Sunday, April 3, 2016

Is Mental Illness More Common than it Used to Be?

Clayton Cramer, in a recent book about mental illness:
Urbanization may not simply have been a factor in making Americans more wary of their mentally ill neighbors; it may have increased mental illness rates as well. While we do not know if this was true in the eighteenth century, some recent studies suggest that being born or growing up in an urban area increases one’s risk of developing schizophrenia and other psychoses. in the twentieth century, comparison of insanity rates revealed that urban areas had much higher rates of mental hospital admissions for schizophrenia and bipolar disorder – almost twice as high for New York City compared to the rest of New York State…older statistical examinations of mental hospital admissions argue that at least in the period from 1840 to 1940, while mental hospitalizations increased (because of increased availability) there was no large and obvious increase in insanity. A more recent study of mental illness data shows, much more persuasively, that psychosis rates rose quite dramatically between 1807 and 1961 in the United States, England and Wales, Ireland, and the Canadian Atlantic provinces. A study of Buckinghamshire, England shows more than a ten-fold increase in psychosis rates from the beginning of the seventeenth century to 1986. In 1764, Thomas Hancock left 600 pounds to the City of Boston to build a mental hospital for the inhabitants of Massachusetts. The city declined to accept the gift on the grounds that there were not enough insane persons to justify building such a facility. Massachusetts had a population between 188,000 and 235,000 in 1764; if the population of the time suffered the same schizophrenia rates as today, that would mean that there were about 2000 schizophrenics in the province. Even accounting for the greater tolerance of small town life for the mentally ill, this lends credence to Torrey and Miller’s claim of rising psychosis rates. Urban life today is not the same as urban life then, and even the scale of what constitutes “urban” is dramatically different – but it is an intriguing possibility that the increased rates of mental illness at the close of the Colonial period were the results of urbanization.

Irish immigration may also have played a role in the increasing development of mental hospitals in America. It was widely believed in the 1830s that Irish immigrants were disproportionately present among the insane. More recent analysis shows that throughout the nineteenth and twentieth centuries, Ireland’s rates of insanity were twice or more than that of the United States, England, and Wales. Irish immigrants were also over-represented in insane asylums in the United States, England, Australia and Canada at the end of the nineteenth century.
Immigrants are still over-represented among the mentally ill; nobody is sure if this is because mentally ill people are more likely to emigrate or because emigration is a very stressful act.

Understanding mental illness in a cross cultural way is very difficult, because cultures understand and react to mental illness so differently. So perhaps it would be better express this finding by saying, not that more people are crazy, but that more people find it impossible to function in our society than in past societies.

But is that true? As even this little paragraph shows, different studies have produced widely varying numbers.

Is it even possible to compare rates of mental illness between different cultures? I absolutely do not think that mental illness is an invention of modern society; all of the cultures I know anything about recognize that people can be crazy. Some cultures think madness can be divine and have a habit of seeking spiritual meaning in the utterances of madmen and madwomen, but although they may consult crazy shamans and priests about the will of the gods they don't ask them to help arrange marriages for their children. But there certainly is a wide variance in what is defined as a serious mental illness. Plus, in the medieval world lunatics (as they were called) were mostly cared for by their families, and nobody bothered to count them.

So knowing whether mental illness has increased is a hard problem, perhaps unsolvable. On the other hand it seems undeniable that we perceive mental illness to be a much bigger problem than anyone before the nineteenth century did. Why is that? It could be because nobody thought about mental illness as a problem, just as nobody thought about how to achieve full equality of the sexes as a problem. Or it could be another side effect of our conquering hunger; when mass starvation was a regular occurrence, paranoia and excessive sadness did not seem like much to worry about.

At any rate, we have a problem with mental illness that seems to be a side-effect of modernity. As to why that should be, that is another hard problem. I can think of several possible causes: environmental poisons such as lead, urbanization, disease, separation from the natural world (people who grow up on farms have much healthier immune systems), the general increase in the complexity of economic and social life, the rapid pace of change; or, on the other hand, a changing definition of what life is all about that makes things like depression much bigger deals than they used to be.

It is something to ponder, when we consider the march of history; if we have made so much progress, why are we crazier than ever before?


Shadow said...

I am not a city person. When in D.C. I hang around the Quad, museums, tidal basin -- open spaces. An unsettling feeling weighs on me when I walk down a street surrounded by tallish buildings, and I am uncomfortable the entire time. It's not claustrophobia -- I can explore caves -- but may have something to do with the blocking out of sun and sky, the number of people, and the sterile unnaturalness of it all. The feeling goes away when I'm in a building. Strange. Going to New York City is an effort for me, not unlike readying myself for a brawl.

Unknown said...

It seems obvious to me that decreasing shame and repression must be a factor; not necessarily the only factor, but an important one. This must in particular affect issues like depression and anxiety, where one can get more or less get by in life keeping one's problems more or less to oneself. Perhaps it is also worth pointing out that alcoholism rates have declined. And how many mentally ill persons simply died younger--perhaps much younger--in former societies?

The changing nature of work may also be a factor. Depression and anxiety may--I stress I'm only suggesting a possibility--but easier to hide (including from oneself) when work is largely physical.

A further suggestion: mental illness may have seemed less frequent in the early modern world, but vagabondage was seen as a huge social problem. How much did mental illness pay a role in that? Which residents of a village would fail first in the village economy, and go on the road? Perhaps the anxious or depressed or borderline or whatever; and could one even, in this case, distinguish cause and effect?

Larkin in The Reshaping of Everyday Life gives a vivid picture of the slow, awkward, flat affect presented by many nineteenth-century American farmers. Some of this may reflect inferiority feelings in the presence of urban observers--but I get the impression that a studied concealing of inner life is one of the key skills inhabitants of small, face-to-face, especially rural societies learn.

John said...

David, I agree that the nature of village life helped the mentally ill get by: physical work in familiar settings with the same people, unchanging from year to year, with strong religious and magical support for dealing with anxieties. (Imagine OCD in 200 BCE: people who refused to leave the house without putting all seven of their protective amulets in exactly the right order and reciting prayers to all seven of their favorite gods.) I also agree that many of the mentally ill probably died young of drink, wounds from violence, or other side effects. In fact I have the general impression that the high death rates had a winnowing effect; on average it was the physically or mentally weak who died young, leaving the strong to forge on.

Unknown said...

I would say again, though, that village life also helped the mentally ill get by because it promoted self-repression and conformity. That is, the place of mental illness in village life isn't just about support networks and other "healthy" things that we no longer have. Modern life frees people from the obligation to hide their mental illness.

Susi said...

From personal experience: In the South it was described as 'quirky' or odd, or other adjectives. Unless it was disruptive to the community, personal oddities were tolerated, excused, or ignored. When a child was born obviously disabled the OB or midwife might commit mercy killing. Accidents of childhood occurred to disabled children, which a normal child might have evaded.
My husband's first wife's family has bi-polar, borderline personality, schizophrenia and other affective mental illnesses in all generations. Her children and all of the grandchildren have it to some extent, some mild, some disabling. In the recent past, and I assume, in the further past, these aberrant behaviors were interpreted more benignly.
I agree with you; the definitions of aberrant behaviors have changed. We more broadly apply the term 'mental illness'.

Unknown said...

Maybe it's my Southeast Texas background, growing up among newly prosperous families with strong rural roots, but I just have trouble with a rosy view of rural life as a haven of tolerance. Yes, you could have a place, but you had to know what it was and you had to keep to it. No, they wouldn't diagnose you or put you on medication. But you better not make any claims to adult rights or a public voice, or speak any resentment. David Hackett Fischer's portrayal of the isolated social failure in Appalachian society is a good example, a powerful statement of what I take to be a frequent fate.

G. Verloren said...

Mental illness isn't more common, it's simply more visible.