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     Humans love to divide things. Especially when those things can be split into one of two categories. It comes naturally to us and it does make a lot of things easier. Day and night. Even and odd. Good and evil. Many problems and conflicts in our lives stem from the fact that we use this binary model too much in a world that is defined by complexity. Nature is complicated. Relationships are nuanced. And the human brain is the most complex thing that exists in the known universe. Yet we call a stroke or brain tumor a physical illness and anxiety or schizophrenia a mental illness. 

 

     Our other organs are complicated but still much better understood than the brain. The heart can be compared to a pump, the kidney to a filter, but exactly how the three pound ball of densely packed and patterned neurons within the skull produces a mind with all its thoughts, feelings, and behaviors remains a mystery even after hundreds of years of speculation and study. A neuron is not conscious, not aware of anything, but when you string enough of them together in the right order, suddenly the collection of them produces consciousness. The lights come on. 

 

     As a result of this mystery, this lack of understanding, disorders of the brain and mind tend to be just as baffling. Heart attacks and kidney failures present in fairly predictable ways and we know why they respond to some treatments and not to others. But a disorder of the nervous system like bipolar disorder or multiple sclerosis can manifest a terrible rainbow of possible symptoms. 

 

     Perhaps an even more insidious problem is that we don’t tend to think of our heart or kidneys as representing who we are as individual humans. They are just shunting our blood around and filtering out toxins. But our brains, they are the seat of our personalities, our behaviors, our hopes and dreams. They are also to blame when we act badly and hurt others. Conditions like major depression and OCD are disorders of the brain just like diabetes is a disorder of the pancreas, but it can be hard to separate mental illness from a sense of who we are, what we are worth, how we should be judged. 

 

     I often find that patients have come to identify themselves with their syndrome of symptoms. “I’m bipolar,” they say. Or, “I’m so OCD!” I have never forgotten a simple lesson taught to me in my residency: we do not say that a person is a schizophrenic, we say that they are a person with schizophrenia. An admirable perspective but one that unfortunately does not solve the inherent insinuation that a mental illness is something that you either have or you don’t. What we call mental health disorders are not binary conditions. There are no tests that verify that one does or does not have a disorder. 

 

     A diagnosis is made based on symptoms, how long they last, and the degree to which they interfere with functioning. All diagnoses and their criteria are listed in the Diagnostic and Statistical Manual of Mental Disorders, or DSM-V. A diagnosis is less an “illness“ in the traditional sense and more a category, a cluster, a syndrome. They can present differently in different people and situations. For instance, there are nine specific symptoms of major depression and one must exhibit at least five of them at a certain severity for a certain period of time to meet criteria for the diagnosis, but one person might display five symptoms and meet the diagnosis while another person has a different set of five symptoms, and they may only overlap on one single symptom, presenting almost completely differently but still being diagnosed with the same disorder; Major Depressive Disorder.

 

     I like to point out that there are not two groups of human beings in this world, those with mental illness and those without mental illness. A helpful antidote to thinking in black and white is to consider a spectrum. We are all on a spectrum and we can all be pushed toward the end that represents severe symptoms and impaired functioning. Many factors can push us in that direction including brain disorders but also other illnesses of the body like thyroid dysfunction or diabetes, work and financial stress, unstable relationships, a pandemic, patterns of negative self talk, unhealthy coping skills, drug and alcohol abuse, trauma, chronic inflammation, impaired focus and memory, and just good old fashioned bad luck. 

 

     One of the many unfortunate effects of conditions like depression and anxiety is that they tend to get us to behave in ways that only make them worse. These are situations in which the nervous system is either over reactive, as in anxiety, or under reactive, as in depression. In the case of anxiety, we helplessly react to even innocuous stimuli as if they are dangerous. Just like pulling away from a hot stove that burns us, we naturally shy away from stimuli like the demands of work, the grocery store, or our own family. In depression, it is difficult to muster the energy, motivation, or interest to do things and to engage with others. Both of these lead to a rut of inactivity, avoidance, social isolation, and much more time available to become lost in negative thinking like worry, rumination, and guilt. 

 

     This is the downward spiral, the self reinforcing loop that can make it harder and harder to pull out of depression and anxiety, and it often leads to the double whammy of not only feeling bad, but feeling bad about feeling bad. Either the withdrawing and disconnecting itself, or the irritability and impatience that comes from being confronted with stimuli that we can’t handle, commonly leads to feelings of guilt and low self worth. 

 

     The way we think about mood problems in general is that they are caused by three different categories of issues that all blend together in different ways, in different amounts, over time. This is referred to as the biopsychosocial model. 

 

      One of these categories, social, includes all of the external factors that play on our thoughts, feelings, and behaviors. Things like stressful jobs, dysfunctional relationships, newborn kids and dying grandparents. These variables don’t require pills, they require problem-solving strategies. Sometimes there are stressors influencing our mood that we are not even fully aware of, and others that we recognize all too clearly but feel helpless to address. One of the goals of psychotherapy is to identify stressors, get them into perspective, and to develop step-by-step strategies aimed at reducing or eliminating stressors so as to minimize a feeling of helplessness and increase a feeling of empowerment in the face of life’s obstacles.

 

     A second category is psychological. This can include a variety of problems and many types of therapeutic approaches. Unhelpful habits and routines, maladaptive coping skills, negative internal dialogue and low self-esteem can all play a role. One way to think about our psychology is that the brain works like a prediction machine. It is constantly making guesses about what is likely to happen to us next, and the assumptions and conclusions that it automatically and largely subconsciously jumps to constitute the reality that we find ourselves living in and reacting to.

 

     Moment to moment, the brain is guessing about what is likely to happen next. The way that it comes to its conclusions is that it is constantly taking in data through our senses; what we are seeing, what we are hearing, what sensations are coursing through our bodies, but it must filter that data, that information flow, through a matrix of our past experiences, our beliefs, our internal narratives, our expectations. Sometimes we are not reading the environment with our senses very accurately. Sometimes we are jumping to the wrong conclusions, overestimating assumptions, making catastrophic errors in these automatic and subconscious thoughts. But we do not recognize this. We trust our brains, even when they are wrong. This can create some very unhelpful feedback loops, especially when one person in a relationship is seeing things through their filter, and the other person through a completely different one. We live in the same reality, but we see that shared reality through different individual lenses.

 

     The final category is biological, and that is typically what we psychiatrists aim to treat. We can use medications, as well as alternative treatments like transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT) to modulate neurotransmitters in the brain in a way that can sometimes decrease the intensity, frequency, and duration of mood symptoms. This task is something like using insulin or other medications to treat diabetes in the pancreas, we are just treating a different organ system. Unfortunately the brain is much more complicated than the pancreas. We don’t fully understand how the brain works when everything is going well, let alone when something is going wrong. And when you treat a disorder like diabetes, you can measure blood sugar and hemoglobin A-1 C to determine whether or not the treatment is helping or hurting, but we cannot measure brain chemistry. There is no direct way to tell whether an antidepressant or other psychotropic medication is doing good or harm. We can only indirectly tell by self report. There are rating scales and questionnaires and mood trackers, we ask lots of questions about how people are feeling and sleeping and eating and focusing, we get collateral information from friends and family, but no medication treatment is administered in a vacuum, separate from the influence of other variables. 

 

     We might start a new medication in a patient for depression, but around the same time they develop thyroid dysfunction, or a family member is in a bad accident, or the days become darker because of daylight savings time. They don’t see improvement over the next month or two. Is it because the medication “didn’t work?“ What does “work“ even mean? What are our expectations? Or perhaps we increase the dose of a medication at the same time that the weather gets warmer, they get a promotion at work, they start exercising regularly. If they then feel better, was that the medication? What percentage of the improvement could be attributed to the medication? If they stop taking it, will they feel worse? These are questions that every patient wants the answers to, and so do their doctors. Unfortunately there is no x-ray or blood test that one can do to tell you the right answer. I like to say that treating mental illness is about momentum. Medication alone does not tend to do the trick, but it can start a snowball rolling. If medication helps to reduce anxiety and depression a little, one might have a bit more energy and motivation to then exercise more, connect with more people, engage with more rewarding behaviors, and all of those things pack more snow onto the improvement snowball, making it easier to take the next steps toward overall growth and health. To reverse the downward spiral.

 

     There are large scale studies on the efficacy of antidepressants, antipsychotics, and other psychotropic medications, but these provide only general ideas about which medications are more or less likely to work for different symptoms and disorders, and the results are not typically very encouraging. While medications help a fair amount of people, and save some lives, they don’t do as much as we’d like and often come along with some undesirable side effects or financial burdens. There are both old and new options for treating psychiatric symptoms that are not in the form of a pill, things that we tend to put into the category of “neuromodulation.” These include ECT, TMS, ketamine infusions, neurosurgery, implanted nerve stimulators, and a horizon filled with possibility in the form of things like MDMA and psychedelics.

 

     I wanted to provide a fairly thorough, though by no means exhaustive, overview of the state of things when it comes to the understanding, the diagnosing, and the treating of mental illness. It is a science that has come a long way since the days of lobotomy and asylums, even though many laymen still see it as having one foot remaining in that dark past. At the same time it is still very much in, if not its infancy, at least its adolescence. The idea of mental illness is as much a cultural construct as it is a medical category. It will be important to consider where psychiatry comes from, the times and limitations and beliefs that shaped it, and where it is today, if we are going to shepherd this most human of sciences into a future where the management of our mental health is better realized, less stigmatized, and ultimately succeeds at the one true mission: the eradication of suffering. This will require us to move further from our history of modern psychiatry, through our present day postmodern psychiatry, and into an age of what we might call metamodern psychiatry. But that is a tale for another day.