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Fall 2023

We are all vulnerable to emotional distress. COVID-19 made as much clear, subjecting many of us to the prolonged pain of isolation, loneliness, job and housing insecurity, and grief. The pandemic increased the prevalence of mental disorders, especially among the young, and worsened the substance use epidemic. And it exposed the inadequacy of our fractured, profit-driven mental health care systems: too many people cannot access treatment, and too many with access do not receive effective care.

But the pandemic had another effect. By increasing attention on mental health issues, it has reduced some of the stigma and discrimination associated with mental illness. It has enabled us, if temporarily, to express our inner struggles more openly.

The authors of the Fall 2023 issue of Dædalus view this moment as an opportunity to fundamentally transform our mental health systems. Drawing from psychiatry, neuroscience, public health, public policy, genetics, and social science, the authors identify the tensions, breakthroughs, and gaps in our understanding of mental health. And they develop a social medicine perspective to envision new models of care. This perspective recognizes the social and historical determinants of mental health; reduces the overmedicalization of mental disorders; helps identify which treatments will be effective for which patients; and employs the resources available in every community to help address the mental health crisis.

Introduction: How Mental Health Matters

The underpinnings of today’s mental health crisis include both social structural inequities and neurobiological vulnerabilities. The COVID-19 pandemic has compounded and escalated a long-standing problem, rendering the mental health crisis and its dangerous consequences visible and exigent. We now possess a clearer and more nuanced understanding of the broken mental health care system and its serious inadequacies, as well as its potential for effective caregiving. The professional forms of knowledge and practice are paralleled by an even more substantial system of care involving families, networks, communities, and, of course, those living with mental health conditions themselves. Even when delivered by community care workers, psychotherapy can be as effective as somatic treatments for some mental health conditions. Harm reduction and other public health approaches offer means of preventing or mitigating the disastrous human toll of the substance use disorder epidemic. Social technology offers new opportunities for enhancing mental health and well-being. With these informal systems alongside standardized health care systems, the future could realize a mental health care system with much greater potential to avert the worst harms and offer effective care to many more.

The Missing Piece: A Population Health Perspective to Address the U.S. Mental Health Crisis

The COVID-19 pandemic has enhanced our focus on mental health. Concerns about the high levels of mental disorders in the United States are not new, with rising trends–particularly among youth–observed prior to the pandemic. However, the pandemic may have exacerbated and accelerated these trends. The silver lining is that we can leverage this moment to reevaluate and reimagine not only how we treat mental health problems, but also how we promote emotional well-being throughout the life course. We argue that scholars, policymakers, and practitioners should broaden their view of mental health, and consider it as a full spectrum ranging from serious mental illness to robust emotional well-being. This perspective recognizes the importance of treatment access and quality, but also elevates the value of prevention, particularly at the population level. Greater attention to preventing problems before they occur will not only reduce manifest disorders but also encourage higher rates of psychological resilience and, ultimately, better physical health.

American Gun Violence & Mental Illness: Reducing Risk, Restoring Health, Respecting Rights & Reviving Communities

Intentional injuries claimed nearly two hundred lives every day in the United States in 2020, about two-thirds of them suicides, each a story of irretrievable human loss. This essay addresses the complex intersection of injurious behavior with mental illness and access to firearms. It explores what more can be done to stop gun violence while respecting the rights of lawful gun owners, preserving the dignity of persons with mental illnesses, and promoting racial equity. Strategies to prevent firearm injury in the United States are uniquely conditioned by a constitutional right to bear arms, the cultural entrenchment and prevalence of private gun ownership, and strident political disagreement on regulatory solutions to stem gun violence. Broad implementation of a range of complementary policies is needed, including community-based programs to address the social and developmental determinants of violence, improved access to a continuum of mental health services, firearm restrictions based on behavioral indicators of risk (not mental illness, per se), licensing for firearm purchase or ownership, comprehensive background checks for firearm purchase, and supply-side approaches to interrupt illegal firearm markets.

Authors Jeffrey W. Swanson and Mark L. Rosenberg 

Rethinking Psychiatry: Solutions for a Sociogenic Crisis

This essay draws on Frantz Fanon’s insights about the sociogenesis of psychiatric disorders, and on the insights of feminist standpoint theory, to sketch a map toward sociogenic mental health. We argue that psychiatry should move away from iatrogenesis (the harms of our current individual-level and pathologizing approach) toward sociogenesis of mental health through robust collaboration with social movements of oppressed people, and their collective healing approaches, ranging from harm reduction centers to community gardens. The essay ends with the outlines of a reinvented, community collaborative psychiatry that supports sociogenesis.

The Protest Psychosis & the Future of Equity & Diversity Efforts in American Psychiatry

This essay chronicles the history of medical associations between schizophrenia and Blackness that emerged during the tumultuous decades of the 1960s and 1970s, when American psychiatrists overdiagnosed schizophrenia in Black men in ways that undermined brain science of the era. I provide data to show how racially disparate diagnostic outcomes resulted not solely from the attitudes or biases of clinicians, but from a series of larger political and social determinants, most notably changing frameworks surrounding mental illness and political protest. I conclude by highlighting how training clinicians to examine their own cultural biases also needs to include training in how structures and institutions produce symptoms and diseases, and how we can only build better structures to support health if we can individually and then communally imagine them.

Democracy Therapy: Lessons from ThriveNYC

Despite massive unmet needs, U.S. mental health care systems and policy continue to aim too low. Laments about brittle foundations—including inadequate funding, fragmentation, stigma, lack of parity, ineffectiveness, unavailability, overmedicalization, and coercion—all share the same source. The mental health system is not working because it has been chasing the wrong goal: to treat illness, rather than to enable people to do nurturing things together. A focus on community nurturing and caring changes everything. It yields better treatment approaches while also engaging with the mutually reinforcing and desperately needed work of social cohesion, emotional well-being, participatory action, and communal learning and connection. In fact, the nurtured emotional health of individuals is fundamental to humane and resilient societies and to democracy itself. And in the face of environmental collapse and the related unraveling of core institutions, the stakes have never been higher. This essay makes the case for a paradigm shift in care and explores a recent effort to implement it at scale: ThriveNYC. The successes and especially the failures of ThriveNYC point to the possibilities and challenges of this essential mission.

Author Gary Belkin

Indigenous Historical Trauma: Alter-Native Explanations for Mental Health Inequities

The well-being of American Indian and other Indigenous communities has long been compromised by ruthless processes of European colonial dispossession and subjugation. As a result, contemporary Indigenous communities contend with sometimes overwhelming degrees of demoralization, distress, and disability. The concept of Indigenous historical trauma has arisen during the past thirty years as an alternative mental health discourse that critically contests prevailing categories of psychological disability, psychiatric distress, and mental disorders (including addiction, trauma, and suicide). Indigenous adoption and promotion of historical trauma affords an explanatory account for community mental health inequities that designates the historical legacies of colonization as central for understanding contemporary Indigenous suffering. In so doing, Indigenous advocates of historical trauma creatively recast these problems as postcolonial pathologies, and ardently call for overdue advances in reconciliation, redress, and repair with respect to Indigenous Peoples. Ideally, such advances will be evidenced by societal transformations, structural reforms, and social justice that can enhance and ensure Indigenous futurity and well-being.

Disorders of Mood: The Experience of Those Who Have Them

Mood disorders are common, painful, and closely tied to suicide and alcohol and substance use. They are also treatable. Mania and depression, a part of the human record for as long as it has been kept, were well-recognized and described by physicians of antiquity. Our knowledge of mood disorders has broadened and deepened in the many centuries since those early times, and crosses many scientific and clinical fields, including genetics, neuropharmacology, neuroimaging, psychopathology, and neuropsychology. We have as well a rich history of personal narratives of depression and bipolar disorder that gives a different but essential perspective; I pre­sent several of these accounts here.

Mental Health’s Stalled (Biological) Revolution: Its Origins, Aftermath & Future Opportunities

The 1980s, by common consensus, saw a big and remarkably rapid pivot away from previously dominant psychoanalytic and social science perspectives in American psychiatry and toward a so-called medical model foregrounding biology and the brain. The standard understanding is that this happened because, after years of wandering lost in a Freudian desert, the field had finally gained some fundamental new biological understandings of mental illness. The standard understanding is wrong. Nothing of sudden significance had happened on the biological front. There had been no major scientific or therapeutic breakthroughs. Why, then, did the field really pivot? This essay aims to explain. The answer is important, not least because choices made back then have directly shaped the fraught world of psychiatry with which we live today.

The Biology of Mental Disorders: Progress at Last

Mental disorders are common, complex, highly morbid conditions for which basic underlying mechanisms are poorly understood. Despite the utility of many existing treatments, there remains vast unmet need for more effective and safer therapeutics. Most current medicines for mental disorders are based on chemical modifications of serendipitously discovered mid-twentieth-century prototypes, and widely used diagnostic manuals remain phenomenological and conceptually confused. After decades of stasis, research on mental disorders has reached an inflection point. Unbiased large-scale genetics provides information that, if interpreted circumspectly and integrated with neurobiology, provides “finding tools” for causal biological mechanisms that can advance discovery of biomarkers, preventive interventions, and better treatments. However, uncritically applied predictive genomic technologies can produce fatalism and exacerbate stigma. Moreover, polygenic risk scores for cognitive ability and risk of mental illness are already being offered commercially for embryo selection with in vitro fertilization, a worrisome resurgence of eugenics hiding in liberal (noncoercive) guise.

Two Sides of Depression: Medical & Social

Two models have dominated portrayals of depression. The medical model views depression as a disease that has distinct symptoms with predictable courses and outcomes. It typically relies on brain-related explanations and responses, although many adherents also use social and psychological causes and treatments. A second model conceives of depression as the result of external stressors, loss events, and other problems of living that naturally subsides when these conditions improve. In this view, optimal responses lie in addressing the social conditions that underlie depressed states. In this essay, we examine how each edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) since DSM-III in 1980 has blurred the medical and social approaches and conceived of all sorts of depressive symptoms as needing medicinal responses. Although the distinction between the social and medical types is often difficult to make, it is an essential first step in developing accurate conceptions of the two sides of depression.

Can Mental Health Care Become More Human by Becoming More Digital?

Over the past two decades, advances in digital technologies have begun to transform three aspects of mental health care. The use of sensors and artificial intelligence (AI) have provided new, objective measures of how we think, feel, and behave. The ease of connecting and communicating remotely has transformed the brick-and-mortar practice of mental health care into a telehealth service, increasing access and convenience for both patients and providers. And the advent of digital therapeutics, from virtual reality for treating phobias to conversational agents for delivering structured therapies, promises to alter how treatments will be delivered in the future. These digital transformations can help to solve many of the key challenges facing mental health care, including access, quality, and accountability. But digital technology introduces a new set of challenges around trust, privacy, and equity. Despite high levels of investment and promotion, there remain profound questions about efficacy and safety of digital mental health technologies. We share our experiences from the front lines creating digital innovations for mental health, with a focus on what a digital transformation of care could deliver for millions with a serious mental illness.

Empowering the (Extra)Ordinary

Psychological treatments are among the most effective interventions for a wide range of mental health conditions but remain inaccessible to most people who could benefit from them, including in many high-income countries. We describe two case studies from South Asia that demonstrate innovatively designed psychological treatments addressing many of the barriers that limit their scalability. The treatments are brief, less complex, and delivered by frontline providers, such as peer counselors in community settings. These case studies, alongside a large and growing literature from around the world, provide the foundation for a paradigm shift in mental health care by rejecting the nihilistic notion that communities do not have enough resources to address mental health problems or that these problems are too complex to address. Central to this notion is the recognition that mental health problems can be addressed effectively with resources that every community possesses: people who care for others in their communities.

Good Mental Health Care: What It Is, What It Is Not & What It Could Be

What makes for good mental health care? What are the barriers to good care and, when they can be overcome, what accounts for successful treatment? What does successful treatment and care, in fact, mean? Can they mean different things to different people? If so, how can we think about them in a practical way that is useful to patients, families, and clinicians? On the one hand, from work in fields as various as neuroscience, clinical psychology, and anthropology, we are learning (and rediscovering) more and more about how the human mind works and the many ways that psychological suffering can be preempted and treated. On the other hand, in many ways, the mental health care system is either dysfunctional or working against what we know to be best for psychological and social flourishing—the disappearance, for example, of true “care” from medical and mental health care systems. In this essay, set against the background of diverse perspectives provided by the foregoing essays in this volume, we attempt to frame and address some of these basic questions, giving priority to practical, down-to-earth, lay, and professional considerations.