Here is the text for today. I found this in an article in JAMA Psychiatry by Peter Sterling and Michael L. Platt (February 2022).

“Every symptom of despair has been defined as a disorder or dysregulation within the individual.”

First, at the risk of casting myself as the good guy in the drama I am about to sketch, I want to tell you how I was thinking of my depression in 2003, the very understandable reaction to my wife’s death. I was coping as best I could; doing the things that had to be done, maintaining the network of relationships that I hoped would be more meaningful later. A friend called to check on me and asked, as part of the conversation, whether I was taking anti-depressants.

That’s the first time that option had occurred to me. An awful loss had occurred in my life and I was depressed as a result. I said that I was not taking them. He asked why not. So I had to stop and think about it again. I answered, finally, that I didn’t think I was any more depressed than I ought to be. After a little further thought, I said I was on the track to recover, eventually, and had every hope of following that track back to health.

That story puts me at the other end of the continuum than the one Sterling and Platt are characterizing. Over at that end of the spectrum, every symptom of despair is defined as a disorder. So I would have had “a depression disorder” and would presumably have been given treatment. [1]

But Sterling and Platt are making a social critique. They are not concerned about my mourning my wife. Their idea is that our society is hell-bent, for its own reasons, on “medicalizing” anxiety, depression, anger, psychosis, and obesity. I’m sure they did not intend that as a complete list.

They suggest that one of the things wrong with this tendency is that it “incorrectly frames the problem.” [2] They have in mind that the issues represented by this list are not only “not medical problems,” but are not even “personal problems.” But that formula won’t work either.

The physical, the personal, and the social are intertwined and there is no use pretending they are not. Let’s take the time for two radically simple metaphors, then come back to the problem. Which setting in a three number combination is most important? You can tell by looking at it that it is a silly question, but when you start to say just why it is silly, it gets slippery.

Football example: the other team has a truly gifted receiver. No one defender on our team can stay with him. Here are three things we can do. We can make our defender faster. We can double cover this dangerous receiver. We can reduce the quarterback’s time for finding the receiver in coverage. Not only is it true that every one of those solutions would work, but it is also true that the weakness of one can be compensated for by the strength of the others.

OK. Back to reality.

Why is our society experiencing a spike in obesity and diabetes? It’s a lot of bad dietary choices. It is the socialization of those choices into socially confirmed practices. It is the food policy of the country, which makes healthful food inaccessible or expensive and unhealthful food readily available and cheap. Note the three levels.

The locker combination example shows us that getting two of those three issues right is not going to open the lock. The football example shows that you can compensate for the weakness in any one element by increasing the strength of the other two. Seems obvious. So why don’t we do that? As the choices move away from the individual—or in physical health examples—the individual’s body—they get more expensive and more conflictful.

It is (relatively) inexpensive for an intact family to teach the children to prefer the kinds and amounts of food that will serve them well. [3] Building a youth culture that will affirm, at best, or at least not punish, good food choices is somewhat more complex and expensive. Making sure the food is available so its choice can be affirmed by the kids is most expensive of all and most strongly opposed. There is a reason the U. S. government is stockpiling, by estimates I have seen recently, 1.4 billion pounds of cheese.

I should have brought most of you along so far as agreeing that the sound dietary choices of the individual are the cheapest and most secure approach to this problem. But somebody is going to have to look at the McGiganticburger ads and the popcorn chicken ads and say, “That’s bad for us. Let’s say no to that.” When that decision has been made and when it is stable, it is inexpensive as well. But how does it get made?

And particularly, how does it get made when “freedom” has been made into the hottest word in the political vocabulary and given as its principal content, “You can’t tell me what to do!” In the otherwise inoffensive line above—“Let’s say no to that!”—somebody is obviously telling somebody else what to do. It helps, in this example, that someone can say “We…” but as soon as some stable part of society or government gets’s involved, “we” becomes “them.” Then the cost skyrockets.

Finally, note that no one in the example I am offering, is making any money on the good food choices program. The kids are not, the families are not, the society is not. [4] The medicalization strategy, on the other hand, is a money making machine and the money is made in the short term by identifiable groups and individuals.

The football equivalent would be to put one team—only one—on stimulants and thereby increase their physical competence during the game. But that sound like a cheap substitute for good football decisions and good strategy. And it is

[1] Three years later, I did have a depressive disorder and was only too happy to have the help SSRIs gave me until I was out of it.
[2] I am not a fan of that way of framing the problem either, but I am also not a fan of the notion of a “correct” framing of the problem. It seems much better to me to think of them as useful or useless; helpful or harmful, etc.
[3] Of course, it isn’t cheap to have an intact family.
[4] There are cost for not doing these things, of course, but they show up later and that makes it very dicey for elected politicians.