Thanks for starting this thread, zoo.
One of the things that always comes up in response to another slaughter-by-firearm is the idea that the fault lies in inadequate mental health treatment. Do we have more of a "mental health" problem in the US than in other countries? Are people with various "mental health" issues more dangerous and likely to become violent criminals? How often does a severe "mental health issue" go undiagnosed until after the fact?
Happy to offer something of interest.
Question 1: Does the USA have more of a mental health problem than other countries:
To answer your question, I think it's extremely important to understand mental health and mental illness. The too long didn’t read is, it’s really hard to tell, but it’s possible (though there may be a better explanation, see below). In a 2004 study published in the Journal of the American Association, The World Mental Health Survey Consortium found “
The prevalence of having any WMH-CIDI/DSM-IV disorder in the prior year varied widely, from 4.3% in Shanghai to 26.4% in the United States, with an interquartile range (IQR) of 9.1%-16.9%. Between 33.1% (Colombia) and 80.9% (Nigeria) of 12-month cases were mild (IQR, 40.2%-53.3%). Serious disorders were associated with substantial role disability. Although disorder severity was correlated with probability of treatment in almost all countries, 35.5% to 50.3% of serious cases in developed countries and 76.3% to 85.4% in less-developed countries received no treatment in the 12 months before the interview. Due to the high prevalence of mild and subthreshold cases, the number of those who received treatment far exceeds the number of untreated serious cases in every country.”
A 2014 meta-analysis published in the international journal of epidemiology published by Steel et al., supported this conclusion. “There was also evidence of consistent regional variation in the prevalence of common mental disorder. Countries within North and South East Asia in particular displayed consistently lower one-year and lifetime prevalence estimates than other regions. One-year prevalence rates were also low among Sub-Saharan-Africa, whereas English speaking counties returned the highest lifetime prevalence estimates.”
So why am I skeptical?
The DSM-5 (Diagnostics and Statistics Manual; and the previous iterations) is a document that was designed as a descriptive rather than explanatory text. To make a diagnosis, you observe a set of behaviors and you say "oh we call these things occurring together major depressive disorder". This is in the direct contrast to the medical model which is explanatory where you observe a set of behaviors and say "You're doing this because you're depressed". Within psychology, there is more or less a consensus to reject the medical model. There is ongoing research to justify the medical model that is primarily conducted by psychiatrists but so far the results do not support an underlying disorder (equivalent to having a virus or bacterial infection) that would explain alterations in human behavior.
The rest of the world (for the most part) uses a different standard of diagnosis which is the ICD (International Classification of Diseases) manual. There have been continued efforts to synchronize these texts, but I do not believe they're at 100% (not my specialty area). What this means is that even from our starting point what we in the USA recognize as a disorder or mental illness is not always (though it is most of the time) what other parts of the world view as mental illness. That is to say, we're comparing apples to something that's very similar to an apple, but not quite an apple.
The next thing we have to understand why people are diagnosed. If we look at diagnostic criteria for a disorder, you regularly encounter something like this: there are 12 possible symptoms, if you endorse 8 of them you “have” the disorder, if you diagnose 7, you don’t. This doesn’t mean that people who are sub-clinical aren’t distressed. It just means that they don’t meet that criteria. To go back to our medical model example, imagine going to the doctor with a bunch of symptoms that are similar to the flu, but you’re told you come back negative for the flu. Would you expect insurance to pay for your flu treatment (that they don’t think you need…because you don’t have the flu)? So psychologists and others will routinely have some flexibility in diagnosis in order to give distress individuals access to treatment. This artificially inflates numbers. It’s also important to note that lots of people just plain suck at diagnosing. You’ll get a lot of things like PTSD diagnosis for individuals who experienced a “social trauma” which is not a diagnostic criteria. The bad diagnosis problem is further complicated by the people who give the most diagnoses and treatment; primary care providers. Even psychiatrists don’t’ receive any training in mental health until after they’re done with med school. Most PCPs have a very limited understanding of mental health despite the fact they are almost always the first point of contact. They want to prescribe meds to help (that’s the tool they have), so they need to provide a diagnosis that justifies the use of meds. All in all, the impact of our insurance system has a HUGE impact on diagnostic over expansion.
Question 2: Are people with various “mental health” issues more dangerous?
The long and short is no. You’ll see certain symptom presentations that do predict an uptake in this such as paranoid features and command hallucinations (a voice telling you to do something).
However, research suggests that overwhelmingly individuals diagnosed with a mental health disorder and likely to be the victims of a violent crime rather than the person who commits the crime. The biggest predictors of violent behavior is a past history of violent behaviors and substance use. Violent acts are overwhelmingly committed against people you know as well instead of strangers. I need to step out of my office so I don’t have the time to find the citation right now, but I’ll search for that in a bit.
Question 3: “
How often does a severe "mental health issue" go undiagnosed until after the fact? “
Diagnosing “after the fact” cannot be done. The people who do this are acting unethically. To make a diagnosis you need to sit down and talk to the person. It’s the same reason people making diagnoses re: Trump or Charlie Sheen are full of BS. You cannot diagnose unless you sit down and talk to a person.
