Thought Economics founder Prof. Vikas Shah discusses the realities of mental health worldwide, the true burden on individuals, communities and countries, and opportunities to deal with our global mental health crisis, with Dr. Thomas Insel, former Director of the National Institutes of Mental Health, currrently a neuroscientist at Verily, Google Life Sciences; Dr. Shekhar Saxena, Director of Mental Health for the World Health Organisation; Paul Farmer, Chief Executive of Mind, the world’s largest mental health NGO; Sergeant Kevin Briggs, Guardian of the Golden Gate Bridge; Marcus Trescothick, international cricketer and mental health campaigner; Professor Vikram Patel, Professor at the London School of Hygiene & Tropical Medicine and the Public Health Foundation of India; and Andrew Solomon, writer and lecturer, Professor of Clinical Psychology at Columbia University Medical Center, and President of PEN American Center.
Q: How does the mental health of a population impact their ability to respond to change?
[Andrew Solomon] The highest rates of anxiety disorders and depression tend to be in societies that are undergoing rapid transformation. In the same way that you get high rates in people who are displaced from one country to another, you also get high rates when a country is displaced from one system of values to another. Places where industrialisation is occurring show a big increase in depression and anxiety; places going from dictatorship to democracy do too. Societies that have been isolated find huge mental health challenges when they’re being integrated into the larger world.
Depression arises when a genetic vulnerability is triggered by external circumstances. If you have a very high rate of vulnerability, you need only minor circumstances to trigger it – and if you have a low rate of vulnerability, you need fairly major circumstances to trigger it.
Societies that are in transition are forcing people away from everything that is familiar to them, into a new way of thinking, being and understanding themselves. The result of this is that the people who have even moderate vulnerability to depression are triggered.
Q: What are your views on our cultural perceptions of suicide?
[Andrew Solomon] Suicide is something we don’t discuss enough, but it’s important to note that discussing it too much can have toxic effects. So we need to be careful not only of whether we talk about it, but also of how we talk about it.
In the aftermath of major famous suicides such as Marilyn Monroe and Robin Williams, there’s an up-tick in suicides because the choices of those famous people seems so normalize the act.
There are prevention strategies for suicide that can be very effective, but I also believe that people have a right to suicide if they really have tried everything they can to get better, and cannot do so. There are very few people for whom it is the right decision, but there are some.
In the United States, we have an appalling problem with gun violence, caused in large part by our lack of gun control laws. The rate of suicide by gun is significantly higher than the rate of homicide by gun; so more than half of people who die by gun in the United States are dying by suicide. If you removed the means of their self-destruction, many would survive; there is clear evidence that when it’s harder for people to kill themselves, fewer of them do it.
People often talk about physical health being urgent and immediate, and mental health as being something of a luxury. Foreign Policy just ran an article about refugee camps in Iraq for Kurds who had returned from conflict. The people running them said that they were fully occupied keeping people safe, and didn’t have time for the luxury of dealing with their mental health. These are people who have post-traumatic stress and extreme depression and high anxiety—as most of us would after going through what they’ve endured. The notion that their mental health is a luxury, akin to giving them freshly baked goods for breakfast, is so misguided. In fact, many of them may die from their psychiatric challenges.
The enormous suffering people go through during, and even in the lead-up to major depression is has costs in terms of the overall level of happiness on the planet, and in terms of the economic cost of all these people who are unable to function. It would be not only humane but also economically wise to provide better treatment to more people.
Q: What are your views on the taboo around medication?
[Andrew Solomon] The resistance to medication for depression frequently comes from people who think they should wage their battles on their own. If the person had diabetes, you wouldn’t tell that person to avoid insulin injections; if someone had pneumonia, you wouldn’t persuade that person to go off antibiotics.
People’s idea that antidepressants aren’t natural contributes to the resistance to medication, but we have plenty of interventions in our life that are not natural yet are important; brushing your teeth for example. The natural thing would be for them to fall out by the time you’re thirty, but no one militates against toothpaste.
Life is short, and if you are really depressed for this whole year? Guess what? You will never get this year back again. If there’s some medication you can take that will allow you not to be depressed for this whole year, there is no moral advantage to avoiding it. There is no scorekeeper out there giving you extra credit for “fighting on your own.”
You need to do whatever you need to live as well as you can.
If you take medication, and you don’t like it? You can stop. People have this misguided impression that taking medication is a Rubicon they will cross, from which there is no turning back from. It’s not so.
People often say it was brave of me to talk about my experience of depression, and my medication. But I grew up as a gay person, very much in a closet. I decided when I got out of that closet, that I was not going to be getting in any more.
Don’t ever make yourself or others feel ashamed about taking medication. We all have illnesses and vulnerabilities. Don’t be a slave to your or anyone else’s notion of what healthy means. This is your voyage of discovery.
Q: What is the role of resilience?
[Andrew Solomon] People can be resilient to their own depression or resilient in the face of shifted and changed societies.
There is an interplay between illness and personality. Some people seem to have greater inherent resilience; they can adapt better even to a condition that undermines many people’s ability to adapt. Beyond native capactiy, however, resilience comes from the personal and social level of reckoning with whatever those specific triggers are. It comes from refusing to ignore your own problems or to sweep them under the carpet. It comes from integrating the story of your own depression into the larger story of your life.
Of the countries that I’ve visited and written about in Far & Away, South Africa has gone through the most successful transition. There have been issues, of course, with the ANC, and there’s a lot to be worried about, but it is essentially a better place now than it was under apartheid. The fall of apartheid was the elimination of something evil and wrong that gave way to something better. The entire population went through the essentially psychotherapeutic process of the Truth and Reconciliation Commission.
Countries that close their eyes to their history are under constant threat of that history recurring, just as peoplewho close their eyes to their own personal history are more likely to be fearsomely depressed.
Societies that examine themselves, examine their changes and understand their history, create a single fluid narrative and are frequently more resilient.
In the United States, in England and in Europe, we’re seeing a rise of populist extremism. People are made anxious by change and frequently, autocratic leaders appear to offer enormous stability. People who are unsettled will often be drawn to that perceived stability, even if it is accompanied by unattractive policies and bigotry. The great trick for governments is to teach people to tolerate the feeling of uncertainty, showing how uncertainty can be the precondition of striving for something better.
(To read the full interview, please visit Thought Economics.)