(This post may be too long for email; if it’s chopped short, go to my Substack site)
In the 1960s and 70s, John Calhoun, an American biologist, was interested in what happens to rats and mice when they’re allowed to breed with no restrictions. Calhoun and his associates conducted a long series of experiments to study the effects of over-crowding on animal behaviour. In the best-known, Mouse Paradise (not to be confused with Rat Utopia), four breeding pairs were put in a pen 2.7m square and 1.4m high. They were provided with unrestricted food and water, lots of interesting nesting sites and ample nesting material. The researchers calculated there was enough room for about 3,400 mice so they settled back to see what would happen.
Predictably, the population soon doubled, and doubled again, and again. After 18 months, it reached a peak of 2,200 animals, but then it started to decline because the mice had stopped breeding. Overcrowding led to a breakdown in normal mouse social behaviour. Males spent more of their time fighting than caring for the pups, or just withdrew from the competition and spent their days grooming themselves. Females hid from the remaining active males or failed to take care of their pups, which starved or were eaten by other adults. Eventually, when the last mouse starved in the midst of plenty, the experiment closed. The rumour is that one of the lab techs took the tiny, emaciated corpse outside and buried it in the garden with a little sign which read “Ozymandias.” Either way, mouse heaven had become mouse hell.
There has always been debate over the significance of these experiments for humans. Some people say that the point is the difference between population density, a mathematical term, and over-crowding, which is a subjective sense of being pressured by not having enough space for privacy. In the wild, due to predation, hunger, disease, etc., mouse population density never approaches overcrowding, but humans are different. We have always preferred to live on top of each other, which may have started for protection but is now about wealth and excitement. The problem is, we won’t know we’re actually overcrowded until we’re well on the way to dying out. We’ll come back to this.
Meantime, the journal Lancet Psychiatry has just published a long (44 page), multi-authored (54 names) report by its long-running (5 years) Commission on Youth Mental Health. We are not told how much this cost but it would have been heaps (they should have spent some of it on editing, as it is clumsily written). Under its energetic chairman, Prof. Patrick McGorry, of Melbourne, the report outlines the current state of mental health of, and services for, young people (meaning about 12-25yrs). Distilling almost 500 references, they discussed the issue from five perspectives. Part 1, The changing landscape of youth mental health, looks at the rapid increase in mental health problems in this cohort. Over the past two or three decades, the incidence of mental disorder shows an accelerating trend:
(Rates) in Australia (2020–22) showed a 50% increase in prevalence of diagnostic-level mental disorders in people aged 16–24 years since 2007, reaching an annual prevalence rate of 39% in 2020–22, which reached nearly 50% in young women … 12-month prevalence rates of anxiety, affective, and substance use disorders in people aged 16–24 years were 32%, 14%, and 7·8%, respectively … In 2007, the respective rates were 15%, 6%, and 13%.
The authors concluded: “Young people are showing the most serious warning signs and symptoms of a society and a world that is in serious trouble.”
The goal of Part 2, Conceptual frameworks and trajectories, is “To inform a new field of youth mental health, youth-appropriate conceptual building blocks and perspectives are needed, including new developmental thinking and clinical staging.” This describes the enormous changes that occur on so many levels between puberty and early adulthood, indicating the specific challenges all humans must face in their changing relationships with self and with society: “Adolescents are particularly sensitive to peer rejection and social approval … uniquely sensitive to prevailing social, political, and economic conditions and structural forces…” It outlines some of the difficulties young people face when trying to find their way through the labyrinth of conventional mental health services which, worldwide, were all designed to meet administrative needs (often colonial), and not what the troubled young person wants:
Key limitations on effectiveness include slow progress in discovery of new treatments, poor fidelity to existing evidence-based care, and insufficient treatment continuity, intensity, and personalisation.
Part 3, Models of care, points out that services for mental disorder have long been stigmatised and starved of funds, or even frankly punitive. Partly this has been due to consistent underfunding of mental health, but also to misallocation of the limited resources. This section looks at different approaches to providing for a group who often don’t want to deal with current mental health services. In particular, young people in low to medium income countries, meaning most of the world, generally have no access to treatment unless they have very wealthy parents. Yet these are the very parts of the world most impacted by wars, poverty, educational failure, corrupt government services, political- and climate-induced famines, etc., matters over which ordinary people have absolutely no control.
In Part 4, the report gives a background to the economic costs of mental disorder in this group and, more to the point, the hidden costs of failing to provide services. Finally, Part 5 considers the need for and the difficulties of political change to treat existing disorders and, vitally, prevent new ones:
To achieve transformational reform, a combination of approaches, including strong economic arguments, emotionally engaging storytelling, real-world solutions, high-profile societal champions, media support, and targeted campaigns are needed … The youth mental health crisis is more than a warning; it might be our last chance to take action.
The theme of this (very expensive) report comes through loud and clear: “This is real, this is an emergency, send more money.” The language is hyperbolic, with the goal inducing a sense of urgency from beginning to end. It opens with a crash “Mental ill health, which has been the leading health and social issue impacting the lives and futures of young people for decades, has entered a dangerous phase.” The sense of dire urgency continues unabated to the last page:
The youth mental health crisis is of the utmost importance globally, given how dependent societies are on the capacities and contributions of young people. As long as so many emerging adults die prematurely, are consigned to a life of welfare dependency, are denied sufficient respect and nurture, and languish in precarity, society itself will become more precarious. The youth mental health crisis is more than a warning sign, and now might be our last chance to act.
This more or less summarises its message: mental disorder starts young and reverberates through the decades of life, with grave repercussions for personal adjustment and productivity; therefore, prevention is the better part of cure. In this age group, mental disorder is the main cause of disability and, either by suicide or by accident, a major cause of premature death. However, the fight is against “global megatrends” such as “rising intergenerational inequality, unregulated social media, wage theft, insecurity of employment, and climate change … and changes in many societies around the world” (731-32).
The unexpected finding is that these trends are most evident in what they call WEIRD countries, for Western, Educated, Industrialised, Rich and Democratic, of which Australia would surely be the poster child. Part of that trend is due to these countries keeping more detailed and accurate figures, but it is still the case that the recent surge of mental disorder in young people is primarily a problem of rich countries. Oddly enough, problems normally associated with non-WEIRD countries aren’t mentioned until well into the report: “… ethnicity, poverty and social adversity, housing insecurity, trauma, war, forced migration, neighbourhood deprivation, social support, education, physical health, and parental mental illness…” (p746). Compounding this, searching the document for “sexual abuse” and “drug abuse/addiction” yields no examples. Given this Eurocentric view of the issue, it is surprising that it offers no explanation for the sudden explosion in psychiatric diagnoses among young people, no formal scientific setting for the committee’s deliberations and, beyond “more, more, more of the same,” no solutions.
In this sense, the whole report is vintage McGorry. As always, to a fanfare of an off-key pipe organ and two air raid sirens, he bursts pale and tremulous through the door to demand all should drop whatever they are doing to join him on his latest crusade. However, I don’t think I can be accused of cynicism by saying that nobody will take the slightest notice of what is, essentially, a pseudocyesis. It will give the newspapers something to chew on for a day or two, it will give the commission’s members something to add to their CVs, it may even make a few politicians squirm briefly but otherwise, nothing will change. The reason is quite clear: it doesn’t give anybody anything to go on. Yes, they’ve got the figures but that’s to be expected, they did the surveys. Yes, it would be a good idea to streamline “the system” so people can access assessment and treatment without going through the administrative traps and without going to a general hospital emergency centre but the problem rests with psychiatry as it exists today. And that is not going to change in a hurry, as I well know.
In 1987, I left Perth in West Australia to head north, to establish a psychiatric service in the remote Kimberley region. This region is a bit bigger than California but the population was then 25,000, about half and half Aboriginal and white. Plenty of the older Aboriginal people lived in the same areas they had been born and spoke little English. The purpose of my job was to stop them being sent to the mental hospitals 2.000 km away (i.e. further than London to Moscow, and culturally light years away for them). Once there, it proved very difficult to get them home again. In the year before I arrived, 52 people had been flown to the mental hospitals in Perth where they stayed, on average, something like 10 weeks each.
On current figures, each trip by Flying Doctor would have cost about $10,000, with lots of extra hidden costs. Mental hospitals cost about $2,000 a day, not including all the Xrays and blood tests and so on, so the total cost of treatment for that small group would be something like $8,000,000. The evidence was it was not money well spent. Life did not get better for their unwilling experience of government largesse. In my first full year, the number of aerial transfers dropped to two, both of them chronic patients who had drifted up from the south and we didn’t want them hanging around. As it were.
The psychiatric service, such as it was, didn’t amount to much. I had no staff, no office, no hospital beds, just a four wheel drive vehicle with two way radio, and that was it. This was long before mobile phones, before the internet and even before faxes: the first fax machine was installed in the hospital soon after I arrived, and computers about four years later. I travelled constantly, visiting each of the six tiny towns every three weeks and many remote Aboriginal communities when possible. Everybody was very happy with the service. Staff were happy having somebody they could call at night who would be on the plane next morning. Patients were happy knowing they wouldn’t be snatched and sent to that far-off, frigid country down south. The government was happy with the massive savings and the rapid drop in complaints. In fact, they were so happy they never bothered to speak to me for the six years I was there (there was one complaint that went nowhere). The RANZCP, which had long talked about the idea of taking psychiatry to the masses, found some other bee in their collective bonnet and never bothered to see how I was going.
The principle was simplicity itself: get the psychiatrist out of the hospital, go to where people live and work, see them in their setting, involve their families and hey presto, many of these intractable problems melt away. I did the same thing after moving to Brisbane, operating from a busy general practice in a working class area. It was most unusual for my patients to go to hospital, while dramas like police calls or overdoses were rare. There’s more to it than that but by offering a genuine outreach service, problems can mostly be managed before they get out of hand. Hospitals, multidisciplinary teams and the like operating from dedicated, purpose-built and usually far-off centres with mission statements and key stake holders and “youth-appropriate conceptual building blocks and perspectives" simply convert the tractable into intractable.
The reason they fail is because the bureaucracy takes over and inserts its own priorities into the system. As Oscar Wilde said, “The bureaucracy is expanding to meet the needs of an expanding bureaucracy.” That is highly likely in any system such as health, education, etc., but it becomes inevitable in psychiatry when, as Part 3 of the report says, “The principles, core features, and strategies seen as necessary for designing, testing, and scaling up new models of youth mental health care are widely agreed on.” They may be but they forgot that essential ingredient, a model of mental disorder that dictates what the principles and “youth-appropriate conceptual building blocks and perspectives" will be about. That is correct. In all of this high-sounding talk, they omitted to say what it is they are actually treating. Which leads to the second important omission: a suggestion as to the explanation of the apparent increase in mental disorder in young people.
Even though I don’t accept them at face value, let’s assume their figures of rates of mental disorder doubling in half a generation are correct: what does this tell us? Straight away, it says all this extra mental disorder has nothing to do with biology. On the basis of their figures alone, we can state with no fear of contradiction: “Mental disorder in this age group is not a biological phenomenon.” Therefore their conceptual building blocks and all that palaver must be focussed on dealing with this surge in demand as wholly psychological in nature, which produces a problem for the McGorries of this parish: the great bulk of modern psychiatrists have next to no training in psychotherapy, and even less interest. Even for their latest trick, so-called psychedelic-assisted therapy, they call in psychologists.
So a properly designed and implemented mental health service for young people would very largely exclude psychiatrists. Indeed, it would be easier to push them out of it so they can only take referrals. “What about the drugs? What about ECT?” they shriek. What about them? I never used ECT, and prescribed antidepressants to less than 5% of my patients, mostly to start them on proper tapering programs. If you deal with the problem in a timely manner, which means going out to where the problem is, the drug prescription rate plummets (when the notorious bank robber Willie Sutton was asked why he robbed banks, he replied “Because that’s where the money is.” When asked why I worked in working class suburbs or in the bush, I gave a similar answer).
That still leaves a huge question hanging over the whole deal: What’s going on? What’s the cause of this rush of people saying they’re mentally-disordered? When I was that age, no way we would walk around with a sign saying “Beware, more than slightly crazy.” This was the age of the Vietnam War (known in Vietnam as the American War). I did medicals for young men who had been notified of conscription. They did not walk in and, with a light laugh, say “Hi doc, I’m ASD with hints of ADHD and a touch of ODD so it looks like I won’t be going.” For a start, none of those things existed but even if they had, the zeitgeist prohibited that sort of thing. A 20 year old man in 1970 was a boomer born in 1950, almost certainly of parents who had either been in the military in World War II or had been greatly affected by the war. By modern standards, children, especially boys, were brought up the hard way (of course, our parents constantly told us how easy we had it).
Compared with them, children today, especially in Australia and New Zealand, live in paradise. They have everything they could imagine and plenty more. Unless the parents are grotesquely incompetent or drunk or smashed, none of them go hungry or are left without necessary care or treatment. For us oldies, modern schools are a joke: children can actually yell at the teachers without being punched to the ground! But still, according to Prof. McGorry, they are falling apart as we stumble into a crisis, a dire emergency that demands intense government action before society breaks at the seams. What’s causing this? Children in Gaza are wakened by explosions and bits of the bodies of their relatives landing on them; they have real cause for nervous trouble but are our young people awake all night worrying about global warming? Perhaps they are, but where are they when we want a crowd of angry voters to confront the politicians who are doing nothing about it? They’re off playing Game of Thrones or some such drivel.
We can make sense of this, but only by using a valid model of mental disorder, which McGorry and his 53 co-authors didn’t have. I will accept that young people today complain much more about mental symptoms than my generation did. I will accept that this can only have a psychological cause and biology has nothing to do with it (so does McGorry’s committee, but we know this only because they left it out). Since depression is the reaction to loss events, and since practically none of these new mental casualties have experienced loss events, any depression they experience isn’t primary. That is, it follows on another cause. All we have to do is find it. And we don’t have to look far. The most communicable of all human emotions is anxiety. The whole thing is an epidemic of mass anxiety. One person gets a bit anxious over some stupid comment on Facebook; the next person says “My friend isn’t well in the head, I wonder if I may have it too? OMG, I feel dizzy at the thought (shrieks loudly). Help help, send a doctor, I’m going out of my mind.”
There used to be a condition called Royal Free Disease, which arose among junior nurses in London’s Royal Free Hospital in the 1950s (that link isn’t a good account but it will do). Over a few months, hundreds of them collapsed with shortness of breath, dizziness, nausea, aches and pains, stuttering, weakness, trembling and twitching and so on, all better known as the classic symptoms of anxiety. But nobody likes to say “I’m an anxious person,” that’s seen as a character defect. Instead, everybody wants to be ADHD or ASD or OCD or neurodiverse or trans or even a cat or a fluffy bear because, these days, that’s socially acceptable. Thanks to biological psychiatry, an actual diagnosis is Not My Fault, whereas a character defect certainly is. And they’ll be given tablets and life will get worse, all because biological psychiatry doesn’t get how serious and how communicable anxiety is. Nor does it want to know: there’s no money in it, no PhDs, no career paths built on anxiety, that’s for sure.
That’s the problem. We taught the younger generation to do the impossible like how to ride a skateboard and how to sort out our frozen computers and how to communicate on TikTok and whatever, but we forgot to teach them how to deal with anxiety. We oldies learned the hard way, and I mean The Hard Way. We tried to spare our offspring but, like Siddhartha, it didn’t work. Instead of saying “This world is a place of pain, junior, others have got it worse so don’t complain, just cope,” we told them “There there dear, don't you worry, mummy and daddy are always here to do for you.” Even as grown adults with children, when something goes wrong, what do they do? That’s right, ring the old folks. We didn’t have phones.
The surge in mental disorder in young people is our era’s version of Royal Free Disease, nothing more, nothing less. It isn’t The end of the world as we know it, the militarists and industrialists and capitalists are seeing to that, so what has this to do with Rat Utopia? In fact, the rats died of overcrowding, not of excess population density. They couldn’t get away from each other. Our current generation are showing much the same behaviour as Calhoun’s rats, i.e. while living in paradise, they stop mixing, they don’t know how to make friends (now called ASD), they stop breeding (fertility rates are plummeting around the world). Modern human population density is nothing new but what is new is the sense of being crowded, of being under surveillance all day, every day, in the American Panopticon called “Universal Full Spectrum Surveillance and Domination.” Think about it. And worry. But don’t make the mistake of thinking there’s anything wrong with you. Danish theologian and philosopher, Soren Kierkegaard (1813-1855) said anybody with an ounce of moral sense lives in anxiety. These days, only a fool wouldn’t be worried about the direction our purblind politicians and financiers and industrialists and generals and academics and spies are pushing us. I worry. But I’m perfectly sane. When the bad news gets a bit much, like most days, I go to the garden to plant things or watch my bees.
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An email from Prof. John Read, psychologist and researcher at University of East London regarding his long-running research program:
ELECTROCONVULSIVE THERAPY (ECT)
RESEARCH PARTICIPANTS NEEDED FOR INTERNATIONAL ONLINE SURVEY
If you are at least 18 years old and have had ECT, other than the last 4 weeks, you are invited to take part in an anonymous online survey.
We also invite family and friends to participate.
This is your opportunity to share your experiences of this treatment, positive, negative or mixed. The survey takes about 30-40 minutes.
If questions about ECT or about the experiences that led you to having ECT might be distressing for you, please seriously consider not taking the survey.
If you have any general enquires about the study, please contact the lead researcher, Professor John Read: john@uel.ac.uk
The study has been approved by the University of East London Ethics and Integrity Sub-committee
Here is the link to the survey: www.ectsurvey.com
The whole of this material is copyright but can be copied or retransmitted on condition the author is acknowledged. Also please note: I’ve retired so cannot give any opinions on individual cases.
Love your writing. It is logical and witty. You are the best Psychiatrist around. The more people that read your work the better off we all are. Very thankful for your work.