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Tuesday 29 November 2011

You Too Can Be Mentally Ill!

Please indulge me in a simulated interview for this post; it's a paraphrase of some conversations we've been having around the clinic. 

Why do we bother diagnosing illnesses?

There are several reasons, some of them a bit cynical. The most important one, from a public health perspective, is to guide treatment. We can take a variety of signs and symptoms, use these as clues to find the common problem producing all of them, and then target that problem. The label guides the treatment.

But why do we treat illnesses?

So that people can be healthier, happier, and (perhaps) more productive.

That’s what I thought.

Yes. But in the field of mental health there are significant controversies about diagnosis.

For one thing, psychiatric diagnosis often fails the treatment specificity test. Knowing a person’s diagnosis is supposed to be useful mainly as a way of informing treatment selection. It does that to an extent, and more for some disorders (e.g., bipolar 1 disorder) than others (e.g., dysthymia), but, on the whole, diagnosis does not help treatment selection nearly as much as it does in many other fields of medicine.

In my own work training clinicians in the treatment of depression, people often become obsessed with determining whether a client fully meets the diagnostic criteria for major depressive disorder, or whether they fall just short of the line. Although of some interest, from a practical perspective for the cognitive behavioural therapist the issue can be almost irrelevant.

Further, knowing that someone has major depressive disorder doesn’t help much with treatment selection. Having packed our client’s individuality into a diagnostic box, we need to unpack it all again and have a look at the person’s life circumstances, triggers, ways of thinking, lifestyle variables, life goals, and activity level. Then we can build a treatment approach.

You can only do this so many times before a still small voice begins to ask “What was the point of spending all that time coming up with the label, when the label doesn’t help you?”

That sounds a bit farcical.

It can be.

You mentioned more than one controversy.

The other big one at the moment is the proliferation of diagnoses, and the watering down of the diagnostic criteria, widening the categories so that more and more people are diagnosable.

In North America, and increasingly around the world, the Bible of diagnosis is the Diagnostic and Statistical Manual of Mental Disorders (or DSM), now in its fourth edition, hence DSM-IV.  (The other is the International Classification of Disease, ICD-10, which includes both mental and physical problems.)

DSM-I, released in 1952, contained 106 disorders.  DSM-II, 1968, contained 185. DSM-III in 1980 had 265, and DSM-IV, released in 1994, has 357. In 42 years the number of mental disorders more than trebled.

Some of this makes sense. Problems that were not recognized in 1952 were added, and some disorders were split into two or more related problems. But the number of people who could find themselves described in the DSM expanded markedly from DSM-I to DSM-IV. As well, the boundary between normal-range experience and disorder was moved in many cases to include more people. In effect, by shifting the definition of abnormality, and hence normality, we created millions of additional cases of “mental illness.”

Currently the American Psychiatric Association is developing DSM-V, scheduled to be released in 2013. Once again, vast swathes of normality are being redefined as mental illness.

Well, vast swathes of normality can still be pretty miserable. If it can be treated, what’s the problem?

Much of the treatment used for mental conditions is pharmacological, and most pharmacological approaches have their downsides as well as potential benefits. The data supporting the treatment of milder conditions is typically much weaker than for their more severe counterparts. So we may be encouraging more and more people to see themselves as mentally ill, and to accept treatments that may or may not be helpful for them.

As well, the boundaries of what it is to be normal are steadily shrinking. Many of us in the field believe we are pathologizing much of the human experience. It is as though we are saying “Pinkie fingers are cancerous growths, and you should seek treatment if you have them.” Sadness, bereavement, shyness, anxiety, anger, and much more are increasingly being viewed as symptoms of mental illness rather than natural elements of being human.

So what’s motivating all this?

Some of it is well-intentioned altruism. If we can help more people to feel better, why not? And in order to treat them, it seems reasonable to try to define what might be going wrong. Critics might say, though, that nothing is going wrong in most people: Life is challenging, and if you find it occasionally difficult this does not mean that there is anything the matter with you.

Some of this widening of mental illness definitions appears to be motivated by profit. If we can convince you that you are ill, we can sell you products. Many of the people on advisory panels for DSM-V also receive funding from pharmaceutical firms. This is no great surprise – pharmaceutical firms and the APA both want good people, and they often settle on the same ones. But the potential for a significant conflict of interest is too great to ignore. The more people we can call mentally ill, the more we can market to them – and the products we market tend not to be curative. So we can have them continue to purchase the product (or have insurers purchase it for them) for many years.

Even the lead developer of past versions of the DSM, Robert Spitzer, has expressed his concerns about the new edition. (This is putting it a bit mildly.) Here is one of his writings on the subject of proposed changes to the description of post-traumatic stress disorder (PTSD):

Can I read more?

Easily. Just google DSM-V and see what comes up. The Society for Humanistic Psychology has been particularly vociferous on the subject.  Here is their blog:

Here is an editorial on, of all things, the Psychology Today blog, by physician Allen Francis:

The problem is not limited to the mental health field, however.  Here is a similar red flag raised for medicine as a whole by health journalist Ray Moynihan, published in the respected British Medical Journal:

And here’s Moynihan’s website:

And where do you sit on all this?

I share the concerns about overdiagnosis and the narrowing definition of normal experience. I do believe that much of the broadening of disease categories is well-intentioned if naïve, but I also believe that much of it is motivated by the desire for profit.

I believe that if we take normal reactions and reclassify them as illnesses, we remove their usefulness to the person experiencing them. So rather than viewing a sense of ennui and anxious sleeplessness as cues to look at my life, I can begin to see them as a resurgence of a mental illness. I will become even more alarmed, and far from taking constructive measures to take charge of my life, I will see myself as more damaged.

In effect, I believe that classifying experiences as pathology can actually create pathology. Overdiagnosis isn’t just misdiagnosis.  It creates distress and, potentially, the very illnesses it predicts. By broadening disease categories we may not be helping anyone; we may be creating additional misery in the world.

Thanks to Johanna Trimble for sparking this post.

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