Turfster

If "they say" that about 5% of people have depression...then it's time once again to bust out "the map is not the territory" and remind people that diagnosis is a hugely political endeavour, which is administered unevenly, badly, and harmfully; who has access to it at all, and of those, who has access to any expectation of due diligence by medical staff, are extremely relevant questions in all medical matters.

In my experience, rates of depression and anxiety are markedly higher than basic demographic assessments will report. For people unfamiliar with how we operate in the field when studying large groups of people, you need to know a few things about the mass-noun problem. Here's just a few basic questions to interrogate your understanding with:

1. Can you verify the reported condition meets criteria per DSM-5?

• If so, which variant of Depression are you addressing? MDD (Major Depressive Disorder) is not Bipolar 1, for example.

2. Has this been recorded in medical records?
3. Are you comparing documentation to interviews and/or self-report?
4. What population biasing do you have?

• Classic example: the MMPI-2 is compiled largely based on white Michigan state residents, and may have limited explanatory or predictive effects for other populations; hence why we have new variants such as the MMPI-2-RF.

5. Are your metrics by which you ask the question Psychometrically Valid?

• You will get very different results depending on how you word something, EG: "I have been diagnosed with a form of Depression by a doctor" vs "I have been feeling extremely sad and unmotivated to the point that it interferes with daily life".
• Your response metrics will influence this, such as a YES/NO binary, a 3, 5 or 7 point Likert Scale (Mostly True / Partly True / Neutral / Partly False / Mostly False), or specific rated responses (Never, 1-3 Days, 5-7 Days, Almost Every Day, All of the Time).
• Metric verification is easiest if you use existing resources, such as the many options for measuring (PHQ-9, HAM-D, MDQ, etc;)

I think this quick version is better than the text blob I have beneath. I don't even talk about Substance Dependency (I wanted to); but there wasn't enough space because I get into a zoomed-out picture for the sake of my perpetual framing of the country as nested within the world.

For those suffering with Suicidal Ideation or Self-Harm, I can only recommend you seek assistance where and how you can within your means. U.S. Residents can dial 988 for the National Suicide & Crisis Lifeline, the website link is here if you click.

TLDR: It's worse than it seems, better than it looks. Demographics are not destiny, but they provide us relevant data to make informed policy decisions upon. Hopefully, we can choose to learn from them for once instead of deny problems exist.

When people start throwing out figures regarding rates of depression or other clinically relevant syndromes, you need to always pinch some salt to sprinkle on top as we have to cut extremely carefully. Many confounds exist such as the method of survey response (via online form, phone call, text message, on the street with pen and paper), or biasing problems with the subset you choose to measure (College Students, people at a Grocery Store, A clinic with Terminal Cancer Patients, etc). What counts as Clinical, Sub-Clinical, and Non-Clinical is also distinct, as are the distinctions between Acute (short length) and Chronic (long length) conditions. Something a former colleague of mine used to say while I worked Rehab was that "we're in a Clinic, people are sick enough to justify going into a locked unit for several days to a full week". The utility of this basic framing is to remind fresh blood that they're not in the field where Healthy and Unhealthy people are mixed in, they're in a funnel where people are focused. Every time you study a population, you filter out people who qualify in a partial manner, often only taking the most clear cases... Rehab often works the same due to the extreme costs.

In my employ in Rehab, my boss gave me many important practical lessons about how we measure success and syndrome in the Clinical and post-Clinical environment. When we measure Depression out in the wild, we're often cutting with the most narrow possible tools available to us as Clinicians and Demographers, and often times the whole concept of Sub-Clinical (just below diagnostic criteria) is sacrificed to present as clean and direct a claim as possible for the sake of publication. There are so many factors that go into diagnosing someone with a Depression-adjacent disorder, it shocks me that we write medication based on a 15 minute screening interview. Sub-Clinical conditions are "below cut-off", and are often Sub-Clinical purely due to the caution Clinicians have to practice when arriving to diagnosis... of course. Mind you, this is three parts Cost Containment, and one part Clinical Diligence. When you study the decision-making processes of insurance providers, you're looking often at a system which is built to deny coverage for basic services under quite literally any excuse. I've lost patients to "just past clinical threshold" cases being denied for not being "acute enough" in our "objective measures".

I'd say that by most Clinical measures, successful suicide is a fail state; but I'm no Pharmacologist and don't pretend to know enough Neuroscience to write a script (not that I'd pass the license exam anyway). Despite this, I spend an inordinate amount of time doing basic pharmacology interaction research after interviews with friends-of-friends who end up with Serotonin Syndrome or god-forbid, medication induced psychosis. Facts on the ground are that our idea of Serotonin Theory in depression is extremely industrial (think mildly better than placebo but easy to sell); the observation clinically speaking is that people are increasingly under economic and social stress, our society is sick, the people are just the canaries in this particular coal mine. Pair this with the social media information space being full of juicy cortisol-producing bad news and algorithms meant to feed it to you, plus you can't walk anywhere, air quality sucks, you can't afford the time to exercise, and you can't even interact with your IRL friends if you have any left because no one can meet anywhere. Oh and don't get me started on the Gut-Skin-Brain Triangle and how seriously fucked exposure theory literature is for epidemiological studies of ASD/ADHD having a common thread in Endocrine Disorders. All of that shit? That shit is so reliable at producing sub-clinical and chronic depressive and anxious states that they survive the transformation from State to Trait.

For your clarification: State is your current status (EG, upset because you stubbed your toe today and are in mild pain); Trait is an element of your personal psychology that survives changes in State (EG, you are prone to use profanity at the slightest inconvenience). The conventional model of PTSD is how you take a State and transform it into a Trait through the HPA-Axis (Hippocampus, Pons, Amygdala), and there are few reasons to assume otherwise as we've observed changes in grey matter density in the cerebellum in a variety of chronic mental disorders (especially treatment resistant MDD). People's brains are being traumatized by our environment, and the scene on the ground is dire. But by all means, insist that the issue only impacts 1 in 20 Americans. You know. Only 16 Million Americans. 16,000,000; that is easy enough to count on your fingers, you can ignore it. It's such a small, reasonable number, isn't it? It's shit like this which underprepares healthcare systems like the NHS and Canada's healthcare model, cost containment through overly wishful thinking. If the issue isn't measured and correctly assessed from a RISK perspective, all public health issues are easily compacted from something deserving tax money into something you can ignore. Depending on who you ask and the ruler you measure with, we may be looking at Sub-Clinical populations of depressive disorders which combined may make up insane quantities of the workforce (think 15 to 40%), and these are very napkin-math projections.

You'll note I'm still using "useful to capitalism" phrasing here by specifically projecting into the "Work Force"; the U.S. Government's definitions of unemployment do not account for people who want to work but cannot due to the inverse economics of the job market. It quite literally costs too much in expenditure of non-fiscal resources for some people to actually work. As an example: Housing and Food insecurity are chiefly responsible for the majority of the cases I am brought in to consult on, and there isn't a pill that can fix a lying job market that never hires. I'm so tired. I spend a lot of time talking people through the distinction between the Neuroscience of Depression and how they are frequently experiencing acute depressive states as a consequence of reacting to stress. Not everyone suffers the brain injury that causes the State to Trait transformation, but if you do, it often becomes Treatment Resistant, and people like me have to teach you management tactics that are more about making comfortable lies hurt less. A lot of people will wiggle around the Health Crisis Demography discussion because they do not fundamentally understand nor conceptualize personal suffering at the scale of society.

All of this bitterness is to say that even removed from the U.S.'s healthcare model, people are denied basic care and basic diagnostic precision that we can accomplish with pretty routine measures. The average person in the role of clinician doesn't have a comprehension of the mechanics of clinical psychology, they're working the job because they can't afford to do anything else. The economics are all wrong, our whole concept of Cost Containment is built around hoping people don't even try. We've wrongly looked at the Strategic Infrastructure of our society here in the U.S. and gone "it doesn't need upkeep". Defunded Education, the Suburbanization Blight, Dominance of the Automobile, and all of these other metrics are evident to sizable portions of the vocal minority of us whom elect to speak out about these issues. But for every one of me who has been excluded from the labor force by Clinical syndromes, there's a dozen sub-clinical me's who are working and suffering rather quietly, and that's not good for your society.

All of this is to say that in the current Global environment, industrialists are in denial about how their levers and machinations are pushing the planet towards an era of Global War. For those people I have to help them distinguish basic Social Infrastructure from Socialism. Mental Health is Strategic Infrastructure, Education is Strategic Infrastructure, and a Society that allows people to exist in Public Space? You guessed it, Strategic Infrastructure. The arts are Strategic Infrastructure, National Parks are Strategic Infrastructure- literally, you cannot wage war or hold economic relevance if you do not account for the very human needs of your very human labor force. But a lot of these same people are not only illiterate in Global Economics and Defense by Deterrence, they are also illiterate in basic social sciences and will cry "woke" when you ask them not to bully perfectly good, albeit disabled, people out of the workforce. Industrialists should be more keenly aware of the problem of human psychological limitations as a permanent need, but instead they only address it as an inconvenience, because the limit of their intellectual capacity is a Master/Slave relationship with the world.