Psychiatry’s social impact: Pervasive and multifaceted

Psychiatry has an enormous swath of effects on the social structure of society, perhaps more than any other medical specialty. Its ramifications can be observed and experienced across medical, scientific, legal, financial, political, sexual, religious, cultural, sociological, and artistic aspects of the aggregate of humans living together that we call society.

And yet, despite its pervasive and significant consequences at multiple levels of human communities, psychiatry remains inadequately appreciated or understood. In fact, it is sometimes maligned in a manner that no other medical discipline ever has to face.

I will expound on what may sound like a sweeping statement, and let you decide if society is indeed influenced in myriad ways by the wide array of psychiatric brain disorders that impact various core components of society.

Consider the following major societal repercussions of psychiatric disorders:

• Twenty-five percent of the population suffers from a psychiatric disorder per the landmark Epidemiological Catchment Area (ECA) study,^1,2 funded by the National Institutes of Health. This translates to 85 million children, adolescents, adults, and older adults. No other medical specialty comes close to affecting this massive number of individuals in society.
• According to the World Health Organization (WHO), 4 of the top 10 causes of disability across all medical conditions are psychiatric disorders (Table³). Depression, alcoholism, schizophrenia, and bipolar disorder account for the greatest proportion of individuals with disabilities. Obviously, the impact of psychiatry in society is more significant than any other medical specialty as far as functional disability is concerned.
• The jails and prisons of the country are brimming with psychiatric patients who are arrested, incarcerated, and criminalized because their brain disorder disrupts their behavior. This is one of the most serious (and frankly outrageous) legal problems in our society. It occurred after our society decided to shutter state-supported hospitals (asylums) where psychiatric patients used to be treated as medically ill persons by health care professionals such as physicians, nurses, psychologists, and social workers, not prison guards. Remember that in the 1960s, 50% of all hospital beds in the United States were occupied by psychiatric patients, which is another historical indication of the societal impact of psychiatry.
• Alcohol and drug abuse are undoubtedly one of society’s most intractable problems. They are not only psychiatric disorders, but are often associated with multiple other psychiatric comorbidities and can lead to a host of general medical and surgical consequences. They are not only costly in financial terms, but they also lead to an increase in crime and forensic problems. Premature death is a heavy toll for society due to alcohol and substance use, as the opioid epidemic clearly has demonstrated over the past few years.
• Homelessness is an endemic sociological cancer in the body of society and is very often driven by psychiatric disorders and addictions. Countless numbers of severely mentally ill patients became homeless when asylums were closed and they were “freed” from restrictive institutional settings. Homelessness and imprisonment became the heavy and shameful price of “freedom” for persons with disabling psychiatric disorders in our “advanced” society.
• Suicide, both completed and attempted, is intimately associated with psychiatric disorders. Approximately 47,000 deaths from suicide were reported in the United States in 2017.⁴ Given that more than 30 million Americans suffer from mood disorders, millions of suicide attempts take place, crowding the emergency rooms of the country with individuals who need to receive emergent health care. The tragic toll of suicide and the heavy medical care costs of suicide attempts are incalculable, and unfortunately have been growing steadily over the past 20 years.
• Homicide is sometimes committed by persons with a psychiatric disorder, most commonly antisocial personality disorder. The rate of homicide often is used as a measure of a city’s quality of life, and urban areas where access to psychiatric care is limited tend to have high homicide rates.
• School problems, whether due to attention-deficit/hyperactivity disorder, below-average intellectual abilities, conduct disorder, bullying, impulsive behavior, substance use, broken homes, or dysfunctional families (often due to addictive or psychiatric disorders), are a major societal problem. Whether the problem is truancy, school fights, or dropping out before getting a high school diploma, psychiatric illness is frequently the underlying reason.
• Sexual controversies, such as expanding and evolving gender identity issues and discrimination against non-cisgender individuals, have instigated both positive and negative initiatives in society. Sexual abuse of children and its grave psychiatric implications in adulthood continues to happen despite public outrage and law enforcement efforts, and is often driven by individuals with serious psychopathology. In addition, sexual addiction (and its many biopsychosocial complications) is often associated with neuropsychiatric disorders.
• Poverty and the perpetual underclass are often a result of psychiatric disorders, and represent an ongoing societal challenge that has proven impossible to fix just by throwing money at it. Whether the affected individuals are seriously mentally ill, addicted, cognitively impaired or challenged, or unmotivated because of a neuropsychiatric disorder, poverty is practically impossible to eliminate.
• One positive impact of psychiatry in society is that artistic abilities, writing talent, musical creativity, entrepreneurship, and high productivity are often associated with certain psychiatric conditions, such as bipolar disorder, autism, obsessive-compulsive disorder, and psychosis spectrum disorders. Society is enriched by the creative energy and out-of-the-box thinking of persons with mild to moderate neuropsychiatric disorders.
• The financial impact of psychiatry is massive. The direct and indirect costs of psychiatric and addictive disorders are estimated to be more than $400 billion/year. Even a single serious psychiatric disorder, such as schizophrenia, costs society approximately $70 billion/year. The same holds true for bipolar disorder and depression. Thus, psychiatry accounts for a substantial portion of the financial expenditures in society.
• And last but certainly not least are the impediments to psychiatric treatment for tens of millions of individuals in our society who need treatment the most: the lack of health insurance parity; the stigma of seeking psychiatric help; the serious shortage of psychiatrists, especially in inner-city areas and rural regions; the poor public understanding about psychiatric illness; and the fact that the success rate of psychiatric treatment is very similar to (and sometimes better than) that of serious cardiac, pulmonary, hepatic, or renal diseases. There are also many flawed religious, cultural, or philosophical belief systems that fail to accept that the mind is a product of brain biology and function and that psychiatric disorders are brain disorders that affect thought, mood impulses, cognition, and behavior, just as other brain disorders cause muscle weakness, epileptic seizures, or stroke. The public must understand that depression can be caused by stroke or multiple sclerosis, that Parkinson’s disease can cause hallucinations and delusions, and that brain tumors can cause personality changes.

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