Monday, June 8, 2015

Another difference between red states and blue

“All people are born alike - except Republicans and Democrats.” — Groucho Marx  

I CAME ACROSS an article in The New York Times about the difference between red states and blue states in how mental health issues are treated — or not. Reading it made me curious about how the United States stacks up against other countries in terms of the prevalence of mental illness.

I did a little digging and discovered an article in The Atlantic from October 4, 2011 written by Alice D. Walton that contained this revealing statistic: "Over a 12-month period, 27 percent of adults in the U.S. will experience some sort of mental health disorder, making the U.S. the country with the highest prevalence." The Atlantic piece is so fascinating that I think I'll share it with you at a later date, but for now, here is the NYT article about the way reds and blues approach mental health.




Talking Red State Blues

By Seth Stephens-Davidowitz
June 6, 2015

WHEN you mull over the differences between states that vote for Republicans in presidential elections and states that vote for Democrats, what do you think about? Perhaps religion: People in red states are far more likely to believe in God. Or maybe media consumption: More people in blue states like NPR.

No surprise there. But there is a little-known difference between blue states and red states that is even more pronounced and perhaps more revealing, too, because it has major public health implications. Blue states are far more likely to use therapy to treat mental illness.

We do not have perfect data on therapy rates by state, but Google searches can give us a pretty good idea. In blue states, there are 54 percent more Google searches for psychotherapists — a broad category that includes searches like “find a therapist,” “counseling” and “cognitive therapy” — than there are in red states. We know that these results are not driven by population size or Internet use because Google data is normalized by total Google searches. According to my analysis of data from the Bureau of Labor Statistics, there are also 76 percent more psychologists or psychiatrists per capita in blue states.

Whatever stereotypes you might have, it is not true that people in blue states are more neurotic or depressed. People in red states and blue states are, roughly speaking, equally likely to take antidepressants.

Why the specific difference in therapy? Certainly, cost plays a big role. Red states, on average, have lower incomes and a smaller percentage of people covered by insurance. A higher percentage of people in red states live in rural communities, which have fewer therapists in comparison with cities.

But cost cannot be the whole story. Searches for many expensive health procedures, including Lasik eye surgery, plastic surgery and chiropractic care, do not show a red-blue divide.

What else is going on? One possible explanation is stigma. About 30 percent of Americans who now have mental health problems but are not in treatment cite stigma as a factor. Studies show that stigma is higher among men than women. Many people will feel O.K. going to a general practitioner and taking a few pills but seek to avoid more comprehensive treatment with therapists.




Is stigma against therapy higher in red states? There are a lot of facts that are consistent with this hypothesis. According to Google AdWords, men in red states make up a smaller portion of visits to therapy sites like allaboutcounseling.com. Or consider this measure of stigma: What percentage of people in therapy tweet about it? If you broadcast it on social media, you probably don’t feel much stigma.

I downloaded a week of tweets that contained the words “my” and “therapist.” I found about 600 for which I could clearly determine a tweeter’s home state and that he or she was referring to a psychotherapist rather than a physical therapist.

I estimate that, per capita, Americans in blue states are about 100 percent more likely to tweet about their therapist.

This does not seem to be driven by people in blue states’ tweeting way more often about medical problems. Americans in blue states were only about 15 percent more likely than those in red states to tweet about their dentist.

There is one more point of evidence that red state residents choose to avoid talking about their problems: Alcoholics Anonymous. This program is freely available to anyone in the United States, so income and health insurance availability do not play a role. The evidence is that people in red states and blue states are roughly equal in their propensity to become addicted to alcohol.

There is no official data on A.A. membership by state. But according to Google search data, A.A. is significantly more popular in blue states than in red states. In fact, 14 of the 15 states where A.A. is most popular supported President Obama in 2012 (Arizona is the exception). This is even more remarkable since God and prayer play big roles in A.A.

How does stigma end? Friends and family play a crucial role, but celebrities do, too. Deborah Serani, a psychotherapist in New York, noticed an increase in the number of young men seeking treatment in August 2012. Some of these men told her they had been motivated by a profile of Bruce Springsteen in The New Yorker, in which Mr. Springsteen says he has spent decades in therapy.

Google data tells us that Mr. Springsteen is significantly less popular in red states in the Midwest and South. (The New Yorker, you will not be shocked to learn, is even less popular in these regions.)

Mr. Springsteen’s admission is part of a broader pattern. Celebrities who are more popular in blue states are more likely to disclose that they are in therapy.

I took a list of the 500 most famous living Americans, based on Wikipedia views. I correlated the popularity of each celebrity in every state with Mr. Obama’s 2012 vote share in that state. Let’s call celebrities who are popular in states where Mr. Obama did well and unpopular in states where Mitt Romney did well blue celebrities. The bluest celebrities tend to be comedians, film directors and baby boomer rock stars.

Right near the top of the list of celebrities more popular in blue states than red states are Howard Stern and Woody Allen. It is hard to think of two celebrities more associated with therapy. Mr. Stern has been telling his millions of mostly blue state listeners for years of therapy’s importance in his life — and recommending it to numerous celebrity guests.

Woody Allen is, well, Woody Allen.

Other men who are more popular in blue states and have spoken about their therapy include David Letterman, Jack Nicholson and Conan O’Brien.



The reddest celebrities tend to be professional wrestlers, military heroes and action movie stars like Chuck Norris. A humor website, Chuck Norris Facts, celebrates Mr. Norris’s toughness. One of its facts: “Chuck Norris doesn’t go to therapy. Therapy goes to Chuck Norris.”

Another red celebrity is Dwayne Johnson, an actor and former professional wrestler better known as the Rock. The only connection between him and therapy I could find was a Facebook post where he notes that weight training is his therapy. “Heavy iron fights the pain,” he wrote. “And it’s cheaper than a shrink.”

For each of the 500 celebrities, I did a Google search with his or her name followed by the word “therapist.” I then coded if any of the top 10 returning links showed them saying they were in therapy. This is a highly imperfect methodology. One problem: Some celebrities, like John Goodman, share their name with many therapists.

Even with this blunt methodology, a very strong, statistically significant relationship emerges. The more popular a celebrity is in blue states relative to red states, the more likely he or she is to have spoken of being in therapy.
Does it matter that people in red states are so much less likely to go to therapy? Yes. Evidence consistently shows that therapy is about as effective as antidepressants for treating depression and that the best treatment is usually a combination of therapy and medication.

For some people, growing up in an environment where few people talk openly about their struggles and their favorite celebrities seem capable of making it on their own can have tragic effects.

Consider the story of Jason Dannen of South Dakota. He told his wife, Stephanie, that he always felt like a “black sheep” because he was adopted, and his siblings were biological. He struggled with depression most of his life.

He eventually went to a general practitioner and told her he needed antidepressants. He took the medications inconsistently, repeatedly complained of side effects, and showed little interest in seeing a mental health specialist or trying therapy. His wife said he felt the need to be the man of the house, which to him meant helping others, not getting help.

“He just thought he could get a handle on it or it would improve over time or something,” Ms. Dannen said. “I’m not really sure what his thoughts were. Without medication and counseling, he wasn’t really doing other things to make it better.”

In 2002, at the age of 28, he killed himself with a rifle shot to the head.

Of course, even with therapy, not everybody who committed suicide would be alive. But some would be, and many more depressions would lift. “We know that many more people could be helped than are actively in treatment,” said Dianne Chambless, a professor of psychology at the University of Pennsylvania.

Compared with blue states, red states have roughly 30 percent higher suicide rates and around 20 percent higher rates of major depression. Among many other factors, lack of therapy is probably playing a role in these outcomes.

Sure, therapy can be pricey, but it is important to keep the costs of depression in mind. A recent study led by Paul E. Greenberg of the Analysis Group, an economic consulting firm, found that the average person with major depression costs some $7,000 per year in lost economic productivity. In study after study, therapy easily passes the many cost-benefit tests that have been applied to it.

I am an economist, so I tend to think about budgets and policy. More people with mental illness need better insurance coverage. Americans in rural areas need access to good care. Perhaps online therapy can play a role here. But the data suggests that the problems with mental health care go far beyond economics.

3 comments:

  1. I am not surprised. Having lived in both red and blue states, I've seen that same pattern. I've seen the attitudes about solving things yourself or with religion and the difference in who will seek help and who will not. I'd add the variant of education level to the charts but frankly, that seems to follow the same general map as well.

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  2. I think the same, or at least a related attitude about solving problems for yourself no matter how big they are, (or thinking that your religious organization should be adequate help for any problems) speaks to who they believe deserves or does NOT deserve outside help.

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  3. Hi DJ M. Nice to hear from you. And you, of course, Liz — always.

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