I’ve been trying to understand mental illness for a long time. I’ve come up with some observations and opinions, but understanding is still bouncing around like a deer in the forest of my ignorance. Even though I’ve researched and directly observed mental problems, I have concluded that understanding mental disease is really hard.

Other people think that understanding mental disease is hard, too. I’ve heard them say so. They say a lot of the same things that I’ve said over the years. We’ve said that everyone’s got problems—the folks who are mentally ill should just suck it up like the rest of us. Or if they can’t do that, they should get some medication and stop doing these disturbing things. Sometimes we’ve said that there’s really no such thing as mental illness. It’s just a conspiracy between psychiatrists and drug companies.

I think these statements contain some truth, but they contain a lot of falsehood, too. Like I said, I have observations and opinions, not understanding. Certainly some people understand more than I do, but here’s my perspective for the heck of it.

I’ll start with whether mental disease even exists. After all, if it doesn’t then we can stop here and grab a drink. Some folks point out that no biomarkers or laboratory tests exist to diagnose mental illnesses. Therefore, there’s no proof that they really exist. That sounds pretty damning. But a little research made me ask myself whether Alzheimer’s really exists. Or Parkinson’s Disease, or angina, or migraines, because no biomarkers or lab tests exist to diagnose any of those. Heck, there’s no lab test for the common cold. So, I admitted to myself that just because you can’t perform a lab test for a disease, that doesn’t mean it’s imaginary.

By the way, sometimes diagnosis is shakier than we’d like. If you live long enough, you’ll probably hear a doctor say he doesn’t know what’s wrong with you, despite blood tests, x-rays, brain scans, and cameras up your bottom.

I’d gotten past the biomarker/lab test objection, but that still didn’t convince me that mental illnesses really exist. In fact, I had to ask myself why anyone would even come up with the idea of mental illnesses in the first place. I’m going to slide right past Freud and the super-ego here in favor of something more down to earth. I suspect that two things led us to the idea of mental illness. First, someone saw a bunch of people doing the same strange and harmful things over and over for no obvious reason. Second, a bunch of people described having the same strange and harmful experiences for no obvious reason. I agree that this explanation seems pretty weak. Watch people do stuff and listen to people describe stuff? Come on.

Yet I was shocked to find that doctors watch what people do and listen to what they say in order to help diagnose physical diseases. Doctors do this a lot, and they have for hundreds of years. Chronic fatigue, hallucinations, confusion, sleeplessness, loss of appetite, pain, and many other symptoms are good enough to diagnose physical illnesses, even though a doctor has to see them happen or ask the patient to describe them. So I expect that these kinds of symptoms may mean something when we’re talking about mental illnesses too. If a hundred men hallucinate because of brain tumors, and another hundred men hallucinate without brain tumors, does that mean the non-brain tumor guys hallucinated for no reason at all? Or maybe there really is something organic going on with these fellows, but we just don’t have a lab test for it.

By this point I was nearly convinced that mental illnesses exist, but my nasty, skeptical brain had to wonder if they’re just a concept invented by the pharmaceutical industry. Drug companies are making an ocean of money from the armada of drugs they sell for mental diseases. These companies aren’t known for turning down a buck, and they might have marketed some unnecessary drugs once or twice. Based on the explosion of psychiatric illness and medications, I suspect that mental illness is diagnosed too often, and psychiatric drugs are over-prescribed. Not every unruly child has ADD, and not every person with ups and downs is bipolar.

But drug companies also push all the drugs they can for physical illnesses—it’s not just a mental illness phenomenon. Doctors observed mental illness long before drug companies sold drugs for them. Hey, drug companies didn’t invent bipolar disorder—manic depression was identified in the late 1800s, long before anyone thought about selling Depakote. (Actually, manic depression was identified and named in 1875 by Jules Falret.) Despite my skepticism, I can’t buy the idea that thirst for profits has led to a gigantic mental illness hoax that practically every medical professional is in on.

So which folks are saying that mental illness just doesn’t exist? I skated around the internet for a while—admittedly a dubious source of information. But I wanted to see what these guys said about themselves. I found some organizations whose sites explained that mental illnesses are no more real than sugar plum fairies. They mainly said it was all a drug company conspiracy, and they used the biomarkers/lab tests argument as evidence. They tended to be a little lax about their research—one cited “a Surgeon General’s report.” I suppose it could have been the Surgeon General of Botswana—no way to tell. Some sites promoted the owner’s tell-all book. Sometimes I had to dig four layers deep to find out the site was owned by a noted research organization such as the Church of Scientology.

And who goes around saying that mental illnesses exist? I wasn’t surprised to find the usual suspects: government organizations like NIH and CDC, research hospitals, medical journals—and of course, drug companies. I understand that just because a lot of people say something’s true, that doesn’t make it true. But overall I found what seems like a lot of evidence on the “yes, mental illness exists” side. So I was convinced. Apart from the other arguments, I couldn’t swallow a giant conspiracy among almost everyone, leaving the Church of Scientology alone in the wasteland preaching the truth.

So if mental illness is real, why don’t the mentally ill just suck it up and stop bothering everybody else? I hear people say they’ve dealt with pain just as awful as any pain the mentally ill might have, and in my opinion they’re probably right. Mental illness doesn’t deepen someone’s capacity for emotional suffering. Most people deal with the pain in their lives and move on sooner or later. Why can’t mentally ill folks just decide to do the same?

Actually, a lot of them do. Some mentally ill people don’t realize or accept that they’re sick, even if the symptoms make them miserable. Others know they’re sick but decide to live without treatment for one reason or another. They may find ways to live a reasonable life. Some hold it together at work and go a little crazy at home—or a lot crazy at home. A few find jobs where outrageous behavior is accepted or maybe even expected. Some drink, or snort coke, or drive fast to self-medicate. There are lots of ways to more or less cope, some pretty benign and others pretty destructive. A lot of these behaviors are the ones that the rest of us find frustrating and that make the lives of mentally ill people unpleasant. Some people don’t cope so well, and they just bounce along out of control, wrecking their lives in colorful ways.

In some cases people will keep going like this their whole lives, and never consider treatment. Others tough it out for a few years or a few decades before they decide that doing something different would be better. Some try treatment and abandon it.

I learned a fascinating thing about mental illness and pain. Mental diseases are incurable. You have them forever, like that candy dish you got as a wedding gift. So the pain from mental illness isn’t exactly like the pain of grief. We know that grief will end; that’s part of what helps us get through it. Pain from mental illness isn’t any more intense, but it’s not going to end—or at least it’s always going to come back, and the owner of that pain knows it. The pain’s more like chronic arthritis and less like slamming your hand in a car door.

Now millions of people deal with arthritis pain without snorting coke or engaging in other bizarre behaviors. So what the heck’s wrong with all these mentally ill people? Can’t they do the same? Here’s another fascinating thing about mental illness. It affects your mind. It literally impairs your thinking machinery so that it can’t function at optimum efficiency. That doesn’t mean that mentally ill folks can’t think and make good decisions. But sometimes, when the disease is slamming them hard, their decisions may suck. It’s a bit like asking a diabetic person to make decisions using his pancreas. They won’t always be good decisions.

Another mental illness fun fact is that symptoms often hit for no obvious reason. Your average person may be devastated because his dog died, and that’s understandable. A mentally ill person may be devastated for no damn good reason other than his brain said it was devastation time. That’s hard to understand, especially when his thinking machinery’s impaired. I once observed a person with a severe mental illness, and I saw two things in her eyes: the realization that something was wrong with her, and the pain of not being able to understand what was wrong with her.

Before I talk too much about how difficult life is for the mentally ill, let me observe that dealing with mental illness isn’t about excuses. Any human can use anything as an excuse. Mentally ill humans are no different. In my opinion, dealing with mental illness is about decisions. That doesn’t mean that a mentally ill person can just decide to be well, or have no symptoms. And it’s true that his brain may not always produce the best decisions. And the options he has to choose from may range from reasonable to horrific. (A situation not limited to the mentally ill by the way.) But those are the options he has, and that’s the only brain he has handy to work with.

And that leads us to decisions about treatment, and especially about medication. Any mentally ill fellow has to decide whether to get help. That decision may seem more obvious if he can’t get out of bed for days, or he sees monsters that aren’t there, or he compulsively spends his family into bankruptcy. But even people with less severe symptoms look for treatment, and treatment is out there.

I personally have thought, “Hey, there are pills for this kind of thing. Take a pill every day, get this under control, and move on.” I thought that before the reality of brain chemistry revealed itself to me like a blossoming flower made of rancid Spam. How can I describe this? Say that prescribing cholesterol medication is like cooking a turkey. You’re dealing with just a few, well-understood factors like the size of the turkey and the oven temperature. You can still burn the heck out of a turkey, but it’s straightforward for the most part. Prescribing medication for a mental illness is more complicated. Instead of cooking a turkey, it’s like cooking a turkey of unknown weight in your neighbor’s fireplace by remote control from your own living room. You are dinking around inside a brain, so you have a lot more complications that are harder to see and less well understood. It’s often a trial and error kind of thing, maybe combining multiple drugs and trying different dosages before you find something that works. So it’s not exactly a “take a pill” proposition.

During the trial and error phase, the mentally ill person often feels worse than before, as an incorrect mix of drugs in the wrong doses careen through his brain like flying monkeys at a tea party. A fair number of people just give up on treatment at this point. Treatment that makes you feel worse seems like bad treatment, right? They go back to living their life without treatment and coping the best they can.

But some people stick with it and get to a drug combo that helps them a lot. That’s great, because now they’re not doing those things that the rest of us find so annoying, and they may be enjoying their lives more. Everything’s going smoothly, so naturally a bunch of them stop taking their drugs at this point and slide right back into all their awful symptoms.

Why the heck would someone do that? It seems crazy. Well, in fact there’s some bad decision making behind it, and we know he can have problems with his decision-making apparatus. But to put ourselves in the mentally ill person’s place, he now feels pretty good, so there’s a strong temptation to stop taking the $500 a month drugs that give him uncontrollable shakes and make him impotent.

As another side note, insurance companies are covering psychiatric drugs less often these days. The new ones are really, really expensive. The old ones are cheap but often have nasty side effects. So for people who can’t afford to pay a lot of money for drugs, there aren’t many great options.

Even with all of that crap going on, a lot of mentally ill people find a medication balance that works for them, and their lives get a lot better despite whatever side effects they’re willing to live with. That may or may not last. Brain chemistry changes, and the drugs that work for someone today may not work for him in five years. But if he hangs on for another round of trial and error, he can usually find another combo that works pretty well.

But there’s really no simple “take a pill” option. And the “just suck it up” option isn’t always realistic, depending on the severity of someone’s disease and their situation.

I still don’t have what I would call an understanding of mental illness, but I do intend to keep all this in mind the next time a mentally ill person is annoying me and I wish he’d just get his act together. As I said before, I think mental illness is about making decisions, not making excuses. A mentally ill person may have some great choices to select from, or all his choices may be appalling. That’s true of everybody though, mentally ill or not. The mentally ill have been metaphorically kicked in the crotch with regards to decision making ability, because their minds aren’t always in the best shape to make good decisions. But in the end, either they make the best decisions they can, or somebody else makes decisions for them, and I know which one of those I’d choose.