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Mental Health Intersecting Contemporary Medical Care
The Ender
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There has been an upsurge - if not an outright explosion - in the recognition & diagnosis of mental illnesses over the last decade. The WHO estimates that up to 1 in 4 persons on the planet may suffer from a serious psychological complication.
Tackling the problem of treating all of these people - closing what has become known as the 'treatment gap' - is going to be a huge challenge for the future: current medical practices & infrastructure are very good at treating acute physical problems (broken bones, lacerations, concussions, heart failure, etc) & hardening populations against infectious disease (via vaccination programs), but aren't prepared or staffed to deal with mental illness. The gap currently leaves about 50% of people suffering from mental illness in the industrialized world without any treatment, and about 90% of people suffering from mental illness in the developing world without any treatment.
How come everybody is suddenly getting sick? Is it the fluoride in our water? Is it HFCS? Is it the vaccines?
This needs to be underlined: what has happened recently is that we have come to better understand and identify mental illnesses. The rate of illness has probably not much changed, only our understanding of how large the problem is. 20~ years ago, children still suffered from ADHD - we just didn't call it that (and stupidly dealt with the problem as a disciplinary rather than medical issue).
This is all about pushing pills! Them pills are no good for nobody and make kids commit suicide!
There is some evidence that, yes, medication may be being over-prescribed to people because doctors are given financial incentives to sell people pills. This fact - while problematic - is exaggerated in it's scope.
Medication for mental health problems is currently demonized unfairly. Human brains are distinct enough that different medications have pretty different results from person to person, but none of them are going to turn you into a personalty-stricken zombie, fundamentally change who you are or turn you into a psychopath. There are statistics occasionally floated around about specific brand name drugs being associated with high rates of suicide; these figures are extremely misleading, omitting the fact that when you control for the suicide risk of the demographic group having the medication administered, most drugs show pretty significant improvements for the patient's outlook.
Why aren't our health care systems dealing with this problem?
Well, this should be said: most health care systems in the west are dealing with the problem as best they can.
The issue stems from this strange sort of dualism that modern health care grew out of, where mental health & physical health were sharply divided and institutionalized in very different ways (and then internally compartmentalized into different fields of expertise). It's not just a matter of trying to fuse these two things together: one field (physical health) has seen growth & expansion, while the other (mental health) has largely stagnated and is way, way too small to deal with health issues at the scale seen by the other - even though by all accounts it owns, in theory, the lion's share of the work to be done. We need to not only integrate two fields of medicine that have stood apart from one another for most of their existence, but massively overhaul & expand mental health care as a whole.
To give you an idea: the WHO suggests that we would need an extra 1.18 million mental health specialists right now to close the treatment gap. As time goes forward and the world population grows, that figure is only going to get bigger.
That's an awful lot of post-secondary graduates we need to churn out, somehow.
Do you have a personal anecdote or human interest story for me chew on?
I do!
I've actually been dealing with both sides of the system in Canada for a little while, on the patient end: I had an eye condition develop just over a year ago (Keratoconus), and was diagnosed with PTSD & depression a few years prior to that.
The difference just boggles the mind. My eye treatment has involved a rigorous schedule of check-ups, treatments, post-op examinations, topological studies, communications back 7 forth between various eye doctors, lens prescriptions & recommendations... even a cock-up & complication as a result of contact use that was easily diffused as a result of this strong network of professionals in a well established industry.
My PTSD & depression treatment amounted to giving me a bottle of medications, with the expectation that I would self-medicate & maybe continue treatment or maybe not, and a list of recommended psychologist offices.
It's like a high level modern bureaucracy compared to the wild Goddamn west.
Mental illness, D&D: because pulling yourself up by your bootstraps is tricky when you're not quite sure where 'up' is, or why you'd even want to pull yourself there to begin with.
With Love and Courage
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"If Physical Diseases Were Treated Like Mental Illness"
To be fair:
the guy in the top left is right, the guy in the top right will need to change his frame of mind to accommodate his new disability and the guy in the bottom left really doesn't seem to be trying very hard to hold his bleeding in.
Also bottom right probably isn't being helped by lying in bed all day.
I realized (literally two days ago) that I need to see someone for my mental health. I'm covered under my girlfriend's extended health care plan. We live in Canada and she is a registered nurse in a large hospital. It turns out that her insurance only covers up to $500 per year for consulting a psychologist. In my area, this barely covers three sessions with a psychologist. Yeah, thanks for nothing.
Nintendo Network ID: PhysiMarc
If 25% of the entire human population has X, it seems really strange to call X a complication or disorder.
1/3 of the US population has metabolic syndrome
you can have big numbers as long as you can demonstrate fixable or preventable harm
Doc: That's right, twenty five years into the future. I've always dreamed on seeing the future, looking beyond my years, seeing the progress of mankind. I'll also be able to see who wins the next twenty-five world series.
ugh... he could have worded that better. "at some point in their lives, 25% of people will suffer from...".
not talking about 1 thing or it being anyone's normal state. So... like, nice quip and all but it isn't really all that relevant to the study. 25% of people get the flu at some point... or what, like, ever, but that doesn't mean we should be talking about normal healthy people being feverish, leaky, hacking bags of coldsweat.
...when X = "a serious psychological complication"?
that's a pretty wide range to be lumped together as "it's probably nothing then"
Not really. I'd bet around 90% of the population will be injured and shred blood in a given year; that doesn't mean having open wounds is normal. Keep in mind that this covers all serious mental issues.
What proportion are acute, would you say? It seems like most of the population is high functioning, but there's an idea that's consistently put forward that mental illness is something that doesn't go away.
Define high functioning? People are really good at faking it, so gauging prevalence can be tricky to say the least. How many times have you heard the "but he seemed so happy" story after a suicide?
Yeah, he could have worded that better.
Can I just say how I am so fucking tired of the whole " Have you just tried not being X " mindset that far far to many people have.
Like, To the point of just shutting down and internalizing because I don't want to hear it again.
Curious about this one. We have a habit of understanding the past in terms of the present, explaining what happened then in terms of our contemporary knowledge.
If we take seriously the notion that mental health disorders are akin to physical diseases (things like flu, cancer, AIDS, etc.) then it may be the case that disorders we find today are recent phenomena. Just as flu strains evolve over time so, too, might the "structure of human consciousness" or "brain states", or however you want to articulate "the parts of a person that cannot be poked with a stick", change through the generations.
Given timelines for biological evolution, it seems safe to say that 20 years ago the mental state we call ADHD was around, but it may not have been around 500 years ago.
My point is: We may want to exercise a bit of caution with respect to the "things have always been this way, but now we have a label for it" story.
I don't want to get out of bed every day. It is a struggle, when my alarm goes off, to pull myself out of bed. On days I have to work, the only thing that gets me moving is that I have a wife and animals at home that need my income to survive. On my days off? I might spend way too long just lying, doing nothing, thinking about all of the things I have to get done and be too afraid to move. But my coworkers have no idea I am like this (except my direct manager who knows I'm having problems with my meds right now). I bust my ass at work and get a ton done. People think I'm happy, though rebellious, and I'm considered one if the hardest workers in the store and the best at welcoming at new people.
People force themselves to be positive and happy in public for different reasons. On the inside? Some of us are on a constant edge of breaking down to tears. We barely keep it in check, and lose control when we're alone taking out the anger on ourselves, or worse, on our loved ones.
https://steamcommunity.com/profiles/76561197970666737/
At least twice as well-adjusted as my aspie ass.
Just about all humans will have a cold at some point in their life. All humans will die at some point in their lives.
The pervasiveness of a problem doesn't make it not a problem.
We have a working theory for why the numbers have changed - differing attitudes in reporting, diagnosing, and treating mental health issues. We have plenty of evidence of changes in these areas.
We have no evidence that human cognition has fundamentally changed since the olden days. In fact we have a great deal of historical evidence that the people of 500 years ago were very similar to ourselves. Nor do we have any evidence that mental illness follows the same patterns of change as mutations in pathogens.
Occam's Razor.
Not great examples, as those are pretty okay, which might be the disconnect. Overall, people seem to be functionally really well, even including my GF's shit show of a social circle (she made all her friends when my studying abroad put her in a bad place), so it's weird to hear that quarter of the population has a serious condition. If you told me that a quarter of the population had a serious physical ailment, I'd be expecting to walk outside and find fucking Chad (of course, it could be that Chad's just throwing off the average on mental illness, too).
Yeah, but that comment was going on another logic pathway. I'd still like to hear an estimate on average progression length or prevalence. I could have sworn somebody replied to my first comment with a number, but I can't find it.
Edit: found it:
Google says that's about 6%, which sounds about right.
Yes, the reporting, diagnosing, and treatment of mental health issues has changed over time. What I am asking is whether the mental states we categorize as mental health issues, themselves, have changed over time.
Argument from ignorance. The fact that we have no evidence for X may indicate that we have shitty methods of inquiry, rather than there being a lack of X.
Well, not really. 500 years ago humanity still maintained a very robust mind/body dualism. When folks assessed behavior, they did so with a different conceptual schema than we utilize today.
Now, it might be the case that Dr. Mc1700s recorded collections of symptoms that are similar to the symptoms we associate with ADHD. But there is a difference between a set of symptoms, and the disorder, the mental state, itself. There is a difference between "Billy gets sad sometimes" and "Billy has a serotonin deficiency", unless you're the Churchlands.
It could be the case that 500 or so years ago brains were super-great at regulating serotonin, and only recently has that system begun to fuck up in the species. We do not have any evidence to suggest that 500 years ago brains were super-great at regulating serotonin, but that is because the chemical compound we now call serotonin was not discovered until fucking 1935.
So, yeah, we don't have any evidence for charting mental disorders over the course of human infancy because psychology, as a medical discipline, is still in its infancy.
If you have evidence rather than speculation, go right ahead and post it.
Your mind/body dualism point is extremely odd. Mind/body dualism is probably still the norm today, and when I read the diaries and fiction of people even 2000 years ago, I find them perfectly explicable.
This is just your usual:
'well I don't know anything about that subject, but I can sure as hell speculate in a way that implies nobody else has posed these tremendously obvious questions before, instead of just reading up on a subject.'
the "no true scotch man" fallacy.
A rather extreme example: syphilis. It's very rare in the modern world today.
Advanced syphilis can cause schizophrenia and extreme paranoid delusions.
A more relevant example: serotonin. Most people know that SRI antidepressants, the most common kind, have to do with serotonin. But serotonin also regulates a whole bunch of interesting stuff in the gastrointestinal tract.
Hell, just check the Wikipedia article, or I'll end up quoting most of it. Point being, there's a very strong link between being depressed and having various physical conditions that we're just now starting to realize are linked.
I've spoken to a doctor in neuroscience that called the GI tract the "second brain" when talking about how important serotonin is.
(Well, okay, he's being a little pedantic.)
I want to respond in more depth later, but for now I'm going to use one comment as a springboard.
Yes, absolutely.
Even within the last several decades, the 'bible' of mental health disorder categorization: the Diagnostic and Statistical Manual of Mental Disorders, printed by the American Psychiatric Association (not to be confused with the American Psychological Association), has undergone significant revisions. The fifth version, DSM-V, was printed last year and caused quite a bit of controversy. (Note that France has its own categorization system, and many other countries use ICD-9/10 rather than the DSM. But the DSM is still used in a lot of countries, particularly those where English is the primary language.)
I call it the "bible" but very few people treat it as such. Rather, there's a recognition, often tacit, sometimes explicit, that these categories are basically like blind men trying to identify elephants. The APA does the best they can, but the categories aren't necessarily real things - they're just created out of convenience for bureaucratic and insurance/single-payer-billing purposes. It is a mistake to reify them.
But digging even deeper than the DSM, whether a mental disorder - particularly a mood disorder like depression - is medicalized in a way that we understand to be medicalized differs from culture to culture and era to era.
In other words, we know that there have always been melancholy people. But whether being melancholy was a individual internal problem that the person had responsibility to solve or rather just an accepted personality trait or a response to the external environment differs from one culture to the next and even European/Christian/English-speaking history has absolutely not been consistent about that over time.
the "no true scotch man" fallacy.
Hell, that's something I've spent hours and hours talking to shrinks about. I'm autistic. Like, actual doctor-on-paper diagnose, not the internet kind.
Where do the traits of my diagnose end and where do I, the person, begin?
Note that the word "serious" does not appear anywhere in the WHO's article. Here is their wording:
Other articles which place high estimates on prevalence (I've seen up to 50%) generally:
1) Talk about lifetime prevalence - the possibility that a human being will suffer from a mental illness at some point in his or her life.
2) Include mild-to-moderate mood disorders, such as anxiety and depression, and other maladaptive disorders such as high-functioning ADHD and high-functioning autism spectrum disorders (aka 'Aspergers' which is starting to become an outdated term).
the "no true scotch man" fallacy.
This isn't to say it's not a serious problem. Let me talk about depression for a minute, because that's the problem I have the most personal experience with. Even moderate depression reduces your health, increases risks of other diseases, increases mortality, reduces productivity, decreases lifetime economic income potential, and just plain sucks.
It's clearly undesirable to feel depressed. But is it a disease?
We recognize that diseases can be caused by external factors. Coal dust can cause black lung; carcinogens can cause cancer; etc. But we see these things as abnormal. They're internal to the body - they've physiologically manifested - but with rare exception they're seen as invaders. Depression is sometimes described, even in nonindustrialized cultures, as a parasite or spirit sucking your vitality away. As Echo said above about autism, "Where do the traits of my diagnose end and where do I, the person, begin?"
If somebody is depressed because, say, they're in an abusive relationship, or maybe they're a gay man living under a homophobic regime, or they're living in poverty, is that a disease-state?
Furthermore, if we label the depression of the person living in such an environment as a disease, then we risk abnormalizing the individual and normalizing the environment. If the individual can't adapt to the society, is that the individual's fault?
It is easy for us, as left-leaning westerners, to say "well, yeah, if a homophobic regime persecutes its gay citizens, they're going to cause depression, but that's not because there was anything wrong with the gay citizens to begin with. The depression was exogenous - caused by abuse." In that case, the depression is more like an injury. It's more like somebody violently breaking your leg, and less like being born with leg-breaking-vulnerability genes.
It's not so easy to look at cultural status quos that we accept as "normal" with the same critical eye. If a student has trouble in classrooms because he has a lot of physical energy and needs a lot of stimulation, does that mean that he has failed the classroom or that the classroom has failed him? If we label him "ADHD" is that value-neutral like labeling him "a visual leaner" or is it value-positive like labeling him "gifted" or value-negative like labeling him "learning disabled?" We can see similar controversies at play with autism ("neuroatypical"), gender issues, and sexual behavior.
There is no single easy answers to these questions, and each "condition" needs to be discussed separately.
the "no true scotch man" fallacy.
Additionally, it's becoming a drain on the taxpayers in the form of law enforcement and judicial involvement. Some people are eventually going to get into trouble, whether they're on medication and/or receiving counseling/therapy. But, there are fewer options for overnight care and it can be a huge drain emotionally on family and friends to provide the level of care some people need. Add on to that, the high level of care some kids need, but they don't meet the strict criteria for adult services once they hit 18.
The body loves to make its secreted and circulating substances perform multiple jobs, some of them far removed from their most famous purposes. The serotonin thing is why SRI antidepressants, also known as Serotonin Reuptake Inhibitors, increase the amount of serotonin and therefore cause nausea, vomiting, and diarrhea sometimes. Thankfully, serotonin itself doesn't cross the blood brain barrier, which means you can mostly wreak havoc on the body's regulation and spare the brain.
There are plenty of illnesses marked with the ability to cause curious behavioral symptoms including: depression, drinking a whole lot of water till you die, being afraid of water, eating things that aren't food, eating a lot of food, just putting things in your mouth for no reason, self mutilation, feeling as if there's always somebody behind you, seeing little dancing men at the bottom of your field of vision, feeling as if there are ants crawling around on your skin, being apathetic, wanting sex a lot, being obnoxiously friendly, engaging in high risk behavior, and a bunch of others I forgot. Actual systematic medical conditions can independently cause strikingly weird behavior that is misdiagnosed as a primary psychiatric problem.
Doc: That's right, twenty five years into the future. I've always dreamed on seeing the future, looking beyond my years, seeing the progress of mankind. I'll also be able to see who wins the next twenty-five world series.
For more fun, the US is also still in the process of updating to the ICD-10 for physical disorders, and I think one other manual. Not a fun time to work with insurers.
In a more datieled note on how classification matters, there are three traditional classifications of "clinical depression" that are categorized together in the DSM IV, the first was melancholia, I think the second was manic-depression, and I'm pulling a Rick Perry on the third. These three react very differently to medications.
Well, I think this is a curious game to play: I mean, everyone in the west has to go school if they want to get much of anywhere. A mental condition that prevents you from performing well at school (or focusing at any given task anywhere, really) is certainly disadvantageous, whether or not you want to refer to it as a disease or disability specifically.
We could posit some fantasy world where a condition that prevents you from focusing on a task & makes you jittery somehow isn't disadvantageous, and then I guess we could say, "in this nonsense fantasy world, AHDH would not be a disease / disorder," ...and I'm not sure what we'd really be accomplishing?
Record lows of unemployment thanks to the efforts of Warioware, Inc. and its subsidiaries
Doc: That's right, twenty five years into the future. I've always dreamed on seeing the future, looking beyond my years, seeing the progress of mankind. I'll also be able to see who wins the next twenty-five world series.
A characteristic being disadvantageous given a particular arrangement of society does not in and of itself imply that a characteristic is a disease.
American Psychiatric Association, 1973:
the "no true scotch man" fallacy.
Mostly because we look at ourselves as we are now rather than over the evolutionary timespans necessary to create large changes in the whole of humanity. We think of 'humanity' as society, not as the result of evolution.
For example, we can imagine a society of depressed people, or wheelchair users, functioning now in the world we've created. But our evolution is deeply bound up with the ability to move on two legs quickly, climb trees and so on. That's just who we are. Organisms with much less mobility have slower metabolisms, or are cold-blooded, and have various reasons to not have unusual brains like ours. It's much harder to normalize depression and imagine how humanity would work if we all had brains that worked that way, but I think if we had been that way for tens of thousands of years, we would be essentially a different species.
This isn't saying that people with these problems are a different species or anything. Just that the concept needs some thought.
I think about what @Echo was saying a lot, because it's a common question within my family.
I think maybe diseases are things that adversely affect you and are treatable. I'm not convinced autism spectrum disorders really fall into that definition.
The other word is disability - something untreatable. But that's such a negative word I doubt anyone with Echo's atypical neurology would care for it.
At the end of the day, separating 'society' from other facts in the world such as the weather and biology seems arbitrary. The world is the world, society ended up this way as surely as the mountains did, and is no more arbitrary. So if a condition makes it hard to function in society, I don't think it makes sense to imagine a different society where it would not limit your life, any more than I should imagine a different biology where I didn't have Crohn's disease.
Oh, and @feral why do you limit diseases to conditions caused by external factors? That seems arbitrary, and excludes things such as auto-immune disease.
Argh that was very rambly. I hope I don't offend anyone.
I don't? If I wrote something that gave that impression, that was not my meaning.
the "no true scotch man" fallacy.
Doc: That's right, twenty five years into the future. I've always dreamed on seeing the future, looking beyond my years, seeing the progress of mankind. I'll also be able to see who wins the next twenty-five world series.
Depression is actually really complicated because while "Hey, just try not being sad!" is not very instructive advice, it's also the case that part of the treatment does, actually, involve the patient making a conscious effort to do things to make themselves less sad. You can be lying in your bed all day doing nothing, knowing you need to get up and do stuff, and at least part of the solution is actually forcing yourself to get up and do stuff.
Similarly, treatment for something like panic disorder involves, in part, making yourself do shit that might terrify you.
And none of this stuff makes a lot of sense unless you have direct experience with it, either suffering from it yourself or being close to somebody who does. We really need some sort of campaign to explain this to people, because as long as nobody gets what a lot of mental disorders are really like, they're going to perpetuate the stigma associated with them.
The behavior related in SmallLady's comic persists specifically because someone who does not suffer from, say, depression cannot distinguish between "I cannot go to class because I am suffering from severe depression and am physically unable to make myself do so" and "I cannot go to class because I am lazy and fuck French lit." Everyone's experienced the latter, and the solution is "Suck it up, asshole, do it anyway."
Like, if the solution for most people to getting shot was literally to will the bullet hole to close and for your lung to rebuild itself, stuff like in that comic would probably happen, too.