Mental illness remains shrouded in stigma. Despite the occasional celebrity going public about their battle with depression, anxiety, or substance abuse, it’s an issue that most of us, most of the time, would prefer not to mention. Sometimes, however, events make it impossible to ignore. The recent shooting by police of a young mother in Washington DC, and the arrest of a women for daubing the city's National Cathedral with green paint, are two such events: irruptions in which mental illness, and its potentially devastating effects, is suddenly visible to us all.
These incidents are, however, merely the tip of an ominously large iceberg. Mental illness may be taboo, but we can all expect to experience it—either personally or in someone close to us. The most reliable national epidemiological survey—the U.S. National Comorbidity Survey Replication—found that around one in four Americans had experienced a clinical psychological disorder in the previous 12 months. That equates to around 75 million adults. Around half of Americans are likely to develop a clinical disorder at some point in their life (a statistic that puts the U.S. the top of international rankings for mental illness).
The Washington cases point to another largely unacknowledged feature of the nation’s mental health. They remind us that psychological disorders (and particularly depression and anxiety) are more common in women than men—a fact that, perhaps for fear of being accused of sexism, most mental health professionals seem to prefer to ignore. Yet our analysis of twelve large-scale, national epidemiological surveys from the U.S., U.K., Europe, Australia and New Zealand, South Africa and Chile revealed that, in any given year, women appear to experience higher overall rates of psychological disorder than men. In fact, the difference is typically as much as 20–40 percent. The Centers for Disease Control and Prevention report that though the national average for “mentally unhealthy days” is 3.5 per month, the figure for women (4.0) is more than a third higher than for men (2.9).
Unlike the Washington incidents, however, women seldom make public displays of their unhappiness; this sort of "externalizing" behavior is seen far more often in men. Women tend to be especially vulnerable to depression, anxiety, eating disorders, and sleep problems: conditions that typically cause us to turn inwards, retreating psychologically from the world and the people that surround us. Plenty of men also suffer from these disorders, of course, but the proportion is markedly smaller than for women. On the other hand, men are more susceptible to alcohol and drug problems and anti-social personality disorder, which are more likely to produce the kind of conspicuously erratic behaviour recently witnessed in the capital.
Why are overall rates of mental illness higher in women than in men? Given that many experts seem unaware of this troubling fact, it’s hardly surprising that the sort of research that could provide a definitive answer hasn’t yet been done. Nevertheless, there are indications that the very particular stresses faced by women today play a significant role. There’s a clear financial incentive, for instance, for women to be thin: a recent study of employees in the U.S. and Germany found that women who are 25 pounds below average weight are paid better than those of average weight. Men, on the other hand, are rewarded when they put on weight. Women, moreover, may have taken their place alongside men in the workplace, but men haven’t reciprocated in the domestic sphere. “Women’s work” has largely remained just that—underpaid, undervalued, and unequally distributed.
We should bear in mind too that women are much more likely than men to have experienced sexual abuse, a trauma that can often have a profoundly negative effect on an individual’s mental health. Studies have shown that as many as five percent women have been the victims of sexual abuse—more than three times the figure for men.
We don’t, of course, know which, if any, of these factors helped produce the actions of the women in Washington. But their cases certainly offer a tragic illustration of the need to improve the way in which society responds to mental illness.
Compared to physical ailments, psychological problems are very much the poor relation in healthcare, receiving far less attention, resources, and cash. The US spends $2.5 trillion on health each year, but only five percent of that goes towards mental health. This is despite the fact that mental illness accounts for almost half of all ill-health in people aged under 65. Indeed, because mental and physical health are often so closely intertwined, with each influencing the other, some scientists have campaigned under the slogan “no health without mental health."
Besides the distress such conditions cause individuals and their families, there is a financial penalty: people diagnosed with a clinical disorder earn an average of $16,000 a year less than other folk. The annual cost to the nation as a whole runs into hundreds of billions of dollars.
Most people in the U.S. with a psychological disorder receive no treatment at all: too often individuals and families have to shoulder the burden alone. (African-Americans and Hispanic Americans are particularly disadvantaged.) The situation is no better when adolescents are involved: research shows that more than half of 13-18 year-olds with severe problems have never been treated. There are more than half a million mental health professionals (of various types) in the US. That may seem like a substantial number until we recall that around 75 million people are in need of help.
Where services are available, stigma means that it may not be sought: no one wants to be thought of as 'crazy’. Moreover, treatment tends increasingly to equal medication. Eleven percent of Americans over the age of 11, for instance, now take antidepressants—a 400 percent increase from the 1990s. Almost a quarter of women aged 40–59 are on these drugs; indeed women are much more likely than men to be prescribed antidepressants even when their symptoms are equally severe. In certain cases, drugs can certainly help. But psychological therapies (and especially cognitive behavior therapy) are more effective in the longer term for many very common problems such as depression and anxiety.
What all this means is that it's frequently the police who must step in when crisis points are reached. Yet law enforcement officers generally aren't trained to deal with mentally ill people. In an atmosphere of febrile—and arguably excessive—fear of terrorism, sensitive and proportionate handling of individuals such as Miriam Carey is even less likely.
As a society, we need to change radically the way we think about mental illness; we must recognize its prevalence, and the particular problems facing women; and we must make treatment, and CBT in particular, readily available to all who need it. If we don’t, and with rates of mental illness likely to increase with current economic instability, further shootings of unarmed civilians seem all too possible.
Daniel and Jason Freeman are the authors of The Stressed Sex: Uncovering the Truth about Men, Women, and Mental Health, published by OUP.
Daniel Freeman is a Professor of Clinical Psychology, and a Medical Research Council (MRC) Senior Clinical Fellow, in the Department of Psychiatry at Oxford University, and a Fellow of University College, Oxford. He is also an honorary consultant clinical psychologist in Oxford Health NHS Foundation Trust. Jason Freeman is a psychology writer. You can follow them on Twitter: @ProfDFreeman and @JasonFreeman100.