Is Mental Illness “Abnormal” If It’s Super Common? – Psychology Today
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I used to teach a course in āabnormal psychology,ā and students were often amazed by the high rates of mental illness. The best studies at that time (around 2015) were based on large, randomly selected cross-sections of the population. The study designs were retrospective āliterally ālooking backwardāāas the research interviewers asked participants a series of detailed questions about their entire mental health history.
Pathologizing Sadness?
The numbers that emerged from these retrospective reports shocked many people. About a third of the sample had experienced a mental health condition in the past twelve months, and nearly half had at some point in their lifetime. Many of my students wondered if the threshold for diagnoses were too lowāafter all, shouldnāt āabnormalā psychology be relatively rare? It was easy to wonder if the boundaries of mental illness were being stretched to include relatively mild experiences of difficult emotions.
I recently discussed these issues on the Think Act Be Podcast with Dr. Jonathan Schaefer , a clinical psychologist and research scientist at the University of Minnesota. Are we pathologizing everyday sadness and anxiety? Schaefer doesnāt think so.
āI donāt buy the argument that if lifetime prevalence is high for mental disorders, it must mean weāre medicalizing normality,ā he said. āWe donāt apply that kind of logic to physical health problems.ā He used the example of a common illness like the flu. āLots of people will get the flu,ā Schaefer explained, ābut that doesnāt mean that diagnosing and treating that condition is āmedicalizing normality.āā
Uninterrupted Mental Health Isnāt Normal
Schaefer is on firm ground when he compares common mental health conditions like depression to physical ailments like the flu. He and his colleagues have shown that results from previous studies were almost certainly underestimatedĀ of the lifetime prevalence of mental illness. The actual number is closer to 83 percent; a full five out of six people in Schaeferās research met the criteria for a mental health diagnosis by age 38. (Schaefer and I are both among the 83 percent.)
Schaeferās data come from an ongoing longitudinal cohort study in Dunedin, New Zealand. Researchers have been following about 1000 participants since birth and administering repeated psychiatric assessments. The most common conditions in the Dunedin sample were anxiety disorders (58 percent of the sample), major depression (48 percent), and substance abuse or dependence (41 percent).
Why had retrospective studies undercounted mental illness? Schaefer blamed it on ārecall failureā: Participants simply forgot that they had had a certain condition. With serious physical health conditions, like heart disease or diabetes, weāll almost certainly remember our diagnosis. But for mental health conditions, āwe know that recall failure happens incredibly frequently,ā said Schaefer.
He attributes forgetting to state-dependent memory. āPeople tend to view their past experiences through the lens of their present circumstances,ā he explained. If weāre in a good mood, itās harder to remember the times when we were feeling down, and weāre likely to think they werenāt as bad as they actually were.
Schaefer and colleaguesā longitudinal cohort study, in contrast, minimized the threat of recall failure, since participants needed to remember only the year since the last assessment and not their entire life history.
State vs. Lifetime History
Schaeferās study was published in the Journal of Abnormal Psychology , which struck me as a bit ironic, given how normal it is to experience a mental health condition at some point in oneās life. But Schaefer clearly distinguishes between whatās normal for a lifetime and whatās normal for our day-to-day experience.
āItās important to think about the lens weāre adopting, and whether weāre looking across lifespans or within lifespans,ā he explained. āWhen weāre talking about what is ānormal,ā this is a lifetime perspective. Itās saying that the average life has at least one period of diagnosable mental illness in it. ā From that perspective, mental illness is a very normal experience.
āBut you can also look within a personās life across people,ā he continued, āand say that the average mental health state for people is to not be in a state of diagnosable disorder.ā We apply the same way of thinking to physical health conditions, since āthe average state of health for most human beings is to not be experiencing a cold or the flu.ā Thankfully the mental health struggles that most of us face will be temporaryāāsort of like wave,ā as Schaefer described them. āThey surge, they crest, and then for most people they recede.ā
Transcending Stigma
The impulse to set a high threshold for what we call āmental illnessā actually may betray a pernicious form of stigma. Itās easier to see mental illness as something that happens to āthose peopleā if itās relatively rare. Conversely, the actual numbers suggest that going through a major mental and emotional challenge is typical of the human experience. Thankfully the work that Schaefer and others are doing has direct relevance to the dehumanizing stigma that continues to surround psychiatric illness.
āYou can think of pretty much any successful person you really admire,ā said Schaefer, āand the odds are pretty good that they probably had a significant mental health problem at some point. That in and of itself is very reassuring and normalizingāand helps you realize youāre not alone.ā
That message can start early, with what we teach young people about mental health. āThe main message for parents is one that emphasizes appropriate socialization around mental health problems, and early intervention,ā Schaefer said. āNormalize talking about emotions and mental health. And make sure your kids know itās perfectly acceptable to go to therapy.ā
We can also provide kids and teens with the tools theyāll need for managing mental health challengesāespecially with the additional challenges brought about by COVID-related isolation. āHelp them to cultivate the coping skills, the self-talk, and the daily routines that other areas of science have shown contribute to psychological resilience,ā Schaefer advised, such as the research-backed practices of cognitive-behavioral therapy (CBT).
We can also instruct young people about what to expect for their loved ones. āPrepare them for the fact that their friends and their future partners will probably have some of these issues,ā said Schaeferāāand thatās okay. Most of the time theyāre temporary, and they happen to almost everyone.ā
So if you or someone you love has struggled with mental illness, take heart, says Schaefer: āYou are in great company.ā
The full conversation with Dr. Jonathan Schaefer is available here: āHow Better Mental Health Epidemiology Can Lower Stigma.“
References
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.
Schaefer, J. D., Caspi, A., Belsky, D. W., Harrington, H., Houts, R., Horwood, L. J., … & Moffitt, T. E. (2017). Enduring mental health: Prevalence and prediction. Journal of Abnormal Psychology, 126, 212-224.