Let’s End the Destructive Habit of Doubting Psychiatric Illness

Does everybody know that mental illness is real medical illness? On one hand, surveys in the United States show that an overwhelming number of the public endorse the idea that mental illness is real and as important as physical illness. And yet, year after year, only half of those with mental illness seek treatment for it. Of those who do get treatment, only half again adhere to it. So while people report to pollsters that they know mental illness is real, the clear majority acts as if it is shameful and unreal.

Meanwhile, a steady series of books and articles reinforce the idea that mental illness is a cultural creation, including such periodicals as The Atlantic, The New York Times, and The New England Journal of Medicine. Psychiatrists, so the story goes, arbitrarily define normal human suffering and eccentricity as a medical illness so that they can go on to prescribe expensive and unnecessary medications for it. After all, committees of psychiatrists simply vote on whether to create categories of illness in DSM, while drug companies persuade doctors and patients that a pill will solve their newly defined problems. This narrative is so engrained that it constitutes the default notion of psychiatry among intellectuals in our culture.

Is mental illness real medical illness? Is our intelligentsia correct? They rightly point out that psychiatrists and neurobiological researchers have failed completely in their attempts to demonstrate a clear neuropathology for any major mental illness (excluding dementia). And yet this argument is vacuous just where it appears to be airtight. A little reflection will tell us that we do not have to know the central pathophysiology of an illness to know that it is biologically and medically real. For centuries, physicians knew that cancer was a deadly medical and biological illness, even though no one knew what caused it until the 1960s and 1970s. Sigmund Freud died in 1939 of throat cancer—does this mean the problem was “all in his head”? In the same way, mental illnesses are biologically devastating and functionally disabling, knocking an average of 10 years off the human lifespan and speeding up biological processes of aging and decline. Should we deny the overwhelming evidence that depression, anxiety, posttraumatic stress disorder, and bipolar disorder are biologically abnormal and damaging, just because we do not yet know the precise explanatory mechanism for each disorder?

Isn’t this just biological reductionism? Many psychiatrists and other educated people become uncomfortable with a strong defense of biological psychiatry. Are we not now denying that mental illness is psychological and social? Are we ignoring the way that inequality, poverty, racism, development, and resilience exert profound effects on mental health? The answer is a simple no. Claiming that mental illness is biologically and medically real says nothing about whether it is psychologically and socially real. For instance, the alarming rise of diabetes mellitus in recent decades is not simply “biologically determined” (whatever that means) but intricately interwoven with political and social systems regulating our food supply, dietary habits, levels of physical activity, and sleep. The more deeply we understand the biology of illnesses generally, the more deeply we understand most chronic medical illnesses as socially and psychologically real.

Why does this even matter? The vague but pervasive notion that psychiatric illnesses are unreal causes untold harm to people that we love. It makes our patients doubt themselves and their treatment and adds to their suffering through shame and stigma. Worse still, it causes untreated persons with mental illness to delay or avoid treatment, with devastating consequences to the course of their lives. It is the notion that empowers insurance companies to deny all manner of mental health treatments with impunity, resulting in further death and morbidity. It causes governments to hesitate in offering full enforcement and support for the treatment of psychiatric illness and causes society to tolerate the treatment of severe mental illness with homelessness and jail.