One “advantage” of working in psychiatry is getting a window into an otherwise invisible world of really miserable people.

I work in a wealthy, mostly-white college town consistently ranked one of the best places to live in the country. If there’s anywhere that you might dare hope wasn’t filled to the brim with people living hopeless lives, it would be here. But that hope is not realized. Every day I get to listen to people describe problems that would seem overwrought if they were in a novel, and made-up if they were in a thinkpiece on The Fragmentation Of American Society.

A perfectly average patient will be a 70 year old woman who used to live somewhere else but who moved her a few years ago after her husband died in order to be closer to family. She has some medical condition or other that prevents her from driving or walking around much, and the family she wanted to be closer to have their own issues, so she has no friends within five hundred miles and never leaves her house except to go to doctors’ appointments. She has one son, who is in jail, and one daughter, who married a drug addict. She also has one grandchild, her only remaining joy in the world – but her drug-addict son-in-law uses access to him as a bargaining chip to make her give him money from her rapidly-dwindling retirement account so he can buy drugs. When she can’t cough up enough quickly enough, he bans her from visiting or talking to the grandchild, plus he tells the grandchild it’s her fault. Her retirement savings are rapidly running out and she has no idea what she will do when they’re gone. Probably end up on the street. Also, her dog just died.

If my patients were to read the above paragraph, there are a handful who would sue me for breach of confidentiality, assuming I had just written down their medical history and gotten a couple of details like the number of children wrong. I didn’t. This is a type.

Here’s another. 60 year old guy who was abused as a child, still has visible scars. Ran off at age 15, got a job in a factory, married let’s say a waitress. There was some kind of explosion in his factory, he got PTSD, now he freaks out every time he steps within a hundred meters of a place where manufacturing is going on. Gradually stopped going outside because there were too many scary loud noises, his wife started yelling at him and telling him he was useless, he started beating his wife, put in jail for a year or two for domestic violence, came out, by this point his wife has run off with another man and took everything he owned with her. Moved in with an abusive uncle who is 80 years old and hates his guts, but the uncle needed a caretaker and the guy needed a place to live and they were each other’s only affordable option. Currently lives off disability payments, but the government keeps trying to cut them off, and he keeps having to spend what little he has on a lawyer to prevent them from taking even that away, but half the time he doesn’t make it to his lawyer appointments because he’s too nervous about going outside. Also he has chronic pain. Also he only sleeps two hours a night because of the nightmares, and he’s tired all the time.

(“You have the pill that fixes all of this, right, Doctor? The one they advertised on TV?”)

A while ago I wrote about how strongly we filter for people who are like us intellectually and politically:

According to Gallup polls, about 46% of Americans are creationists. Not just in the sense of believing God helped guide evolution. I mean they think evolution is a vile atheist lie and God created humans exactly as they exist right now. That’s half the country. And I don’t have a single one of those people in my social circle. It’s not because I’m deliberately avoiding them; I’m pretty live-and-let-live politically, I wouldn’t ostracize someone just for some weird beliefs. And yet, even though I probably know about a hundred fifty people, I am pretty confident that not one of them is creationist. Odds of this happening by chance? 1/2^150 = 1/10^45 = approximately the chance of picking a particular atom if you are randomly selecting among all the atoms on Earth. About forty percent of Americans want to ban gay marriage. I think if I really stretch it, maybe ten of my top hundred fifty friends might fall into this group. This is less astronomically unlikely; the odds are a mere one to one hundred quintillion against. People like to talk about social bubbles, but that doesn’t even begin to cover one hundred quintillion. The only metaphor that seems really appropriate is a bizarre dark matter parallel universe.

Since starting working in psychiatry, I have realized that we also filter for misery. I think a big part of this is sorting by social class. But it’s in a more subtle way than you might think. That first patient, the 70 year old, might on paper have more than the median income if her dead husband’s pension is high enough. I could even imagine the second patient getting a decent payout from his factory and being financially in the clear for a while. It’s more complicated than that – something to do with being the sort of person who ends up in these sorts of situations.

I have three non-mutually exclusive theories for this:

1. The people who come to a psychiatrist are disproportionately the unhappiest and most disturbed. This is obviously true to some degree. But I got the same sort of people when I worked in general medicine and primary care. Even the people who come to a primary care doctor are going to be a little biased towards the sorts of conditions that produce or result from sickness, but people were still much worse off than I thought.

2. My ordinary life shields me from these people. I don’t live in an especially bad neighborhood, so I won’t meet the unhappiest people there. Unhappy people are really depressing, so their lives won’t be covered as much by newspapers and TV. And insofar as they stay in their homes all the time and never come out or talk to anyone else, that in itself is going to prevent me from meeting them.

3. Or maybe many of the people I know are in fact this unhappy, but they never tell anyone except their psychiatrist all of the pieces necessary to put their life story together.

If it were mostly (1), that would be pretty encouraging and mean I’m just biased toward seeing very unlucky people. If it were mostly (2) or (3), that would be pretty bad, and mean everyone else is biased toward not realizing how unlucky everybody else is.

So I made a short script based on the following information:

– About 1% of people are in prison at any given time

– About 2% of people are on probation, which can actually be really limiting and unpleasant

– About 1% of people are in nursing homes or hospices

– About 2% of people have dementia

– About 20% of people have chronic pain, though this varies widely with the exact survey question, but we are not talking minor aches here. About two-thirds of people with chronic pain describe it as “constant”, and half of people describe it as “unbearable and excruciating”.

– About 7% of people have depression in any given year

– About 2% of people are cognitively disabled aka mentally retarded

– About 1% of people are schizophrenic

– About 20% of people are on food stamps

– About 1% of people are wheelchair-bound

– About 7% of people are alcoholic

– About 0.5% of people are chronic heroin users

– About 5% of people are unemployed as per the official definition which includes only those looking for jobs

– About 3% of people are former workers now receiving disability payments

– About 1% of people experience domestic violence each year

– About 10% of people were sexually abused as children, many of whom are still working through the trauma.

– Difficult to get statistics, but possibly about 20% of people were physically abused as children, likewise.

– About 9% of people (male and female) have been raped during their lifetime, likewise.

These numbers might be inflated, since I took them from groups working on these problems and those groups have every incentive to make them sound as bad as possible. There’s also a really big problem where a lot of these are conditional upon one another – that is, a person in prison is not also in a nursing home, but a person who is unemployed is far more likely to be on food stamps. This will likely underestimate both the percent of people who have no problems at all, and the percent of people who have multiple problems at once.

Nevertheless, I ran the script twenty times to simulate twenty different people, and here’s what I got (NP stands for “no problems”):

01. Chronic pain

02. Alcoholic

03. Chronic pain

04. NP

05. NP

06. Sexually molested as a child + suffering from domestic violence

07. Unemployed

08. Alcoholic

09. NP

10. NP

11. NP

12. Abused as a child

13. NP

14. Chronic pain

15. NP

16. Abused as a child + unemployed

17. NP

18. Alcoholic + on food stamps

19. NP

20. Clinically depressed

If the two problems mentioned above haven’t totally thrown off the calculations, this makes me think Psychiatrist-Me is getting a much better window into reality than Normal-Person-Me.

And remember, this doesn’t count all of the problems that don’t fall into easily quantified categories, like “everyone hates them because they’re really ugly and annoying”. It doesn’t count things that I couldn’t find good statistics on, like “had a child die recently”. It doesn’t count things that I would have gotten in trouble for including, like “autistic” or “single mother”. It doesn’t count a lot of things. Consider that the first patient I mentioned – the homebound seventy year old with no friends who’s being extorted by her drug addict son-in-law – would appear on this list as “NP”.

The world is almost certainly a much worse place than any of us want to admit. And that’s before you’ve even left America.

This is part of why I get enraged whenever somebody on Tumblr says “People in Group X need to realize they have it really good”, or “You’re a Group X member, so stop pretending like you have real problems.” The town where I practice psychiatry is mostly white and mostly wealthy. That doesn’t save it. And whenever some online thinkpiece writer laughs about how good people in Group X have it and how hilarious it is that they sometimes complain about their lives, it never fails that I have just gotten home from treating a member of Group X who attempted suicide.

This is also why I am wary whenever people start boasting about how much better we’re doing than back in the bad old days. That precise statement seems to in fact be true. But people have a bad tendency to follow it up with “And so now most people have it pretty good”. I don’t think we have any idea how many people do or don’t have it pretty good. Nobody who hasn’t read polls would intuitively guess that 40-something percent of Americans are young-Earth creationists. How should they know how many people have it pretty good or not?

I think about all of the miserable people in my psychiatric clinic. Then I multiply by ten psychiatrists in my clinic. Then I multiply by ten similarly-sized clinics in my city. Then I multiply by a thousand such cities in the United States. Then I multiply by hundreds of countries in the world, and by that time my brain has mercifully stopped being able to visualize what that signifies.

This wasn’t supposed to be a Christmas post, but it took me longer than I expected to write, so here we are.

And this wasn’t supposed to be advocating any particular response, but I was recently asked to plug Giving What We Can’s pledge drive, and maybe one of the good responses to realizing how awful things are is committing to donate a little bit of what you’ve got to making them better.