How to Have a Better Conversation About Mental Illness

July 13, 2018
The New York Times
By Lisa Pryor
July 11, 2018


Jaminwell/E+, via Getty Images






SYDNEY, Australia — As public conversation about mental health has grown louder and busier in recent years, mental illness has become more than a category of disease with social and psychological dimensions. Especially in the case of depression and anxiety, mental illness has come to be seen as a proxy for what is wrong with the modern Western world.

Depression is like a Rorschach test: People see in it whatever they like, in order to make whatever point they like, about what they perceive to be the ills of society. Blame for depression is found in capitalism, loss of religion, social media, processed food. Recently a book was released promising to tackle anxiety “for good” with a two-week sugar detox.

Much good has come of the increased willingness to discuss mental disorders. There is greater acceptance than in the past that mental illness is real and common, and that when it arises, its causes are complex and cannot be explained away as weakness or lack of character. All of this is vital in reducing stigma, which in turn encourages people to step forward and seek help without shame.

But as a doctor who works in mental health, I think the direction of the conversation should give us pause. I work in a public hospital where our patients include those with many conditions that have been slower to shed stigma, such as schizophrenia, mania, severe depression and personality disorders. This stigma differential is something I feel keenly when observing which diagnoses patients will or won’t accept.

It is common for patients to resist a diagnosis with a psychotic component, insisting instead that what they really have is depression that should be treated with antidepressant medication rather than antipsychotics. They may describe themselves as having an anxiety disorder, when there is in fact a longstanding diagnosis of a personality disorder.

The conversation about mental health has become so focused on mild to moderate illness and stigma reduction that it does a disservice to people living with mental illness at the more debilitating end of the spectrum, fueling misunderstanding of the nature and risks of these illnesses and under-resourcing of treatment.

Furthermore, the narrative that “mental illness does not discriminate” and “mental illness can happen to anybody,” which has been important in tackling stigma, has had the unintended consequence of disguising the political and economic dimensions of the way that mental suffering, and the treatment of suffering, is unfairly distributed.

With so much of the recent focus of public discussion about mental illness based on celebrities — like the recent suicides of the designer Kate Spade and the food writer Anthony Bourdain — and so much attention on high rates of mental illness in the United States, people would be forgiven for thinking that mental illness is evenly distributed through the population or even disproportionately suffered by people in wealthy countries.

But far from the cliché that depression is a crisis of the wealthy West, depression is a global problem, and developing nations are not immune. World Health Organization data show that the highest prevalence of depression by region is for women in Africa, at 5.9 percent. Suicide is also a global problem. In 2015, 78 percent of suicides occurred in low- and middle-income countries.

Suffering is compounded when the groups that are most in need of treatment for mental illness are the very groups who are less likely to receive it.

This is the case even within wealthy countries. Consider a recent article summarizing research in Australia that showed that rates of high distress in the community have remained steady despite increased mental health spending by successive Australian governments. The authors suggested a major reason for the lack of a shift in outcomes is that increased spending is not getting to the people who need it most.

They showed that the greatest levels of mental distress, suggestive of depression or anxiety, were experienced by those in the most socioeconomically deprived areas. And yet it was the people in the most advantaged areas that were most likely to be receiving psychological treatment — even in a country where these sessions are often subsidized by the government with the express purpose of providing better access.

This is not to say that wealthy people suffering distress are wrong to access those services, or that they are unnecessary. No one would begrudge economically advantaged people accessing treatment for high blood pressure, or asthma, or sporting injuries, and nor should they be considered to be acting inappropriately for accessing treatment for mental illness. But it does point to a terrible unfairness that will never be rectified by public awareness and stigma reduction alone.

When it comes to the public conversation about mental illness, we need to inflect that conversation with nuance. After all, speaking of mental illness in blanket terms is no more useful than speaking about “illness” in blanket terms. There is a world of difference between the common cold, cancer and diabetes.

A nuanced discussion of mental health might include the fact that even within the diagnosis of depression there are degrees of severity, that other illnesses like psychosis deserve recognition, that there is an entire dimension of human suffering in the form of personality vulnerabilities and personality disorders that can be borne of trauma and that need much greater understanding and discussion.

But ultimately, raising awareness, that impotent entreaty of our time, is not enough. Greater funding is needed, and it needs to be targeted at the greatest suffering.

Lisa Pryor, a medical doctor, is the author, most recently, of “A Small Book About Drugs” and a contributing opinion writer.


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