Earlier this month was Mental Illness Awareness Week—meaning you may have seen your friends share memes and headlines about the mental health “epidemic” in America, with depression on the rise and an enormous percentage of Americans likely to fit the criteria for a mental disorder at some point during their lifetimes. As NPR reported recently, millennials in particular “tend to get a bad rap” where mental health is concerned: According to various journalists and pundits, we’re plagued by anxiety and crippling narcissism.
But is the state of mental health in America truly worse, or are we simply diagnosing disorders that were once unknown? Is the millennial generation actually more depressed than the generations that lived through two world wars? The answers aren’t exactly simple.
One problem with quantifying the change (or lack thereof) in the incidence of mental health problems over time comes from simply defining mental illness. In 2010, Wired interviewed Dr. Al Frances, the lead editor of the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, also known as the “psychiatric bible.” Frances’ remarks were startling. “There is no definition of a mental disorder,” he proclaimed. “It’s bulls--t. I mean, you just can’t define it.”
Frances was one of a number of experts to rebel against DSM 5, the fifth and latest edition of the manual. His disillusionment with the “mental-disorder dictionary” seems to stem partly from his own mistakes; he now claims that, thanks to errors he made in the previous edition, he bears “partial responsibility for two . . . false ‘epidemics’—of attention deficit and autistic disorders.” When APA approved the new manual, Frances declared it “the saddest moment” in his forty-five years of practicing psychiatry, warning that it would “lead to massive overdiagnosis and harmful overmedication.”
Among the portions of DSM 5 that Frances and others opposed: removing the so-called “bereavement exclusion.” This rule ordered psychiatrists not to diagnose patients with major depressive disorder if their symptoms had begun within a few months of the death of a loved one, on the grounds that this was a sign of normal grief, not a mental disorder. The new DSM removed this guideline—a decision that was, and continues to be, extremely controversial.
“I can’t help but see this as a broad overreach by the APA,” Eric Widera, a geriatrician at the University of California, San Francisco, wrote at the time. “Grief is not a disorder and should be considered normal even if it is accompanied by some of the same symptoms seen in depression.”
This is just one example of the type of hotly debated decisions in psychiatry, which can recalculate the very definition of a mental illness. In 1952, the DSM defined only 106 illnesses. By 2013, that had nearly tripled, to 297. According to one study, about 50 percent of Americans will meet the criteria for at least one mental illness, as defined by DSM 5, within their lifetimes. That’s a stunning number—and one that more than a few experts view skeptically.
But for Frances, at least, this does not mean that all concerns about mental illness are overblown—the problem is a misplaced use of resources, as non-illnesses become overdiagnosed, and more serious illnesses are left untreated. “We are massively overtreating those who don’t need it and shamefully neglecting those who do,” he says. “For the severely ill, there has never been a worse time than now or a worse place than the U.S. More than 350,000 are in prison for nuisances that could have been avoided if there were adequate community treatment.”
All of this is to say that mental illness is a slippery concept—and while it’s possible that some illnesses seem to be on the rise because we’ve given names to conditions that once went undiagnosed, it’s also quite possible that, in other cases, we’ve essentially redefined what it means to be “healthy” and “ill.”
Even if you accept APA’s new terminology, several recent studies cast doubts on the numbers of the supposed “epidemic.”
Take depression—the most common type of mental illness, according to the Centers for Disease Control and Prevention, which affects more than 26 percent of U.S. adults. Between 1988 and 2011, antidepressant use increased a staggering 400 percent—a statistic which has, quite reasonably, been the cause for some alarm.
But statistics such as these don’t necessarily prove an increase in actual rates of depression. In the first place, antidepressants are commonly prescribed to treat illnesses other than depression: Approximately one-fifth of all prescriptions go to treat conditions such as anxiety and pain.
Additionally, rising prescription rates tell us only that more people are being treated for depression—not that more people are exhibiting and experiencing the signs of depression. This is true for other diseases, such as bipolar disorder: Diagnosis has rapidly increased, but experts caution that this does not necessarily reflect a true increase in its incidence.
A 2007 study of mental health between 1981 and 2004 concluded that the data “do not suggest an epidemic of depression or that we are entering an age of melancholy”—with the exception of an increase in prevalence of depression among middle-age women. Even that curious trend, they found, was stabilizing or declining.
What about young people? As NPR noted, there’s little evidence to back up the popular notion that mental illness is on the rise among the young. Just this May, a report in the New England Journal of Medicine found, contrary to past alarmist studies, that the rate of severe mental illness among children and adolescents has actually dropped significantly in the last generation. The researchers rebuked past studies for insufficient rigor, accusing the CDC and others of using a “flawed assessment methodology that includes many kids who have very mild impairment or no impairment at all.”
“Right now we have all these different agencies doing surveys, each using a different method,” Kathleen Merikangas of the National Institute of Mental Health told the New York Times. “It’s a nightmare. We need to do better.” Again, we encounter the difficulty of accurately measuring a phenomenon with terms no one can agree to.
Another critical point emphasized by researchers is the difference between “incidence” and “prevalence”—incidence being the number of new cases of an illness within a period of time and prevalence the total number, including both old and new cases. This distinction sheds light on a major reason why mental illness appears to be so much more common: the steadily rising age of the population. During the twentieth century, according to the U.S. Census Bureau, America’s elderly population increased by a factor of eleven and now enjoys the longest life expectancy in history. This rise in population skyrockets the prevalence of certain mental illnesses because the number of pre-existing cases in a given time period will increase as people continue to live longer. But this does not mean the incidence is increasing.
One study, for example, that reviewed data on anxiety disorders and major depressive disorder between 1990 and 2010, found “no evidence for an increased prevalence” of either. “The perceived ‘epidemic’ of common mental disorders is most likely explained by the increasing numbers of affected patients driven by increasing population sizes,” the researchers concluded.
If mental health issues aren’t necessarily growing, why does it seem that way? Perhaps it’s because we’re talking about it more now. And maybe that’s not entirely a bad thing. The truth is that mental health is like any other health concern today; whether it’s increasing or decreasing, it’s worth our attention for every person to get the care they need. And if talking about it makes that more likely and helps reduce the stigma for those seeking help, then that’s certainly a silver lining, even to the otherwise cloudy national conversation.