[AI] age of unreason: Special Report The Economist

avinash shahi shahi88avinash at gmail.com
Thu Jul 9 11:07:45 PDT 2015

IT ALL BEGAN when she lost her head. According to legend, Dimpna, a
7th-century Christian heroine, fled her native Ireland when her
father, mad with grief at the death of his wife, developed an
incestuous passion for his daughter. The father came after the girl
and, rebuffed once more, beheaded her in the flatlands of what is now
northern Belgium. Dimpna was canonised, and in medieval Europe
developed a reputation for divine intercession that could heal
madness. Her cult centred on Geel, a small Belgian town that forms one
point of a triangle with Brussels and Antwerp. By the 19th century
Geel had developed a system of foster care for the mentally ill in
which patients, or guests as they are referred to, are adopted by
families. It continues to this day. When at the turn of the 20th
century the Belgian government threatened its existence with a decree
that the insane should live in institutions, the whole town designated
itself as an asylum.
Geel’s system can make heavy demands on the host families. Not
everyone is deemed suitable for a foster placement—a high suicide risk
and a penchant for pyromania are two counter-indications—“but the list
of exclusions is not so long,” says Bert Lodewyckx, who runs a team at
the local hospital that looks after elderly patients. In a town of
just 35,000 souls, about 270 families have people living with them who
would otherwise be kept in an institution. Foster families are told
nothing about the psychiatric history of their new companions. “For a
time, being a foster family was prestigious, a bit like owning a
Mercedes-Benz,” Mr Lodewyckx explains. Host families are paid about
€20 a day, but their main motives are tradition and altruism.

The way the mentally ill are treated in Geel is unusual. At most times
and in most places, caring for such people has been the responsibility
of the biological family, which is not always kinder than strangers.
Medieval Europeans sometimes locked up family members in basements or
shut them away in pig pens. In China, where care of mental patients
continues to fall largely on their families, such treatment is
sometimes still being reported. In one case a man fashioned a homemade
restraint for his son by fitting chains to a chair; in another a woman
suffocated her sister with a pillow to lift the burden on the family.

China’s psychiatric system, such as it was, was largely shut down
after 1949; the new Communist government made no provision for mental
illness in a rationally ordered society. Yet as the country has grown
richer and more urbanised, demand for mental-health care has grown. In
2012 China passed its first national mental-health law.

This is a typical pattern. The rise of psychiatry in America coincided
with the post-war economic boom. Surveys by the World Health
Organisation (WHO) show that spending on mental-health services
increases sharply once GDP per person reaches around $20,000—the same
level at which people start buying insurance, yogurt and other
middle-class indulgences.

Two things lie behind this. Richer societies put more resources into
diagnosing and treating mental illness, and older societies have more
people with dementia. China is on its way to becoming both rich and
old. This shift is usually accompanied by an expectation that society
ought to shoulder more of the cost of treating mental illness, which
can become too heavy for a single family to bear.

The statistical relationship between mental illness and development is
new evidence for an old theory. Since the 19th century, people have
been arguing that mental illness is a price to be paid for progress.
In “Civilisation and its Discontents”, Sigmund Freud popularised the
notion that neurosis increased in tandem with profit. Before Freud, an
American neurologist, George Beard, had noted that a nervous disorder
he labelled neurasthenia (and others nicknamed “Americanitis”) was on
the rise. He put it down to the speeding up of modern life,
facilitated by the telegraph, the railway and the press.

Neurasthenia disappeared from the psychiatrist’s lexicon in
20th-century America but enjoyed a long afterlife in China; Chairman
Mao himself was said to suffer from the condition. It faded from view
only after Arthur Kleinman, a Harvard anthropologist, conducted
fieldwork in China in the 1980s and concluded that the symptoms of
neurasthenia were rather like those of depression. Drug companies
spied an opportunity to sell pills that they were already making.
Rates of diagnosis for depression, which was virtually unknown in
China 20 years ago, are now catching up with those elsewhere.

This is not because economic progress, of which China has seen more
than any other country over the past three decades, makes people sick.
Rather, it is due to a combination of the profound effect that growing
richer has on diagnosis and the less forgiving standards for normal
behaviour set by modern service-sector jobs. Dealing directly with
customers makes different demands on the brain from work in a factory
or on the land.

Surveys suggest that the incidence of serious mental illnesses such as
schizophrenia (a condition characterised by hearing voices and
withdrawal from society) and bipolar disorder (which causes extreme,
uncontrollable mood swings) is fairly constant at between 1.5% and 3%
of the population around the world. By contrast, the incidence of
milder forms of mental disorder varies much more between and also
within countries. This is true for common depression, anxiety,
post-traumatic stress disorder, attention-deficit disorder and many
others. In the rich world, these conditions taken together affect
about 20% of the population at any point in time. America’s federal
government estimates that in 2013 about 44m of the country’s
population of around 325m suffered from some kind of mental illness,
with depression and anxiety the most common.

The OECD, a club of mostly rich countries, reckons that the direct and
indirect costs of mental illness already exceed 4% of GDP in some
places. A report from the Harvard School of Public Health and the
World Economic Forum says that between 2011 and 2030 mental illness
worldwide will cost over $16 trillion in output forgone (in 2010
dollars), more than physical ailments such as cancer, heart disease or
diabetes (see chart). But such predictions should be treated with
caution, for reliable numbers on mental illness, both within and
across countries, are very hard to come by.

This is because, in the absence of a proper understanding of mental
illness, the various disorders, syndromes and character traits that
are labelled as such are really just thoughtful descriptions of
changeable symptoms. In America, health-insurance companies rely on
the definitions provided by the American Psychiatric Association’s
Diagnostic and Statistical Manual (DSM) to determine what counts as
sickness and what is merely within the usual range of variations from
the norm. Each edition of the DSM removes some disorders and adds
others. (The WHO maintains its own system, called the International
Classification of Diseases, or ICD, whose definitions differ from the

The most recent edition of the DSM lists around 300 mental illnesses.
But the symptoms of mild depression are so different from the
disabling effects of the severe sort that the two things probably
ought not to share a name, and neither has much in common with, say,
post-traumatic stress disorder (PTSD). This special report will try to
make sense of this tangle by looking at the main afflictions of the
brain at different stages of life. The first sort affects children as
their brains develop; the second shows up in adolescents and younger
adults; and the third appears as people get older and their brains
begin to waste away.

Chasing a chameleon

The choice of definition, which is itself subject to change, has an
effect on the diagnosis. But the thing doctors are trying to pin down
is also inconstant. At the beginning of the 20th century it was common
for people in the West to be diagnosed with nervous disorders. These
have been replaced by conditions such as anxiety and depression.
Soldiers in the first world war suffered shellshock, which could cause
loss of the power of speech and, in some cases, partial paralysis,
with no apparent physiological basis. By the middle of the 20th
century other varieties of distress caused by battle had taken over.
More recently PTSD has become an increasingly common psychiatric
diagnosis for returning soldiers, displaying slightly different

Symptoms change not only over time but from place to place. “To say
that someone has a conduct disorder does not mean the same thing in
Mozambique as it does in Manhattan,” says Shekhar Saxena, who runs the
mental-health arm of the WHO. In some places hearing voices is
considered normal, even desirable when part of a religious experience.
In other it might be cause for prescribing antipsychotic medication.
The difference is subjective: psychiatrists are usually interested
only in voices that are distressingly insistent or say something

Other factors that affect the incidence of mental illness include
people’s willingness to talk about it. Some might not want to admit
that they are having problems. On the other hand, eligibility rules
for welfare payments may provide an incentive for being diagnosed with
anxiety or depression.

Diagnosis is also sensitive to advances in pharmacology. The current
popularity of antidepressants, which are taken by one in ten Americans
at any one time, has a lot to do with drug companies’ success in
coming up with a form of drug delivery that is safe and does not have
nasty side effects. Antidepressants that act on serotonin, a
neurotransmitter that affects mood, have been around since the dawn of
the jet age, but became widely used only once drugs such as Prozac,
which were convenient and considered safe (and therefore easy for
family doctors to prescribe) were developed. Until then, doctors had
been fairly free with tranquillisers. In the 1950s Miltown, the brand
name for meprobamate, a mild calming drug, was taken by about one in
20 Americans, mostly for anxiety.

The use of psychiatric medication itself sometimes seems like an
epidemic in the rich world, but it can go down as well as up. In the
late 1990s France was the world leader in malaise, with about 30% of
its citizens taking psychiatric drugs, but since then the numbers have
come down. Cognitive behavioural therapy, a form of short talking
therapy that aims to break self-destructive patterns of thought and
replace them with something more positive, has been found to work at
least as well as pills for treating mild depression and is becoming
more widely available.

Do not despair

Because mental illness is so hard to pin down and measure, it is easy
to lose sight of how debilitating it can be. One widely used yardstick
is the “Disability-Adjusted Life Year” (DALY), which the World Health
Organisation defines as one lost year of “healthy” life free from
physical or mental disability. Mental illness now accounts for a
significant chunk of DALYs (see chart).

A more objective measure used in most health systems is the suicide
rate. In Detroit, where a high murder rate, high unemployment and many
abandoned houses meet any definition of a stressful environment, the
Henry Ford Health System, which looks after much of the city’s
population, has cut suicide among its patients by systematically
assessing their risk.

In 2009, with the effects of the financial crisis still reverberating,
the Henry Ford Health System managed to bring the number of suicides
among its patients down to zero, an impressive achievement for an
outfit that in 2013 counted 3.2m outpatient visits. There is no way of
stopping those who are determined to kill themselves—“when someone is
telling you that they want to make it look like an accident so their
family gets the life insurance, then you know it’s really serious,”
says Doree Ann Espiritu at Henry Ford. But many suicides are
opportunistic acts of despair that can be prevented by putting netting
under bridges, making it harder to jump onto subway lines and
controlling access to large quantities of painkillers.

Because of the link between economic development, ageing and mental
illness, the coming decades are likely to resemble an age of unreason.
That is why Geel, which has been caring for people with such
conditions for half a millennium, is worth paying attention to. What
is striking about the town is how thoroughly normal it seems: the town
square with its fake Irish pub; American pop music playing at a polite
volume on the main shopping street. Mental illness, so often
frightening, seems ordinary here. Geel’s system embodies principles
for dealing with it—dignity, openness, kindness, patience—that should
be embraced by societies everywhere.


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Avinash Shahi
Doctoral student at Centre for Law and Governance JNU

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