Depression Is Not A Proxy For Social Dysfunction

I.

Here is a terrible article from the New York Post: Sorry, Liberals, Scandinavian Countries Aren’t Utopias.

Its thesis is interesting and worth exploring, but instead of a principled investigation, the article just publishes a bunch of cherry-picked smears about Scandinavia. Did you know that 5% of Danes have had sex with animals?

(What percent of people in other countries have had sex with animals? I don’t know. More important, I see no sign that the New York Post knows either.)

But the part that really caught my eye was statements like these:

Why does no one seem particularly interested in visiting Denmark? Visitors say Danes are joyless to be around. Denmark suffers from high rates of alcoholism. In its use of antidepressants it ranks fourth in the world. (Its fellow Nordics the Icelanders are in front by a wide margin) … Finland, which tops the charts in many surveys, is also a leader in categories like alcoholism, murder, suicide and antidepressant usage.

The Post is not the only paper to make this argument. The Guardian (“The Grim Truth Behind The Scandinavian Miracle”) has said much the same thing:

Take the Danes, for instance. True, they claim to be the happiest people in the world, but why no mention of the fact they are second only to Iceland when it comes to consuming anti-depressants?…Finland has by far the highest suicide rate in the Nordic countries.

I’ve heard this same argument applied to other issues; for example, in his debate with Noah Smith, Michael Anissimov argues against the supposed success of modern liberal society by pointing out rising rates of depression and suicide.

It’s really tempting to equate depression with misery and misery with social dysfunction. Danes and Finns have high levels of depression, therefore their lives must be unusually miserable, therefore Denmark and Finland are poorly-organized societies.

But first of all, it’s not clear that Scandinavian countries really have very high depression and suicide rates. There are a lot of collections of statistics, and many of them show Scandinavia around the middle. Going by “antidepressant prescriptions” is a terrible way to do things, because it mixes amount of depression with resources devoted to treating depression – if the Scandinavian health systems are as good as everyone says, maybe they just treat a greater percent of their depressives than everywhere else.

But more important, even if Scandinavia does have very high rates of depression, that doesn’t tell us much about whether they’re happy or not. Depression is not the same thing as being sad. Sadness is a risk factor for depression – although even there I suspect that it’s very specific kinds of sadness that we haven’t yet teased out from the general construct – but it is not the condition itself. The condition itself is a complicated mess of neurotransmitters, cytokines, hormones, changes in brain structure, and goodness only knows what else.

Off the top of my head, here are six plausible reasons why Scandinavia could have higher rates of depression than the United States, even if it is a utopian society of perfect happiness.

1. Light. Scandinavia is far north [citation needed] which puts its citizens at very high risk for seasonal affective disorder, which can present as depression.

2. The midnight sun. Scandinavia’s weird day-night cycle could easily disrupt people’s circadian rhythms. Studies find that “increasing evidence points to a role of the biological clock in the development of depression…it seems likely the circadian system plays a vital role in the genesis of the disorder. This is why some European countries use melatonergic substances as antidepressants.

3. Parasite load. It’s positively correlated with temperature, which means Scandinavia probably has some of the lowest parasite load in the world. But low parasite load causes the immune system to get antsy and start attacking random stuff, leading to increase risk of autoimmune disease. If there’s an immunological component to depression – and right now lots of people think there is – then that’s another risk factor right there.

4. Diet. The Scandinavian diet has unusually little fresh food, because the area is a frozen wasteland and most things have to be imported from elsewhere. They’re big on frozen stuff, processed stuff, and canned stuff. I am neither an expert in Scandinavian cuisine nor in nutrition, but if depression is linked to diet and imbalance in the gut microbiome, which there’s some evidence it is, then diet is heavily implicated and the Scandinavians are in a good position to get hit extra hard.

5. Genetics. The New York Post article mentions that Scandinavians have an unusual variant of the MAO-A enzyme (I told you it was a weird hit piece. Scandinavia is too liberal, therefore they have bad genes?). MAO-A is also known as “the thing that processes serotonin” and “the thing that MAO inhibitors, some of the most powerful known antidepressants, inhibit”. I’m not saying this gene in particular is responsible for Scandinavian depression, I’m saying that the article itself is admitting that Scandinavia contains some genetically distinct populations and for all we know this could be involved.

6. Culture. Maybe the biggest factor in the level of depression and suicide in a culture is whether it is culturally acceptable to be depressed and commit suicide. Some of the lowest suicide rates are found in heavily religious cultures and communities who believe suicide is a mortal sin. On the other hand, one of the most suicidal countries in the world is Japan, with its heavily-mythologized history of heroic samurai taking “the honorable way out” when they had brought shame upon themselves. Well, Scandinavia is one of the least religious regions in the world. And all I know about their culture is that they produce about 100% of good death metal, and their native mythology ends with the world being plunged into eternal winter and the gods being eaten by wolves.

II.

But all this is just speculation. Let me give a concrete example of a case where social dysfunction doesn’t track depression and suicidality in a predictable way.

What about white versus black Americans? To some degree these two groups live in separate “societies”. Most people would consider the white society better off in most ways – higher income, better health, more family stability, less involvement with the criminal justice system. If White America and Black America were countries, White America would get all of the accolades currently given to the Scandinavians.

But American whites have higher rates of depression than blacks. There are the usual contradictory studies and arguments about how to adjust for which confounder, but I’m pretty sure this is something like a consensus position right now. More solidly, white Americans have much higher suicide rates than black Americans.

(although I feel bad mentioning this, because the stereotype that blacks never commit suicide is wrong and sometimes prevents black people from getting the help they need.)

We can go a few centuries back and get even more surprising results. Although it’s difficult to get data from the era, analyses of suicide rate among African-American slaves in the antebellum South describe it as “surprisingly low”. I can’t find any hard evidence proving Kurt Vonnegut’s contention that “the suicide rate per capita among slave owners was much higher than the suicide rate among slaves”, but it seems to have been commonly believed. Kneeland writes:

“[These low suicide rates are] consistent with suicide rates for Africa and for people of African descent living in other areas of the world, and further supports the theory that a low suicide rate is an element of African culture.”

If you’re going to say that Scandinavia’s higher depression and suicide rates mean Scandinavia has it worse off than America, you also need to theorize that white people have it worse off than black people, including black slaves. Why don’t you go post something to that effect on Tumblr and see what they have to say? I’ll wait.

III.

Or maybe we’re barking up entirely the wrong tree. What if it’s not even that happy, well-functioning societies can sometimes still end up with high suicide rates? What if people become suicidally depressed precisely because they live in happy, well-functioning societies?

This is the fascinating hypothesis of Daly, Oswald, and Wu (2011), who after crunching the numbers find pretty convincingly that “suicide rates tend to be highest in happy places”:

A little-noted puzzle is that many of [the happiest] places have unusually high rates of suicide. While this fact has been remarked on occasionally for individual nations, especially for the case of Denmark, it has usually been attributed in an anecdotal way to idiosyncratic features of the location in question (eg the dark winters in Scandinavia), definitional variations in the measurement of well-being and suicide, and differences in culture and social attitudes regarding happiness and taking one’s life. Most scholars have not thought of the anecdotal observation as a systematic relationship that might be robust to replication or investigation…this paper attempts to document the existence of a happiness-suicide paradox: happier areas have a higher percentage of suicides.

They then go on to show a strong positive relationship between average self-reported happiness and suicidality across Western nations – Greece is both the least happy country and the one with the lowest suicide rate – and US states, where confirmed hellholes New York and New Jersey are at or near the bottom. The relationship holds whether you adjust for confounders (including income!) or not.

I expected this to be a straightforward effect of modernization/industrialization/liberalism, as per Michael Anissimov’s hypothesis. The country-level data maybe sort of vaguely supports that trend – Greece and Portugal are our token incompletely-modernized countries and have very low suicide rates, Scandinavia is high, and everywhere else is sort of a toss-up. But US states really really don’t support that hypothesis – New York and Jersey both seem high on the modernization/industrialization/liberalism axis, and they’re right in the bottom left corner of the study’s graphs along with Greece and Portugal. Meanwhile, tropical paradise Hawai’i is suicidal as heck, even though it doesn’t seem espcially modern/industrial/liberalized. The US state data also torpedo – albeit less conclusively – an attempt to make the whole issue one of latitude.

One caveat I do have about the US data is that several of the happiest and most suicidal states – at least on the unadjusted plot – are also high-altitude. Utah, Wyoming, Colorado, Montana, Idaho are all up there at the top left side of the graph. But we already know there’s a strong positive relationship between altitude and suicide in 2584 US counties, probably because the brain’s emotional regulation system doesn’t work well in low-oxygen environments. If we assume people living in beautiful open forested mountain areas are especially happy, that takes away a big chunk of the graph right there. But it leaves other chunks untouched, and I don’t think it’s going to be that simple.

The authors’ preferred explanation is that suicide is an effect of relative rather than absolute misery. If you’re depressed and everybody around you is very happy, that makes things worse than if you’re depressed and everyone around you is also pretty miserable. Thus suicide is more common in happier societies.

I really don’t like this theory. Although everyone else should be happier in these societies, the person in question who might or might not commit suicide should also be, on average, happier. There’s no reason to think that the average hedonic distance between potential suicides and their neighbors is higher in these areas. Indeed, given that Scandinavia – and many of the other happy societies – are also some of the most equal societies, I would expect an unusually low hedonic distance between people. And in fact, I notice that suicide rates by country are negatively correlated with inequality – that is, the more unequal the country, the lower the suicide rate (wow, I definitely don’t remember seeing that one in The Spirit Level.)

On the other hand, I can’t for the life of me think of a better theory, so whatever.

Other things that increase suicide rates, by the way, include springtime, nice weather, high levels of education, and very occasionally antidepressants. My father, a very hard-headed internist, makes fun of me for doing psychiatry because “the whole field is just common sense”, but sometimes it really isn’t.

So you should probably think very carefully before using a difference in depression or suicide rates to support your pet theory about which societies work better than others.