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mental health mondays :: big, crazy world

one of the arguments used to discredit claims about mental illness is that it's somehow a disease of the rich and privileged: the people who seek therapy are generally white, middle class or higher, and mostly located in north america. the implication of that argument is that mental disorders are fabrications of people who don't have "real" problems to worry about. it's malarkey, of course, but it has a remarkable staying power. the first two points- that there is a racial and an economic factor at work in determining who develops mental disorders- are easily disproved. the third, however, is a little more complicated and warrants a closer look.

first, there are a few of what i like to call "duh" points:

  • there is not a long history of mental health treatments because the whole idea is still fairly new.
  • furthermore, since the bulk of medical research into the subject is done in highly industrialised countries, it stands to reason that there is more information available in those areas.
  • following from that, more research has led to more open discussion of mental health issues, which doesn't occur in other places. in fact, the stigmatisation of mental health problems seems to be one of the few universal constants left.

so in those little factoids, you already have the seeds of why mental illness might be perceived as a disease of affluent white people- it's been most closely studied in the areas where affluent white people live.

luckily, there are some studies emerging that allow us to get a comparative sense of how widespread various mental disorders really are. the world health organisation has made a concerted effort to document and analyse incidents and treatment of mental health problems around the world and their information is the best that we have in terms of making a statements about where these problems are the most acute. [please note :: statistical data is measured in disease-adjusted life years. huh? d.a.l.y. is a method of measuring the overall impact of a disease on a population, that is to say how much time, measured in years, is lost to the condition.]

as one might expect, the question of who has the greatest prevalence of mental disorders changes depending on which specific disorders are being discussed. cases of schizophrenia, for instance, seem to run at a stable 0.4% to 0.7% of the total population just about everywhere in the world. considering that the status of schizophrenia as a single disorder is now being widely questions, that's kind of a remarkable figure. one would expect that where it is difficult to achieve consensus on what exactly the condition is, that there would be significant variations from one region to another in terms of the reported rates. but the opposite is the case, with a small caveat.

that caveat is that there does seem to be a higher burden in southeast asia. although there isn't a lot of range between the countries with the highest and lowest reported cases of schizophrenia, it's interesting that seven of the ten countries with the highest rates are in southeast asia, including all of the top five. indonesia has the highest rate, followed by the philippines, thailand, malaysia and sri lanka. ironically australia, only a short distance away, has the lowest incidence of schizophrenia and the rest of the "bottom ten" are all from europe. [see the full list here.]

it is tempting to conjecture that this reflects patients' access to treatment rather than absolute differences in the number of cases, since the lowest rates are all in highly developed countries. however, the countries with the highest d.a.l.y. scores for schizophrenia aren't exactly underdeveloped. malaysia [5th] and singapore [7th] have major metropolitan centres whose size and amenities rival any of those in the west. [i'm including australia as part of the "west", even though it's a geographical fallacy.] and if it were only a matter of access to medical help, one would expect that countries where access to services was even worse would be much higher up the list. but that clearly isn't the case. central and sub-saharan africa is home to the poorest countries in the world, with the most unreliable infrastructures, but only one country in the region even makes it into the top 100 in terms of its d.a.l.y. [africa also has the lowest ratio of psychiatric doctors to patients of anywhere in the world as well.]

further, countries with the highest rates of schizophrenia are more likely to have not only specific health care policies for mental health, but to include mental health as a facet of their general health policies. that would indicate that they are more aware of mental health issues than those countries that don't include mental health as a pillar of overall public health. countries like canada.

all in all, however, rates of schizophrenia are fairly stable everywhere. the same can't be said for other conditions, however. in particular, depression shows much greater variation from the united states, where it affects about 17% of people, to japan, who report an incidence of only 3%. a lot of people would be unsurprised that the united states would have the highest rate of diagnosis, but japan having the lowest seems a little surprising, doesn't it? it seems surprising even in light of other data on depression, such as that it is considerably more common in urban rather than rural areas and that rates increase as population density increases. by those metrics, one would expect japan to be near the top of the list.

what's even stranger about japan being the happiest, or the least depressed, place on earth is that, once again, seven of the top ten nations most burdened with depression are in asia. but none of those countries is among the top ten countries with highest schizophrenia burden. in fact, if you were to take a map of southeast asia and compare countries most affected by schizophrenia versus those affected by depression, they would be like photo-negatives of one another.

looked at on a global scale, the americas- north, south and central- are considerably more hurt by depression, except for mexico, where the d.a.l.y. score is among the lowest in the world. on the other side of the world, india, and almost every country with which she shares a border, has an alarmingly high score, and scores drop noticeably the further away one moves. africa as a continent has lower rates than any region on earth, and the only areas which drift into even moderate levels are all located along the northern coast. stranger still, the countries located on the other side of the mediterranean- spain, italy and greece- have very low scores. [it's worth noting that this information, from the w.h.o., was published in 2004 and therefore doesn't take into account changes that may have occurred in the wake of post-2008 economic upheaval. see the full list here.]

while it might be tempting to interpret the data on depression as validating the "disease of the white and wealthy" theory, there are a number of factors that should be considered. for instance, while countries in africa have the lowest reported rates, they also have the lowest rates of people to whom problems could be reported, lessening the chance that a person will seek help for a problem that doesn't seem to be immediately life-threatening. if cases are under-reported, then the measurement of depression's effect on the country is invalidated. but even if we assume that there is no problem with the african results, there are other reasons to attribute depression to race or financial status. 

take, for example, the scandic peninsula, comprising finland, sweden and norway. all three countries are predominantly white and relatively affluent, which should mean that all three rate fairly low in their d.a.l.y. scores. at the very least, one would expect their relative burdens to be similar. in fact, finland has one of the highest scores of the world [11th overall], while sweden is much lower [59th] and norway lower still [70th]. if there are to be any hard and fast rules that explain depression, they will have to explain how three such similar countries [and no, that does not mean they are the same, i know they're not so don't send me hate mail] can have such different results.

just to throw a wrench in the works, there are the incidence of bipolar disorder. estimates are that between 2.5% and 3% of the population worldwide have some form of bipolar disorder and, like schizophrenia, it is a relatively stable rate around the world. however, the data in this case clearly reflect that access to treatment is the greatest single factor in determining the impact that the disorder has on the country. wherever treatment is easily accessible- north america, europe, australia- the burden of the disease is much lower. where treatment is hardest to find- mainly africa and china- it is higher. this would seem to indicate that bipolar disorder is recognised as serious- in a way that depression may not be- but that many places simply do not have the resources to treat it. [sadly, poorer countries not only have less money per capita to invest in mental health care than richer ones, but they invest it at a lower rate.]

as always, however, there is one anomaly that makes generalisations difficult. in this case, it's south korea. south korea has an advanced economy, good access to health care and a comparatively wealthy population. it also has one of the highest bipolar disease burdens of anywhere in the world. with china, at least one can explain the overall high burden by citing the disparity in access to services from one region to another. tiny south korea, however, shouldn't have this problem. except that it does.

the net result of all this data talk? it's a lot more complicated to explain the relative incidence and impact of mental disorders than broad generalisations would lead you to believe. so if you come across someone who is trying to tell you that mental disorders are a western phenomenon, try asking them a few probative questions to see how deep their knowledge really runs.

p.s. :: one thing that has been argued is that western concepts of the insane may be "colonising" other nations simply by establishing norms for the world that come from the west. that doesn't affect the numbers of people with certain conditions, or the severity of their conditions, but it may affect whether or not they are properly diagnosed, since the "checklist" of symptoms for a certain condition is universal, whereas there could be significant cultural differences in how the same disorder is expressed. it's a much bigger topic than i can handle in a post script, and maybe a topic for a future mhm, but in the meantime, you can read this essay from the new york times.

p.p.s. :: if you want to know where the "sanest place on earth" is, or at least the place where your least likely to be bothered by insanity [your own or that of others], you should consider moving to australia, spain or greece, with italy a reasonably close fourth choice. all three countries have low d.a.l.y. ratings for depression, bipolar disorder and schizophrenia. clearly then, access to both urban and rural landscapes, the ocean and lots of wine are the common denominators to good mental health.

p.p.p.s :: the image at the top of this post is a world map made up of doctor-to-patient ratios in each region. it's taken from this amazing collection of re-imagined maps.

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