Mental Illness in the USA

I have been consistently surprised by the numbers of people in the USA diagnosed with a mental illness. For example, consider this statement from an excellent review on the apparent epidemic of mental illness in the USA:

The number of people treated for depression tripled in the following ten years, and about 10 percent of Americans over age six now take antidepressants. The increased use of drugs to treat psychosis is even more dramatic. The new generation of antipsychotics, such as Risperdal, Zyprexa, and Seroquel, has replaced cholesterol-lowering agents as the top-selling class of drugs in the US. 

The Epidemic of Mental Illness: Why?, Marcia Angell, The New York Review of Books

Read the link to that statement, the author of the review, Marcia Angell, provides some very interesting information concerning this USA trend. Remember when mental illness was believed to be due to a "chemical imbalance" in the brain? The hypothesis was never proved, was very ad hoc in that it was arrived at by noticing that drugs which helped alleviate mental illness typically affected some important neurotransmitters, particularly dopamine and serotonin. Yet when you consider the complexity of the brain, and the varied way in which these neurotransmitters have roles in the brain, the idea of "chemical imbalance" not only seems quaintly naive and simplistic but downright misleading. It was very misleading but that didn't stop a great many mental health professionals proclaiming that mental illness could be understood by reference to the chemical imbalance hypothesis.

There is a strong tendency amongst some to perceive nervous system function as something divorced from the environment. Our nervous systems are in constant contact with the environment. Accordingly we cannot understand our nervous systems work without reference to the environment. To try and do the same is akin to trying to study aerodynamics on the moon. The chemical imbalance hypothesis was very much about perceiving nervous system as processes operating independently of the environment. On that criterion alone the chemical imbalance hypothesis had to be wrong.

There are now a number of studies, including meta analyses, indicating that the efficacy of anti-depressants for mild to moderate depression is no better than placebo. So now we have a large group of people asserting that anti-depressants are a waste of money. I disagree with that. Statistical analyses are very valuable but I'm inclined to the view that if an anti-depressant is helping an individual, and many people will testify how the happy pills have changed their lives for the  better, then, irrespective of whether the effect is placebo driven or not I am prepared to accept that these drugs have a valuable role in treating depression. I consider it very foolish to tell a person that the effect of the drug is "all in their mind" and they would be better off without it. Anti-depressant drugs generally have a very safe profile and have saved many lives. A problem with statistical analyses is the presumption of over riding commonality in our life experience and physiology. We are much more unique than we often give ourselves credit for, so while a statistical analysis may find no "statistically significant" result for a particular drug, for those people for whom a drug does work, and often wonderfully well, are we justified in demanding cessation of the treatment just because the latest paper says the effect must be placebo or there is no benefit at all?

As noted in the review, Kirsch, one of the authors' whose books are reviewed in this article, asserts that principle benefit might be in the placebo effect. Thus he notes research on "active placebos", drugs that emulate the side effects experienced with anti-depressants. It may seem strange but placebo effects do vary. I have addressed this in a previous post. This is not just about emulating side effects, even the size and colour of the pill we are taking can impact on the placebo effect.

A fascinating aspect of many anti-depressants is that they seem to enhance neurogenesis: the creation of new brain cells. This has been well documented in various animal studies. This is a fascinating issue in itself and I can't do it justice in this post. The nutshell goes like this:

A key region implicated in depression is the hippocampus, which receives new neurons from the nearby structure, the dentate gyrus. Longstanding depression can induce sufficient cell death in the hippocampus leading to measurable atrophy of that region. Recovery from depression can induce recovery of hippocampal volume due to increased neurogenesis in the dentate gyrus. This effect is not unique to humans, studies on other mammals also point to the ability of some antidepressants to stimulate neurogenesis irrespective of whether or not depression is present.  

Having gone through all these twists and turns do I think the current rate of antidepressant use is a problem? Yes, and here is why:

• The emergence of depression as an epidemic is not going to be solved by placing ever increasing numbers of citizens on anti-depressants. "Soma"(Brave New World), is not a solution. If depression truly has become that widespread then it points to a fundamental problem with the structure of society, not our brains. 
• Particularly in the USA there is a strong trend to medicate at earlier and earlier ages, with far too many children being placed on antidepressants and this in spite of a lack of sufficient empirical evidence to justify such a strategy. We may very well be creating a generation that becomes overly dependent on happy pills and we have no idea of the long term health implications for children taking these medications. 
• There are many ways to treat depression but there is far too much reliance on happy pills. Exercise, meditation, enhanced social life, sunlight, thyroid function, immunological balance, regular sleep habits, omega 3-omega 6 balance, tryptophan in the diet(tryptophan is an amino acid that is a precursor for serotonin production)can all be very important in keeping us happy. The current emphasis is preventing a thorough examination of all possible approaches to treating depression. We live in a "go fast" culture and want "go fast" solutions when the very problem could be that we are all going too fast. Given that the USA is a "very fast" culture perhaps we should not be surprised that the USA consumes circa 73% of all antidepressants! 

Should we be aiming to reduce reliance on antidepressants? At a societal and treatment level, most definitely. At the individual level though we need to proceed very cautiously. If you are taking an antidepressant don't stop taking it just because someone has told you it is all down to the placebo effect. That might be true at the statistical level but at the individual level it could also be true that the antidepressant is providing benefit that is not through the placebo effect. For each individual case we cannot know if the effect is placebo or otherwise. It is very important to remember that the placebo effect is NOT "all in your head", there are measurable physiological changes occurring. 

Never stop taking an antidepressant "cold turkey". If you are taking an antidepressant and wish to stop being reliant on the drug you must discuss this with your doctor and simultaneously begin other strategies to help manage your condition. Additionally, if possible, advise a partner or close friend that you have stopped taking the drug so they can monitor your behavior. Depression can creep up on us, indeed many people can be mildly depressed and unaware of it. An honest and astute observer can warn you of changes in your behavior that suggest depression is creeping up on you. 

While I don't see any substantive risk for individuals taking antidepressants I have very real concerns about the increasing use of antipsychotics. These drugs can be particularly dangerous with increasing evidence that these drugs can induce cerebral atrophy. The increasing use of these drugs in children and dementia patients is  without empirical support and is placing these groups at serious risk for dangerous side effects and cognitive decline. I am at a loss to understand why so many clinicians are now prescribing these drugs and believe that in the years to come many psychiatrists are going to be fighting legal battles because of their antipsychotic prescribing habits. 

Psychiatrists are caught between a rock and a hard place. They are often called upon to address conditions that are arising from the environment within which individuals must function. If the increasing incidence of mental illness continues we will be overwhelmed and our mental health strategies will be inadequate (already are!) to help all those suffering from mental illness. We need to take a step back and remember that the brain exists in a body and environment. Our ongoing failure to account for general health issues and environmental contingencies in addressing the challenge of mental health will suck our societies into a consuming vortex that will not only make the lives of mental health sufferers much worse but will have wide ranging implications for society. At the end of the day we need to seriously heed the advice of Nancy Andreasen, former Prof. of Psyhiatry at Harvard. At the end of her entertaining text: Brave New Brain, she writes:


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"We simply lack the knowledge to cure society as well as individuals.

Confronting this fact seems especially imperative at this time. Psychiatrists are frequently called on to prescribe quick treatments for a variety of social ills, such as the rising rates of crime and violence. Instead of appealing to the speciality of psychiatry to "fix" violence or reduce general unhappiness, all of us, as members of the human community, need to recognize that the sense of "self" in our post-turn-of-the-century worlds may be in need of repair. There has been a widespread move toward materialism, quick fixes, instant gratification, and a superficial sense of success, which is reinforced by the fast-paced cyberworld that we live in. The answer to our many current social problems must come from individual people, who must reappraise their sense of "self" and reach an appropriate perspective on what constitutes a sound moral compass and meaning in life. The need to search for a personal moral compass to guide our individual lives in the twenty-first century is a need that transcends medical intervention, but which has a very real impact on how we choose to employ medical science and what we expect from it. In the era of the genome, fraught as it is with a variety of crucial moral questions, we must all make an agonizing reappraisal of who we are, what life is, what life means, what we must do to help the other human beings who share our world with us, and what we can do to make it a brave new world."