As Donald Trump stumped his way across America, now positioned to secure the GOP nomination next week, the media wrote about “Trump traumatic stress disorder “and “Trump phobia”. A Letter to the Editor described “Trump phobia” as an “epidemic among liberals.” There is a website dedicated to this “new” mental illness, and advice for combatting it ― move to Canada or “get over it.” As a psychiatrist, I find the jocular and dismissive tone of these articles off-putting. First, Americans have the right to hold different political opinions; this does not make them mentally ill. Second, calling concerns about a Trump presidency a “phobia” belittles the millions of Americans who suffer every day from severe anxiety and fears that wreck their lives. This trivialization of mental illness—and anxiety disorders in particular― smacks of ignorance and perpetuates stigma.
Over 93 million Americans will suffer from an anxiety disorder in their lifetime, according to a large epidemiological survey. In this survey, these disorders―from most to least common―included: specific phobias, social phobia, posttraumatic stress disorder, generalized anxiety disorder, separation anxiety disorder, obsessive-compulsive disorder (OCD), and agoraphobia. At the rate of 28.8%, anxiety disorders were more common than all mood disorders (20.8%) and all substance use disorders (14.6%). This makes anxiety disorders more common than most illnesses, including diabetes, congestive heart failure, and prostate and breast cancer. For comparison, there have been 1,133 cases of Zika virus reported in the United States (as of 7/6/16).
Anxiety disorders are not only common, they are also disabling. In 2012, when the World Health Organization, or WHO, listed the top 20 diseases that cause global disability, anxiety disorders were 6 on this list. Anxiety disorders disable in many ways. Because they typically start in childhood or adolescence, they can interfere with normal development. For example, a child with social phobia may not speak up in class or socialize with their peers; this can lead to poor grades and social isolation during adolescence and failure to launch to independence, with lifelong consequences. Anxiety symptoms also interfere with daily function. It is hard to perform at your job or to care for your family if you worry incessantly, as in generalized anxiety disorder, have recurrent panic attacks, as in panic disorder, or spend hours each day obsessing and ritualizing, as in OCD. Finally, people with anxiety usually avoid situations that trigger it. Thus, a person with a needle phobia may avoid medical care, a person with fear of open spaces, or agoraphobia, may become house-bound, and a person with OCD fears of contamination may avoid physical contact with loved ones. This avoidance then becomes disabling―like the woman I treated who developed end-stage heart failure because her pill phobia prevented her from swallowing her blood pressure medications; the man with social phobia who suffered a heart attack in Central Park but walked himself to the emergency room because he was too fearful to ask a stranger for help; and the mother with OCD who could not hold her newborn because of intrusive thoughts that she would harm him.
The good news is that effective treatments exist. These include cognitive-behavioral therapy, or CBT, and specific medications. Either alone or in combination these treatments can help many, although not all become well. Given that anxiety disorders often predate other disorders like depression and substance abuse, early intervention for anxiety might even prevent or mitigate the subsequent development of these other disorders. Thus, treating anxiety makes good public health sense.
The bad news is that many do not receive effective treatment. Some people feel stigma and avoid seeking help, some health care providers do not know how to diagnose or treat anxiety disorders, and some insurances still stint on mental health coverage, despite parity being the law. Another problem is that CBT—one of our most effective treatments—is often not available in routine practice.
Many diseases deserve attention. For example, the Bill & Melinda Gates Foundation chose in 2010 to focus on combating infectious diseases in developing countries, an important cause. However, to rescue children from the frying pan of infectious disease only to toss them into the fire of untreated mental illness―with anxiety disorders in childhood leading the way―seems problematic at best. Others advocate focusing on mental illnesses more likely to lead to hospitalization, e.g., schizophrenia, or death, e.g., anorexia nervosa. However, given the societal costs of anxiety disorders in the U.S.―estimated at over 42 billion dollars per year in 1990--and the effectiveness of current treatment, treating anxiety disorders makes good economic sense. In fact, a recent study in the Lancet found that the return on investment for scaling-up effective treatments for anxiety was favorable across the globe.
If society mobilized around anxiety disorders, the public health and economic impact could be great. Three steps are needed. First, launching comprehensive public education campaigns―that include teachers, primary care providers, and pediatricians―to spread the word that anxiety disorders are real, serious, and treatable. Second, ensuring that evidence-based treatments, including CBT, are widely accessible in all health systems, which technology can help. Lastly, supporting research as to what causes anxiety disorders to pave the way for prevention and cures. These steps are well within our reach. If we don’t take them, we ignore the plight of millions of Americans and miss a rare opportunity to improve the health of both