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Dr. Carr is an assistant professor at the Institute for Society and Genetics at U.C.L.A.
What if the cure for our current mental health crisis is not more mental health care?
The mental health toll of the Covid-19 pandemic has been the subject of extensive commentary in the United States, much of it focused on the sharp increase in demand for mental health services now swamping the nation’s health care capacities. The resulting difficulty in accessing care has been invoked widely as justification for a variety of proposed solutions, such as the profit-driven growth of digital health and teletherapy start-ups and a new mental health plan that the Biden administration unveiled earlier this year.
But are we really in a mental health crisis? A crisis that affects mental health is not the same thing as a crisis of mental health. To be sure, symptoms of crisis abound. But in order to come up with effective solutions, we first have to ask: a crisis of what?
Some social scientists have a term — “reification” — for the process by which the effects of a political arrangement of power and resources start to seem like objective, inevitable facts about the world. Reification swaps out a political problem for a scientific or technical one; it’s how, for example, the effects of unregulated tech oligopolies become “social media addiction,” how climate catastrophe caused by corporate greed becomes a “heat wave” — and, by the way, how the effect of struggles between labor and corporations combines with high energy prices to become “inflation.” Examples are not scarce.
For people in power, the reification sleight of hand is very useful because it conveniently abracadabras questions like “Who caused this thing?” and “Who benefits?” out of sight. Instead, these symptoms of political struggle and social crisis begin to seem like problems with clear, objective technical solutions — problems best solved by trained experts. In medicine, examples of reification are so abundant that sociologists have a special term for it: “medicalization,” or the process by which something gets framed as primarily a medical problem. Medicalization shifts the terms in which we try to figure out what caused a problem, and what can be done to fix it. Often, it puts the focus on the individual as a biological body, at the expense of factoring in systemic and infrastructural conditions.
Once we begin to ask questions about medicalization, the entire framing of the mental health toll of the Covid crisis — an “epidemic” of mental illness, as various publications have called it, rather than a political crisis with medical effects — begins to seem inadequate.
Of course, nobody can deny that there has been an increase in mental and emotional distress. To take two of the most common diagnoses, a study published in 2021 in The Lancet estimated that the pandemic had caused an additional 53.2 million cases of major depressive disorder and 76.2 million cases of anxiety disorder globally.
Let’s think about this. The fact that incidences of psychological distress have increased in the face of objectively distressing circumstances is hardly surprising. As a coalition of 18 prominent mental health scholars wrote in a 2020 paper in The Lancet: “Predictions of a ‘tsunami’ of mental health problems as a consequence of [Covid] and the lockdown are overstated; feelings of anxiety and sadness are entirely normal reactions to difficult circumstances, not symptoms of poor mental health.”
Things get even less surprising when you look more closely at the data: If you bracket the (entirely predictable) spike in psychological distress among health care workers (a fact that itself only reinforces the idea that the major causal vectors in play here are structural), the most relevant predictors of mental health are indexes of economic security. Of course, it’s not simply a question of the numbers on your bank statement — although that is a major predictor of outcomes — but of whether you live in a society where the social fabric has been destroyed.
Before we go further, let me be clear about what I am not arguing. I am not arguing that mental illnesses are fake, or somehow nonbiological. Pointing out the medicalization of social and political problems does not mean denying that such problems produce real biological conditions; it means asking serious questions about what is causing those conditions. If someone is driving through a crowd, running people over, the smart move is not to declare an epidemic of people suffering from Got Run Over by a Car Syndrome and go searching for the underlying biological mechanism that must be causing it. You have to treat the very real suffering that is happening in the bodies of the people affected, obviously, but the key point is this: You’re going to have to stop the guy running over people with the car.
This principle is what some health researchers mean by the idea that there are social determinants of health — that effective long-term solutions for many medicalized problems require nonmedical — this is to say, political — means. We all readily acknowledge that for diseases like diabetes and hypertension — diseases with a very clear biological basis — an individual’s body is only part of the causal reality of the disease. Treating the root cause of the “epidemic” of diabetes effectively, for example, would happen at the level of serious infrastructural changes to the available diet and activity levels of a population, not by slinging medications or pouring funding into clinics that help people make better choices in supermarkets filled with unregulated, unhealthy food. You’ve got to stop the guy running over people with the car.
But if the public health consensus around diabetes has shifted somewhat in response to what we know, it’s been remarkably hard to achieve the same when it comes to mental health.
Psychiatric sciences have long acknowledged the fact that stress is causally implicated in an enormous range of mental disorders, referring to the “stress-diathesis model” of mental illness. That model incorporates the well-documented fact that chronic stressors (like poverty, political violence and discrimination) intensify the chance that an individual will develop a given diagnosis, from depression to schizophrenia.
The causal relationship may be even more direct. Remarkably, all throughout decades of research on mood disorders, scientists doing animal studies had to create animal models of anxiety and depression — that is, animals who showed behaviors that looked like human anxiety and depression — by subjecting them to weeks or months of chronic stress. Zap animals with unpredictable and painful shocks they can’t escape, force them to survive barely survivable conditions for long enough, put them in social situations where they are chronically brutalized by those higher up in the social hierarchy — and just like that, the animals will consistently start behaving in a way that looks like human psychopathology.
This doesn’t mean that all psychiatric symptoms are caused by stress, but it does mean that a whole lot of them almost certainly are. There is increasingly strong evidence for the idea that chronic elevation of stress hormones has downstream effects on the neural architecture of the brain’s cognitive and emotional circuits. The exact relationship between different types of stress and any given cluster of psychiatric symptoms remains unclear — why do some people react to stress by becoming depressed, while others become impulsive or enraged? — indicating that whatever causal mechanism exists is mediated by a variety of genetic and social conditions. But the implications of the research are very clear: When it comes to mental health, the best treatment for the biological conditions underlying many symptoms might be ensuring that more people can live less stressful lives.
And here is the core of the problem: Medicalizing mental health doesn’t work very well if your goal is to address the underlying cause of population-level increases in mental and emotional distress. It does, however, work really well if you’re trying to come up with a solution that everybody in power can agree on, so that the people in power can show they’re doing something about the problem. Unfortunately, the solution that everyone can agree on is not going to work.
Everyone agrees, for instance, that it would be good to reduce the high rate of diabetes plaguing the United States. But once we begin to de-medicalize it, diabetes starts to look like a biological problem arising from a vast swathe of political problems: transportation infrastructure that keeps people sedentary in cars, food insecurity that keeps a racialized underclass dependent on cheap and empty calories, the power of corporate lobbies to defang regulations, and so on. These are problems that people do not agree on how to solve, in part because some are materially benefiting from this state of affairs. This is to say, these are political problems, and solving them will mean taking on the groups of people who benefit from the status quo.
That the status quo is once again benefiting the usual suspects is all too obvious in the booming market of V.C.-backed mental health tech start-ups, which promise to solve the crisis through a gig economy model for psychiatric care that has been criticized for selling psychiatric medication irresponsibly, with little accountability.
But even publicly funded solutions risk falling into the trap of medicalizing a problem and failing to address the deeper structural causes of the crisis. President Biden’s plan for mental health, for instance, makes many genuflections to the language of “community” and “behavioral health.” A section outlining a plan for “creating healthy environments” makes a great show of saying the right things, including: “We cannot transform mental health solely through the health care system. We must also address the determinants of behavioral health, invest in community services and foster a culture and environment that broadly promotes mental wellness and recovery.”
But then the plan goes on to focus on several proposals aimed at regulating social media platforms — a strange target that seems relevant only in a downstream way from major infrastructural determinants of health, like wealth inequality and public services — until you remember that it’s one of the few policy goals that both Democrats and Republicans share.
Sure, parts of the proposal do seem to offer genuinely needed care. For instance, a proposal to establish scores of behavioral health clinics that can offer subsidized substance use treatment like methadone tapering is an exigently needed — if depressingly belated — response to the phenomenon of mass opiate addiction pushed by corporations like Purdue Pharma and Walgreens.
But despite the fact that much of the proposal seems to have been drafted with the opiate addiction crisis in mind, the billboard-size implications of the so-called opioid epidemic seem to have failed to register. It is hard to imagine a clearer demonstration of political conditions undergoing the reification switch into a medicalized epidemic than what everyone now knows happened: The despair of the post-industrial underclass was methodically and intentionally milked by pharmaceutical companies for all it was worth. It was so obvious that at last even a political establishment that remains largely indifferent to the poor eventually had to get around to sort of doing something.
And yet when the plan addresses suicide, it focuses on crisis intervention — as if suicide were a kind of unfortunate natural occurrence, like lightning strikes, rather than an expression of the fact that growing numbers of people are becoming convinced that the current state of affairs gives them no reason to hope for a life they’d want to live.
The proposal’s main plan to address the so-called epidemic of suicide has been the rebranding of a national suicide hotline — which will encourage callers on the brink of killing themselves to refrain from doing so, and may or may not connect them to resources like three cognitive behavioral therapy sessions (most likely conducted through teletherapy) that insurance companies will be required to cover for their customers — depending on what the state the caller is in has decided about funding. (Like all of Biden’s proposal, the plan is yet to be passed into law.) It’s not so much that the hotline is a bad idea; it’s that the sheer scale of failure to comprehend the political reality that it displays, the utter inability to register how profoundly the “suicide epidemic” indicts the status quo, is ultimately more terrifying than outright indifference. It’s worth recalling that in the 2016 presidential election, even though Hillary Clinton touted a “suicide prevention” campaign plank, communities most affected by so-called deaths of despair voted overwhelmingly for Donald Trump, who addressed, however disingenuously, their economic situation and promised to bring back jobs.
Solving the mental health crisis, then, will require fighting for people to have secure access to infrastructure that buffers them from chronic stress: housing, food security, education, child care, job security, the right to organize for more humane workplaces and substantive action on the imminent climate apocalypse.
A fight for mental health waged only on the terms of access to psychiatric care does not only risk bolstering justifications for profiteering invoked by start-ups eager to capitalize on the widespread effects of grief, anxiety and despair. It also risks pathologizing the very emotions we are going to need to harness for their political power if we are going to win solutions.
Danielle Carr is an assistant professor at the Institute for Society and Genetics at U.C.L.A. She is working on a book about the history of neuroscience.
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