The unconscionable neglect of the mentally ill

Steven Hyman is a former director of the National Institute of Mental Health. He has an impassioned editorial in Science: Translational Medicine that makes three key points. First,

Mental disorders have high aggregate prevalence, are responsible globally for nearly a quarter of all years lived with disability, and represent the largest cause of lost economic output among all classes of noncommunicable disease worldwide.

The Global Burden of Disease Study estimated the total of the person-years lived with disability for the entire planet. The study found that mental illnesses and substance abuse disorders were, collectively, the leading cause of disability, measured this way.

Hyman’s second point is that we have the means to treat many of these illnesses.

Cost-effective treatments, including both generic drugs and brief, manualized cognitive therapies are available to address this burden.

Mental illness can be treated through medications, many of them now generic, and evidence-based psychological treatments such as cognitive-behavior therapy. As with many non-communicable diseases, mental health treatment is often not curative. But even so, many patients enjoy profoundly reduced suffering and increased functioning.

Third, even though we could provide effective care,

treatment of mental disorders remains a low priority worldwide.

This is shocking, because with cost-effective means to treat mental illnesses we could relieve an enormous burden of human suffering and greatly increase human productivity. But we neglect the care of the mentally ill relative to our care for those with other disorders. Hyman documents how policy makers discount the importance of mental illness and asks why.

One reason is the stigmatization of the mentally ill. But then what explains stigmatization?

I believe that a seemingly more arcane but powerful cognitive distortion also plays a role in the deprioritization of mental illness: the belief that mental disorders should somehow be controllable, if only the affected person tried hard enough or adhered to a better set of beliefs.

The symptoms of mental disorders are derangements of thought and emotion. Our sense of personal autonomy tells us that we determine what we think and can at least shape what we feel. So if we can control ourselves, why can’t they?  The suspicion that the mentally ill are responsible for their state may be built into who we are.

But spend time with someone with major depressive disorder. Or schizophrenia. Or a person with obsessive compulsive disorder who has to

check the stove twenty times to make sure it’s really turned off, wash your hands until they’re scrubbed raw, or drive around for hours to make sure that the bump you heard while driving wasn’t a person you ran over.

And they have to do these things even though they know it’s crazy. You will see that these people are overwhelmed by mental processes they cannot control and that they are not responsible for their distress. It’s unconscionable that we slight them and neglect their suffering.


TIE has published a lot on mental illness, for example, here and here, on its stigmatization here, and on our responsibility for our health here.

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