depression | Normative Narratives

February 17, 2015
by bzupnick 3 Comments

Transparency Report: Debt, Depression, and College Drop-Outs

The graphs in this blog come from a recent report co-authored by the Pell Institute and The University of Pennsylvania:

In addition to the direct (tuition, room and board, cost of living) and “opportunity cost” (foregone wages) of attending college, there is mounting evidence that suggests there is an emotional / psychological cost associated with taking out student loans.

Despite the intense interest in this issue among researchers, this is the first paper that attempts to understand the emotional cost of carrying student loan debt. This question is, in fact, more fundamental than the others being posed in this genre of research, since it could help to explain the mechanism through which debt may be affecting other outcomes (i.e. emotional health, graduation rates).

Based on their analysis, the authors report, “cumulative student loans were significantly and inversely associated with better psychological functioning.” In other words, individuals with more student debt reported lower levels of psychological health, when other things are held constant (including occupation, income, education and family wealth). The effect is statistically significant, but it is quite small. They also find that “the amount of yearly student loans borrowed was inversely associated with psychological functioning,” which implies that taking on debt is emotionally costly for students.

Unfortunately, this emotional / psychological “cost” seems to be affecting a greater number of incoming college students:

High numbers of students are beginning college having felt depressed and overwhelmed during the previous year, according to an annual survey released on Thursday, reinforcing some experts’ concern about the emotional health of college freshmen.

The survey of more than 150,000 students nationwide, “The American Freshman: National Norms Fall 2014,” found that 9.5 percent of respondents had frequently “felt depressed” during the past year, a significant rise over the 6.1 percent reported five years ago. Those who “felt overwhelmed” by schoolwork and other commitments rose to 34.6 percent from 27.1 percent.

Not coincidentally, the frequency and magnitude of student loan debt has increased greatly during this period of increasing student unease and depression, according to data released by the NY Fed:

More U.S. students continued to borrow larger sums for their college education last year, according to data from the Federal Reserve Bank of New York, while total student loan balances tripled over the last decade.

At 43 million, the number of student borrowers jumped 92 percent from 2004 to 2014, while their average balances climbed 74 percent, according to New York Fed researchers. The average balance was some $27,000.

Obviously correlation does not prove causation. But given the logical link between debt, depression, and dropping-out of school, these trends cannot be purely coincidental–more research on the subject is needed.

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“It’s a public health issue,” said Dr. Anthony L. Rostain, a psychiatrist and co-chairman of a University of Pennsylvania task force on students’ emotional health. “We’re expecting more of students: There’s a sense of having to compete in a global economy, and they think they have to be on top of their game all the time. It’s no wonder they feel overwhelmed.”

While I cannot speak personally about the burden of student loan debt, I have experienced depression first hand, and understand how being depressed could make one more likely to drop out of school.

Depression is particularly difficult to battle in a college atmosphere. The pressure to maintain a social life, despite anxiety and financial issues, can reinforce negative feelings associated with depression. The abundance of drugs and alcohol certainly does not help the situation either.

The general pessimism which accompanies depression compromises a person’s ability to clearly assess long term goals, such as completing a degree. Depression also affects ones cognitive abilities, hampering academic outcomes.

I can only imagine the pressure on someone who is both depressed and has student loan debt to consider; some combination of the two surely accounts for more low-income drop-outs than is currently recognized.

I had to take a semester off to get myself back in the proper state of mind to complete my degree; not everyone has this luxury. However, everyone should have the support needed to realize their educational and emotional potential.

Due to my personal experiences and knowledge of economics, I vehemently support President Obama’s proposed Community College plan. Lower income students could learn if pursuing a bachelor’s degree is “for them” without taking out tens of thousands of dollars in loans, likely leading to better emotional, educational, and economic outcomes.

Furthermore, community colleges are more likely to have the the social counseling and financial advising services missing from for-profit universities, which predominantly attract low income students.

The Obama administration is attempting break the vicious cycle of student debt, emotional suffering, and dropping-out of college. Dropping out of college with student loan debt in a competitive global economy is a poverty trap for low income individuals, and has become a drag on economic growth in the macro.

By expanding mental health parity through the ACA, getting treatment for depression is no longer a luxury reserved for the wealthy. If our lawmakers pass a free community college bill, the synergy between these two public policies would go a long way towards bringing equity to America’s higher education system and reinvigorating the American Dream.

June 24, 2014
by bzupnick Leave a comment

Transparency Report: The Supply Of and Demand For Mental Healthcare

Original article:

Shootings in places like Isla Vista, Calif., and Newtown, Conn., have turned a spotlight on the mental health system, and particularly how it handles young, troubled males with an aggressive streak. About one in 100 teenagers fits this category, according to E. Jane Costello, a psychiatric epidemiologist at Duke University School of Medicine, and they often have multiple diagnoses and are resistant to treatment.

Most of these young men will never commit a violent crime, much less an atrocity. But the questions of how best to help them and how to pay for it are among the most intractable problems hanging over the system.

Thousands of families know this experience too well: No single diagnosis fits, no drug brings real relief, and if the teenager rejects the very idea of psychotherapy, there is little chance of lasting improvement.

Congress has taken steps to bring about so-called parity for mental health, requiring insurers to cover treatments for mental illnesses as they do those for diseases like cancer and diabetes. But parents like the Serpicos have found that, even with good insurance, they often cannot get the expensive, long-term residential treatment they believe their child needs.

And it is not clear how effective intensive residential treatment is for teenagers. Some improve, experts say, but they are usually discharged to the same environment in which they got into trouble, and precious few studies follow them for longer than several months.

“The problem is that, while some kids may benefit from these extremely costly services, we don’t know which ones they are, and we don’t have a good model for distributing those services, no matter who’s paying,” said Sherry A. Glied, dean of the Wagner Graduate School of Public Service at New York University.

Lena and Robert Serpico knew something was not right before their son was in kindergarten. They had taken him and his younger brother in as foster children from a mother who used drugs, and they later adopted both.

As the teenager became increasingly indifferent to school and defiant, the family got him into a highly recommended day therapy program. He was thrown out for bringing a razor blade to a session. The family tried again, at another day program, and this time the program kicked him out for refusing to participate.

“It’s useless, all this stuff,” he said in a brief interview. “It’s a waste of my time.”

He entered an alternative school last fall, and his parents, who both work outside the house, decided they had only one option left, recommended by their son’s doctor and therapist: long-term residential care. Costs ranged from $10,000 to $60,000 a month.

“No way we could afford that,” Ms. Serpico said.

Out of options, the Serpicos did what many affluent families do: They hired a lawyer. In January, they petitioned the school district to pay for their son’s education at a therapeutic school. A consulting psychologist hired by the district concluded that their son needed “a 24-hour-a-day therapeutic milieu over an extended period of time, i.e., longer than two months, in order to keep him safe and gain the skills necessary to function post-high-school.”

Last month, they learned that the suit had been successful. The Geneva School District will pay for the young man to attend a therapeutic school in Montana for one academic year. There will be horses, physical labor, and group and one-on-one talk therapy. Ms. Serpico and her husband broke the news to their son this month.

When asked about going to the new school, he shrugged and looked away.

“I don’t know,” he said. “Probably useless, too.”

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Economics traditionally treats people as rational actors seeking to maximize their “utility”. While this idea is contentious even in “normal cases”, when considering those suffering from mental illnesses, the rational maximizer model becomes almost completely irrelevant. Despite the obvious benefits for those who need mental healthcare, potential patients (particularly young men) often reject the idea of therapy because of the stigma of “weakness” or embarrassment associated with it–I know this because I was once one of these young men.

Health care reform–so called insurance “parity” for mental healthcare–has gone a long way in making treatment affordable to those who need it. This was a fix to the “supply side” of the equation. However, it is very clear that there are “demand side” issues related to mental healthcare that are leading to under-treatment.

Demand traditionally focuses on the willingness of a person to pay for a particular good or service. However, young people are almost never expected to pay the cost of their own mental healthcare–those who need treatment the most often reject it even if it is being paid for by their parents or the state (or some combination of the two). To get these people the help they need, we must address the non-monetary concerns–the stigma–associated with mental healthcare.

This is a difficult task, but it can be aided by cultural and technological progress. Culturally, those in the public spotlight (movie stars, musicians, athletes, etc.) who are comfortable with their mental health issues should open up about them. It is amazing how someone who is perceived as “cool” can get through to people and change public perceptions. To this end I would like to commend All-Pro Wide Receiver Brandon Marshall, who has become a poster-boy for mental health awareness, to the benefit of both the general public and, according to him, himself; we need more role models like Mr. Marshall. Of course, these public figures can always utilize social media to amplify the effect of their message.

Another cultural shift which makes sense would be changing how we educate kids about mental healthcare. My first semester in college, we had something called “University 101”, where students where prepped and talked about the challenges and opportunities present during college life. It seems to me like there should be a similar class required during ones first semester in high school–a common time for mental health issues to arise–with a greater focus on mental health awareness. I also took a a health class in high school, but it focused much more on drug use and safe sex, and not nearly enough about mental health issues.

Often times young people are not comfortable talking to their problems with peers, for fear that news of their issues will become public knowledge before they are ready to be open about them, or used against them by bullies. In such an instance, virtually connecting with groups dedicated to peer-to-peer dialogue via social media (Facebook, Skype, etc.) could offer a way for children to start opening up about their issues to people they can relate too (other kids), without having to worry about those issues coming out in their immediate social circles.

As someone who went from rejecting the very idea of therapy to realizing its incredible benefits, this issue is deeply personal to me. I can say one thing–seeking mental healthcare is by no means a sign of weakness, or something one should be embarrassed about. The open, self-reflecting, honest approach needed for therapy to be effective requires incredible strength of character. This is the lesson we should be teaching our kids–pursuing mental healthcare is a sign of strength, not weakness.

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For those who think Mental health issues are only a “rich country problem”, think again. According to a recently release United Nations report, depression is the number one cause of illness and disability globally among adolescents (10-19 yrs old).

In an increasingly complex and global world, it is only natural for new sources of anxiety to affect current and future generations of children. These new sources of anxiety will be reinforced by old social and cultural stigmas related to mental illness / healthcare. In the coming decades youth populations are expected to grow in developing countries, where youth unemployment tends to be highest and (relatedly) conditions are very conducive to mental health problems. The problem will only become more pronounced, unless we use all the tools we have to address adolescent mental health issues in a holistic and inclusive manner.

In a political / media landscape dominated by debates over fiscal responsibility and climate change, the potential of looming global mental health epidemic is not discussed. You want to talk about a “Great Depression”? Aggregate all the lost output that will systematically come out of the global economy if the proper resources are not dedicated to youth employment, mental healthcare and awareness programs. And then there are the linkages to poverty, insecurity, human suffering…

May 17, 2014
by bzupnick 2 Comments

Transparency Report: Youth Unemployment and Depression

According to a recently release United Nations report, depression is the number one cause of illness and disability globally among adolescents (10-19 yrs old):

We hope this report will focus high-level attention on the health needs of 10 to 19-year-olds and serve as a springboard for accelerated action on adolescent health,” said Flavia Bustreo, Assistant Director-General for Family, Women and Children’s Health at the UN World Health Organization (WHO).

An estimated 1.3 million adolescents died in 2012, largely from preventable causes, according to the UN agency’s Health for the world’s adolescents online report released today.

Depression was found to the be the greatest cause of illness and disability in this age group, with suicide raking third as the cause of death among young people.

This report reminded me of a journal article I read during my studies, “Development Economics Through the Lense of Psychology” (abstract excerpt below):

Economists conceptualize a world populated by calculating, unemotional maximizers. This view shapes our understanding of many crucial elements of development economics–from how rural villagers save, to how parents decide on whether to send their children to school.

Psychological research, however, has documented the incompleteness of this perspective. Individuals have self-control and time inconsistency problems. They can give into shortrun temptations and later regret it. They can have strong feelings about others that drive them to commit both generous and spiteful acts. They often passively accept defaults rather than make active choices. They let the institutions around them make choices for them. And they may misread new data in a ways that fit their beliefs. In short, the rational maximization model may not be a very good approximation of human behavior.

While this journal article does not explicitly cite mental illness or depression, due to my own experiences with depression my thoughts turned to the subject. There is no one cause of depression; there are elements of both “nature” (genetic predisposition) and “nurture” (experiences in life). However, “nurture” causes tend to be more direct and therefore preventable: dehumanization / pessimism related to poverty, uncertainty about the future, and unemployment:

In the shadow of the Great Recession lies a deep depression: Youths in their 20s and early 30s are hitting new lows. Compared with older workers who have lost their jobs, young people face more complex and layered hardships that could last most of their lives. They are experiencing disproportionately high unemployment, stretching indefinitely into the future, in an increasingly unequal and uncertain social landscape. And just when they are most in need of social support, the recession has led lawmakers to erode the welfare and employment programs that youths need to move themselves — and the economy they have inherited — toward recovery.

For young people in the United States and Europe, there is an emotional layer to this economic malaise. According to a recent U.K. survey of 2,161 people ages 16 to 25 by nonprofit advocacy group the Prince’s Trust, the unemployment epidemic is driving a mental-health crisis. While overall happiness levels for the surveyed youths stayed about level over the past year, reported emotional health fell significantly for the segment that is out of the workforce and not in school or job training. These young people experienced feelings of despondency and hopelessness at a higher rate than their peers. Chronically unemployed youths were more likely to have experienced panic attacks, engaged in self-harming behavior or felt suicidal. Mental-health problems struck 4 in 10 jobless young people “as a direct result of unemployment,” according to the Prince’s Trust.

One woman interviewed for the study said, “Being out of work stripped away my self-worth and made me feel like a waste of space.”

While this study considers young people in the U.S. and Europe, one can assume that young people in the developing world experience similar issues, as youth unemployment is expectedly worse in many less developed countries.

Depression stunts personal development; how can someone invest in themselves or act as a long-term “rational maximizer” when they cannot see any hope in their future? But children are the future, and the number one illness affecting them is depression. To not pay the price to treat depression in adolescents is incredibly shortsighted–perhaps policy makers also do not act as “rational maximizers”, at least if the thing we hope to maximize is long-term social welfare.

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The costs of inaction are not limited to lost economic output, human suffering and suicide, there are also security risks associated with leaving depression untreated:

Adam Lankford, a professor from the University of Alabama, concluded that many suicide terrorists weren’t ideologues at all—but were, in fact, classically suicidal. He cited Israeli scholarly research of would-be Palestinian bombers: Forty percent of them exhibited suicidal tendencies; 13 percent had already attempted suicide, unrelated to terrorism. Lankford went on to mention a 9/11 hijacker who wrote a final note to his wife and lamented how he never lived up to her expectations. Lankford described other terrorists in Palestine and Chechnya who were in poor health, recently divorced, or financially insolvent in the months prior to an attack. He also talked about the terrorist recruiters who admitted to looking for the “sad guys” for martyrdom.

While this study is far from conclusive, it would be closed-minded to refuse to consider the relationship between mental illness and terrorism. People with depression are often looking for meaning and companionship; joining a terrorist organization provides both.

And this security risk is hardly confined to the developing world; one would be hard pressed to find a mass killing anywhere in the world that is not linked to some form of mental illness. To be fair, no statistical relationship between teen depression and violent crime has been established, although this does not rule out the strong possibility that there is some relationship between mental illness and violence.

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As someone who has experienced depression, this reports findings hit close to home. I am fortunate to have been born into an upper-middle class American family and receive top notch treatment–most people are not so lucky. Depression and other forms of mental illness are often seen as a “rich person’s disease”, and treatment as a luxury. This study refutes this misconception–depression can affect anyone; old or young, rich or poor. The universality of depression gives hope that it is an issue the global community can rally around and adequately address.

Increased access to mental healthcare must be part of healthcare reforms in both developed and developing nations. This is not an abstract concept, inaction has real costs that affect many people. Further compounding this problem is the existence of a stigma against people with mental illnesses (which is likely more prevalent in less developed places). When one feels ashamed of having a mental illness, the condition generally becomes worse and treatment is not sought. Part of the solution may be educating people to break this stigma.

The prevalence of depression amongst the world’s youth is alarming, but unfortunately to this social scientist / previously depressed young adult, it is not surprising. If depression can affect people who have had all their needs met, imagine how prevalent (and under-diagnosed) it must be the world’s most impoverished areas. Failure to treat mental illness not only impedes an individual’s positive liberties, it can also result in the most grievous violation of ones negative liberties possible–murder.

For some, finding employment is enough to alleviate the symptoms of depression. For others, treatment and therapy are required. Many anti-social behaviors can be tempered by a global push to address depression in adolescents, hopefully this U.N. report focuses a stronger spotlight on preventing and treating adolescent depression.