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Part I
The Mental Illness Epidemic
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1
Everything Is Not OK
Itās natural to think that we have it all figured out. We believe that we no longer suffer under the misguided notions, superstitions, and prejudices that misled our predecessors. āHow could they have believed such things?ā we wonder, and congratulate ourselves that we know better.
While itās easy to fall victim to this cultural delusion, surely there are many things we fail to see today, blind spots that will astound our descendants. In a hundred years or so, will they look back and wonder, āHow could they have thought that?ā
One of the major blind spots of our time is our failure to recognize the pervasiveness and the dangers of mental illness. We are a long way from acknowledging that psychiatric disorders and the distress they cause belong on the same level as other sources of human suffering.
But why donāt we see it? To find out, letās take a trip back in time and see why our ancestors may not have realized the ways they were ill. Imagine if we could travel back to the Middle Ages and were able to use our current medical knowledge to treat everyone who was sick. What might we find? We would probably end up treating a lot of people, possibly even the majority of the population. Of course, we probably would not encounter modern-day scourges like type 2 diabetes, high cholesterol, or high blood pressure, which stem largely from too little activity and too much food. The people weād meet would have an opposite set of problems.
What we would find would be people with infections of every typeāskin, respiratory, gastrointestinal, and so onāand nutrition problems galore. Weād also find the villains that have afflicted humankind for most of its history: syphilis, plague, and malaria, to name a few. And lastly, there would be the diseases that we now know well and can usually treat, such as thyroid problems, some cancers, and heart disease. Itās highly likely that, to our eyes, most of the people weād meet in the Middle Ages would need medical care, if not immediately, then soon. And itās also likely that many of our patients would not consider themselves sick for a variety of reasons. Maybe some illnesses were taboo and would be kept secret, while others were so common as to be thought of as just a regular part of life.
Perhaps, just like our ancestors in the Middle Ages, we may not consider something to be an āillness,ā even if we have a name for it and theories about it. Could it be that mental illnesses are pervasive in our population and that, like our ancestors did with their ailments, we think our mental health problems are normal for our times and do not truly understand their harmful effects?
It may be difficult to think that we are as sick and oblivious to our illness as our patients from our travel back in time, but in a way, we are. Mental illness is everywhere, and yet with each crisisābe it a celebrity suicide or a rise in substance abuseāwe are as shocked and puzzled as if the gods had capriciously struck one of us dead.
Year by year, decade by decade, mental illness is becoming both more common and more severe in modern societies, a fact documented in several large and well-controlled scientific studies. In recent years, the news media and the medical literature have reported that the number of people receiving care for a mental disorder has risen dramatically. Currently, one in six adult Americans is taking a psychiatric medication.1 And young people, who in the 1990s were more depressed than a similar-aged group just a generation before, died by suicide in record numbers in the first decade of the twenty-first century. Sadly, there is no shortage of examples of how mental illness is swelling the waiting rooms of hospitals and clinics across the modern world.
There are different interpretations, many critical in nature, of what these frightening trends mean. Some ask, āAre we turning normal sadness into clinical depression and normal shyness into social anxiety disorder?ā Those critics of the idea that mental illness is on the rise suggest that too often we are medicating normal life problems. Others worry that the medical professions are succumbing to pressure, misleading advertising, and the promise of financial reward from the pharmaceutical industry. Still others wonder if the fascination with neuroscience and its potential to explain human behavior has overtaken our common sense and twisted our understanding of what it means to be human. Do we no longer see ourselves as people with weaknesses and strengths, but instead as computer-like organisms that, with medication, we can reprogram to our liking? Some even see a future in which we treat psychological features like something akin to a facelift, where weād stretch and tighten things up to our liking, making the mind a fashion feature judged more by preferences than by achievements and abilities.
This problem of just what it means that more people are seeking out mental health treatment is obviously deep and complex. But I believe there is a simple explanation: people are availing themselves of mental health treatments of all sorts (not only medication) because they need it.
Each of the critiques listed above contains a kernel of truth, as most criticisms do. But people tend to conflate all of these criticisms and fail to see that an expanding number of people with actual mental disorders does not contradict these other points. Misleading pharmaceutical advertising does occur, as do cases of prescribing medication for mental struggles before other treatment ideas have been tried, but certainly not to the degree necessary to explain the massive worldwide epidemic of mental illness that we now face.
Many studies that carefully assess peopleās mental states find psychiatric disorders to be more prevalent. We also canāt ignore tragic, unassailable facts. There is a rise in the number of suicides, overdoses, and ER visits for attempts at both, and people face long waiting lists for treatment services of any kind, due in part to shortages in our mental health system and lack of health insurance. This data, combined with the experiences of mental health professionals and primary care doctors, all tell the same grim story: we have the makings of a public health disaster on our hands.
Something is happening at a societal level and, in a limited way, everyone seems aware. Countless times Iāve heard patients say they find the modern world to be extremely stressful. Many also seem to suggest that their symptoms of depression and anxiety should come as no surprise. āOf course Iām anxious, Doc. Look at the news!ā āJust look at my life. Everyone I know is depressed!ā āThatās just how life is nowadays.ā These are the easy and understandable explanations I often hear for a poor state of mind. Yet it reflects an almost universal intuition that life has gotten away from us and we canāt catch up.
As a psychiatrist, I am frequently pulled aside by friends, colleagues, and neighbors who ask about treatment for themselves or a loved one. I can honestly say that in no case did any of the problems described to me by these people seem like āproblems of livingā that were simply being exaggerated. The same holds for the thousands of people whoāve consulted me in practice. They had psychiatric problems that caused much suffering and dysfunction. Sadly, many of the worst problems could have been treated and the most severe symptoms avoided if only help had been available earlier.
The fact is that mental illness is common. It comes in all degrees of severity and affects almost everyone or someone they love. Yet help for mental illness is still seen as a sad and secret part of only a few peopleās lives, an uncommon tragedy. Everyone else has āissues.ā Iāve even heard newscasters from major networks say things like āthe lunatic fringeā and āthe aluminum foil crowdā (referring to making antennas from aluminum foil to receive alien or intelligence agency transmissions, sometimes done by people with psychoses). Aside from the obvious cruelty of these words, they inaccurately imply that there is only a āfringeā of mentally ill people. Mental illness exists across a spectrum of severe to mild and everything in between, and can affect almost everyone at some point in their lives, just like any other medical illness.
There are many forces working to change this perception, including the tendency of younger generations to discuss their therapy sessions among friends, which is a remarkable improvement on the generations before them. But we need to do more. We need, as a society, to tackle the question of why more people now suffer from mental illness than in past generations.
Is it something to do with modern society? The simple answer is yes. Life in the industrialized world is changing at a bracing pace. The most influential aspect of this change is technology and how it has permeated every aspect of life.
The effects of technology on mental health have already been of interest to researchers and have recently been captured by the news media. In the late summer of 2017, multiple articles appeared in major news outlets reporting on startling new research revealing a rise in teenage depression associated solely with the use of smartphones. The claim was based not just on one study, but a body of work showing a relationship between teenagersā use of smartphones and their subsequent feelings of depression. Part of the work even showed that decreasing phone use reduced symptoms of depression. Not surprisingly, these troubling findings spread across the news and social media, stoking a pervasive, uneasy sense that technology is taking a toll on our minds in ways we have yet to fully understand or control.
Although eye-opening, the smartphone story misses the larger context in which this disconcerting news about teenagers and depression is playing out: massive cultural change fueling a worldwide epidemic of mental illness. In a sense, the smartphone study is a microcosm of the broader phenomena affecting our lives: modern life and how we cope, or fail to cope, with the changes to society brought on by technology. These changes create a type of stress that is new to humanity and not manageable by the ways we have handled complex challenges in the past. I believe it is this very struggle to cope that leads to what Iāve named Frontal Fatigue, a modern condition that explains how modern life and the effects of technology have led to a rise in mental illness.
In the chapters that follow, I hope to accomplish several things. First is to demonstrate that the increase in mental illness is scientifically well supported. Also, I will explain why I will be leaving some important disorders out of the discussion. I believe this is an important exercise not only to lend support to my claims about the rise in mental illness, but also to be clear about what these illnesses entail.
The journey to the explanation itself is a story of ideas and their connections. Each chapter will bring us closer to a fuller understanding of Frontal Fatigue. A quick summary of what Frontal Fatigue is follows the path taken in the book. It goes essentially as follows: the pervasive effects of technology on all aspects of modern life have produced a type of stress that is new to humanity. This stress is most evident in the particular and pervasive mental demands modern life puts on us. These demands are handled by a large part of our brains called the prefrontal cortex (PFC).
The PFC has an amazing range of abilities, but also has two major liabilities. One is that it does not work well, if at all, under stress. Second is that, once stressed, any vulnerabilities to mental illness may then become active. It is just this process of stressing the PFC by the relentless demands of modern life that places so many people either at risk for mental illness or actively suffering from a particular disorder.
Frontal Fatigue is then the background condition that most of us now suffer, which makes us all more prone to mental illness. Those who are genetically predisposed to such illness or have enough previous stress and trauma in their lives (or commonly, both) may then be added to the expanding ranks of those with mental illness. The more technology-centric modern life, the more Frontal Fatigue, and the more mental illness.
The science you will be reading about is intentionally not cutting edge. Such science is often controversial and may be eventually disproven. Rather, I have depended on more established areas such as our understanding of the functions of the PFC and the many available psychiatric public health studies.
We must stay grounded in science or we risk gambling with our understanding of our current, incomparable era. Modern times have brought us countless wonders and defeated many of humanityās most difficult challenges, mostly via technology. Hopefully, we are about to add triumphing over COVID-19 to this list. But as we know in medicine, there are rarely treatments that have no side effects.
While infections yield to amazing science, mental illness has taken over as the health problem that characterizes our culture. My hope is that this book opens a new perspective in the battle for our collective and individual peace of mind.
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2
Mental IllnessāThe Cost We All Pay
The extensive incidence of mental disorders in all societies has, in part, been known for decades. I say in part because it is the severe, incapacitating illnesses like schizophrenia and bipolar disorder that have mostly been studied. These disorders have long been relatively stable as to the number of cases that arise within different cultures, though the impact of these illnesses on peopl...
