The Rise of Therapy in America: An Inquiry into Worsening Mental Health Trends
The United States has witnessed an unprecedented surge in therapy engagement. Counseling, once confined to the confines of private sessions, has now blossomed into a cultural phenomenon. It’s woven into popular literature, podcasts, and cinema, and public figures spanning athletes, celebrities, and politicians candidly share their mental health struggles. Conversations are peppered with terms from the therapy lexicon—references to gaslighting, toxic relationships, and setting boundaries.
This heightened consciousness is substantiated by statistical evidence: current federal estimates reveal that approximately one in eight U.S. adults is prescribed antidepressants, and one in five has recently sought mental health support. This represents an upsurge of nearly 15 million individuals receiving treatment since 2002. Notably, between 2019 and 2022, the utilization of mental health services surged by nearly 40% among millions of U.S. adults with private insurance, as reported by a recent study in the JAMA Health Forum.
However, a perplexing disparity emerges. Despite the escalating numbers seeking therapeutic intervention, the state of U.S. mental health is deteriorating across various indicators. Suicide rates have surged by roughly 30% since 2000. A staggering one-third of American adults report symptoms of depression or anxiety—triple the figures from 2019. Around one in 25 adults grapple with severe mental illnesses such as bipolar disorder and schizophrenia. Astonishingly, the proportion of U.S. adults who assess their mental health as “excellent” plummeted from 43% two decades ago to a mere 31% by late 2022.
Amidst this incongruity, experts grapple with an enigma: a scenario where care is sought more fervently, yet mental health outcomes are on a deteriorating trajectory. Dr. Thomas Insel, former director of the National Institute of Mental Health (NIMH) and author of “Healing: Our Path from Mental Illness to Mental Health,” remarks on the anomaly, stating, “This isn’t the case with cancer survival, heart disease survival, diabetes diagnosis, or nearly any other medical domain. The discord is perplexing.”
According to Dr. Robert Trestman, Chair of the American Psychiatric Association’s (APA) Council on Healthcare Systems and Financing, a complex interplay of positive and negative factors is at play. The destigmatization of mental health has encouraged more individuals to seek treatment, thereby expanding the population receiving diagnosis and care. Conversely, societal upheavals such as the pandemic and the Great Recession have driven an increased demand for mental health services, often stretching an already strained system to its limits, leaving some individuals underserved.
However, some mental health professionals posit that the underlying issues extend beyond mere access concerns, challenging the very foundations of contemporary psychiatry. For these experts, the crisis doesn’t stem solely from a supply-demand mismatch but from the fundamental shortcomings of therapeutic approaches that barely scratch the surface of a vast mental health landscape.
Inadequacy of Diagnostic Precision
In most medical disciplines, objective metrics underpin diagnostic and treatment strategies. Elevated blood pressure warrants hypertension drugs, while cancer cells in a biopsy necessitate chemotherapy.
Psychiatry, however, lacks such definitive benchmarks, despite numerous endeavors to establish them. Under Insel’s stewardship, the NIMH embarked on extensive research projects aiming to uncover genetic or biological factors underlying mental illnesses, yielding limited results. Conditions like schizophrenia may exhibit clearer genetic links, yet as a whole, Insel notes, “Biomarkers are sparse. The elements commonly found in other medical arenas are largely absent here.”
The Diagnostic and Statistical Manual of Mental Disorders (DSM), often referred to as psychiatry’s guiding text, shapes diagnostic criteria based largely on symptomatic presentation—how symptoms manifest, their duration, and their disruptive impact. In contrast to other medical domains, this subjective approach hinges on clinicians’ judgment, determining whether symptoms have transcended normal thresholds to constitute a disorder. Notably, these evaluations increasingly transpire during brief teletherapy sessions, potentially overlooking nuances.
Dr. Paul Minot, an outspoken psychiatrist with nearly four decades of experience, critiques his field for glossing over the “ambiguity” of mental health, presenting diagnoses as definitive when shades of gray persist. The field grapples with both misdiagnosis and overdiagnosis, a 2019 study even concluding that the foundation of psychiatric diagnoses is “scientifically meaningless” due to inconsistent metrics, overlapping symptoms, and limited scope. A grave concern, as diagnosis directs treatment.
Dr. Alex Williams, Psychology Program Director at the University of Kansas and co-author of a review article, acknowledges that certain therapies yield promising results. However, he underscores the importance of relying on therapeutic methodologies with robust evidence, particularly considering that half of the analyzed therapies lacked credible substantiation.
Excessive Dependence on Treatment
Even proven therapeutic methods can yield varied results depending on the clinician’s approach. The rapport between patient and provider, a crucial determinant of therapy’s efficacy, amplifies the unpredictability—some emerge empowered, while others remain unchanged.
“Shorty,” a 31-year-old from North Carolina, cites disappointment with therapy, particularly during his college years while contending with substance abuse. He remarks, “We conversed, but we weren’t really resolving anything. I felt like I was simply paying.”
While some may indeed benefit from therapy, Shorty expresses frustration over the notion that it’s viewed as a universal panacea for life’s challenges, despite evidence suggesting it’s not universally effective. The APA states that around 75% of psychotherapy participants experience some form of benefit, but this is not uniform, and a fraction may experience adverse effects. The necessary investment of time, finances, and energy for therapy to yield results might explain the popularity of medication—offering quicker relief in contrast. As of 2020, approximately 16% of U.S. adults had used psychiatric drugs in the past year, with antidepressants dominating the category.
While some individuals report improvement after taking antidepressants, research underscores that their efficacy is variable. Notably, antidepressants are most effective for severe depression, and individuals grappling with anxiety and other conditions may also derive benefits. However, the data supporting antidepressant effectiveness is not as robust as their widespread use would suggest.
In the early 2000s, the NIMH initiated a comprehensive, multi-stage trial to compare various antidepressants, aiming to determine if specific drugs exhibited superior performance across the board or among specific patient groups. However, the outcomes proved otherwise. Insel explains, “What emerged was evidence that none of them were particularly effective. The underperformance of antidepressants across the entire population was remarkable.” Multiple trials were necessary, and approximately 30% of participants never experienced complete relief.
Recent studies continue to provide mixed findings on antidepressants. A 2018 meta-analysis examining data from 522 trials found that all 21 drugs analyzed outperformed placebos, albeit to a “modest” degree. A 2019 review pushed further, concluding that the effects of antidepressants are “minimal and potentially inconsequential for the average patient with major depressive disorder.”
