Mental Health Matters: Where, as a society, do we go from here? (opinion)
August 12, 2016
As a practicing physician and psychiatrist, my focus was on the life of a particular person who came to me for help. My job: Find out what's "wrong" and "fix it."
First, obtain a history, then formulate a problem list, including a "diagnosis."
Always, because physical ailments can masquerade as emotional problems, rule out physical causes. Then, suggest medication, if indicated, and psychological therapies.
Notice my singular focus is on the person with the problem, their strengths and weaknesses, and whatever therapeutic levers are available for that individual.
“How do you make a person sane when the world is uncontrollable, crazy and violently unpredictable? How do you control the stress of an inherently stressful universe?”
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Because I worked in a variety of settings over the years — a hospital in a tiny section of San Francisco, a clinic in the rural south, a state mental hospital, a public residential treatment institution, and consulting work in prisons — it became apparent that socioeconomic and educational factors outstripped the importance of a psychiatric diagnosis in helping people. Here are a few examples:
A single woman on pubic assistance, with children, living in the rural south, has relations with a boyfriend and doesn't want to get pregnant. She's had virtually no schooling, doesn't know what a thermometer is, or the meaning of unprotected sex. She's "depressed," unable to take time away from her otherwise unsupervised children, and can't afford antidepressant medication.
A married man in his forties, a principal in a venerable architecture firm, wants help because he drinks too much. He's "depressed." He can readily afford medication, detoxification and a residential drug rehabilitation program.
A single man in his thirties on public assistance, with virtually no job history, and a story about incarceration for drug possession, feels "depressed" about his future life prospects.
A college educated woman in her forties has successfully raised two children with her financially successful husband who has embarked on a relationship with a younger woman. She's "depressed." She can afford the time and cost of individual treatment and her husband is willing to participate in couples therapy.
Each of these people was "depressed," but the likelihood that I could help depended, mostly, on socioeconomic and environmental circumstances.
How do you make a person sane when the world is uncontrollable, crazy and violently unpredictable? How do you control the stress of an inherently stressful universe?
Over time, the obvious became clear: Those who obtain a decent education and achieve a measure of economic stability have more possibilities, more potential, more opportunity and a better grounding in what might work and what can work, than those who do not.
Days ago, I'm laboring on a military style assault, walking up the mountain. A man on rented bicycle, coming down the mountain, stops. He says "hi" to me, a broad smile washing over him, looking down on majestic Lake Tahoe: "Boy, it sure is stressful around here."
Precisely. Living, laboring in a largely bucolic world, free of major crime, with neighbors you know and trust, is a precious gift. Contrast it with the grime of inner city tenements and public housing infested with criminality, violence, leaking faucets, plugged plumbing and mothers praying that their children come home alive at the end of the day, day after day.
Or, a town gone belly up, the factory closed and moved overseas, a seeding ground for opiate epidemics and death. Or rural pockets of rusted out trailers where sad-eyed people try and survive beyond the reach of any community.
No surprise, the lower the socioeconomic status (SES) of a person, the higher the rate of mental illness. Poverty, says the World Health Organization, is the "greatest cause of suffering on earth."
In 2014, according to the National Poverty Center, 14.8% of all Americans lived in poverty, including 26.2% of blacks and 23.6% of Hispanics. And children comprise 1/3 of the poor population, 15.5 million.
Strikingly, American poverty and accompanying higher rates of mental illness occur in an era of unprecedented inequity, of unrivaled wealth among its elites.
Beyond dry statistics, the evidence is visual and visceral. Tour the America of decaying and dying neighborhoods, crime, homelessness, drugs and mental illness. Then, taxi across town, across the railroad tracks or the river, beyond the rainbow, and see evidence of spectacular wealth — second, third and fourth mega mansions that are empty, devoid of life, for much of the year.
The Founders and their heirs, warning about monarchies and unequal distribution of opportunity, gave away much of the land to white men willing to work it. Now, to rebuild an America equal to the intent of the Founders, we will have to do more.
Curing mental illness will require massive infusions of money, new social enhancement programs, improved neighborhoods, better schools and expanded mental health programs. Where will we get the money?
Incline Village resident Andrew Whyman, MD, is a clinical and forensic psychiatrist. He can be reached for comment at email@example.com.