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Written by: Alexander Pralea '24 Edited by: Ishaani Khatri '21  One need not be a statistician–although it certainly helps–to notice a trend: a rise in diagnoses of mental health conditions. A 2017 Pew Research Center Report based on representative data from the 2017 National Survey on Drug Use and Health confirms the commonly held wisdom, reporting that among adolescents aged twelve through seventeen, 20% of girls and 7% of boys had experienced an episode of major depressive disorder within the past year alone [1]. Especially startling is that these percentages represent a 59% increase from the 2007 values. So what is behind this rise? Is it merely the result of an increased emphasis on mental health care and a reduction in stigma (accompanied by a loosening in diagnostic criteria), or something far more sinister? Coinciding with a more nuanced understanding of mental illness and a subsequent decline in the associated stigma, the “concept” of mental illness has expanded, a phenomenon explained by the theory of “concept creep” proposed by social psychologist Nick Haslam [2]. There are a plethora of examples. “Asperger’s syndrome” no longer appears in the up-to-date psychological literature found in the DSM-5, now encompassed under the broader umbrella of autism spectrum disorder, which includes less disruptive clinical presentation not characteristic of autism. "Shell shock," referring to the highly stigmatized condition World War I veterans faced after the horrors of the front line, has been reinvented under the label of post-traumatic stress disorder (PTSD), a more ambiguous diagnosis describing varying levels of trauma from causes as different as childbirth, infidelity, the loss of a loved one, and more. Indeed, based on the criteria of the DSM-5, 50% of Americans will have at least one diagnosable mental illness throughout their lives, raising concern that efforts to adopt objective biomedical labels to subjective mental illnesses have resulted in bloated diagnostic criteria–from the DSM-I to the DSM-5, the amount of listed mental illness has tripled–of little clinical utility [3].
Of course, concept creep is not the only factor behind the expanded definitions of mental illness that Western societies have enshrined; equally as important is the rise of biological psychiatry. As Harvard historian of medicine Ann Harrington has detailed, psychiatry and the pharmaceutical industry are inseparable, having both relied on the other for legitimacy. Direct marketing of psychiatric medications to consumers, along with the close affiliation between academic psychiatrists and drug companies, has helped convince consumers that behavior that a century ago would have been considered normal is actually abnormal, in need of Prozac or Zoloft [4]. This is not to argue that psychiatric diagnoses and medications have been useless; for patients with moderate to severe mental illness, they have been revolutionary, enabling many to be freed from the asylum of the 19th century. However, there is ample evidence that those with mild anxiety or depression would be better suited by cognitive behavioral therapy (CBT) and other forms of therapy rather than medication, for whom the latter works no better than a placebo [5]. Psychiatrist Derek Summerfield, writing in the opinion section of the British Medical Journal, echoed this finding, decrying the recasting of negative emotion as mental illness, noting that the seven-fold increase in the prescription of antidepressants since the 1990’s has not brought about a commensurate improvement in overall well-being [6]. Nonetheless, regardless of the influence of concept creep and biomedicalization, suicide, which is strongly associated with depression, has also risen, indicating that expanded awareness of mental illness reflects a substantive rise in severe psychopathology [7]. From 2000 to 2016, suicide rates increased by 30% according to the American Psychological Association, making suicide the second leading cause of death among those aged 10 to 34 [8]. Meanwhile, self-harm, poisoning, and depressive symptoms more broadly have all risen since 2000 and have disproportionately afflicted young girls, with the most marked increases occurring after 2010 [9] [10]. Even an intermittent follower of current events knows that the 2010s have been marked by a rapid adoption of social media platforms, many of which either came out in this decade (Instagram or Snapchat) or soared to new heights of popularity in this stretch of time (Facebook or Twitter) [11]. While social media is not the sole cause of this epidemic of mental illness, there have been no clear underlying economic or genetic changes consistent with the hypothesis that they could be potential predictors. Although by 2010 the United States economy had yet to recover from the Great Recession, between 2014 and 2020, unemployment had plummeted to new lows, while real wage growth was no longer sluggish by 2016, even for low-income workers, crossing out economic anxiety as the likely catalyst for this phenomenon [12]. Moreover, genetic changes across human populations could not possibly have prompted such dramatic changes, especially given the short time frame of this development and the demographics of those struggling with mental health problems, who tend to be young adults and teenagers who reached adolescence during the social media era. Therefore, social media, which has revolutionized the fundamentals of human interactions, is likely the main culprit, according to psychological studies. Most studies have been observational, plotting some survey value of well-being as a function of hours of screen time or digital media use; still random-assignment experiments, the gold standard in scientific research to evaluate causality, have determined that even very minimal use of social media (20 minutes daily) can reduce well-being, while limiting social media use can help ameliorate depressive symptoms. Psychologist Jean Twenge suggests that the mechanisms for social media’s negative effects on mental health are multifaceted. On one hand, the use of social media substitutes for more fulfilling time spent with friends in-person; regardless of an individual’s choice to use social media, if friends use social media, then this effect can be inescapable. Relegated to a foreign past, dinner conversations have been replaced by text conversations, illustrating how technology encroaches on traditional social interactions. All these changes on average affect girls more so than boys, the former of which are especially prone to making excessive social comparisons in an unhealthy social media landscape that idealizes unhealthy body images, thereby promoting eating disorders. Lastly, social media can induce depressive symptoms through interfering with sleep; studies in cognitive neuroscience have determined the importance of sleep in the consolidation of emotional memories, indicating that reduced sleep could be associated with worsened consolidation of positive memories, resulting in the sense of worthlessness and helplessness often associated with depression [13]. Our current efforts to treat mental health conditions–psychotherapy and psychiatric medications–cannot respond adequately to this tidal wave of social media alone despite their immense value. Preventive efforts toward behavioral health may require a higher upfront cost, but the benefit in terms of reduced long-term use of mental health services will pay for itself over. Of course, it is far easier to diagnose a problem than it is to solve it, and any effective intervention must acknowledge that social media use is nuanced in that it can offer a creative outlet and boost connectivity. Rethinking how social media is regulated for and marketed toward children and adolescents could be one of many solutions; requiring that people link their accounts to real identities through IDs would ensure that users be eighteen or older as well as reduce the veil of anonymity that facilitates cyberbullying (and no, merely asking users if they are eighteen or older, which they can easily lie about, is not enough). Other approaches are up for legitimate discussion, although given the influence of lobbyists seeking to limit reform, their legislative feasibility is uncertain. Still, given that social media platforms are specifically engineered to ensnare unwilling users, we cannot accept that those whose brains are most vulnerable will be guinea pigs in a mass natural experiment. References:
[Image Citation] MissLunaRose12 (2019). File: Mental Illness Icon 1. PNG. Retrieved 2020, from https://commons.wikimedia.org/wiki/File:Mental_Illness_Icon_1.png.
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