The psychologist Richard Bentall has noted that a child diagnosed with leukemia, the most common childhood cancer, in the 1970s faced roughly a 20 percent likelihood of survival, but in the present day, the likelihood of survival for a child with leukemia was roughly 80 percent. This 300 percent improvement in the survival rate can be attributed to advances in medical science and treatment.
British medical anthropologist James Davies draws on this example in his bestselling book, Sedated: How Modern Capitalism Created Our Mental Health Crisis, to argue, unsparingly, that during the same period of time, nearly every field of medicine managed to significantly improve patient outcomes in its own way through scientific advancements. The exception? Psychiatry and mental health.
Outcomes for people living with many types of mental health challenges today are generally no better than they were a century ago, and by certain measures, they are worse. This is true in spite of psychiatry and psychology developing substantially as specialized fields during this time. Since 1952, there have been five editions of the expansive Diagnostic and Statistical Manual of Mental Disorders, which classifies mental disorders based on clinical symptoms, as well as diagnostic screening tools like the PHQ-9 for depression and the GAD-7 for anxiety, which are used to identify signs of mental illness and get people treatment. Since the 1970s psychiatry and pharmaceutical companies have pushed an increasingly biological view of mental illness, one that relies on the idea that mental health problems are caused by chemical imbalances in neurotransmitters. The public has come to have a warped understanding that these drugs work not by producing an effect that alters brain function or reduces symptoms, but rather, by reversing a known biochemical abnormality in the brain, as insulin might for diabetes. Despite no good scientific evidence to support this theory, the disease-based (or biomedical) model was adopted wholeheartedly by the psychiatric profession and the pharmaceutical companies.
Each year, more and more Americans are screened for and diagnosed with mental disorders, and many of them are treated with prescribed psychiatric drugs. According to recent data, more than 20 percent of U.S. adults “experience mental illness each year,” and more than 16 percent of Americans are currently taking psychiatric drugs—each figure representing a substantial increase from thirty years ago.
And yet, despite these interventions, mental health disability rates continue to increase, outcomes continue to flatline, and for those diagnosed with the most serious forms of mental health problems, life expectancy is now estimated to be up to twenty-four years shorter than that of the general population. In virtually every other area of public health, increased screening, diagnosis, and treatment of a disease translates to better outcomes, a lower incidence of disease-related disability and death, and a decrease in the disease’s overall prevalence. In mental health care, however, increases in our current forms of intervention have not yet led to improvements in any of these areas.
To explain this, Davies and other critical scholars and practitioners of psychology and psychiatry argue that we have fundamentally mischaracterized mental health problems by treating them as individual, apolitical, and solely medical in nature. By diagnosing and treating mental illness through a primarily biomedical lens, we sever people’s behavior and inner emotional worlds from the social and economic conditions in which they live, chalking their distress up to chemical imbalances in their brains in spite of recent challenges to the validity of that model. What’s more, we medicalize trauma, turning people’s natural human responses to overwhelming circumstances like abuse or neglect—which are not only painful, but painfully common—as disorders requiring clinical treatment. Through this lens, sadness and despair around an increasingly precarious future and unlivable planet are reinscribed as depression; fear and overwhelming stress over how one is going to afford next month’s bills becomes an anxiety disorder. And so on.
The turn toward medicalization of distress has grown out of several decades of austerity-driven economic policy and upward distribution of wealth—the cost of living has skyrocketed while wages have stagnated affordable housing development has cratered, and funding for social services has been slashed. But it has proven quite profitable for pharmaceutical companies, who have made hundreds of billions dollars in the past half-century from the steady increase in individuals seeking treatment. The cycle is self-perpetuating, as the funding for new research and diagnostics tools that shape the field increasingly comes from pharmaceutical companies like Eli Lilly and Pfizer—the latter of which manufactures two of the most popular drugs for the treatment of depression and anxiety, and also funded the development of the PHQ-9 and GAD-7 screenings for those conditions.
As someone with a background in mental health policy, I have encountered countless stories of people who present severe distress that is clearly derived from economic and social causes. Here are some fictionalized examples, based in real life. Say a mobile crisis team receives a call from a woman who believes her father is exhibiting symptoms of depression. When the team arrives, they speak with the man, who tells them he is a recent immigrant from Latin America, and does not speak English well. He has few friends here, and finds there is little to no community fabric like there was in his home country. The political rhetoric surrounding immigrants and the threat of being ensnared in the Trump Administration’s deportation machine worries him day and night, despite the fact that he came to the United States legally.
Or say the same crisis team is called by the neighbors of a man who they say has been increasingly withdrawn and isolated. The man tells the team that he recently lost his job because of a prolonged medical absence due to a chronic condition, and now has thousands of dollars in medical debt. He feels paralyzed by the fear that he will be evicted and end up homeless in the final years of his life. He is hounded every day by debt collectors, cannot sleep, and finds it difficult to do anything he once enjoyed.
These are hypothetical accounts, but they are based on the types of presenting problems that mental health care workers encounter every day. What are crisis teams, psychiatrists, or other interventions supposed to offer to those whose suffering is a natural response to extremely difficult life circumstances inflicted upon them by public policy? The solution to these individuals’ suffering is not more medical treatment—it’s improving the economic and social conditions that created this suffering in the first place.
To be clear, I am not arguing that mental health problems are “not real,” in the sense that they reflect changes in a person’s biology that negatively impact them, or that we are not currently facing a significant increase in mental distress nationwide—we most certainly are. But our understanding of what might fix this crisis is bound up in the gap between our deteriorating social and economic conditions and a mental health care system that does not treat through a lens of social or economic repair. Many left-leaning Americans believe that fixing our broken mental health system is a matter of providing more funding for the programs and services that currently exist. It is true that public mental health services in the United States have been starved of funding for decades—waitlists are long, and providers are almost impossible to access for many people without high-quality private health insurance, resulting in countless avoidable crises and even deaths. But we cannot address the root causes of the problem through medical interventions alone.
This has become an increasingly consensus view across the rest of the world. The World Health Organization and the United Nations have both released reports emphasizing the major influence of social and economic conditions on the prevalence of mental health problems. In 2019, The Guardian interviewed the then U.N. Special Rapporteur on the Right to Health, Lithuanian psychiatrist Dainius Pūras, and reported that “measures to address inequality and discrimination would be far more effective in combating mental illness than the emphasis over the past thirty years on medication and therapy.” This assessment is in line with European treatment models that center community and the self-knowledge of patients—including those pioneered in the mid-twentieth century by radical psychiatrists Franco Basaglia and François Tosquelles in Italy and France, respectively.
But the United States has continued to pursue an approach that is fundamentally out of step with this consensus. The most notable shift in U.S. mental health care policy in the past two decades has been the embrace of civil commitment and forced treatment by both the Trump Administration and state-level elected officials, including Democrats such as California Governor Gavin Newsom and former New York Governor Andrew Cuomo.
These circumstances, bleak as they may be, present a rare opportunity for the U.S. left. As the public searches for answers to the increasing rates of mental distress, we can offer an answer, by presenting a new narrative around mental health—one that is unafraid to name the material and political forces responsible for our increasing rates of mental distress, and articulate clear solutions that go beyond clinical treatment to address root causes at a social level. The solutions are already central to the political vision of leftwing elected officials such as Vermont Senator Bernie Sanders and New York City Mayor Zohran Mamdani: mass investment in public goods and services that improve the material conditions in which people are born, live, and work. Concretely, this means building more public and affordable housing and public transportation and investing in things like universal child care, Medicare for All and a higher minimum wage. Finally, it means reorienting fiscal policy so that it no longer benefits the wealthy few at the expense of the many—progressive taxation of high incomes and a tax on wealth would not only reduce economic inequality but also help to fund the public goods and services that are critical to good mental health. For too long, we have been offered a false choice between abandoning those who are suffering and treating their struggles as apolitical, but with a new progressive paradigm we need not choose.
Decades of research have highlighted the ways in which expanding public goods and services improves mental health and mental health outcomes, and, conversely, research has also shown the ways in which austerity and disinvestment harm mental health and increase rates of mental distress. In public health, we call the conditions in which people are born, grow, live, work, and age the social determinants of health. These social determinants—things like affordable housing, a living wage, access to green space and public transportation—have a greater impact on health than individual biology or even medical care.
I take great inspiration from Franco Basaglia, who revolutionized mental health care in Italy during the 1970s, eventually leading to the closure of asylums across the country. Basaglia believed that in order to truly help people living with mental health problems, one had to put the “diagnosis into brackets”—to work toward understanding the social, political, and economic forces that had contributed to an individual’s suffering. In this sense, Basaglia believed that mental health was inherently political. And right now in the United States, as the public looks for a strong alternative vision to the ongoing nightmare of the Trump Administration, the left has a unique opportunity to finally treat it as such.