Anyone reading this is (not) crazy

Psychological problems are not black and white.

How do you determine whether someone is in good mental health or not? According to the psychiatric manual the difference should be clear. But in practice that’s anything but the case.

Text: Margot Smolenaars

In the Diagnostic and Statistical Manual of Mental Disorders, the difference between healthy and not healthy is as clear as day. For example, is someone displaying at least five of the manual’s nine symptoms of depression for two weeks and are they affecting his or her daily life? Then this person is suffering from depression (see the box ‘Textbook depression’ ).

(photo credits: Peter Dazeley, Getty Images)‘How crazy is the Netherlands?’ Isn’t that a stigmatizing research title? On their website, the researchers write that it’s meant in a humorous way. ‘In fact, the aim of our research is to stigmatise less and stop categorising people so quickly.’

There are lists with criteria for other disorders as well, such as anxiety, which at first sight seem completely unambiguous. But reality is decidedly more complex. This is illustrated by How crazy is the Netherlands?’, the first large-scale online population study on psychological problems.

Some people are depressed and yet say they’re happy.

Depressed yet happy

Over 1,200 people kept a diary for a month about their mood for this study, which was launched in 2013. The scientists behind the study used the diaries to develop personal models for each participant containing the factors related to his or her mood. Are people happier when they’re busy, for example, or more melancholy when they don’t get much exercise? As it turns out, even the most common risk factors for psychological problems, such as loneliness, unemployment and youth traumas don’t apply to everyone.

As many as 15,000 people also filled in questionnaires. The subjects answered questions about well-being, mood and personality, but also about issues such as youth experiences, empathy and bodily awareness. Indeed, most people with psychological problems say they function perfectly well. ‘There are even people who say they’re extremely happy, even though they’re suffering from depression or anxiety,’ says research leader Peter de Jonge, professor of developmental psychology at the University of Groningen. What’s more, the questionnaires confirm what De Jonge already believed: you’re not simply depressed or not depressed. There are many shades of grey between these extremes. So it’s pointless to draw a firm line between ‘good’ and ‘bad’ mental health.

Different than breaking a bone

Psychological problems are quite simply not that clear-cut, explains De Jonge. For example, most people have experienced a moment of panic, anxiety or melancholy thoughts. There’s a gradual process at work between occasionally having these kinds of feelings and being afflicted by them on a daily basis. But if it’s never black or white, can you say someone is ill? ‘If someone feels extremely down for a very short period, is that person ill? What about someone who’s normally extremely extraverted and suddenly becomes completely timid? Is that person ill?’ You always have to see it in relation to the actual person, says the scientist. It’s completely different than breaking a bone, for example. ‘You can’t say: that’s where the problem is and that’s how we’re going to fix it.’ Analysing symptoms and making a diagnosis for psychological problems requires a tailor-made approach.

Depression is not a checkbox

The circumstances are extremely important as well. De Jonge gives an example. ‘In 2006 I was doing research on depression following cardiovascular disease.’ The literature showed that many people suffer from depression following a heart attack. That can even speed up the onset of death. De Jonge cast a critical eye on the questionnaire that doctors were using to determine whether people in these situations were suffering from depression. ‘Imagine, you’re lying in the cardiology ward and someone asks you: “Do you think of death sometimes?” Of course you do, you’re lying in a cardiology ward and doctors have just got your heart to work again. “Do you have less interest in sex?” Obviously, you’ve just had an operation, sex is the last thing on your mind. The list doesn’t take the circumstances into account. So if you show enough symptoms, then you’re depressed – even though it makes sense that you feel that way, given the situation.’

Feeling down? Pop a pill!

Even though it’s impossible to divide people into those who are in either good or bad mental health, it happens all the time. A million Dutch people have been prescribed antidepressants, for example, and have therefore been labelled ‘depressed’. De Jonge believes that three quarters of these people probably don’t benefit from it. ‘They’re often suffering from a mild depression as a result of a problem in their lives that they’re unable to solve.’ Loneliness, for example, or prolonged stress at work. So being labelled depressed in not a solution, according to him. If anything, it leads to a mistaken feeling: apparently I’m ill and can’t do much about it myself. ‘Even though there’s always something you can do yourself to alleviate a psychological problem.’ For example, by bringing an issue such as stress out into the open at work. This kind of self-reliance isn’t usually discussed in your GP’s surgery. Usually the doctor will conclude, after a ten-minute talk, that it looks like a depression. ‘Often he will realise that the source of the problem is deeper,’ De Jonge says, ‘especially if it’s someone he’s been treating for a longer period of time.’ But: time pressure. Policy. Protocol. ‘So an antidepressant is prescribed. About 75 to 80 per cent of all antidepressants are prescribed by GPs. Which makes perfect sense from the GP’s perspective.’ But it’s not advisable, according to De Jonge. People are not getting the treatment they need, and so the underlying causes are not being addressed.

Happiness is the key

De Jonge stresses that antidepressants are definitely not without value, and it’s emphatically not his intention to get people to stop taking these pills. ‘Stopping medication must always be done under medical supervision, let’s be clear about that.’ ‘However,’ he continues, ‘antidepressants don’t work for everyone. They have some effect on some people, while others become dependent on them. But they don’t solve the problem.’

So another approach needs to be found. That’s one of the things that De Jonge has been studying since 2013 in ‘How crazy is the Netherlands?’ The key to a successful approach? According to him they have found it. Indeed, many participants in the study say that they do experience happiness, despite their psychological problems, as described above. ‘So you can be depressed and simultaneously enjoy the visit of your grandchildren. What if we were to reinforce these positive experiences? If someone suffering from anxiety is afraid to go out into the street, but loves to walk in nature, how can you use their social network to get them into the woods after all?’

The cut-off point between ill and healthy is not so important, De Jonge reiterates. The question that it ultimately all comes down to is: ‘What factors propel someone towards a disorder and how can we pull them back from it again?’ ‘How crazy is the Netherlands?’, which is still running, should help to find answers to these questions.

Textbook depression

Is someone displaying at least five of the nine symptoms of depression listed below for the best part of the day for two weeks? And is it impossible to attribute this to another illness? Then according to the psychiatric manual DSM that person is suffering from depression.

  1. Depressed mood, characterised by emptiness, sadness, hopelessness.
  2. Clearly a decreased interest or pleasure in activities.
  3. Weight loss or weight gain as a result of decreased or increased appetite.
  4. Inability to sleep or getting too much sleep, including during the daytime.
  5. Feeling of restlessness.
  6. Fatigue, loss of energy.
  7. Feeling of worthlessness or excessive guilt.
  8. Inability to think or concentrate, indecisiveness.
  9. Recurring thoughts of death, frequent thoughts of suicide.

The problem in figures

  • Every year, 546,500 Dutch people go through a period of depression, and 135,600 of them are experiencing it for the first time.
  • Slightly more than a million people in the Netherlands take antidepressants.
  • The most commonly used antidepressant is amitriptyline. It improves your mood and reduces anxiety and pain. Number two on the list is citalopram.
  • Overall, one in five Dutch adults have been labelled as ‘depressed’ in the past.
  • An almost equal number of people were once diagnosed with an anxiety disorder. Social anxiety disorders occur most frequently.
  • Depression and anxiety disorders are diagnosed more often in women than men.

(Sources: Trimbos Institute, Zorginstituut Nederland/National Health Care Institute)

Read more