Every few years some prestigious institution publishes the newest survey on the prevalence of mental illness in America. This often coincides with efforts by various people and groups to expand the number of diagnoses covered in the DSM (Diagnostic and Statistical Manual, now on version IV) . The DSM-IV is the standard instrument for American Psychiatry; the various diagnoses recognized in the DSM-IV are typically reimbursed by insurers for mental health treatment. Here is part of today's report in the Washington Post on the prevalence of mental illness in America, Study: U.S. Leads In Mental Illness, Lags in Treatment:
One-quarter of all Americans met the criteria for having a mental illness within the past year, and fully a quarter of those had a "serious" disorder that significantly disrupted their ability to function day to day, according to the largest and most detailed survey of the nation's mental health, published yesterday.
Although parallel studies in 27 other countries are not yet complete, the new numbers suggest that the United States is poised to rank No. 1 globally for mental illness, researchers said.
"We lead the world in a lot of good things, but we're also leaders in this one particular domain that we'd rather not be," said Ronald Kessler, the Harvard professor of health care policy who led the effort, called the National Comorbidity Survey Replication.
I will not spend too much time on pointing out how even a story as supposedly factual as this one contains a slant; not surprisingly, a slant that casts doubts and aspersions on the good, old US of A. It is not until paragraph 18 that the author of the article reveals:
Almost half of Americans meet the criteria for such an illness at some point in their lives, the survey found. Most cases are mild and probably do not require treatment. But every year about 6 percent of adults are so seriously affected that they cannot perform even routine activities for periods averaging three months. Because schizophrenia, autism, and some other severe and relatively common disorders were not included, actual prevalence rates are somewhat higher, Kessler said.
And even later in the article, there is this little tidbit:
It is not clear why Americans have such high rates of mental illness, but cultural factors clearly play a role. Immigrants quickly increase their risk of mental health problems, especially if they do not live in native ethnic communities. Minorities also tend to have lower levels of mental health problems despite lower economic status, suggesting that the social support they provide each other is protective.
(In both cases, the emphasis is mine.)
So here we have a news article, reporting on the facts (and what could be so difficult about telling people news) and they cannot help themselves from slanting the news. Since the USA has so many immigrants and they often have problematic social networks, these dislocated, isolated people tend to have more mental health troubles than those of us with good social networks. This is a very old finding and might have been mentioned earlier in the article but that would detract from the message that America somehow breeds more mental illness.
Another source of aggravation for me is the lack of perspective shown in this article (and often in the DSM-IV and in the field of Psychiatry as a whole.)
Now, I think it is important that I point out my perspective on Psychiatry and Psychiatric diagnosis: I am a Psychiatrist and a Psychoanalyst, which means I specialize in using medication, where appropriate, and various forms of psychotherapy, where appropriate, to alleviate the pain of people who are in emotional distress. I am not on any provider panels for any insurance plans because they force Psychiatrists to treat all patients with the most minimally intensive treatment possible (usually medication), which in my opinion is often a mistake, and I no longer belong to the American Psychiatric Association because I believe they long ago sold out to their desire to be seen as scientific and as such, rely much too heavily on neurochemistry and medication to explain and treat mental distress and mental illness.
I think medication is a shotgun approach to psychiatric disorders, often necessary in cases of severe or life altering illnesses (major depression, schizophrenia, severe anxiety states, etc), but often not the best approach for every situation in which a person falls short in their level of contentment or happiness.
If I may elaborate. I see a lot of people who fall into the spectrum of unhappiness called by too many "depression." Too many people are unhappy with their lives and their position in life and thereby conclude that they are depressed. Others, often influenced by drug company commercials trying to create markets, discover to their relief and surprise that when they go to parties and feel anxious, that they are actually suffering from "social anxiety." The problem is that we are now labeling so many things as psychiatric disorders, with the immediate implication that they are based on easily altered neurochemistry that we are losing sight of the fact that normal is an abstract construct and to be human means to suffer form all sorts of uncomfortable emotional states from time to time. Too many active, highly physical boys are now diagnosed as Hyperactive, in part because it is easier to give a child a pill than try to arrange a classroom to work with highly charged, action-oriented boys. Too many people are now called depressed because it is easier to give a pill than for them to take the initiative to make changes in their lives. In our efforts to see all symptoms as evidence of illnesses to be treated we are risking losing some of our essential humanity.
Our new medications, the SSRI's (Selective Serotonin Re-uptake Inhibitors, anti-depressants which affect the neurotransmitter Serotonin, like Prozac), and the atypical anti-psychotics (like Zyprexa and Seroquel) are amazing medications. They help very sick people return to functioning. They are also so much safer than our past therapeutic armamentarium that there is little hesitation in using them for anyone who complains of emotional distress. However, while the cost of anesthetizing our emotional life may be non-quantifiable, perhaps it should be of greater concern to our society.
As one patient put it, she faces the choice of feeling less distress in her unhappy life situation by using lots of medication, or suffering the ups and downs of her Bipolar disorder but at least feeling fully alive. (Her diagnosis was given to her by a previous Psychiatrist who poorly tolerated her mood fluctuations; the diagnosis may in fact be an overreaction to her tendency to overreact to emotional states.) Often it is a difficult choice, but perhaps there is something less than human in wanting and needing to have every pain medicated.
As an aside, I think our current understanding of how these psychoactive medications work is sorely deficient and we desperately need some new models to better describe and understand the concept of therapeutic action. This is a complex subject and will likely take some time.
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