The Most Expensive Paragraph in History

A paragraph written in 1845 holds the key to a multi-trillion-dollar problem.

That’s a clickbait line. I don’t care.

Let me show you the price tag first, and then the paragraph.

The price

According to the Lancet’s editorial for World Mental Health Day 2020, poor mental health cost the world economy approximately $2.5 trillion in 2010—a figure projected to rise to $6 trillion by 2030. Anxiety and depression alone cost the global economy $1 trillion every year in lost productivity. Almost a billion people worldwide currently meet criteria for a mental disorder.

Inside the United States, more than 17,000 facilities for mental health and substance use treatment operate with combined annual revenue of roughly $50 billion. Broader behavioral health spending—counting pharmaceuticals, primary care, and ancillary services—approaches $300 billion.

Add addiction. NIDA estimates that abuse of tobacco, alcohol, and illicit drugs costs the United States more than $740 billion annually in healthcare, lost productivity, and crime—roughly $300 billion for tobacco, $249 billion for alcohol, $193 billion for illicit drugs, and $78.5 billion for prescription opioids.

Roughly forty-six percent of Americans will meet criteria for a mental health condition at some point in their lives, per Kessler and colleagues’ National Comorbidity Survey Replication, funded by the National Institute of Mental Health.

The trend line is the most important number. The Lancet’s projection—$2.5 trillion in 2010 to $6 trillion by 2030—is not a forecast of a problem getting solved. It is a forecast of an industry growing.

Hold that curve in your head.

The paragraph

In 1845, the French alienist (psychiatrist) Jean-Étienne Dominique Esquirol’s Mental Maladies: A Treatise on Insanity was published in English translation in Philadelphia. Esquirol had spent forty years observing the inmates of European asylums. The thesis of his life’s work, distilled to a sentence:

Insanity is a disease of civilization.

He meant it descriptively, not poetically. Asylum populations were almost entirely urban, almost entirely industrial, almost entirely drawn from the most “advanced” sections of European society. The hunter-gatherers, the rural villagers, the small-scale communities—they did not produce inmates. Civilization did.

He documented the observation across forty years of clinical practice, with precision and without polemic.

The data backed him then. The data backs him now.

The 130-year quiet

Between 1828 and 1960, almost every observer who looked for psychosis in technologically undeveloped areas of the world reached the same conclusion. It was uncommon.

A government physician named Lillybridge, who supervised the removal of the Cherokee in 1827-29 and personally observed more than 20,000 of them, reported that he had never seen or heard of a single case of insanity among them. The 1916 textbook The Institutional Care of the Insane of the United States and Canada recorded this observation, and many like it, as a baseline.

In 1973, the psychiatrist E. Fuller Torrey conducted epidemiological research in New Guinea. He found a twentyfold difference in schizophrenia prevalence across districts. The districts with higher prevalence were the ones with more contact with Western civilization. Torrey’s 1980 book is titled Schizophrenia and Civilization. Its central finding, stated plainly:

Schizophrenia appears to be a disease of civilization.

Torrey was not and is not a heterodox figure. He went on to help build the National Alliance on Mental Illness into a powerful political force. He is a strong advocate of biochemical models and forced medication. His New Guinea data, by his own account, surprised him.

And yet around 1950, something interesting happened. The idea became current in psychiatric literature that schizophrenia occurs in about the same prevalence in all cultures and is not a disease of civilization. The observation that had been the consensus of the field for 130 years was, without much fanfare, retired.

The data did not change.

The theory of mind did.

What replaced the observation

After 1950, the dominant frame became biochemical. Mental illness was a brain disease. Brain disease called for medication. Medication called for pharmaceutical research. Pharmaceutical research called for a market.

A 2005 government survey, reported in the New York Times, found that only 11 percent of psychiatrists were providing talk therapy to all of their patients. The other 89 percent had moved to a model called “medication management”—which is to say, they were no longer asking what people’s lives were like. They were checking symptoms and adjusting doses.

You cannot diagnose a disease of civilization in a fifteen-minute medication-management visit. You can only detect the symptoms it produces in individual nervous systems. You can prescribe for the symptoms. You can prescribe for the side effects of the prescriptions. You can prescribe for the side effects of the side effects.

This is, broadly, the industry. This is the $300 billion. This is the $6 trillion forecast.

The number that does not move

Spending on mental health treatment in the United States has risen for decades. Pharmaceutical penetration has risen. The number of clinicians, facilities, modalities, certifications, and apps has risen. The number of Americans diagnosed with mental illness has also risen—across nearly every demographic, across nearly every condition.

Suicide rates have risen. Among adolescents, the trend is catastrophic: CDC data show youth suicide rates rose 57 percent between 2007 and 2017, from 6.8 to 10.6 per 100,000 for ages ten through twenty-four—after holding statistically stable for the seven years before that.

Treating a problem more and harder, year after year, with measurably worse outcomes, is the empirical signature of a misdiagnosis.

Statistics don’t cross over. Something is wrong with the theory.

What the 1845 paragraph was actually pointing at

You cannot get to a structural diagnosis by examining individuals one at a time. The structure does not show up at the scale of a single nervous system. It shows up at the scale of the species.

Human beings evolved for groups of roughly 150—the Dunbar number, the upper bound of how many people a single mind can hold in working social memory. Below that number, coordination is mostly relational: you know who can do what, you know who owes whom, you know the unspoken rules because you helped write them by being there. Beyond that number, coordination has to be done some other way.

The way we settled on is command-and-control hierarchy. Rules, ranks, schedules, sanctions, scripts. It is coercion by another name, and it is the only known method for organizing strangers at scale.

Coercion has a cost, and the cost rises with size. The more people inside a command-and-control system, the worse the system gets at collective intelligence—the worse it gets at noticing what is actually happening, at integrating dissent, at responding to information the rules did not anticipate. Each additional layer adds friction. Each additional rule reduces local responsiveness. At sufficient scale, the system’s ability to learn falls below the threshold of the individual’s ability to suffer.

That is the point at which defection becomes rational.

You can defect against a coercive system externally—quit, leave, drop out, organize, revolt. Most of these are expensive, and most people do not take them. The other option is to defect internally. The body refuses. The mind refuses. The nervous system goes into something the system can no longer reach.

Much of what we call mental illness is, structurally, internal defection from a system whose demands the organism cannot meet and cannot escape.

This is what the 1845 paragraph was pointing at without quite naming. It is what Bruce Levine, a clinical psychologist who has spent three decades inside the modern system, names directly: Coercion—the use of physical, legal, chemical, psychological, financial, and other forces to gain compliance—is intrinsic to our society’s employment, schooling, and parenting. Coercion produces fear. Fear produces resentment. Resentment, sustained over years, produces what the DSM picks up under various labels.

Gallup’s polling, a decade ago: seventy percent of Americans either hate their jobs or have checked out of them. By high school, only forty percent of students report being engaged with their schooling. In The Interactional Nature of Depression, a 1999 meta-analysis edited by psychologists Thomas Joiner and James Coyne, the single best predictor of depression relapse was found to be the answer to one question: How critical is your spouse of you?

These are not biochemical findings. These are structural findings. They are findings about the conditions a person is being asked to live inside. They map cleanly onto what Esquirol and his contemporaries saw in their wards.

The window and the key

The current treatment model is a series of broken-in windows. Each one passes you through, and each one cuts you on the way. Medication helps some people and harms others, often the same people in sequence. Hospitalization can save a life and can take a different one. Diagnosis can be the beginning of a real conversation or the end of one.

Sometimes the window is the only thing available. Sometimes the window is what kept someone alive long enough to find a door.

But a key opens a door, and the door leads somewhere. What the 1845 paragraph is pointing at—what Esquirol saw, what Torrey rediscovered and then had to misfile, what Levine has spent his career trying to make audible inside a system that does not want to hear it—is that the key is not in the patient.

The key is in the environment.

The key is in what we are asking people to spend their days doing, who we are asking them to spend their nights next to, how we are asking them to raise their children, what we are doing to their attention, what we are doing to their bodies, and what we are doing to their sense that any of the above can change.

The most expensive paragraph in history

The paragraph is not expensive because we missed it. The paragraph is expensive because we found it, refuted ourselves, and built a multi-trillion-dollar industry on the refutation.

We are now spending close to a trillion dollars a year, globally, treating individuals for a problem being produced at the scale of the society. The trillion will become six trillion. The six trillion will be paid by people who increasingly cannot afford it, to address suffering increasingly produced by the conditions of their own lives.

There is no version of this where the line goes down without addressing the variable Esquirol named.

Not because medication is bad. Not because therapy is bad. Not because biochemistry doesn’t matter. But because no amount of intervention at the scale of the individual can absorb the cost of a structural diagnosis the field stopped making in 1950.

We just keep paying the bill.

Tolkien gave Gandalf a passage worth recalling. “Many that live deserve death. And some that die deserve life. Can you give it to them? Then do not be too eager to deal out death in judgement. For even the very wise cannot see all ends.”

The judgment we have been too eager to deal out is the one we deal against people for failing to thrive inside conditions that are producing the failure. We do not have to claim certainty about what comes next. We only have to stop being certain about what we have already been told doesn’t matter.

Even the very wise cannot see all ends.

But the 1845 paragraph is still on the page. The least we can do is read it.