Here’s a true modern puzzle for you: why is the rate of mental health problems, including depression, anxiety, and obesity, increasing in the US, Australia, urban China, and most Western countries?
Which mental health problems again? Depression, anxiety, and obesity are the big growth areas. And, yes, I view obesity as a mental health problem, ie the result of a lack of willpower.
Let me give you the quick stylised facts on these arising from the literature.
An authoritative paper on depression in 1989 said on the increase since WWII that
“Several recent, large epidemiologic and family studies suggest important temporal changes in the rates of major depression: an increase in the rates in the cohorts born after World War II; a decrease in the age of onset with an increase in the late teenaged and early adult years; an increase between 1960 and 1975 in the rates of depression for all ages; a persistent gender effect, with the risk of depression consistently two to three times higher among women than men across all adult ages; a persistent family effect, with the risk about two to three times higher in first-degree relatives as compared with controls; and the suggestion of a narrowing of the differential risk to men and women due to a greater increase in risk of depression among young men. These trends, drawn from studies using comparable methods and modern diagnostic criteria, are evident in the United States, Sweden, Germany, Canada, and New Zealand, but not in comparable studies conducted in Korea and Puerto Rico and of Mexican Americans living in the United States. These cohort changes cannot be fully attributed to artifacts of reporting, recall, mortality, or labeling and have implications for understanding the etiology of depression and for clinical practice.”
A recent 2011 paper on the US summarises the available evidence thus:
“Almost all of the available evidence suggests a sharp rise in anxiety, depression, and mental health issues among Western youth between the early 20th century and the early 1990s. Between the early 1990s and the present, more serious problems such as suicide and depression have receded in some data sets, whereas feeling overwhelmed and reporting psychosomatic complaints have continued to increase. Other indicators, such as anxiety, have remained at historically high levels but not continued to increase. This mixed pattern of results may be rooted in the increasing use of antidepressants and therapy and the improvement in some cultural indicators. However, the incidence of youth mental health problems remains unacceptably high.
Just a few generations ago, depression and suicide were considered afflictions of middle age. However, throughout the 1960s, 1970s, and 1980s, the average age of onset for depression moved downward (Klerman & Weissman, 1989), and the suicide rate for young people (aged 15–24, per 100,000 population) skyrocketed from 5.2 in 1960 to 13.3 in 1995 (U.S. Bureau of the Census, 2011). Numerous studies reported sharp increases in the lifetime prevalence of depression, including among adolescents and young adults (e.g., Lewinsohn, Rohde, Seeley, & Fischer, 1993). Only 1%–2% of Americans born before 1915 experienced a major depressive episode during their lifetimes, even though they lived through the Great Depression and two world wars. By the 1990s, the lifetime rate of major depression was 10 times higher—between 15% and 20%. Some studies put the figure closer to 50%. (Kessler et al., 1994; Wickramaratne, Weissman, Leaf, & Holford, 1989).”
So for depression in the US, we are talking about up to 50% of the population who will experience a bout of it, a ten-fold increase from the generation born in WWI. For anxiety, studies say that some 30-50% of the current generations in the US and Europe will be affected by some anxiety disorder or another in their life, again orders of magnitude higher than two generations ago.
For obesity, the same can be said: from being a problem that afflicted a couple of percent in 1900, we are fast approaching a situation where the majority of the population in the US is obese. This is already true for the 50 to 60 years of age population and rates in other western countries are on the rise too, showing sign of a slow-down.
The role of medicine is interesting here: the effects of anxiety and depression seem to be kept manageable by medicines preventing the sufferers from committing suicide or becoming psychotic. The effects of obesity are similarly countered by medicines, through blood thinners, bypass operations, and the like. So whilst rates of mental health problems are at an all-time historical high, medicine is successful at reducing the impact on people’s lives.
Here is the puzzle: what on earth is going on here? On any objective measure, life is better now for the vast majority of the population than ever before. People are richer, live longer, run fewer risks, are surrounded by less violence and large shocks, and essentially have less to fear and be depressed about. Indeed, people are as happy now as ever, reflecting the fact that these are good times. Why then the increase in mental health problems in societies like the US, Australia and most of Europe?
One can basically out of hand reject the excuses most individuals give for their problems as being the reason. The rate of increase rules out any reasonable role for genetics. The fact that the poor suffer more from obesity, whilst it is cheaper to eat less and whilst food has always been cheap for the rich, rules out any obvious effect of the lower price of food or the availability of fast-food. The sustained increase over a long time rules out any story depending on some major current crisis. Like it or loath it, but it is clear that one must look at ‘cultural factors’ to have a hope of understanding what is going on.
A big hint comes from cross-national differences amongst rich countries, where things like wealth and food affordability dont differ much. As you can see here, the Anglo-Saxon countries, and then particularly the US, stands out. Whilst a third of adults in the US are now obese (with about 25% of Australian adults), only 4% of Koreans and Japanese are such, and in the more egalitarian Northern European countries (Sweden, Norway, Holland) rates are below 10%. The same holds for Italy and France, though rates in those countries too are quite a bit up from what they were 50 years ago. So your one major clue is that there are major unexplained differences over countries.
Which cultural factors though and what underlies changes in these cultural factors? This is a wide-open and currently empty field in health economics. Your suggestions are thus greatly appreciated in the comment boxes!
How do they assess what the levels were before access to mental health services/understanding of mental health issues was more widespread and socially acceptable?
Tyler has a point. Depression and mental illness were taboo subjects until fairly recently.
Tyler,
Yes, fair question. Rising rates of suicide co-moved with the rise in depression amongst teenagers until the 90s and that is seen as one of the key bits of evidence that the reported mates of depression is not just measurement and social acceptability, which indeed a clearly important element here too. Apart from that there is the clinical literature that purports to have measurement instruments less susceptible to social factors.
“The suicide rate in Australia has decreased by 17% over the past decade, from 12.7 to 10.5 deaths per 100,000 people, according to the Australian Bureau of Statistics (ABS). ”
ABS.
Sorry, but IMOH, that’s just nasty and the insinuation that mental health problems such as depression and anxiety are merely weaknesses of character implicit in including obesity, so defined, with them as a mental health problem doubly so.
Of course I’m biased. I’ve just thrown a couple of jobsworths calling themselves a ‘Crisis Assesssment Team’ out of the house, with a flea in the ear for each of them. I suspect that this course provided the total extent of their knowledge of mental health and it’s even conceivable that they got Centrelink assistance to put them through the course and get them off welfare.
This post reminds me too much of Carmen Lawrence’s infamous remark about the ‘worried well’ for which she quite properly apologised.
If you’re going to write on mental health issues, even if it’s merely from the economic perspective, it might be a good idea to start from a better understanding of the nature of mental health problems with a little research in the relevant medical and psychological literature.
As for this:
There’s a fallacy of reasoning in there – if not several – which right now I haven’t the time or mental resources to parse out. Provisionally I’m going to call it ‘the Economist’s fallacy’. It’s something a lot like The Politician’s Syllogism.
“Of course I am biased”
Indeed you are. Lets hear your explanations instead of righteous indignation at something I didn’t say.
Paul,
Whatever your standing within the economics profession, however well regarded your publications in the refereed journals might be, you’re not writing for your professional colleagues here. You’re writing for a general audience and, just as in your ‘Thoughts on Gonski’ right now you’re showing that you have a tin ear for the sound of your own subtext.
In your Gonski post you described how, in your opinion a good National Curriculum could at least extract at least some value from ‘dumb’ teachers by e.g. by giving them good teaching materials they could work through more or less by rote and at least their students would learn something from them. Have you ever actually experienced that style of teaching?
I did in the 1960s, (in 4th Form Mathematics). I blitzed the year anyway, thanks to natural mathematical aptitude but I suspect that a for a lot of the other kids in the class who were sick of maths, it reinforced their desire to drop the subject ASAP – i.e. the following year, when the final internal streaming into humanities students and science students started. It was exactly the sort of operationalised, dehumanised teaching you were propounding as a possible desirable outcome of Gonski and the National curriculum and it sucked.
Now here you drop in this casual, unexamined declaration:
You’re not a Biggest Loser fan, by any chance, are you? Regardless, explain to me how a lack of ‘willpower’ is a mental health problem, how you would diagnose it, and how you would treat it. Or rather, how you would suggest it can be diagnosed and treated. In most of the material I’ve ever read on ‘willpower’ its generally been treated in very normative terms – a person of good character has willpower, a person of bad character doesn’t. Please explain to me the precise clinical application of the concept of willpower.
Later – after your expression of perplexity at the situation you write:
Excuses such as? Please provide examples for the other major mental health problems you raised at the beginning of your post i.e. anxiety and depression.
Like it or not, this response will just have to do by way of explaining that ‘righteous indignation’ which I prefer to regard as a quite reasonable and justified – if futile and self-defeating – anger. Just as you did in your Gonski post you are pontificating on matters which you clearly do not understand and haven’t taken the trouble to understand before you began your pontifications. Whether, given the general tone of this response I obviously have no good reason to expect an answer to any of my questions.
Funny, I have a very similar opinion of your writings, ie shallow and often plain wrong. Where we differ is that I don’t bother you with that opinion and I suggest you do same.
As to the statements you don’t like, why don’t you ask me why I say them rather than assume the role of god and judge that I am not allowed to say them unless accompanied by 5 more pages of text that you would then instantly dismiss as too much verbiage for that general audience! Or do you reserve the right to say anything of interest just for yourself?
No idea, but you indeed find many studies claiming a role for ‘supply induced’ demand for psychiatric labels, including the studies linked to. If you force me to guess, I’d say easily half the increase is measurement.
suggest you go to the big literature on social capital – connectedness (or more precisely, its lack) in the countries you cite is a large part of the explanation. Start with Andrew Leigh’s latest book, but there is a very very large body of work. Also, Bob Cummins work on wellbeing is relevant. Suggesting these Australian sources because they are easiest to get hold of but the international work is much wider.
yes, I know that literature (some of it is also reviewed in the studies linked to above. The ‘Bowling alone’ thesis is famous). Are there particular stories that you think ring true though and that have causal levers? For instance, do you buy into the idea that people have less friends now than they used to (less connections) and that they become depressed/anxious/obese out of loneliness? If so, what has been the emerging market failure in the market for friends and what can thus be done?
I partially want to hear your thoughts because the literature on cultural factors outside of economics is not settled but very murky. The literature on connectedness for instance almost never considers connections as just another good that individual acquire, meaning that the issue of market failures for those goods does not get asked and an economist is left with the story that connections ‘somehow’ reduced. Even if you buy into connections and take it for granted that their distribution has been changed by some unknown outside force, its not really such a great story. For instance, rates of depression, anxiety and obesity haven’t just gone up amongst middle-aged single people. They have gone up almost across the board even amongst families and individuals that have no lack of connections.
Paul I’m fond of bomb-throwing myself, mate, but there are bombs and bombs.
Gummo is right that you have a bit of a tin ear for tone, which wouldn’t be so much of a problem if you weren’t in this case also “pontificating on matters which you clearly do not understand and haven’t taken the trouble to understand” (though I suppose that’s one of the things blogging is for :-) ).
The result: a nasty flame war in which neither party learns anything at all about the issue and both learn more about each other than they might wish to.
Wise words DD. Now in deference to Paul’s express wish above it’s time for me to retire once more.
Some of the conditions that contributed to the vehemence of my response can be found in my most recent post on Mental health Crisis services. The information there has explanatory value only, it does not excuse my earlier behaviour. Nor does the little life lesson I gained from this incident, to wit, do not trust valium induced calm to keep you equable.
“a tin air for tone”
yeah, that one has an element of truth about it, but I would say that is a good thing in that it assures you I don’t say things to please you. I say them because I mean them. Its a politician’s job to worry about your sensitivities all the time.
but
“pontificating on matters which you clearly do not understand and haven’t taken the trouble to understand”
is just not true. You and Gummo make the mistake of thinking that because I use simple language and ask the readers to give their thoughts on a genuine puzzle, that I don’t know a whole lot more already. Don’t confuse ‘unwelcome and unpopular’ with ‘uninformed’.
Paul,
First, the overdue apology for flying off the handle. That said (deep breath):
Tone really is important in blogging and I’m sorry to say that your rationalisation of it doesn’t cut it with me. It’s just as public a form of writing as writing newspaper columns and has to be treated with the same care. Right now, I’m out of practice, probably need to reinstate a few self-imposed rules from my early career the most important of which is this – if readers misinterpret what you say, then you haven’t said it clearly enough.
In this case you made a number of errors in your post – the obesity as mental illness remark being the most egregious. If you are willing to enter into private corro e-mail me at my old blogging address gummo.trotsky@gmail.dot com and we’ll see what this surly old cur of a blog veteran can teach the new dogs some tricks and vice versa. Maybe we can get some sort of Todd Sampson/Russel Howcroft thing going. I don’t want either role, incidentally – I dislike the whole show and all who sail in it.
Forget the gummo.trotsky address – you have access to my regular address of course, since you have site access privileges.
Hi Gummo,
thanks. If its any consolation, in no way was I aiming to offend anyone. Indeed, I was so tired when I wrote the blog that it didn’t even register that people might disagree or take offense at the ‘obesity is a mental health issue’ line, which I by the way completely stick to. Simply because I was tired doesn’t mean I didn’t mean it and I would find it cowardly to backtrack on it (the problem is more that I have in my own mind categorized obesity as a mental health issue for so long now, I need to be switched on to remember that the majority of the obese population will have an entirely different story in mind).
The issue of tone is where you have a point. Whilst there is no good reason for a scientist to worry about the sensitivities of people who might read it, there is also no good reason to cause offense if a small effort (such as in this case replacing the word ’causes’ by ‘is related to’) can convey the same meaning and circumvents a direct collision with some particular sensitivity. Having said that, in this case of course I am essentially already asking the reader to step over the ‘usual excuses’ given for the rise in obesity (and other mental health issues) so am already asking them to discard their sensitivities in that regard. Maybe it was accidentally efficient to scare off those who cant do that in the second sentence.
As to the blogging-as-journalism issue, I think I blog for different reasons than you. With an average of about 500-1000 hits per blog, I do not see blogs as primarily journalistic output (though it is certainly a medium to reach journalists who of course are prone to take out the bits offending their readers). I’d feel myself a very dumb and failing economist if I thought that was worth my time.
Blogging for me is only partially about making thoughts available and marketing my output. It is also a record-to-self and a means of getting feedback on current thoughts, ie it is by itself truth-seeking, this blog in particular. Crowd-sourcing my literature review, if you like.
Take the reactions so far on clubtroppo and core (where I cross-post). They have taught me that:
1. There are people who as a first-line defense say that the obesity increase is as a result of a conspiracy, ie that people have been tricked into eating more. If only subsidies to farmers would reduce, obesity would decline. Its clearly the sort of thought that is highly unlikely if you reflect on it, so the fact that you get that response tells you parts of the audience have no desire to think about the issue but have been happy to float along with a crowd-pleasing ‘its the fault of those nasty capitalists’ story. In turn this alerts me to several cultural lock-in effects surrounding this debate, ie protective layers of nonsense surrounding the more likely underlying issues. Worth knowing.
2. People who have been on task forces (ie the bureaucracy) think there is something to the ‘connectedness’ idea. Now, you should perhaps know that I write a lot on connectedness (using different labels), so it tells me that the ‘official family’ is receptive to that kind of argument and that they are consuming and championing those thoughts (rather than other ones doing the rounds in social science). Worth knowing.
3. The idea that obesity has something to do with willpower is something that raises strong negative emotional reactions. I guess I should have realised that before, but, as I said, I was tired and it didn’t even cross my mind that that would be a bone of contention (just ask yourself: how can obesity not be related to willpower? Aliens force-feeding the human population? Gross-ignorance as to what is causing obesity? Obesity as a desirable fashion statement?). Worth knowing.
4. That many others, like me and the literature, are aware that there is a strong supply-induced demand effect in mental health issues. Worth knowing.
5. The one new bit of information I was less aware of (thanks Stephen!) is that there is a part of the literature that seriously thinks the rural-urban divide is a real clue, ie a clincher in terms of persuasive information. That is a judgment call on how to read the literature, and to be honest I hadn’t paid that distinction much attention because urbanisation rates are huge in Japan and Korea too (where the mental health issues are much lower) so I had always discarded the urban-rural issue as not-so-informative. Now I am thinking that perhaps the rural-urban divide is different across countries and that it might thus be a bigger clue. Its for instance the case that turnover in US cities is probably greater than turnover in Japanese/Korean/Northern European cities.
Paul, what do you think of the role of non-connectedness environmental factors, such as lead:
http://www.motherjones.com/kevin-drum/2013/01/lead-and-crime-linkfest
?
Lead poisoning is a golden-oldie in social science, sometimes blamed for the collapse of the Roman empire. Still, given that we now take lead out of petrol and that there is a large variation in lead concentrations over regions that saw increases in mental health problems, I have a hard time believing it explains much. Not impossible though that some chemical factor is really important, but lead is too obvious (we’d have spotted cross-regional variation on that dimension long ago).
Hi Paul
Your question can in part be answered by disaggregating the statistics on wellbeing. Prof. Cummins’ material helps. The report he publishes as the Australian Unity index is only the tip of the iceberg for a wealth of survey material that separates out the factors at play – and he is very open to other researchers contacting him for access to the datasets. For example, in relation to connectedness, small towns (not surprisingly) are much better than large cities. Arguably socially we have made a tradeoff between social connections for the benefits of urban agglomeration.
Getting data is not however easy – there are too many indices, too much contestation about what matters (I chaired a taskforce on this, report may still be online at Open Forum). Bob Puttnam’s work was an interesting hypothesis but it too as I’m sure you know has been attacked for relying on poor data.
Drug use of the sort that can F the brain is much more common thes days and use by young unformed brains is also more common. A factor?
A review of a book on the subject, with this interesting comment:
I
Paul, this blog is an excellent source of information and ideas and obesity.
I don’t think the increase in obesity can be put down to a sudden loss of willpower by huge chunks of the population. Such an explanation is about as satisfactory as explaining unemployment as a spontaneous outbreak of holiday taking.
Not a sudden loss of willpower, but a need for it that did not previously exist?
“how can obesity not be related to willpower? Aliens force-feeding the human population? Gross-ignorance as to what is causing obesity? Obesity as a desirable fashion statement?”
Obesity is strongly associated with low socio-economic status. That is the surely the key and generalising about all people muddles things. Willpower would be only obliquely relevant. People were raised on sugar (and other junk) in recent times much more than previous generations. The bogans carry on. Unlike the middle classes, they don’t read and they don’t grasp the concept of cause and effect: what happens in this world is a mainly a matter of luck and fate (so it makes sense to play the pokies).
With no cause and effect they pervasively mistrust so they have difficulty connecting with others. Their longing for sociality makes them gullible which results in betrayal and reinforcement of the mistrust. In that context the middle-class fads that pervade the media are just a load of crap.
Ask yourself why these people smoke. The middle classes have abandoned cigarettes but not the flannel-shirts. Even the young women smoke. Willpower? Bah: granddad smoked thirty a day and lived till he was ninety. Thus the anti-smoking campaign that concentrates on health is a waste of time. It worked for the middle classes but it can’t influence the bogans especially since smoking has become so unacceptable indoors: going out for a smoke is now a way to make connections with the like-minded, an expression of solidarity, a confirmation that the world is unsympathetic.
I don’t see much hope on obesity. You might get them off the smokes by a campaign that somehow portrayed not smoking as pro-social but you can’t do that for food. It’s not that obesity is fashion or pro-social; on the contrary, thinness is social, but the cause-effect distance between dieting and thinness is impossibly great and all you’d achieve from emphasising the sociality of thinness is more depression.
The only hope on obesity, smoking, and gambling would be regulation. Not increased taxes for all that does is deprive their children but coercive restriction. That’s something this class does understand. The depression incidence would plummet.
If only it were just the poor who were obese, the answers would be much easier. Alas, no. 50% of Americans in the 50-60 range are not poor, and neither are the 28% of Australian obese adults. Whilst the poor are over-represented, obesity has gone up across the spectrum.
There is a danger in looking only at individual groups and coming up with a story specific to them, like you do above: one tends to get seduced by arguments that localises the problem so that one can believe it does not afflict us. Plenty of such stories abound for various groups, including the oft-heard argument that we used to have physical jobs in the olden days, or that eating out has become so much more normal, or that the reduction in smoking leads to bigger appetites, or that the portions have just gotten bigger. Its the kind of story where it handy to bear in mind that there are other countries where all these things are also true and obesity has not risen so much. So whilst they may be a contributing factor, they are unlikely to be major factors and more likely to be effects than causes.
Btw, for someone who professes to abhor cultural explanations, you do seem to harbour a few cultural beliefs yourself! :-)