Mental Health, Clinical Examination and Social Examination

Depression New

If despite impressive increase in mental health facilities, mental health problems rise to almost an unprecedented extent in several advanced societies, it may be time to re-examine the entire perspective of present-day approach.

Treatment of mental health problems has made remarkable progress from several points of view. Many new medicines are available. Several advanced forms of counseling are available. Several specialists have made exciting new contributions. Medical health budgets in several countries, particularly developed countries have increased considerably. Facilities for basic and advanced education in mental health have increased. Several senior academics have offered brilliant and promising new insights. More learned scholars in this field are now available than ever before.

According to the available data on the expenditure on mental health services in the USA, this increased rapidly from 147 billion dollars in 2009 to 238 billion dollars in 2020. A recent White House document (Reducing the Economic Burden of Unmet Mental Health Needs, May 31, 2022, hereafter referred to as the White House document) noted—“The federal government covers some of the costs of treating mental health disorders. Around $280 billion were spent on mental health services in 2020, about a quarter of which came from the US Medicaid program.”

There are an estimated 577,000 mental health professionals supported by 682,000 more in social worker jobs in the USA. The Health Care Cost Institute’s 2018 Report disclosed that per person spending on mental health admissions increased by 33% between 2014-18 while spending on outpatient psychiatry increased by 43%. Between 2007 and 2017 the percentage of medical claims associated with behavioral health more than doubled. According to a report of the National Center for Health Statistics, in the age group over 12 years, from 1988-94 to 2005-08, the use of anti-depressants increased by an astonishing 400%, with nearly 10% Americans using these medicines and as many as 23% of women in their 40s and 50s using these medicines. This trend continued to increase. In 2018 13.2% of US population over 12 years age said that they had taken anti-depressants during the previous month. (all data in this paragraph is US data).

Despite all these important trends of increase of mental health expenditure and increasing use of mental health medicines, however, mental health problems and disorders were being reported on an increasing scale, with the result that on the one hand expenditure on mental health increased but number of people not able to access treatment for mental health orders also increased. In the USA for instance, among the persons who need treatment for mental health orders about half are unable to access/afford this, according to official data. A study of 36,000 people stated that 62% of people who suffered from mood disorders, 76% of people who suffered from anxiety disorders and 81% of people who suffered from substance use disorders were not accessing treatment.

What is clear from the available data is that the number of people suffering from mental health disorders has gone on on increasing over the years despite there being better medicines, increasing number of hospitals and related infra-structure. This increase is perhaps the most marked for the youngest age groups.

The latest official statistics of ‘Youth Risk Behavior Survey’ (YRBS), USA, 2011-2021 released recently by the Centers for Disease Control and Prevention, (CDC) tell us that in year 2021 42% of US high school students “experienced persistent feelings of sadness or hopelessness”, up from 28% in 2011. In the case of female students, this percentage is even higher—in 2021 as many as 57% of female high school students experienced persistent feelings of sadness and hopelessness. Further, as many as 22% high school students in the USA “seriously considered attempting suicide”. Here also we see an overall increasing trend from 16% in 2011 to 22% in 2021. In the case of female students this number was as high as 30% in year 2021. In other words, almost one-third of female high students in the USA were so distressed as to “seriously consider attempting suicide” during this year.

There have been several other indications of such disturbing trends, including the call given twice in recent times by top child health organizations in the country for declaring a mental health emergency for children, given the scale of these problems.

According to the White House document quoted above, “there are several indications that Americans were experiencing a mental health crisis prior to the pandemic”. Between 2008 and 2019, the percentage of adolescents ( age 12-17) that reported having experienced at least one major depressive episode in the past year increased by 90%, in the age-group 18-25 this increased by 81%. Suicide death rate in the age-group 10-24 increased by 47%. Disturbing trends have been starting very early in childhood. As the White House document tells us, approximately one in six US children aged as little as 2-8 years  have a diagnosed mental, behavioral and development disorder. What is more, this document informed, one half of all lifetime cases of mental disorders are estimated to start before age 14.

In Europe also there appears to be a somewhat similar trend of increase of mental health facilities and expenditure co-existing with increasing mental health problems, particularly in the context of children and adolescents. According to statistics given in a report of UNICEF ‘On My Mind’, suicide is the second leading cause of death among young people in Europe and 3 adolescent lives are lost in Europe because of mental health problems every day. One in five European boys of 15-19 age group suffer from mental health disorders, as do 16% of girls. 9 million adolescents (age 10-19) are living with mental disorders in Europe, with anxiety and depression accounting for more than half of these.

When mental health problems increase, advanced countries with adequate resources can substantially increase treatment facilities. But what happens if even after years of this, mental health problems continue to increase and at least in some contexts of younger people, even reach unprecedented levels (after years of remedial actions as suggested by top experts). In such a situation clearly we need to move from just clinical examination to social examination, from individual diagnosis to also social diagnosis to find out the real reasons for persistence and accentuation of mental health problems despite increase in treatment facilities and expenditure. Of course good mental health facilities and the invaluable help given by brilliant specialists should continue to increase. But in addition there should be social examination and remedial action based on this too.

Such properly conducted social diagnosis, which should be able to examine clearly the deeper issues and not just the more obvious ones, will make it possible to take several preventive steps which can result in durable and sustained gains for mental health. However it is important to probe deeper and avoid turning away from unpleasant realities.

To give an example of what may be at work, schizophrenia is a mental illness often defined in terms of big disconnect with reality, or very strange/abnormal interpretation of reality leading to strange behavior patterns. But then hasn’t USA policy , when it pursued relentless wars in the name of peace, or when it toppled democratic regimes and installed or supported dictatorial ones while chanting the mantra of democracy all the time, itself been repeatedly schizophrenic? Or even in domestic policies, while talking all the time of the welfare of ‘the American people’, have not policies actually led to decline of welfare of the genuinely needy sections by deliberately increasing inequalities and gifting big gains to the richest billionaires, again displaying a schizophrenic streak.

The social diagnosis should not fight shy of such difficult issues, and it should examine deeply the hypocrisy, the double-speak, the glaring difference between the stated ethical norms and reality. In terms of sincere remedial actions, it should suggest ethical values which should guide national life and policy.

Note of caution–For anyone having depressive thoughts helplines and other help are available.

Bharat Dogra is Honorary Convener, Campaign to Save Earth Now. His recent books include Protecting Earth for Children, Planet in Peril, Earth without Borders and A Day in 2071.

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