What Went Wrong with the American Dream?
What Went Wrong with the American Dream?
Abstract and Keywords
This chapter considers a number of indicators relating to the well-being of American children and adults in order to examine the extent to which the American Dream is fulfilling its promise. For children, it considers levels of happiness, academic achievement, mental health, and economic mobility. For adults, it considers happiness, mental health, and life expectancy (including the rise of “deaths of despair”). All these indicators show that the United States is failing radically with respect to both children’s and adults’ well-being. These results are not surprising, the last section of the chapter shows, when we take into account the health of the nation’s families. Neither adults nor children can thrive without sound family ties. Yet indicators show that American families are in bad shape, and in considerably worse shape than families in other countries.
Most Americans believe that our nation has veered badly off course, but they aren’t clear about what exactly has gone wrong. We hear a steady drumbeat of bad news about the state of the nation—the mediocre school performance of our kids, the opioid crisis, skyrocketing rates of mental illness and teenage suicides, decreased lifespans—but it’s difficult to figure out what the common thread is. This chapter brings these issues into clearer focus.
These problems, the rest of the book will show, are all tied to the collapse of the American Dream in the past five decades. I don’t mean “American Dream” in the way the term is often used today, simply to describe people having the chance to get rich. The more generous version of the Dream that I’m talking about, sounded more loudly in the past, dreams much bigger: as articulated by James Truslow Adams in the introduction’s epigraph, it envisions a country that doesn’t stand passively by while fate or forces buffet its citizens. Instead it constructs (in Adams’s words) a “social order” aimed at ensuring that all people attain “the fullest stature of which they are innately capable,” regardless of where or to whom they’re born. And, further, that social order allows everyone the opportunity for a “better and richer and fuller” life. This is a more ambitious way to think about the goals of society than we Americans generally think about them today. The Dream means that the social order is supposed to do much more than just allow people the opportunity to compete in the market: it’s supposed to enable them to flourish. And it’s the loss of this vision of our social order that is responsible for Americans’ deep slide downward on so many measures, as well as their pessimistic view of our country.
One helpful way to think about this broader conception of the Dream’s promise is to see it as setting up an infrastructure or scaffolding that supports Americans as they lead their lives.1 For that promise to be fulfilled, that scaffolding needs to handle two projects particularly well. First, it needs to support kids’ thriving and developing their potential so they achieve their full promise as (p.4) adults. Second, it needs to support the basic well-being and soundness of adults, so that they have the opportunity to live their lives well.
This chapter pulls together indicators to consider how well America is faring on these two projects. The picture that emerges shows that we are failing radically on both counts. Children aren’t thriving, and they’re falling far short of achieving their potential. Meanwhile adults are, in increasing numbers, unhappy and anxious, and they feel cut off from the social fabric of the community.
These results are not surprising, the last section of the chapter suggests, when we turn to consider the health of the nation’s families. American thinkers too often conceive of people as creatures who build their own lives from the ground up. But humans don’t construct their lives from scratch. Instead, they are born into families and lead their lives as members of institutions—family, school, place of worship, work—that shape them and that, in turn, they negotiate and reshape over time. The well-being of citizens is integrally related to the well-being of these institutions. When these institutions founder or citizens are distanced from them and find no suitable replacements, large holes are created in the social fabric. Of all these institutions, the one most closely associated with both children’s well-being and potential and adults’ flourishing is the family. Yet American families are in dismal shape because, as I’ll show, our social order doesn’t support them. It is no coincidence that, with our families in turmoil, the well-being of both children and adults are undermined.
The State of America’s Children
The American Dream should offer its greatest promise to our nation’s children. Whether Americans will lead rich, full lives later on depends in large part on whether they get the support they need to flourish as children. To what extent does our social order today support getting children what they need?
A substantial portion of this book will link US kids’ failure to flourish to the economic stress our system puts on families. That stress interferes with the ability of families to raise their children well, particularly in those crucial early years. Families need to serve several functions in order to raise sound children. To begin with, parents must satisfy children’s needs for “attachment.” The critical importance of the bond between parent and child was first recognized when researchers studied orphans during World War II. As the British psychologist John Bowlby observed, “[M]other-love . . . is as important for mental health as are vitamins and proteins for physical health.”2
Beyond attachment, children need loving interactions with a parent. It turns out that whether children receive this loving care early on affects the (p.5) most basic aspects of their development, including the way their brains are wired for the rest of their lives. The National Scientific Council on the Developing Child put it this way: “Young children experience their world as an environment of relationships, and these relationships affect virtually all aspects of their development—intellectual, social, emotional, physical, behavioral, and moral.”3 Kids’ interactions with their parents are so important that neglect can be a bigger threat to children’s development than abuse: young children who are severely neglected often wind up having more extreme cognitive and behavioral problems as they mature than children who were abused physically.4
Families serve other important functions for children as well. For one, they provide or arrange for the tens of thousands of hours of caretaking kids need before they are old enough to care for themselves. It turns out that the quality of caretaking kids receive is critical to both their academic achievement and their social and emotional development.5 Families also provide or arrange for much of the human development necessary for children to gain the knowledge and skills they need to take their place in school, in the social world, and, later, in the workplace. Parents do this directly by reading to young kids, talking to them, taking them places, and playing games with them, as well as making sure they get their homework done in later years. Families also facilitate their kids’ development indirectly through enrolling them in daycare and preschool programs and, later, in schools and aftercare programs.
And last, but every bit as important, families provide the income for many of the market goods and services that children depend on. Children need a constant stream of resources to do well—a roof over their heads, food, diapers, clothing, books, and at least a few toys. If children don’t get the resources they need, it fundamentally and permanently interferes with their development.6 While we don’t expect families to provide all the goods and services that children require—for example, the government pays for public schooling during the K–12 years—in the United States today, we do expect families to pay for many of these resources.
There’s no single indicator that, in and of itself, shows how well kids are doing or whether they’re developing to their full potential. But four measures together can give us at least a strong preliminary sense: kids’ reports of their levels of happiness, as well as measures of academic achievement, mental health outcomes, and economic mobility. In the United States, the picture of our children shown by these indicators is not a happy one. Our society is doing a disturbingly bad job of giving our next generation a sound start. On many measures, we are doing a much poorer job than in past decades. What’s more, compared with those of kids from other countries, our kids’ outcomes range from mediocre to downright subpar, depending on the measure.
Let’s start with children’s own sense of satisfaction with their lives. You might think the United States would top the scale given our great national wealth. Not so. When children from developed countries are ranked on life satisfaction, US kids fall below the average. One recent United Nations study of twenty-seven industrialized countries ranked our country tied for fifteenth along with seven other countries, including the Slovak Republic and the Czech Republic. That puts us below not only wealthy countries like Sweden, the Netherlands, and Spain but also countries that are far poorer than our own such as Estonia and Slovenia.7
But if our kids aren’t the happiest, at least they outperform students from other countries in academic achievement, right? Wrong. Despite the considerable pressure American kids feel to do well in school, as well as the comparatively long hours they put in studying, our kids’ academic performance is stunningly mediocre compared with kids’ performance in other wealthy countries.8
As Figure 1.1 shows, the United States ranked fortieth on the mathematics portion of the Programme for International Student Assessment (PISA), a test administered to fifteen-year-olds worldwide in 2015.9 That’s well below the average of our peers in the Organisation for Economic Co-operation and Development (OECD), a group of wealthy nations of which the United States is a member. We were beaten by, among others, Vietnam, Russia, the Czech Republic, Portugal, Spain, Latvia, Malta, and Lithuania. Almost three in ten US students didn’t even reach the baseline level of competence on math, the level that enables students to participate fully in modern society.10 Our students did somewhat better, but not well, in science and reading, finishing in the twenty-fifth and twenty-fourth places, respectively.11 All this is in spite of the fact that many of the countries that left us in the dust on the PISA spend far less on primary and secondary education than we do.12
Our kids’ mental health outcomes are even more troubling. According to the Centers for Disease Control and Prevention, up to one in five American children aged two to seventeen has a diagnosable mental, emotional, or behavioral disorder in a given year—and these rates are rising.13 There’s good (p.7) (p.8) reason to believe that these rates are far higher than those in the rest of the developed world.14 Rates of serious depression, anxiety, and suicide are shooting up among our teens.15 And five or more times as many US college students today meet diagnostic cutoffs for mental health disorders as met them during the Great Depression, even controlling for changes in diagnostic standards.16
Faith-Ann Bishop, a teen who lives outside Bangor, Maine, has lived these issues firsthand. When she was in eighth grade, late at night while her parents slept, she cut herself with a metal clip from a pen while sitting on the edge of the bathroom tub. The first cut was in her hand. The next sliced into the skin near her ribs. The act made her feel intense relief, dulling the throbbing intensity she felt the rest of the time—about grades, her future, school, and everything else. “It makes the world very quiet for a few seconds,” said Faith-Ann. “For a while I didn’t want to stop, because it was my only coping mechanism. I hadn’t learned any other way.” Her doctors eventually diagnosed Faith-Ann’s cutting as the expression of deep-seated depression and anxiety—conditions she shares with millions of other US teens.17 What they couldn’t explain was why so many US teens suffer from these conditions today, and why their rates are still rising.
Perhaps unsurprisingly, youths from poor and low-income families have higher rates of anxiety and depression than the national averages. But it turns out that the rates among youths whose families are at the top of the income ladder are also far higher than average. If anything, the recent rise in anxiety and depression is concentrated among teens from well-to-do families.18
Last but not least when it comes to measures of our next generation’s well-being is economic mobility. The American Dream suggests that each generation will do better than the last, as each generation raises its children to exceed its own level. The Dream also contemplates that children’s potential won’t be constrained by which family they happen to be born into. Sadly, neither of these promises holds for our nation’s children today.
When the Harvard economist Raj Chetty and his colleagues calculated the proportion of US kids in a generation who, when they grew up, earned more than their parents had, a measure called “absolute economic mobility,” they discovered the rate had fallen sharply in the past five decades. As Figure 1.2 shows, nine in ten children born in 1940 earned more at age thirty than their parents had at the same age. But only five in ten children born in the 1980s (p.9) did the same.19 Put another way, generational progress on wages has flatlined; we’re no longer providing our next generation with what it needs to exceed us economically.
When we turn to look at the extent to which young adults are constrained by their parents’ place on the economic ladder, a measure known as “relative economic mobility,” there’s good news and bad news. The good news, again calculated by Chetty and his colleagues, is that our rate of relative mobility hasn’t dropped in the past few generations. The bad news is that our rate is stuck at a disturbingly low level. Only one child in thirteen from a family in the bottom fifth of the income distribution will make it to the top fifth of the income distribution in adulthood. That’s a far lower proportion than in many other countries. More than one in seven children born into the bottom fifth of the income distribution in Canada will do the same, as will more than one in nine children in Denmark. As Chetty bluntly put it, “[Y]our chances of achieving the ‘American Dream’ are almost two times higher if you’re growing up in Canada relative to the United States.”20
The State of America’s Adults
To what extent is our social order supporting adults in leading the rich, full lives that the American Dream promises? Here, as well, our indicators suggest that something has gone badly awry in our nation. In the next chapters, we’ll (p.10) see that the downturn in adults’ well-being is linked to the stress our economic system is putting on family relationships. For now, let’s briefly note the important role that these relationships play in the lives of adults. Families, of course, don’t play the same formative role for adults that they do for children. Yet solid family ties—whether in a family of birth or of choice—are still critical to the well-being and happiness of adults. Humans need caretaking and are social by nature. So when the American Dream offers a life that is “better and richer and fuller for everyone,” for most adults that’s a life woven through with close family relationships.21
Robert Waldinger is the director of the Harvard Study of Adult Development, which has been following a group of more than seven hundred men for three-quarters of a century. When these men were first interviewed, as sophomores in college, they believed that having a good life required fame, wealth, and achievement—exactly the narrow interpretation of the American Dream that many hold today. They were wrong. As Waldinger put it:
The clearest message that we get from this 75-year study is this: Good relationships keep us happier and healthier. Period. . . . We’ve learned . . . that social connections are really good for us, and that loneliness kills. It turns out that people who are more socially connected to family, to friends, to community, are happier, they’re physically healthier, and they live longer than people who are less well connected. . . .
Once we had followed our men all the way into their 80s, we wanted to look back at them at midlife and to see if we could predict who was going to grow into a happy, healthy octogenarian and who wasn’t. And when we gathered together everything we knew about them at age 50, it wasn’t their middle age cholesterol levels that predicted how they were going to grow old. It was how satisfied they were in their relationships. The people who were the most satisfied in their relationships at age 50 were the healthiest at age 80. And good, close relationships seem to buffer us from some of the slings and arrows of getting old. Our most happily partnered men and women reported, in their 80s, that on the days when they had more physical pain, their mood stayed just as happy. But for the people who were in unhappy relationships, on the days when they reported more physical pain, it was magnified by more emotional pain.22
Solid family ties are important for more than adults’ happiness. As parents age, it’s most often their adult children who step up to help with caretaking.23 (p.11) When family members face serious illness, economic hardship, divorce, incarceration, or drug abuse, other family members play critical roles in helping them through—stepping in with caretaking, money, household upkeep, and driving.24 In a world that is, in many ways, less stable than it used to be, families remain an important source of stability.25
When we consider a range of indicators relating to US adults—happiness, mental health, and life expectancy—just like the indicators relating to US children, it’s clear that something has gone very wrong. Despite the promise of the American Dream, an increasingly large proportion of adults are not thriving, and many feel desperately removed from even the possibility of leading rich, full lives.
As with our kids, our country’s wealth hasn’t helped adults’ happiness much. Among the citizens of thirty-eight developed countries compared in one recent study, Americans reported that they were less satisfied with their lives than adults in fourteen other countries. That puts us far behind countries much less wealthy than our own.26 What factors might be dragging down our happiness levels? In the words of Carol Graham, an economist who studies happiness: “A stable marriage, good health, and enough—but not too much—income are good for happiness. Unemployment, divorce, and economic instability are terrible for it.”27
While we often think of depression and anxiety as stemming from a problem with brain chemistry, accumulating evidence suggests that they have as much or more to do with our social circumstances.28 As the World Health Organization put it, “Mental health is produced socially: The presence or absence of mental health is above all a social indicator and therefore requires social, as well as individual, solutions.”29 How is our social order doing at supporting sound mental health? Badly. The United States has the third most depressed population in the world, as indicated by the number of quality years of life lost due to disability or death, a measure widely used to track the burden of disease. That’s not just a comparison with other wealthy countries, but with all countries: we come in third behind China and India. When it comes to rates of anxiety, schizophrenia, and bipolar disorder, we also come in third place.30 Overall, about one in five adults in the United States experiences a mental illness each year.31
Measures of life expectancy reveal an equally disturbing picture. In the three years between the beginning of 2015 and the end of 2017, American life expectancy declined each year. That made it the longest period of decline since the years between 1915 and 1918, a period that included World War I and a vicious flu pandemic that killed roughly 50 million people worldwide. Unlike a century ago, though, we have no major war or worldwide pandemic to explain this decline. And in other developed countries, life expectancy has continued to tick steadily upward for decades.32 This decline is, in one expert’s words, a “uniquely American pattern.”33
Experts point to two causes of the drop in life expectancy. The first is the rise of drug overdoses, fueled by the opioid crisis. In 2017, the nation set a record of 70,000 fatal drug overdoses. Opioids alone took a total of 47,600 lives in that year, six times the number of opioid deaths as in 1999.34
The second factor in the drop in life expectancy is the suicide crisis gripping the nation. Our national suicide rate has risen 25 percent in the past twenty years.35 Almost 45,000 Americans took their own lives in 2016 alone.36 And this increase has occurred despite the fact that, during the same period, options for treating depression have multiplied. Experts don’t think the wider availability of treatments for depression is somehow backfiring and causing more suicides. As one put it, “I think the increase in demand for the services is so huge that the expansion of treatment thus far is simply insufficient to make a dent in what is a huge social change.”37 Single Americans are particularly vulnerable. In 2005, single, middle-aged people were about three times as likely to take their own lives as were married people.38
How can we account for the opioid and suicide crises, and the accompanying drop in US life expectancy? In 2015, two Princeton economists, Angus Deaton and Anne Case, noted that death rates had begun to increase significantly at around the turn of the century for one particular group—middle-aged whites with no more than a high-school education—a group that used to be identified as the “white working class.” That increase is especially shocking given that death rates have decreased in every other age group, every other racial and ethnic group, and every other wealthy country during those years.39 Figure 1.3 charts the death rates since 1990 for people aged 50–54 in other developed countries compared with the death rates for US whites with no more than a high-school education in that age range.
When Deaton and Case sought the source for the increase in death rates among this group, they discovered that it came from a growing number of suicides, drug overdoses, and alcohol-related diseases, which they came to call “deaths of despair.” They surmised that shrinking job opportunities for less-educated white (p.13) Americans have caused a cascade of changes, including changes in family life, that have contributed to patterns of risky behavior that cause early death. In their words:
These changes left people with less structure when they came to choose their careers, their religion, and the nature of their family lives. When such choices succeed, they are liberating; when they fail, the individual can only hold him or herself responsible. In the worst cases of failure, this is a . . . recipe for suicide. We can see this as a failure to meet early expectations or, more fundamentally, as a loss of the structures that provide meaning to life.40
Key among the structures that lend stability and impart meaning to Americans’ lives is a sound family. And in America today, that structure has become unsteady.
Sound Families and the American Dream
Our country should have real advantages when it comes to maintaining sound families. For one thing, in the wealthiest country in the world, most families can afford labor-saving devices and services that lighten their workloads. For (p.14) another, Americans still believe in strong marriages and stable families, and continue to put family at the top of their list of priorities. Somehow, though, a yawning gap has opened up between our desires and our lived reality. This gap is present between parents’ desires and the way their families function on a day-to-day basis, with parents being constantly overwhelmed trying to balance their work and family lives. And the gap is there even when it comes to the basic structure of families, as adults’ desires for stable partners and families have failed to be realized: the United States now leads the world in family instability—a prize that no country hopes to win.41
American families are stretched thin and stressed out by the conflicting demands of home and paid work. Add the long hours that American parents spend in the workplace to the unpaid hours they spend parenting, and the sum is long days and crazy weeks. The total paid and unpaid workload in middle-class families where both parents work full-time is a stunning 135 hours a week—close to ten hours a day, seven days a week for each parent. And that workload increases for single parents.42
The result is that more than half of American parents find it difficult to balance work and family life, and more than a third always feel rushed, even just to do the things they have to do.43 In one study, zero percent (not a typo) of mothers said they often had time to spare, and just 5 percent of fathers said the same.44 To compensate, working parents empty out the other areas of their life beside work and children. Today’s parents are far less likely than parents were two generations ago to spend time together with their spouses eating, socializing with friends, or working on projects around the house.45 Sleep goes by the wayside—employed mothers get three fewer hours a week than those who don’t work for pay. Another casualty is leisure time. Employed mothers have nine fewer hours of free time a week than women who don’t work for pay.46 Most full-time working mothers report that they have too little free time for themselves. Most married fathers say the same.47
A major consequence of this stress is that US parents are much less happy than grown-ups who don’t have kids. As I described in the introduction, the “happiness gap” between parents and nonparents is much larger in the United States than in other developed countries. Figure 1.4 shows that the United States had the largest gap of the twenty-two countries compared by researchers, and by a substantial margin. In eight of the countries surveyed—Portugal, Hungary, Spain, Norway, Sweden, Finland, France, and Russia—parents reported being happier than nonparents.48
It’s not just how American families are functioning that is under stress; even the stability of our family structures is under siege. Americans still believe that marriage is the best form of family life. Those who marry believe that their marriages will last forever.49 And most of those who haven’t been married would like to be.50 These beliefs, though, don’t translate into stable relationships. After just five years, more than one-fifth of American married couples have either separated or divorced.51 And cohabiting relationships, which are on the rise, are even less stable than marriages. Almost half of cohabitating couples break up within five years, and the breakup rates appear to be increasing.52 The instability of these relationships means that a high proportion of American children will see their parents break up during childhood.53
(p.16) How do we stack up against other countries on family stability? Poorly. Our divorce rates rank among the highest across wealthy nations.54 For US children born to married parents, approximately 25 percent will see their parents break up by the time they’re twelve, compared with less than 15 percent in Norway and France, and less than 10 percent in Belgium.55 And while couples in other countries have more children outside of marriage, their cohabiting relationships are also far more stable than our own.56 Compared with the almost half of American children born to cohabitating parents who will see their parents’ union dissolve by age twelve, only about one in five children will see the same in France, Norway, and Belgium. And children in these other countries will experience far fewer familial transitions on average than US children.57 In fact, Sweden’s relationships generally are so much more stable than US relationships that a set of unmarried parents in Sweden is more likely to stay together than a set of married parents in the United States.58 Overall, more than 21 percent of kids aged zero to five in the United States live with just their mother, the highest rate by far of any OECD country. By comparison, this value is 8 percent in Finland and 10 percent in France.59
The instability of American families, though, is concentrated among particular economic groups. To begin with, people’s rung on the economic ladder has a lot to do with whether they’ll get married. As Figure 1.5 shows, women with bachelor’s degrees are far more likely to marry than their less-educated counterparts (p.17) (the same is true of men). Of college-educated women in their early forties, three-quarters are married. Women that age who have finished high school but not a four-year college trail behind by about 10 to 15 percentage points depending on whether they have some college education; women who haven’t finished high school trail those with bachelor’s degrees by almost 20 points.60 This is a significant twist compared with the past. In the 1950s, those with high school but not college degrees—the group most identified with the working class—were the most likely to be married. Today, less-educated couples increasingly find themselves confined to the far less stable institution of cohabitation.61
A big divide exists as well when it comes to divorce. About half of first marriages in the United States survive at least twenty years. But women with a college education have a far higher chance of still being married: eight in ten. Meanwhile, women with some college have a five in ten chance of still being married. For women with a high school degree or less, that chance drops to four in ten.62 In recent years divorce rates overall seem to be declining somewhat, but that’s largely because less-educated Americans are marrying less often than they used to, thereby removing the least stable relationships from the pool of marriages that could end in divorce.63
The same massive disparity shows up when it comes to nonmarital births. In 2017, 52 percent of births to women without a high school degree occurred outside of marriage. That figure was only slightly reduced—50 percent—for women with high school degrees but no college education. But only 13 percent of women with college degrees gave birth outside of marriage.64 The bottom line is that today few college-educated women will have children outside of marriage. Just the opposite is true for women without college degrees: only three in ten will have all their children within marriage.65
The growth in family instability toward the bottom of the economic ladder has created a huge divide in the family structures in which American kids are raised. If you were a child in the early 1980s, it didn’t much matter which side of the tracks your family lived on; you were very likely to be raised by both your parents.66 Today all that has changed. Eight in ten fourteen-year-old girls whose mothers are college graduates live with both parents. But this is true for just six in ten girls of mothers with high school but not college degrees, and just half of girls whose mothers haven’t graduated from high school.67 In terms of race and ethnicity, over half of black children and almost a third of Hispanic children live with a single parent. The same is true for less than a fifth of white children.68
As the law professors June Carbone and Naomi Cahn summed up the situation, “Marriage, once universal, . . . has emerged as a marker of the new class lines remaking American society. Stable unions have become a hallmark of privilege.”69 Marriage is still flourishing among the third of Americans with college degrees, even as it is increasingly unattainable for everyone else.70 In the middle (p.18) of the twentieth century, stable families weren’t confined to any particular portion of the economic spectrum. Today, though, families toward the bottom of the economic ladder have far less chance of achieving stability than their more well-heeled counterparts.
The steady stream of bad news about Americans’ declining well-being is delivering the message loud and clear, if only we will listen, that our social order is badly failing us. Children are unhappy, anxious, and aren’t coming close to achieving their full potential. Adults are in no better condition, and their despair is reducing their lifespans. Meanwhile, the fragile state of the nation’s families leaves them unable to perform the tasks we need them to perform. The common link connecting all these things is the expectation underpinning American public policy that families will privately arrange the circumstances they need to flourish without any help from government. I turn to this expectation and the nation’s public policy system built upon it in the next chapter.
(1.) The term “infrastructure” is used by Heather Boushey in her book, Finding Time (2016).
(7.) OECD (2015a), 174, fig. 4.32, analyzes data from the World Health Organization, Health Behaviour in School-Aged Children (HBSC, 2009/2010 Survey). See also UNICEF (2013), 39, fig. 6.0; OECD (2017a), 39, fig. III.1.1, which rates the US average life satisfaction score of fifteen-year-olds twenty-eighth out of forty-eight countries and economies.
(15.) Twenge et al. (2019). Regarding suicide rates, see Plemmons et al. (2018); Curtin et al. (2018), 3; Centers for Disease Control and Prevention (2017). Regarding the prevalence of anxiety and depression, see Bitsko et al. (2018), 399; Weinberger et al. (2018), 1310; BlueCross BlueShield (2018), 6; Mojtabai, Olfson, and Han (2016), 4. See also Perou et al. (2013); Twenge (2015).
(25.) Bengston (2001).
(30.) World Health Organization (2018).