The Biggest Health Crisis of 2020: Mental Health
The Biggest Health Crisis of 2020: Mental Health
(Ironically,) I saw a funny ad on social media the other day. It was an ad for a T-shirt company that said 2020 - and below it was a one star review like it was some restaurant on yelp. If you ask most Americans if they are “happier” now then 1 year ago it will be a very small minority that answer in the affirmative. Health concerns about “getting the ‘rona”; social distancing that for many has progressed to social isolation; impersonal, zoom conference calls replacing direct human interaction; masks (which I support wearing) that hide emotional expression; protests, riots, and strained race relations; contentious political rhetoric in an election year; financial struggles from job losses and mandated closures; and consumer’s modifying their prior behavior with the resulting long term financial impact for many. The world has changed, but beyond short term behavioral modifications we are all having to experience, there are some long term mental health changes that will be even more profound. The human psyche/mind is not comforted by change, it perceives most change as a stressful event - and as the world continues through this, stressors don’t let your system, your mind or body relax.
If these existential threats were not enough proverbial tinder to start a mental illness fire, we are additionally subject to the one-two punch of mental bonfire accelerant - new style tribal journalism/media and social media. Both of these outlets are purposefully designed to engage and addict us for maximal attention and maximally stimulate our excitatory / stress neurotransmitters with the progressive result of isolating us into camps or schisms that promote animosity and negative emotions. I know that’s a powerful accusation against the most successful companies in the world. But I think you will see in a moment that it is fundamentally true. This combination of previous trends, an isolating pandemic, and powerfully engaging, but stress inducing social media has led to a new epidemic of mental health issues that will last far longer than the direct effects of Covid 19.
Physiology of depression and anxiety
Before talking about sexy topics like the evil of social media, I think its important to understand Stress, Anxiety and Depression from a medical point of view.
It is often said that mental illness is a “Chemical imbalance”. At its heart that is true, albeit far overly simplistic. Indeed what I am about to write in a paragraph or two is a gross oversimplification of a group of diseases that have multifactorial causes, co-morbidities as well as the pathologies, but its an explanation worth going through anyway.
Like most things, genetics matter. For the conditions we are talking about one of the most key genetic factors is each of our individual genetic predisposition to how we respond to stress. A lot of this response is hardwired at birth. Some of us are just more wired to roll with stress and others to hyper-respond to it. Beyond this hardwired genetics, the epigenetics take over - our lifestyle and our life experiences can accelerate or slow down these pre programmed responses.
The initiating cause of anxiety or depression often starts with a stressful event. Whatever this event is it stimulates a cascade of hormones and neurotransmitters in our brain that activates the cortisol releasing system. I have talked about this cortisol response before in my blog on meditation but to recap, this system which affects the entire body (neurological, cardiovascular, immune, metabolism, respiration and digestion) - prepares our body for flight or fight. Evolutionary this is designed for vital protection from life or death threats that rarely exist in our modern world. As our world evolved from one of predators being our activators of this cortisol system, to our modern day stress activators, our brains did not evolve. So any stress (including something as non-life threading as a reactionary twitter post) to our body or mind, activates this system just as if it was a life or death predatory event. While in this state, our neurotransmitters elevate, and even the slightest ADDITIONAL perceived threats will up regulate our “action neurotransmitters” and down regulate our “mood stabilizers”. Our mind/body can maintain this heightened state, in a vicious cycle of more and more threat hormone release with suppression of calming hormone until the (real or perceived) threat is gone. Once we can identify the threat is gone, we get “reward” neurotransmitter activation, and release of calming hormones. What if our mind does not perceive the threat gone, as often happens in our modern world? what if it stays activated? The result is anxiety, depressed mood and ultimately major depression. What if the event is a more severe trauma? This is even worse and even after resolution, that memory of that trauma is stored in another area of your brain and every single new experienced you ever had, subconsciously gets “checked” for similarities to it and if its at all similar (even if its just a picture or a video that your mind perceives as similar) your body perceives it as a threat and starts the stress cycle.
The reward neurotransmitter hormones post stress is critically important to shut down the response. When we were hunters who escaped the bear attack - getting those high fives from the other members of the tribe when we retold the story back at the cave, closed the stress cycle and returned us to a normal state.
Modern day attempts to short circuit the stress cycle with alternative rewards - crushing a pint of Ben and Jerrys, downing a bottle of wine, or posting on social media to get some dopamine hits from likes...doesn’t shut down the cycle, and in fact these attempts perpetuate the stressors as soon as that hit of dopamine is gone.
Mental health: The Numbers
So is this all that big of a problem? Covid is only gonna be here for just a minute more as vaccines are around the corner so why does it matter?
Like some other disturbing trends (see below) that the Covid Pandemic has accelerated, Mental health was becoming its own American epidemic prior to Coronavirus hitting our shores.
Mental illness numbers overall -
Prior to covid, around 18% of Americans would have a diagnosable and clinically significant anxiety disorder annually - that’s nearly 1 in 5! Over 50 million people in this country alone!
Clinical diagnosis of Major Depression (not just sadness or feeling blue) effected 17 million people or about 8% of the US adult population. Again nearly 1 in 10 people you know suffer from this. Even worse that number is almost DOUBLE in the 15-25 year old age group...our younger generation has been suffering terribly.
Again, we are not talking about feeling sad for a day or anxious about something for a couple days. We are talking about major episodes or chronic illness that impairs daily living.
As bad as these pre-Covid numbers were, the numbers since Covid began (and our responses to it) are startling. Per their June year over year report 41% of adults have reported at least one mental or behavioral health condition including: General Anxiety Disorder, Major Depressive Disorder or Trauma and Stress Related Disorder (TSRD). Nearly half off all americans. If its not you, it is one of the next two people you call. It is that common.
If this was not bad enough, it gets worse. 13% of people reported using illicit substances for the first time in the last 12 months or increasing their use to cope with these disorders. Many will not get back off easily.
Scariest of all, 11% of respondents have thought about suicide. That’s 1 in 9. But yes media/social media, lets continue to talk only about pulmonary complications of Covid that effect 0.02% of people without co-morbidities.
Have I got your attention enough with 1 in 9 people thinking about suicide? How bout the deeper dive numbers under this. Minority ethnic groups (Hispanic, African-American) the suicidal ideation rate was 15-18%. Essential health-care workers - 21% (1 in 5). 18-24 year olds? That’s 24% (that’s 1 in 4). Sole unpaid care givers to adults? 31% (nearly 1 in 3).
How are we not talking about this?
FAANG market value - The so called FAANG stocks - Facebook, Apple, Amazon, Netflix and Google that dominate our digital world have thrived during the pandemic. The combined market cap (value) of these 5 companies was around 4 TRILLION in January of 2020. Despite the rest of the world melting down, this basket of companies INCREASED its value over the last 9 months to over 6 TRILLION. Clearly for these companies the trend is positive and investors are not only rewarding increasing profits this year but are betting on continued increasing profits going forward. So why is this under negative trends? Well its certainly positive for the employees, owners and investors in these companies but probably negative for the rest of us. Their value only goes up when their companies are used more. As we will see in a moment these companies are playing a significant contributory role toward mental illness so increase in use will likely parallel an increase in illness.
Retail apocalypse? This past month I travelled to another city to discuss expansion of Formula Wellness to that city with a major real estate developer. We spent several hours together and the topic of what a post COVID retail world looks like came up. He said their will always be retail but its going to look very different as many major retailers you know of are done. Per him, they have all been kept alive by financial companies and markets on the greater fool theory - build more and someone bigger will buy them out of their investment, even as the stores weren’t working. In his estimation over 55% of retailers were (not as a corporation but on an individual store level) not truly cash flow positive if you broke each store out individually on cash basis financials - they have been zombie operating stores that as a chain (with online presence) worked, but as a store didn’t. Covid will cause their rapid destruction. Restaurants are probably even in a worse position with an estimated 83% were behind on rent in September and between 20-30% likely to permanent fail by spring. I write this not as a cautionary investment tale but as a cautionary mental health tale for individuals. Socially, the retail / restaurant experience is also something we as Americans do in person with each other - not isolated online, but actively in the real world. As teenagers you hang with your friends in the mall or go try on things together. As adults you meet and have lunch after shopping. Post work you go meet a group for drinks and maybe dinner. Losing these human to human experiences with nothing definitive to replace it drives us further to the FAANG world with resulting increased manipulation and depression.
Above we talked about generalized anxiety / depression / suicide numbers immediately pre and post Covid. Additionally we hinted at a higher rate for high school and college age kids. There is a far more disturbing long term trend however and that is in Gen Z females. This demographic, is the first age group that smart phones and social media existed while in middle school. Smart phone adoption which started in the middle part of the first decade of the 2000’s collided with the the App Store and the popularity of facebook, twitter (and then ultimately Instagram and Snapchat) around 2010. If you graph out depression and suicide rates in teenagers it had been remarkably consistent throughout the decades. Over the last decade the numbers started to go up year over year for both males and females but rapidly accelerated for these Generation Z middle and high school females - there are multiple sources and surveys but the summary of the results are:
· The number of young adults ages 18 to 25 who experienced serious psychological distress increased by 71 percent from 2008 to 2017. This increase was most extreme in adolescents ages 20 and 21.
· Symptoms of major depression rose 52 percent in adolescents from 2005 to 2017 and 63 percent (from 8.1 to 13.2 percent) in young adults age 18 to 25 from 2009 to 2017.
· Furthermore, between 2008 and 2017, suicides among young adults ages 18 and 25 grew 56 percent. Suicidal ideation rose by 68 percent. In that same time frame, suicide attempts rose 87 percent among 20- and 21-year-olds and 108 percent among 22- and 23-year-olds.
That’s the teen group in general but if you look at adolescent females in specific the numbers are worse. Note the charts below.
So what has been behind this disturbing trend? Guns in the schools and shootings? Violent video games? Broken homes? All of these were ruled out. Consistently study authors point to the following:
“When you think of how lives have changed from 2010 to 2017, a clear answer is that over time, people started spending more time on phones and on social media, less time face-to-face with their friends, and less time sleeping. As we know from other studies, spending more time with screens, less time sleeping, and less time face-to-face with friends is not a good formula for mental health.”
—Jean Twenge, PhD, lead study author
We were losing our daughters to mental illness before the pandemic. As hard as it is for the adult mind to overcome the manipulation by the algorithms of the social media companies, the adolescent mind, which is very sensitive to peer pressure and bullying, combined with this age group’s naturally heightened self-consciousness on body image, its just too much. The statistics above foretell an acceleration of already terrifying trends. Too much social media, too much unrealistic photo filters and false standards of beauty, too much screen time with not enough human connection, and not enough sleep. It’s a recipe for a lifetime of behavioral disease.
Social media algorithms
So I have alluded to it multiple times above, social media algorithms are contributing to these mental illness trends. What does that really mean and how harmful can they really be.
As mentioned above the FAANG companies are the wealthiest group of companies in the world. It’s no secret that these companies collect data on you. Everyone has figured out that if they google search a product then click on facebook, ads for that product show up in their feed like magic.
Their level of sophistication goes way beyond that. Now, let me start by saying that these companies are not inherently evil but for them to be effective at what they do, the need immense amounts of data on you. These companies, take this data and build a living profile of each one of us. What you search for on google, what links entice you to click on facebook, the amount of seconds you spend looking at a picture on instagram, even where your eye contact is on a YouTube video. All of that builds an online profile on which may be a little terrifying but that’s just the beginning. To really get to know you the algorithm populates your feed with what’s called A/B tests - are you more likely to click on Story A or Story B? It keeps interjecting this testing and your results give it more predictive power for them to be able to target paid advertising to you that you will be more likely to engage with. This increased engagement produces their billions in revenue.
If it stopped there it wouldn’t be so inadvertently sinister. I mean, I kind of like it when I’m thinking about buying a new pair of running shoes and see an ad of a brand I never heard of, right? This is where the unintended power of the machines takes over. It’s not satisfied with me just clicking on the shoe ad. It is still testing and later when I see a news story on the protests and riots, I click on it. A day later I see two more stories, one with a “peaceful protest bent” and one with an “out of control rioting slant”. I click on one. The algorithm wants my engagement and wants me to come back and so the next day it puts more A/B tests in my feed. As humans we tend to be more engaged by extreme things so, ever so slightly, the A/B testing gets a little more polarizing. You don’t notice it but subtly over days, weeks, months and years - you have been A/B tested so much that your feed is more polar and it feels like the whole world is agreeing with a progressively more polar viewpoint. What started out as an advertising test for running shoes has now begun to put me into a camp or tribe where I wasn’t before. The computers are so fast, so smart and literally know the trends of my wants and desires that they can lead you down a path that is in some part of your own creation, but a path you may not have chosen had it not been for social media. Our polarized red/blue, progressive/conservative...name your modern day societal schism, is not a natural phenomenon, its been fueled by media and social media walking us further with enticing content. Add in inflammatory user comments that engage us further and you have an intense emotional response that starts that flight or flight stress response.
As someone who is steadfast resistant to conspiracy theories it is a bit hard to swallow. But this is not theory. It is simply the output of a computer algorithm that is designed to get you to stay on their app/website for as long as possible, to click on things that monetize their product as much as possible. Remember the customer of facebook, twitter...is not you, its the advertiser who pays them for the product. The product is oft stated to be your “eyeballs” but more specifically, the product is your mind and your minds desires that can be subtly walked and nudged a certain direction.
To keep you engaged though it needs something beyond a story of a bonfire in Portland for you to click on. It needs to activate your reward center. Think of a casino. The drinks are free, the energy seems electric. You put your money in the slot machine and pull down on the handle and …. wait while the wheels spin - is there a reward? Bells and whistles! Or no reward, silence – I try again. It’s 2020. We have the technology to capture servers full of data on each user, don’t we have the technology to auto refresh an app while we are inside of it? (Of course we do, your Insta feed isn’t static, the algorithm changes what’s coming up next based on what you liked or spend time looking at). Why then do we have to pull down on the mail or gmail app or the facebook/instagram app to refresh it to see if there is new mail or likes? It’s the same reason that slot machines don’t just show you in 1 second if you won or not. The pulling down and slight delay increases anticipation and leads to a bigger dopamine hit that makes you want to do it again, and again and again...Add in the emotional feeling you get when some leaves you a positive comment on your post or you get tons of “likes” on your picture. The dopamine is so addicting that especially for millennials and generation Z, they begin to feel more drawn to interacting with the virtual world with excessive dopamine hits then the “relatively boring” everyday world of regular human interaction. The virtual experience is maximally designed to give you rewards, while they test you, categorize you, sell you and lead you down an ever more engaging path.
So now that I activated your threat system and cause some anxiety about the pandemic of behavioral illness around (and inside) us, what is the dopamine payoff of a solution? Well, not sure that I have all the answers. The world has big problems that I am neither smart enough or powerful enough to fix. However, there are things you can do to begin to fix yourself.
To fight against the confluence of experiences working against us we need to adapt the most basic algorithm I use in functional medicine. This in general works from everything from food allergies to heart disease prevention, from weight loss to mold toxicity:
Step 1: use a diagnostic tool to give some objective assessment of the problem
Step 2: change the environment: remove whatever is effecting you negatively
Step 3: Initiate Healthy user effects (see January blog)
Step 4: Personalize a supplement response to the problem
Step 5: Use Traditional Medicine when necessary
So how does that play out with anxiety and depression?
Step 1: Diagnosis - Mental illness is real and with the incidence being so high there should be zero stigma about talking about it. To put names to things we need to use objective medical criteria. There are a litany of tests that do a good job at this but as we live in an age of technology it would be great to have something beyond a bubble sheet you fill out in a doctors office and wait a week for the results. We have for a few months been evaluating a simple, but state of the art diagnostic mental health software screener for the evaluation of depression, anxiety, ADHD, Bipolar disorder and other conditions. We are live on this platform now. To practice what I preach, and since I believe that mental health is our greatest existential medical threat right now as a population, the testing will be entirely free to anyone. Lifelong member, sporadic IV patient, individual who came in for a covid test or just a reader of the blog. If you want it – we will email you an assessment for free.
Step 2: It’s easy and trite to say to eliminate social media. As a business owner, it is pretty much business suicide to do that in these modern times. Plus although I highlighted the negative, there are inherent positive things about social media that you lose by completely unplugging. So instead of eliminating it - we need to change our relationship with it. First - Turn off all social and email notifications - Check on these apps only at a time of your choosing, not after being “nudged” to do it by the apps algorithm that is purposely inducing increasing screen addiction. Second, keep dosing the red pill and stay “woke” when you reach for your phone. Acknowledge you are entering a world controlled by artificially intelligent machines that are far smarter at subtle testing and manipulation then the human brain and you are unlikely to have the discipline to win a war of engagement with it while you are on the app - You are simply playing on their turf against a superior opponent.
To put a name to this new relationship with it - It’s about getting more “meta” before and after the engagement with your “phone” (I put that in quotes because how often do I use it as a phone versus as a app device anyway?). Meta refers to an abstraction, one mental level of thought above your simple reaction level. Am I about to click on the app out of habit/addiction? Or is it because it sent me a dopamine-inducing notification that something new just happened? Or am I launching the app because I have the time and I am consciously choosing to engage with it. If you are sad, angry, anxious, depressed after a “session” – ask yourself is that how I was feeling before I launched the app or did the algorithms drive me into an emotional-stress inducing-rabbit-hole. You can emotionally disengage just by asking the question: Is this really my thoughts or what the algorithm is inducing me to think? It doesn’t matter which way you answer - Just by asking the question and going meta, you stop the cortisol threat cycle. You have dis-engaged from the threat and your brain can readjust and re launch those mood stabilizing neurotransmitters.
Additionally - even though the virus still lives all around us, it shortly should be time to re-engage human to human more. I had the privilege of being invited a month or two back to the home of a patient who put together a group of a dozen men and women to discuss the world events. Although much of the viewpoints were like minded, even when someone disagreed it was a civil, respectful discourse amongst those present - the opposite of what happens on twitter or facebook. People are much meaner behind a keyboard and when the algorithms incite you to post more ugly comments or see all the others engage, it just makes hate more accessible. Like my patient, I am going to make more of an effort going forward to put together some increased direct human engagement (from 2 to a dozen people) with no agenda, just to interact, discuss the world, engage and have fun.
Step 3: Engage in more healthy user behaviors - how great do you feel an hour after you have that “cheat meal” or the morning after cracking the second bottle of wine...You don’t, you feel worse and ask why you did that. With the stress of 2020 we don’t need more processed escapism, we need more healthy user effects (exercise, nutrition management, red light therapy, sauna, massage, meditation...). These have all been scientifically proven to improve mood, relieve stress and strengthen positive neural pathways. David Goggins the motivational speaker, athlete and former navy seal – says that whenever he feels that delay in getting up to go work out he “tape records the conversation in his head” and plays it back. He listens to it like to the bitching, the weak excuses that quickly become cyclical in his head leading to more inactivity. He gets meta, breaks this negative nuerochemical mental cycle and forces himself to restarts the healthy user behavior.
Step 4: Supplements: It doesn’t take many office visits with me before I mention stress defense supplement to you. I rarely ever afternoon crash and when I do, I always attribute it to adrenal stress overload and I supplement and give some love to my adrenal glands (the organs that release cortisol) and the energy comes back. I give love to the primary energy production organ - the adrenal, but I have long ignored the end organ that the hormone cortisol effects - the brain. If I have over used my adrenals due to physical or mental stress, that has taken its toll on my brain as well. If I know I am having a stressful period I need to start some serotonin (mood elevator, “I need a hug” hormone) or dopamine (energy, reward, movement) precursors or boosting supplements. Keep your eyes posted for an email shortly of new additions to our supplement line that address this.
Step 5: Medications - Although per my test results above I don’t currently need one, I am lowering my threshold for myself or others to prescribing these. As with all medications it will be the goal that when we get on, we will create a game plan on when and how to get back off. However the fear of big pharma should not over rule this mental health epidemic, where for many, the resulting outcome of NOT taking medication may be self harm or suicide.
This email isn’t meant to be alarmist. It’s meant to start the conversation that we as a society had mostly ignored prior to covid, but now has become the REAL life threatening pandemic to a massive amount of Americans . Hopefully this information and the tips are helpful to some of you individually. If you are lucky enough not to be afflicted by any of these conditions, please be aware that someone very close to you is. They are suffering. They are thinking about hurting themselves. They cant stop the anxiety or negative thoughts. They are thinking about suicide. Engage them in person. We focus a lot on Covid testing but we should all just as often get mental health tested and encourage others to get tested. If you have Generation Z age kids - particularly females from middle school to college - directly ask them how they are doing and if there is any doubt get them tested. Keep up the healthy user effects and encourage others to do the same. Lastly if someone needs help, be there for them and be proactive. If we are all doing all of these behavioral changes for a virus that in the long term effects less then 1% of us negatively, why are we not doing it for a devastating group of diseases that is effecting 1 in 3 of us not just for the next few months but for the long term?
Thanks and as always, Be Well
Brian Rudman, MD