One in four of us will struggle with a mental illness this year, the most common being depression and anxiety. The upcoming publication of the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM) will expand the list of psychiatric classifications, further increasing the number of people who meet criteria for disorder. But will this increase in diagnoses really mean more people are getting the help they need? And to what extent are we pathologising normal human behaviours, reactions and mood swings?The revamping of the DSM – an essential tool for mental health practitioners and researchers alike, often referred to as the ‘psychiatry bible’ – is long overdue; the previous version was published in 1994. This revision provides an excellent opportunity to scrutinise what qualifies as psychiatric illness and the criteria used to make these diagnoses. But will the experts make the right calls?
The complete list of new diagnoses was released recently and included controversial disorders such as ‘excessive bereavement after a loss’ and ‘internet use gaming disorder’. The inclusion of these syndromes raises the important question of what actually qualifies as pathology. Are we really helping more people by expanding these diagnostic criteria, discovering problems that were always there but previously unaddressed, or are we just creating new problems that now need to be treated? Moreover, the crucial questions of what these treatments entail and who will really benefit from them needs to be asked, not only for these new diagnoses but for our mental health care system as a whole.
There has been an explosion in psychiatric diagnoses over the last 30 years, due in large part to a change in ethos in the treatment and research of mental illness. This began in 1980 with the publication of the DSM-III, the first major revision of the manual to consider psychiatric disorders as physical diseases with biological origins, rather than mental illnesses stemming from intra- and interpersonal roots. This shift coincided with the development of the first effective psychiatric drugs (e.g. Prozac), thus enabling psychiatrists to prescribe medicine in treatment rather than relying on cognitive or psychoanalytic talk therapies. Since then, psychiatric diagnoses have more than doubled in the last 25 years, with this trend especially prominent in childhood disorders.
Attention deficit hyperactivity disorder (ADHD) is particularly exemplary of this phenomenon, with diagnoses skyrocketing over the last 10 years, up 66 percent in the United States since 2000. This may be partially due to a recent change in the diagnostic guidelines from theAmerican Academy of Pediatrics, suggesting that children as young as 4 and as old as 18 be screened and treated for the condition (ADHD was previously only diagnosed in children aged 6-12). Widening this age gap may enable parents to start seeking help for a troubled child earlier on, or include adolescents and adults previously thought to be too old to have ADHD, thus contributing to the increase in numbers. However, it is unlikely that this age change alone explains the ADHD boom.
Accounts by parents and clinicians alike suggest that the more common diagnoses of ADHD become, the easier they are to obtain. The spread of the disorder seems to have taken on epidemic proportions, stretching across geographical and socio-cultural boundaries. As such, acquiring a classification of ADHD has become remarkably easy. Diagnoses are made based on a clinician’s observations and subjective self-reports from the child, alongside comments and complaints from teachers and parents. There is no chemical or objective diagnostic test to identify ADHD, just as there are no such tests for the vast majority of psychiatric disorders. Clinicians must instead base their decisions on the symptoms described by the patient and his or her parents, matching their complaints to the criteria listed in the DSM. While this practice can be seen as progressive, giving those in need easier access to the treatments they require, it can also result in the undesirable consequence of widespread over-diagnosis in those who would not have originally qualified for the disorder.
This increase has also resulted in a dramatic rise in the number of prescriptions for psychostimulant medications used to treat ADHD, up 375% as of 2003. Pathologising and subsequently prescribing medication to help control a ‘problem child’ is a worrying side effect of the broadening of diagnostic criteria. A concerning trend has emerged for parents to give their children psychostimulant medication to treat inattention or hyperactivity in school, without an official diagnosis of ADHD. Clinicians willing to go along with this practice believe that these sub-threshold children can benefit from the calming and focusing effects of the drugs, and that they will help improve their academic performance. However, this seems a highly dubious practice, as the referring clinician may have a financial investment in writing these prescriptions, receiving perks or consulting fees from the very drug companies whose medications they are prescribing. This conflict of interest can significantly contribute to the free-flowing prescriptions for psychoactive medications, particularly in cases where the full-fledged diagnosis of ADHD is not warranted. (...)
An important question that needs to be raised regarding these recent increases in psychiatric diagnoses is what role does the multi-billion pound pharmaceutical industry have in this trend? With the rise in diagnoses comes a spike in prescriptions, poising pharmaceutical companies to make millions off the expansion of these varying diagnostic criteria.
This is particularly applicable in the recent changes made to the qualifications for clinical depression, with the DSM deciding to drop the exclusion of bereavement in its classification of the disorder. This means that individuals going through the natural grieving process following the loss of a loved one can now be prescribed anti-depressant drugs to help them cope. In the previous version of the DSM, only cases of ‘excessive bereavement’ (severe depressive symptoms lasting longer than eight weeks) were covered under the criteria for depression, enabling those who needed help to receive it, but without truncating or pathologising the normal grieving process. However, doing away with the time restriction and enabling those experiencing sadness immediately following the death of a loved one to receive pharmaceutical treatment unnecessarily medicalises this process. Additionally, the antidepressants prescribed in these situations (usually serotonin reuptake inhibitors, or SSRIs) are not entirely innocuous, and can be accompanied by unpleasant side effects. Furthermore, SSRIs can take up to four weeks to have full effect, and prescriptions usually last for several months. Thus, the immediate benefit to the patient when they need it the most would be limited, and it is likely they would be on the medication for longer than necessary.
The Washington Post recently investigated the decision behind this change and discovered that 8 of the 11 members on the board of the APA, the American Psychiatric Association, who were responsible for the revisions to the DSM have various financial ties to several different pharmaceutical companies. These include owning stock options, receiving consultation fees, and obtaining grant funding from the industry. These conflicts of interest can create serious potential bias in those members to best serve the financial interests of these companies; and in the current dilemma regarding the medicalisation of bereavement, the potential increase in profit from the rise in prescriptions is tremendous, almost undoubtedly influencing the decisions of those on the board. Furthermore, one of the chief advisors to the committee was the lead author of a study promoting Wellbutrin, an antidepressant drug developed by GlaxoWellcome, as an effective treatment for the alleviation of depressive symptoms following the loss of a loved one. The consultation from this individual, who could benefit both personally and professionally from such a change, was clearly biased in this situation, and most likely ended up swaying the board’s decision to its present outcome.
