A diagnosis of mental illness is more common than ever – did psychiatrists create the problem, or just recognise it?
When a psychiatrist meets people at a party and reveals what he or she does for a living, two responses are typical. People either say, ‘I’d better be careful what I say around you,’ and then clam up, or they say, ‘I could talk to you for hours,’ and then launch into a litany of complaints and diagnostic questions, usually about one or another family member, in-law, co-worker, or other acquaintance. It seems that people are quick to acknowledge the ubiquity of those who might benefit from a psychiatrist’s attention, while expressing a deep reluctance ever to seek it out themselves.
That reluctance is understandable. Although most of us crave support, understanding, and human connection, we also worry that if we reveal our true selves, we’ll be judged, criticised, or rejected in some way. And even worse – perhaps calling upon antiquated myths – some worry that, if we were to reveal our inner selves to a psychiatrist, we might be labelled crazy, locked up in an asylum, medicated into oblivion, or put into a straitjacket. Of course, such fears are the accompaniment of the very idiosyncrasies, foibles, and life struggles that keep us from unattainably perfect mental health.
As a psychiatrist, I see this as the biggest challenge facing psychiatry today. A large part of the population – perhaps even the majority – might benefit from some form of mental health care, but too many fear that modern psychiatry is on a mission to pathologise normal individuals with some dystopian plan fuelled by the greed of the pharmaceutical industry, all in order to put the populace on mind-numbing medications. Debates about psychiatric overdiagnosis have amplified in the wake of last year’s release of the newest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the so-called ‘bible of psychiatry’, with some particularly vocal critics coming from within the profession.
It’s true that the scope of psychiatry has greatly expanded over the past century. A hundred years ago, the profession had a near-exclusive focus on the custodial care of severely ill asylum patients. Now, psychiatric practice includes the office-based management of the ‘worried well’. The advent of psychotherapy, starting with the arrival of Sigmund Freud’s psychoanalysis at the turn of the 20th century, drove the shift. The ability to treat less severe forms of psychopathology – such as anxiety and so-called adjustment disorders related to life stressors – with the talking cure has had profound effects on mental health care in the United States.
Early forms of psychotherapy paved the way for the Mental Hygiene Movement that lasted from about 1910 through the 1950s. This public health model rejected hard boundaries of mental illness in favour of a view that acknowledged the potential for some degree of mental disorder to exist in nearly everyone. Interventions were recommended not just within a psychiatrist’s office, but broadly within society at large; schools and other community settings were all involved in providing support and help.
A new abundance of ‘neurotic’ symptoms stemming from the trauma experienced by veterans of the First and Second World Wars reinforced a view that mental health and illness existed on a continuous spectrum. And by the time DSM was first published in 1952, psychiatrists were treating a much wider swath of the population than ever before. From the first DSM through to the most recent revision, inclusiveness and clinical usefulness have been guiding principles, with the profession erring on the side of capturing all of the conditions that bring people to psychiatric care in order to facilitate evaluation and treatment.
In the modern era, psychotherapy has steered away from traditional psychoanalysis in favour of more practical, shorter-term therapies: for instance, psychodynamic therapy explores unconscious conflicts and underlying distress on a weekly basis for as little as a few months’ duration, and goal-directed cognitive therapy uses behavioural techniques to correct disruptive distortions in thinking. These streamlined psychotherapeutic techniques have widened the potential consumer base for psychiatric intervention; they have also expanded the range of clinicians who can perform therapy to include not only psychiatrists, but primary care doctors, psychologists, social workers, and marriage and family therapists.
In a similar fashion, newer medications with fewer side effects are more likely to be offered to people with less clear-cut psychiatric illnesses. Such medications can be prescribed by a family physician or, in some states, a psychologist or nurse practitioner.