The Greatest American Challenge

The claim that the spread of severe mental illness in our mighty nation has reached “epidemic” proportions has been heard so often that, like any commonplace, it has lost its ability to shock.

The “severe mental disease” in question is the set of disabling conditions diagnosed as manic-depressive illnesses (including major unipolar depression) and schizophrenia. It has proved to be impossible to distinguish, either biologically or symptomatically, between unipolar depression and the depressive stage of manic depressive illness, on the one hand, and between mania and schizophrenia, on the other, which means that these conditions, most probably, constitute a continuum. This continuum is, likely, one of complexity, rather than severity, because the most common condition, unipolar depression, is the least complex in terms of its symptoms, but also the most lethal: 20% of depressed patients are estimated to commit suicide.

Whether or not we decide to regard depression, manic-depressive illness, and schizophrenia as varieties of the same disease, it is important to understand that all of them are psychotic conditions, characterized by the patient’s loss of control over his or her actions and thoughts, a recurrent state in which s/he cannot be considered an agent with free will. This is widely recognized in regard to manic depression and schizophrenia. But obsessive suicidal thinking and paralyzing lack of motivation allow the classification of depressed patients as psychotic as well.

Psychotic conditions are often accompanied by elaborate delusions--images of reality that confuse information generated in the mind with that provided from outside. Often the distinction between symbols and their referents is lost, and the patient begins seeing people solely as representations of some imagined force. Such delusions may be responsible for random acts of violence against strangers, such as Newtown shooting or Boston Marathon bombing, among others, though such acts are extremely rare and the characteristic form of violence of the mentally ill is, of course, violence against one’s own self. However, even when there is no violence, the judgment of people affected by mental illness is likely to be impaired.

A massive statistical study conducted in 2002 and 2003 by the US National Institute of Mental Health estimated the lifetime prevalence of major depression alone among American adults (ages 18-54) at over 16%. Lifetime prevalence for schizophrenia was estimated at 1.7%. There is no known cure for these chronic diseases; after onset (often before the age of 18), they are likely to last until the end of the patient’s life. Surveys among US college students (here and here) estimated that 20% fit criteria for depression and anxiety in 2010, and that 25% fit these criteria in 2012. Other studies have consistently shown rising rates of prevalence with each successive generation, and it is argued that, if older statistics were faulty, they erred on the side of underestimating the spread of mental illness. All of this suggests that as many as 20% of American adults--one in five--may be severely mentally ill (let’s disregard the suggestion that among students the rate has risen to 1 in 4 in 2012). As these conditions are presumed to spread uniformly through the population, this means that 1 in 5 senators and congressmen, policymakers, corporate executives, educators, and military personnel of all ranks are severely mentally ill and recurrently rendered psychotic, delusional, and deprived of judgment. And if it is deemed sensationalist to characterize this situation as terrifying, one may add: a much larger population (credibly estimated at close to 50%) is affected by mental disease in a less severe form that only occasionally disturbs their functionality.

These statistics are often disputed, because it is very hard to believe them. Indeed, they appear incredible. But these are the statistics we have. No study can be construed as arguing against the very high level and continuing increase in the rates of mental disorders in the United States.

Comparative epidemiologists have repeatedly noticed a remarkable thing about these illnesses, however: only Western countries (or, more precisely, societies with monotheistic traditions) – particularly prosperous Western countries--are subject to prevalence rates of this order. Southeast Asian countries appear to be especially immune to the bane of severe mental illness; in other regions, poverty, or lack of development, seems to offer a protective barrier. The reason for such uneven distribution, as I argue in my recent book Mind, Modernity, Madness, lies in the very nature of Western societies. The “virus” of depression and schizophrenia, and of their milder forms, is cultural: the embarrassment of choices that these societies offer their members in terms of self-definition and personal identity leaves many of them disoriented and adrift. The US offers the widest scope for such choices; therefore, it also leads the world in judgment-impairing disease. Unless the prevalence of serious psychopathology is reversed, it is likely to endanger every other aspect of American leadership.

We do not have to give up on our values and change our way of life in order to protect ourselves from mental disease. There are ways to prepare ourselves to challenges of life in a modern open society through education. But we must not remain passive and indifferent to the onslaught of this illness. It is time to deepen our understanding and deal with it.

Liah Greenfeld is the author of Mind, Modernity, Madness: The Impact of Culture on Human Experience

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