Tuesday, January 05, 2016

Is Everyone Mentally Ill?

We talk about mental illness based upon a standardized set of symptoms, where the symptoms co-occur in groups/clusters/syndromes in ways that enable us to cluster them together (i.e. make a diagnosis), treat the illness we've defined, and have some means of predicting outcome (i.e. 90% of people will have full remission of their symptoms within 6 months).  We talk about these clusters of symptoms as being illnesses or disorders, and we look for biological correlates -- changes in brain chemistry, anatomy, metabolism -- to divide those people who have the disorder from those who don't in the hopes that someday we will have tests to tell us who will respond to various treatments.  It would be very nice to get rid of all this trial and error medication cocktail stuff and just have a test that says "Meds won't work for you, you need TMS," or "no point in using an second generation antipsychotic, go straight to clozapine."  So far, no great breakthroughs in terms of either diagnosis or treatment predictability, but give it time. 

So there was an article in the New York Times on January 2nd titled "Is the Drive for Success Making Our Children Sick?" Vicki Abeles talks about how childhood stresses lead to illnesses, including ulcers, as well as more medical illnesses as children age into adults.

Abeles writes:
STUART SLAVIN, a pediatrician and professor at the St. Louis University School of Medicine, knows something about the impact of stress. After uncovering alarming rates of anxiety and depression among his medical students, Dr. Slavin and his colleagues remade the program: implementing pass/fail grading in introductory classes, instituting a half-day off every other week, and creating small learning groups to strengthen connections among students. Over the course of six years, the students’ rates of depression and anxiety dropped considerably.

But even Dr. Slavin seemed unprepared for the results of testing he did in cooperation with Irvington High School in Fremont, Calif., a once-working-class city that is increasingly in Silicon Valley’s orbit. He had anonymously surveyed two-thirds of Irvington’s 2,100 students last spring, using two standard measures, the Center for Epidemiologic Studies Depression Scale and the State-Trait Anxiety Inventory. The results were stunning: 54 percent of students showed moderate to severe symptoms of depression. More alarming, 80 percent suffered moderate to severe symptoms of anxiety.

“This is so far beyond what you would typically see in an adolescent population,” he told the school’s faculty at a meeting just before the fall semester began. “It’s unprecedented.” Worse, those alarming figures were probably an underestimation; some students had missed the survey while taking Advanced Placement exams.

Okay, so wait, at least half of a group of students surveyed were moderately to severely depressed (?what about mildly depressed), and 80% were moderately to severely anxious?  And the symtptoms abated when the stress disappeared?  This doesn't make sense -- are our disorders illnesses --- brain diseases (as some like to call them)-- or are they part of the spectrum of normal reactions to stress, pressure, and likely lack of sleep? 

In a clinical setting, I'll tell you that sometimes it feels really clear cut: there are people who get sick and they get severely psychotic, or they markedly change from their usual personality. They shut down and lose their usual vitality and ability to function; they aren't showing up for those AP exams.  They become so symptomatic that they become someone totally different, and there is no 'hiding' their illness.  In other cases, it's not so clear cut -- people come in complaining of symptoms of depression, loss of interest, sleep changes, libido changes, suicidal thoughts, and any mix of symptoms that meet criteria for a disorder, and they attribute their distress to a given set of life circumstances.  But they're functioning in their usual roles,  and they are able to mask their symptoms: the rest of the world may not know how badly they feel.  If they are coming to see me as a psychiatrist, they often want medications, and medications often help.  Would they need medications if we could remove the stress?  Often they say 'yes' but we can't make that happen.  Maybe you're thinking about school stress and pressure to achieve, but there are other stresses -- illnesses, financial burdens, divorce, family chaos -- which don't go away by dropping a class or giving up tuba. 

If the studies cited above are accurate -- and I didn't look at them -- and the symptoms are persistent, then this doesn't fit with our idea of mental illness.  It comes to be about a normal reaction to stress, a need -- as noted above-- to change our environment, and a question as to what gives resilience to those few who don't have symptoms. 

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