"The Mental Health Crisis" ...is a Crisis
The kids are not wrong.
1This article very frankly discusses suicide, loss, statistics, and sadness. You have been forewarned. The stats are from CDC, for the most part.
Did you know we have a mental health crisis? Of course, you did. Because nobody can shut up about it, it doesn't matter how little you know. It doesn't matter how much you know. Everyone’s got an opinion. Unlike most other opinions about problems that require doctoral-level training to understand, that opinion is not subjected to the same level of scrutiny; all opinions are the same.
If that sounds snarky, it is. I'm doing it to make a point: I don't believe that the dismay of the average citizen, enraged at what they see, is any less accurate than that of professionals or pundits.
We should probably define what we mean by “crisis.”
I'm also going to introduce myself as your narrator. My name is Owen Scott Muir, MD, And I am a child, adolescent and adult psychiatrist. I am also a health technology enthusiast, sometimes a citizen journalist, and a grump.
But first, in an article about a crisis, establish it's a crisis. This is traditionally done by using statistics. And don't worry; they're coming. Why do we use statistics to make points in the first place? I'm trying to be convincing. Anyone who's writing a polemic is trying to convince. Convincingness, addressed now, puts all my cards on the table.
I'm going to attempt to change your mind. You believe things. I'm going to acknowledge those things. I will build trust by sounding reasonable and writing true things. I will attempt to stick to god’s truth, whatever that is. This starts with marking my intentions. It’s not a scam—it’s a con job. Con, in this context, is an abbreviation for “convince.” Is that not what people usually mean?
In laying out the following statistics, I will do other things to establish the validity of the crisis, which establishes the rationale for the reading you already started. I'm going to acknowledge the perspective I suspect you have.
In acknowledging your perspective, or what I imagine, I will do something surprising. I admit that I'm not the expert, or at least not necessarily the expert, yet, in your mind. You are the expert on what's in your mind. I build trust by leaning into: “I can’t know for sure.” Thus, I become more convincing!
A crisis is a problem that gets so big that we can't just refer to it as problem anymore. We don't refer to “the crisis of what to have for breakfast.” We may not have had a good brunch in a while, but the crisis of great brunch options is not standard nomenclature.
Crisis is a word used to motivate people to action. The word crisis has an ancillary benefit for the polemicist: it terrifies people. Terror and careful thinking are antithetical. So a crisis is a great framework if you want people to do something—but are not too particular about what.
Ironically, the mental health crisis, is a cumulative crisis about individual crises. It’s a crisis…of an accurate perception of reality. To Wit:
People are killing themselves—all the time. Especially young people. I think it’s because they are hopeless about an awful reality. Art prepared us for this:
The Leftovers was a show on the now-deceased HBO. It's my gold standard for a depiction of unimaginable despair:
In a global cataclysm, "The Sudden Departure," 140 million people disappeared. Three years later, Mapleton, N.Y. residents try to maintain equilibrium when the notion of "normal" no longer applies. Intense grief has divided families and turned faith into cynicism, paranoia, and madness, leading some traumatized to join the Guilty Remnant, a cultlike group.
This is close to our reality…
The average American knows about 600 people. How do we know this? Researchers led by my Columbia colleague Tian Zheng posed a series of questions to a representative sample of 1,500 Americans: How many people do you know named Kevin? How many are named Karen? How many named Shawn or Sean, Brenda, Keith or Rachel?2
Other estimates put this closer to 255.3
If you live in the universe of The Leftovers and the Rapture-but-not-called-that has happened, it means about 12 people would've died probably in your life. This is my “Unimaginable Loss” threshold.
We (physician-scientists) usually describe death in a certain way. Epidemiologists –The people who count how many people die at a massive scale— use X number / 100,000.4
Let's convert “The Leftovers” number into the above format. 2% of everyone would be 2000/100,000.
The conceit of that TV show is that they vanished immediately without a trace. This is unsettling. But you can't do a TV show about a moment. Thus, a TV show about the fallout.
Here's a fact about humans: things that happen all at once are unsettling, but we eventually get back to a regular baseline because that's what we do. We do less well when it comes to relentless stress, which keeps coming. We are approaching the “leftover loss threshold.”
We are closer and closer to the asymptote of unbelievable suffering in our experience.
The long-term mortality numbers for humans are rock solid and haven't changed forever. The case-fatality rate for being born is 100%, Over a long enough time scale. The 100,000/100,000 death rate for “the living” is not a matter of dispute. Everybody dies. It's a question of resolution, time scale, and coping ability.
The actual crisis that we are in is a crisis of hopelessness. The dead are factored out.5
What does hopelessness look like, and why is it so bad now?
Empiricists–People who like to look at the data to answer questions–Love to start with base rates. I could claim that there was a death crisis because 100,000 people out of 100,000 people died; it would be hard to prove this was a crisis because this is the same thing that's been happening all the time. Everyone dies.
The base death rate in the United States in any given year is worth knowing. If that's been going up, we have a problem. We start by getting a sense of what was:
2020
The US death rate was 835/100,000
2021
1043/100,000.
The difference between a global apocalypse in which everybody goes insane and joins the cults, in the minds of TV writers, is 2x the rate in 2021.
More people are dying. That means more of us know people who die. This is sad. However, one of the other conceits of the show is that some death, mainly the unexplained or unexplainable, leaves more and bigger holes in our hearts.
Suicide is a good place to start and a terrible place to end. We have terrible explanations, in our minds, for suicide. I'll talk about the “why” and “what to do about this” later, but it's probably not a stretch to think that most people are not fans of death by suicide.
That has been getting worse. Forty-nine thousand nine hundred seventy-nine people died by suicide in 2020.
Population rates of death by suicide:
2020
14.5/100,000
That is only a tiny fraction of deaths, not 2000/100,000. It's the very, very tip of a very dark iceberg of hopelessness. For every completed suicide we see, the following numbers follow:
A lot of people are thinking about something very few people are doing. To be clear: this is because it's awful. People think about awful things more than they do awful things. But thinking about awful things is its kind of awfulness. The suicide rate is getting worse:
1950
4.6/100,000.
2020
14.5/100,000
It's getting worse.
In young people, it is now the same as the population wide numbers in 1950:
X
Using the numbers above per completed suicide, we can multiply how many people are seriously considering it. That means the “considering suicide” numbers in 2020, and rising, are 4015/100,000.
So, although we haven't lost people into the void, in the same way as The Leftovers, twice as many people think about oblivion as were raptured in a fictional TV show about a horrible world.
We aren't living a fictional nightmare—it's twice as bad. When somebody looks absent-minded at the bar, is it because they're thinking about suicide? Sometimes.6
The catastrophe is real–so many people are lost in dark, hopeless thoughts that it's hard to have a regular conversation.
I wanted to convince you this was a bigger problem than you thought. I did this by taking the problem you already thought was big and pointing out that it was bigger.
I intentionally omitted some mathematics that would take the numbers around overdose, addiction, specific psychiatric illness like depression, or any of it. I omitted details around how bad that would be on a population basis for younger people versus older people.
I wanted to convince you of something, but I suspected that giving you the heads up that I'm trying to be convincing would have you on guard. Now, I drive home that I'm not done, and the problems is worse.7
It's a crisis. It's worse now than ever. Many more people are thinking about death and dying than they were previously; it’s worse in younger people, it's worse than girls, and the world is a shitty awful place for many people.
And that's impacting their mental health. It's not just a problem with mental health; the fact that we have no idea how to address mental health in a meaningful or helpful way is part of the overall crisis of hopelessness. It's here, it's real, and we need to unfuck this situation promptly.
It starts with recognizing that our behavior fuels this despair. Which behavior? I kind of behavior that takes people like this:
Who appeals only to the worst parts of the worst men and makes them famous. Girls can't help but notice that this is the kind of man capable of garnering tremendous attention for his point of view. Like, for example, the following should be encouraged:
Girls are noticing this. They're living it every day. It is demonstrably the case that adults who can make decisions about whether the above should be lionized have decided the answer is yes. Among girls, they have noticed the world is hostile:
Nearly 1 in 3 (30%) seriously considered attempting suicide—up nearly 60% from a decade ago.
And as much as we might want to blame a biological vector or a fixation on mental health crisis, it is also possible that the world sucks vastly more for them. Boys also feel worse, at lower rates, but at still shocking levels of attempts and higher levels of mortality:
And the attempt rates should terrify us all:
Keep in mind the best predictor of completing suicide is attempted suicide. Those attempts will turn into completed suicides later. We don’t know which ones.
And all of that would be horrifying, if it weren't for the fact that the kids are not, as they say, incorrect about the fact that the adults of the world do not seem to care if they are murdered:
And if that is what you were living and seeing all around you, you might feel hopeless too. The data strongly supports this assertion. Again, data from the CDC:
The rate of growth of your friends being shot to death and the rate of hopelessness among girls is around 1:1. The kids are not wrong. However, I’m not sold that there is a “primary psychiatric” issue. Here is what every DSM-5 diagnosis includes as criteria:
The symptoms above must not be related to any other medical condition that the individual has or the physiological effects of a substance, such as the side effects of a medication they are on.
And, of course:
The symptoms must not be explained by the presence of another condition
It doesn’t specify social conditions…which is a failure of imagination….but on June 23rd, this ruling making guns more accessible is what happened:
The kids are noticing exactly what's happening. They have demanded change:
And it's only going in the wrong direction:
We are avoiding talking about hopelessness and unimaginable grief. It's too painful. It is worse when you don't know that there are solutions. To avoid the madness, we call it a mental health crisis. We do not say we are facing a
"the world has gone crazy, and I don't know what to do, and everyone's dying by overdose or suicide or gun violence around me, and I'm gonna lose it”
crisis…because it’s an avoidance behavior.
It is not pathological to notice the world doesn’t care if you live or die. It is, for youth, an accurate observation. And that, well? That is pretty depressing.
It is not stopping. Our hearts will be ground into the dirt.
After adjusting for various factors (for example, the names are not evenly distributed in age across the population), we determined that participants knew an average of 8.4 people with those names. Social Security records suggest that 1.4 percent of the population has one of the names, and 8.4 divided by 1.4 percent is 600 people.
We are growing thin on connection to other humans.
This lets us avoid saying 0.01%. Because although that seems small, it can be a lot.
Getting factored out of this crisis and not having to deal with it anymore is one of the limited perks of having died.
We are Guilty Remnants in our lives, with our friends, in silence and secret.
I also want to prepare you for that convincingness; statistics are a bit of a double-edged sword. There are a lot of biases built in.
Sounds like a great podcast subject for us