4 percent of all US adults. About 66 percent of them received some form of treatment.15
So, what happens to all of these people who get treatment for depression? Do they get better—and most importantly, stay better—over the long run?
One study tried to answer this by recruiting a group of people seeking treatment for major depression from five different academic medical centers and following them for twelve years.16 The study included 431 people, and researchers assessed their symptoms of depression on a weekly basis. What they found was that even with treatment, 90 percent had persistent symptoms. On average, over the twelve-year period, the people in the study had symptoms of depression 59 percent of the time. Their symptoms would fluctuate, sometimes going away but then coming back, even with treatment, even if they took medications every day. In other words, 90 percent of the people were not cured of their depression. They either continued to have low-grade lingering symptoms or they would come in and out of bouts of major depression. Depression was found to be a chronic, but episodic, illness. These researchers found that if people had only one episode of depression, like John, the chances of a full and lasting recovery were greater. However, there weren’t many of those people.
This study is not an outlier; it is a reflection of what anyone who has worked in the mental health field for a number of years already knows to be the case. Almost two-thirds of depressed patients don’t experience remission—meaning get all the way better, even temporarily—with the first treatment they are offered.17 As the statistics suggest, many people go on to suffer for years, despite trying treatment after treatment. It’s not just a failure of medications, either. Many people try numerous treatments—medications, psychotherapy, group therapy, meditation, positive thinking, stress management, and more. Some even try transcranial magnetic stimulation (TMS) or electroconvulsive therapy (ECT, also known as “shock therapy”). People for whom no treatment seems to be very successful are said to suffer from “treatment-resistant depression,” though there are many more people who do find some relief, but not in a complete or durable way. The fact that depression is the leading cause of disability in the world clearly speaks to the lack of effectiveness of our current treatments. What are we missing? Why can’t we get most people with depression all the way better and keep them better?
You may be wondering about the outlook for mental disorders other than depression. Sadly, the statistics for many other disorders are even worse. I won’t go through the data for every condition, but disorders like OCD (obsessive-compulsive disorder), autism, bipolar disorder, and schizophrenia are all at least as bad as depression in terms of both treatment success and the chronic nature of their afflictions.18 Many of these patients are told that they have lifelong disorders and that they will need to lower their expectations about what they will be able to achieve in life.
Understandably, many patients are frustrated by the ineffectiveness of mental health treatment. They hear stories like John’s and assume they should be cured like he was. They often come to believe that the professionals treating them are incompetent, or that they haven’t gotten the correct diagnosis, or that they just haven’t found the right pill yet. Unfortunately, these usually aren’t the reasons they aren’t getting better. For most people, it’s simply because our treatments don’t work all that well.
Some professionals in the mental health field won’t like this assessment or approve of me sharing it this way. They may fear that pessimism about treatment will deter people from seeking help. This is a legitimate concern. It is important that those suffering from mental illness reach out for support from professionals—sometimes this can be enough to keep someone alive through a suicidal crisis. Nonetheless, the data I’ve presented is accurate; to claim that mental health treatment works for everyone (or even most people), and works completely, is misleading at best. A bigger concern is that these types of claims can serve to further shame and stigmatize those with mental disorders. If people are told that our treatments work, and then those people don’t get better, some will blame the treatment or professionals, but others will blame themselves. And it isn’t just the patients: If we make these kinds of claims to families, other clinicians, and society at large, what happens when patients don’t get better? Do we say that the patient must have a “treatment-resistant” version of the disorder, implying that they have a more severe form of mental illness (which may very well not be true) and possibly adding to the stigma they suffer? Or do we suggest that it is the patient’s fault? Is the person not trying hard enough in therapy? Does the person somehow “want” to be sick? Unfortunately, these kinds of implications are all too common from clinicians, family members, friends, and others. And so we are back where we began, with the choice to come clean and say that for most disorders, treatments don’t work long-term for the majority of people. This brings with it the risk of discouraging those who need it from seeking treatment in the first place.
Given everything I’ve outlined in this chapter—that these disorders are common and becoming more common, that they are an enormous burden on society both in terms of economic impact and human suffering, and that our treatments have proved unequal to the task of relieving that burden—it seems clear that mental illness is a global health emergency. We have poured money into research in the hope of shedding light on the problem and uncovering new solutions. In 2019, the National Institutes of Health (NIH) spent $3.2 billion on mental health research. What do we have to show for the research that has been done?
This is what Dr. Tom Insel, the former director of the National Institute of Mental Health (NIMH), had to say in 2017 after leaving the NIMH:
I spent thirteen years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realize that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.19
This was brave of Insel to acknowledge. Those in the mental health field know it to be true. So, again, what are we missing?
The fact is, in order to make real progress, we have to be able to answer the question: “What causes mental illness?” And up until now, we have failed.