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Are we over-stressed or over-diagnosed?
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Is it mental illness or just normal behavior?
Date published: 4/6/2008
CHICAGO-- The United States has reached a point where almost half its population is described as being in some way mentally ill, and nearly a quarter of its citizens--67.5 million--have taken antidepressants.
Studies indicate that 40 percent of all patients fall short of the diagnoses that doctors and psychiatrists give them, yet 200 million prescriptions are still written annually in the U.S. to treat depression and anxiety.
Those who defend such widespread use of prescription drugs insist that a significant part of the population is under-treated and, by inference, under-medicated. Those opposed to such rampant use of drugs note that diagnostic rates for bipolar disorder, in particular, have skyrocketed by 4,000 percent and that overmedication is impossible without over-diagnosis.
To help settle this long-standing dispute, I decided to study why the number of recognized psychiatric disorders has ballooned so dramatically in recent decades. In 1980, the Diagnostic and Statistical Manual of Mental Disorders--used by schools, prisons, courts, and mental-health professionals around the world--added 112 new mental disorders to its third edition (DSM-III). Fifty-eight more disorders appeared in the revised third (1987) and fourth (1994) editions.
After several requests to the American Psychiatric Association, I was granted complete access to the hundreds of unpublished memos, letters, and even votes from the period between 1973 and 1979, when the DSM-III task force debated each new and existing disorder. Some of the work was meticulous and commendable. But the overall approval process was more capricious than scientific.
DSM-III grew out of meetings that many participants described as chaotic. One observer later remarked that the small amount of research drawn upon was "really a hodgepodge--scattered, inconsistent, and ambiguous." The interest and expertise of the task force was limited to one branch of psychiatry: neuropsychiatry. That group met for four years before it occurred to members that such one-sidedness might result in bias.
Incredibly, the lists of symptoms for some disorders were knocked out in minutes. The field studies used to justify their inclusion sometimes involved a single patient evaluated by the person advocating the new disease. Experts pressed for the inclusion of illnesses as questionable as "chronic undifferentiated unhappiness disorder" and "chronic complaint disorder," whose traits included moaning about taxes, the weather, and even sports results.
Social phobia (later dubbed "social anxiety disorder") was one of seven new anxiety disorders created in 1980. At first it struck me as a serious condition. By the 1990s, experts were calling it "the disorder of the decade," insisting that as many as one in five Americans suffers from it.
Yet the full story turned out to be more complicated. For starters, the specialist who in the 1960s originally recognized social anxiety (London-based Isaac Marks, a renowned expert on fear and panic) strongly resisted its inclusion in DSM-III as a separate disease category.
Read more stories about Fredericksburg
Date published: 4/6/2008
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