Are we in the midst of an epidemic of mental illness?
My dictionary would suggest the word “epidemic” is appropriate when discussing some that is “excessively prevalent” or “characterized by very widespread growth.” Is mental illness really growing as much as some critics claim?
It’s with some interest to examine the claims of those who say we’re in some sort of “epidemic” of mental illness. But owing to their sloppy premise, loose research efforts, and illogically connecting dots that have little to do with one another, I find it a hard claim to swallow.
In fact, research shows that prevalence rates for mental illness have actually declined somewhat from 1994, making it hard to understand where some are coming from about this “epidemic” nonsense.
Bruce Levine, over at Salon, borrows much of his beginning argument for his article from a 2011 New York Review of Books review by Marcia Angell (which he at least attributes):
Severe, disabling mental illness has dramatically increased in the United States. “The tally of those who are so disabled by mental disorders that they qualify for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) increased nearly two and a half times between 1987 and 2007 — from one in 184 Americans to one in 76. For children, the rise is even more startling — a thirty-five-fold increase in the same two decades,” as Marcia Angell summarizes in the New York Times Book Review.
Angell also reports that a large survey of adults conducted between 2001 and 2003 sponsored by the National Institute of Mental Health found that at some point in their lives, 46 percent of Americans met the criteria established by the American Psychiatric Association for at least one mental illness. ((Ronald C. Kessler, PhD; Patricia Berglund, MBA; Olga Demler, MA, MS; Robert Jin, MA; Kathleen R. Merikangas, PhD; Ellen E. Walters, MS. Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602. doi:10.1001/archpsyc.62.6.593.))
The problem is, neither Angell nor Levine — as skeptical researchers should — ask, “What are some alternative explanations for this data that might offer a ‘best fit’ model for this data?”
It’s not hard to find one right away — the relaxing of medical criteria in order to qualify for SSDI. If the programs relax their criteria in order to qualify, then it’s not surprising to see an uptick in the number of people who take advantage of that change. ((In other words, it would be astounding and counter-intuitive to find that numbers of people would go down for a “free government money” program after they government relaxed the criteria for it.))
Worse is that neither author has bothered to put these kinds of statements or numbers into any sort of context. What does it mean when we say “46 percent of Americans met the criteria established … for at least one mental illness”? Is that better or worse than it was, say a decade earlier?
Levine believes this is proof of an epidemic. Sadly, he (and the original book reviewer) failed to note what the DSM-III-R (the DSM-IV’s predecessor) numbers were.
Based on nearly 100 fewer diagnoses between the two editions, a study conducted by some of the same researchers back in 1994 ((Kessler RCMcGonagle KAZhao SNelson CBHughes MEshleman SWittchen HUKendler KS. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;518- 19)) found an even higher prevalence rate:
Nearly 50% of respondents reported at least one lifetime disorder, and close to 30% reported at least one 12-month disorder. ((The newer study found, “Later onsets are mostly of comorbid conditions, with estimated lifetime risk of any disorder at age 75 years (50.8%) only slightly higher than observed lifetime prevalence (46.4%).”))
Hmmm… New study found 46 percent lifetime rate, old study found a 50 percent lifetime rate for qualifying for a mental illness diagnosis. As you can see, the rate has actually decreased since 1994.
Which is exactly the opposite of what Levine is arguing.
The 2005 Kessler et al. study (( Ronald C. Kessler, PhD; Wai Tat Chiu, AM; Olga Demler, MA, MS; Ellen E. Walters, MS. Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627. doi:10.1001/archpsyc.62.6.617.)) that reported on 12-month prevalence rates actually found a similar decrease:
Twelve-month prevalence estimates were anxiety, 18.1%; mood, 9.5%; impulse control, 8.9%; substance, 3.8%; and any disorder, 26.2%.
Hmmm… 30 percent in the older study, and 26 percent in the newer study — a similar 4 percent decline.
And that’s the problem, in my opinion, with what passes for journalism today. It took me all of about 20 minutes to research this data (and this without anyone providing research citations — thanks folks!) and see that when you put this data in context, it actually makes a case that is in direct contradiction of Levine’s “epidemic” argument. And these aren’t tiny pilot studies conducted on a convenience sample of college students. These are studies with thousands of subjects.
Finally, one obvious explanation for the rise in people being treated for mental illness is because we’ve come a long way in the past two decades in helping to eradicate some of the stigma, ignorance, prejudice and discrimination that has traditionally been associated with mental illness. When people learn their concern is actually a real illness and there are treatments that work for it, they’re more likely to seek them out.
The data from research studies don’t lie. So don’t always believe the hype — especially when it flies in the face of such data.
Read the full Salon article: How our society breeds anxiety, depression and dysfunction
Read our previous discussion of the “epidemic” hype: An Epidemic of Mental Disorders?
6 comments
suffering from bipolar I, i can say this is a very dissabling mh condition. its seems to me that bipolar is overly dx. in alot of cases.
The increase has been seen mostly in studies that span the 20th century. They show both higher prevalence and earlier onset illness. Also studies of immigrants and urbanization consistently show increasing rates of mental illness.
I have been interested in this question from a philosophical perspective. Please see my blog: modernworldmodernmind.com.
Mark Rego, MD
Many thanks to Dr. Grohol for, once again, debunking the “mental illness epidemic” myth, which has been propounded mainly by people who don’t understand medical epidemiology.
I am aware of no credible epidemiological data showing that any of the major psychiatric disorders (often lumped under the rubric, “serious mental illness)have shown a substantial increase in prevalence or incidence when studied across many decades, using (roughly)the same diagnostic criteria. This includes schizophrenia,
bipolar disorder, and major depressive disorder. That said, there may be some subgroups (such as recent immigrants)who have shown increased rates of some psychiatric disorders; but these are not representative of the general population trends.
This, of course, is a different matter from changes in the frequency of “chart diagnoses”, as written by family doctors, psychiatrists, etc. These don’t constitute a reliable basis for computing actual prevalence or incidence of a disease, and are subject to many confounds, such as insurance coverage, parental pressures to diagnose some conditions, etc. Similarly, disability determinations–often cited by some
“epidemic mongers”–are not a stable or reliable way of computing actual incidence or prevalence of a disease, and are also subject to many pressures and confounds.
For more on these issues, please see my article cited in Dr. Grohol’s earlier piece:
Is There Really an “Epidemic†of Psychiatric Illness in the US?
Best regards,
Ronald Pies MD
Hmm, and yet you are quoted in an earlier post about medicating normalcy in saying the following:
“He [Dr Pies] then describes the primary role of psychiatry today, which is rather simple: to relieve suffering and incapacity in whatever way is possible. “So long as the patient is experiencing a substantial or enduring state of suffering and incapacity, the patient has disease (dis-ease).†That mission, asserts Pies, is not to medicalize normality. It is an ethical imperative.”
What exactly does “in whatever way is possible” and “an ethical imperative” mean?
Either or both of these statements could be interpreted to support medicating “dis-ease” even if it is short lived and non repeated. Hence to then pad stats that could in fact falsely support a claim for an epidemic.
Seems incongruent to me from there to here. Anyone else read the prior and current posts with thread to support or dissent my interpretation?
I would suggest part of the problem is semantic and another part is nosological. Journalists and health professionals essentially live in different worlds, and the vocabulary used sounds the same but often means different things. “Epidemic” is one of those words that mean different things to journalists (and the general public), M.D.s/D.O.s in practice, and medical researchers including epidemiologists and others doing applied research. I would say journalists, the public and most physicians in practice have minimal understanding of statistics, and words like “incidence” vs. “prevalence” vs. “occurrence” all mean pretty much the same thing to them – but for me and thee (we), they do have different meanings.
Stats come from many places and were gathered and analyzed for many reasons, often not fully specified in presentations like reports, and may also include older figures, or figures based on poor study design or collection methods. But readers may not have a way to know that – or understand the importance of such things.
The other issue is that what constitutes diagnosable mental illness constantly changes. What we call schizophrenia now is not the same as the disease that was originally identified as a syndrome or disease of “split personality” – and not just the name has changed. We no longer use terms like “neurotic depression” in formal diagnosis (they are tinged with judgmental overtones), although there are still those of a certain age and type of training who still use the terms, even in published articles. I recently did a quickie study of dermatological publications related to “delusional parasitosis” and “Morgellon’s Disease”, and multiple fairly recent articles in so-called “peer-reviewed” journals used terminology that sounded positively archaic (although, to be fair, some – but not all – were using old articles in reviews to introduce their own, and probably had heard the terms in their own training and didn’t consider them outdated; the problem is whether they actually use them on live patients in diagnosis instead of current terminology.
Which has just changed again for some disorders, so where does that leave definitions and statistics for mental illness incidence and prevalence? How do we compare new DSM-5 diagnoses to reports using DSM-III or DSM-III-R diagnosis, which were, after all, in use during the professional lives of many of us?
Given all this, is it really any wonder there is confusion over whether or not there is an “epidemic” of mental illness? What about all those Asperger’s kids who are now either not disordered or else autistic? Where does the fact come in that the population keeps growing, and not just from immigration? What about increased awareness of disorders because of advertising for psychopharmacological products – and the decreased stigma that has accompanied this awareness? How is incidence or prevalence of various psychotic disorders measured if some of the disorders have changed categories, been combined, disappeared, or renamed, and some disorders have done this several times over the past 15-20 years?
Just saying…I don’t think it’s hype, I don’t think it’s intentional misstatement, I think it’s confusion, and some of it is the professions’ (in their larger contexts, as described above) own fault.
More important: How are we explaining the changes and the impacts of those changes to people suffering mental illness, their families and their doctors and insurance companies?
i’m not quite as sophisticated as all of you, but I do know that the cause of increase in mental health issues is due greatly to prescription medications…why is it that they now prescribe an anti depressant as a pain killer…yes it also works as a pain killer, but if the patient did not have a mental health issue to be treated…they do now. Not only that, but the power of attraction…I had a friend read a book and said she had some of the symptoms of which the book explained to be borderline personality disorder. My friend was a happy healthy mother with a full time job. Now she is on SSI, threatened to have her kids taken, and more depressed than ever. And guess what, she got put on another pill last week because the 13 she is already on is causing her more problems, both physically and mentally…so who is at fault here…patients, pharmaceutical companies, or the trusted doctors in which keep passing out these DRUGS that are worse than the ones found on the street! And the government is paying for it!!