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.