Mental Health in the US is Suffering—Will It Go Back to Normal?

Pies, however, sees it differently. He points out that even a contingent response to a specific situation can constitute a major health concern. “Consider this scenario,” he writes. “An elderly hiker with stable but underlying heart disease has a heart attack when a 12-foot grizzly bear suddenly appears in front of him. This poor fellow may have had an ‘understandable’ or even a ‘predictable’ response to the bear—but a heart attack is a heart attack!”

The debate about whether or not causes of emotional distress should be taken into account when making a psychiatric diagnosis is not new. It raged in the pages of academic and mass media publications as the DSM-5—or, more formally, the Diagnostic and Statistical Manual of Mental Disorders, which guides clinicians in diagnosing every disorder—moved toward its ultimate publication in 2013. The previous edition had included a “bereavement exclusion” for major depressive disorder, which stipulated that a person could not be diagnosed with depression if they had experienced the death of a loved one in the past two months and were not experiencing severe symptoms, like suicidal ideation. Though bereavement is an emotionally intense experience, it does typically improve on its own as time passes—and extreme sadness is a normal reaction to a major loss.

But the American Psychiatric Association, which has published the DSM since its first edition, decided to remove the bereavement exclusion with the publication of the DSM-5 in 2013. “The argument put forward for that was, ‘Well, we want to be able to help people who are struggling with grief, and there is really no objective difference between the two experiences, because, if you just focus on the symptoms, they are very similar,’” Tekin says.

And from some perspectives, this argument does make good sense. Imagine, for example, a doctor who is trying to treat a purely physical problem like a cough. Their patient will likely find relief from their symptoms with cough drops or Robutussin, regardless of what is causing their cough. But even in the case of physical symptoms, context can still matter. Someone who is suffering from seasonal allergies could feel better simply by changing their environment —say, staying inside and turning on an air purifier—while someone who is coughing because they have Covid-19 may ultimately need to be rushed to a hospital.

Similarly, Tekin says, in the case of psychiatric conditions, “even if you very simplistically say they have the same symptoms, when you look at it, what causes someone’s symptoms is going to be extremely important in the therapeutic context.” Someone who is grieving a recent loss probably needs a very different sort of help from someone who is experiencing depression with no obvious cause.

If a therapist understands someone’s symptoms as the product of the death of a loved one or of Covid-induced isolation, rather than as a fundamental pathology, they may recommend a less aggressive form of treatment. “There may be a way short of medication—maybe some talk therapy just to make you feel like you have human contact—but short of more heavy-duty interventions that have side effects,” Wakefield says.

That’s not to say, of course, that medication only works in some circumstances, and therapy in others. Medication may help people who are responding to difficult circumstances, and talk therapy can do a great deal for those whose symptoms have no obvious causes. But focusing on causes does open treatment possibilities that might not otherwise have been available.

And Browne thinks there are societal risks to treating emotional responses to events like the pandemic as medical issues. “The bigger risk that I see with medicalizing things when we may not need to, is that it places the problem in individualistic terms,” she says. “Anxiety and depression, especially in response to something like this global pandemic—those are not problems with you as an individual.” A person who has been suffering recently because of fear of contracting Covid-19, stress from its economic fallout, or anger over racial injustice in the wake of the killing of George Floyd is not feeling poorly because of factors specific to them. “The root cause is systemic,” Browne says.

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