November 29, 2011
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association. The DSM provides a common language and standard criteria for the classification of mental disorders, which is used in the United States and to some extent internationally, by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, and policy makers. The DSM is produced by a panel of psychiatrists, many of whom have financial ties to the pharmaceutical industry. It is considered the “bible” of American psychiatry. The latest edition — DSM-IV — was published in 1994.
In 1952, the DSM was a small, spiral-bound handbook (DSM-I), but the latest edition (DSM-IV), is a 943-page magnum opus. Over time, psychiatric diagnoses have increased in the American population and in turn, drugs that affect mental states are then used to treat them. The theory that psychiatric conditions are caused by a biochemical imbalance is often used as a justification for their widespread use, even though the theory in unproven. Since there are no objective tests for mental illness and what is normal and abnormal is often unclear, psychiatry is a particularly fertile field for creating new diagnoses or broadening old ones.
Medications are widely used to treat the symptoms of mental disorders such as schizophrenia, depression, bipolar disorder, anxiety disorders, and attention deficit-hyperactivity disorder. Sometimes medications are used with other treatments such as psychotherapy.
While I am sure research in mental disorders account for some of this increase, I cannot help but believe that there is a certain amount of disease-peddling going on. That is, instead of promoting drugs to treat diseases, diseases are promoted to fit the drugs. For example, shyness as a psychiatric illness made its debut as “social phobia” in DSM-III in 1980, but was said to be rare. By 1994, when DSM-IV was published, it had become “social anxiety disorder,” now said to be extremely common, thus, boosting sales of antidepressants. Now, social anxiety disorder is “a severe medical condition.” In 1999, the FDA approved a drug for social anxiety disorder. After a successful marketing campaign, the sales of Paxil soared.
Presently, a revised version of the DSM is set for publication in 2013. The proposed revision has proven quite controversial. A group of psychologists with the Society for Humanistic Psychology, for examle, has filed a petition objecting to many of the revisions, arguing that they broaden the definition of mental health disorders, which, in turn, could lead to over treatment with drugs. Some, but not all, of the objections of the Society — along with the British Psychological Society and the American Counseling Association — to the proposed DSM-V include:
- The proposed DSM “fails to explicitly state that deviant behavior and primary conflicts between the individual and society are not mental disorders. Given lack of consensus as to the ‘primary’ causes of mental distress, this proposed change may result in the labeling of sociopolitical deviance as mental disorder.”
- “Several new proposals with little empirical basis also warrant hesitation: For example, ‘Apathy Syndrome,’ ‘Internet Addiction Disorder,’ and ‘Parental Alienation Syndrome’ have virtually no basis in the empirical literature.”
- “…clients and the general public are negatively affected by the continued and continuous medicalization of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation.”
Do we really need more mental disorder diagnoses creating the need for more drugs in a society that some would say is already over-medicated? Let’s look at some statistics. According to the Centers for Disease Control and Prevention (CDC) the percentage of Americans who took at least one prescription drug in the past month increased from 44 percent to 48 percent over the past ten years. The use of two or more drugs increased from 25 percent to 31 percent. The use of five or more drugs increased from 6 percent to 11 percent. And in 2007-2008, 1 out of every 5 children and 9 out of 10 older Americans reported using at least one prescription drug in the past month.
And Americans are spending more on drugs. According to the CDC, spending for prescription drugs in the U.S. was $234.1 billion in 2008, which was more than double what was spent in 1999.
And the pharmaceutical industry is profiting. According to Fortune 500 (May 3, 2010 issue date), the profits for the twelve largest pharmaceutical companies was almost $64 billion in 2010. Clearly, Pharma has a financial interest in a DSM with more mental disorders because it will mean a demand for more drugs to treat them.
The critics — and the public too — have a stake in the proposed DSM-V. More mental disorders may mean just more drugs in our over-medicated society.
Supreme Court Justice Oliver Wendell Holmes once quipped, “If all the drugs were thrown in the ocean, everyone would be better-off . . . except for the fish.” While this is a an overstatement, it does contain a grain of truth.