As both a psychiatrist and a patient, I know how slippery a diagnosis can be
At the outset I must make this perfectly clear. Psychiatric disorders exist, have as yet an undiscovered physical substrate which may have a genetic and environmental components, typically a result of the gene and environmental interaction. Psychiatric drugs have made huge improvements to society and individuals. My focus on this post is where psychiatry and psychology needs to change.
The controversies surrounding psychiatric diagnosis are decades old. Thomas Szasz is the seminal figure on the issue and his work, "The Myth of Mental Illness"(1961), began a debate that continues today. Today the problem is worse. The above article is another example of how psychiatry as a profession and our culture needs to seriously reevaluate how psychiatric diagnoses are made and how psychiatric conditions are treated.
Unfortunately Szasz is often perceived as a leading figure in the antipsychiatry movement. Szasz was not an anti-psychiatry proponent, he was against coercion in psychiatry and with considerable justification argued that psychiatry was too often about diagnosing the unusual and quirky people in society as in need of treatment. I have no difficulty imagining that state of affairs in the 1960's but I think society has become more accepting of individual differences though psychiatry seems to find ever more creative ways to diagnose unusual behaviors.
Don't be Different
While it would be nice to think that his views gave way to a more tolerant attitudes towards such individuals the publication of ""Saving normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life"(2013), by Allen Francis who was the head of taskforce responsible for DSM-IV, indicates that even in the 21st century psychiatry remains stubbornly rigid in its desire to apply pathological labels to anyone whose behavior is considered unusual.
Szasz's acknowledges that psychiatric conditions exist but his problem was in part with the phrase "mental illness", which suggests that the conditions exist independently of any physical substrate. Another important aspect of Szasz's ideas is that many people who report mental health problems have "problems with living". In relation to the current epidemics of depression and anxiety that is a very relevant observation. This is highlighted from this statement in Saving normal ...
"There has been much controversy whether antidepressants work better than placebos precisely because many patients treated in studies are not very depressed or not depressed at all and really don't need an active medication."
That highlights a very serious problems with clinical trials because over recent decades the definition of depression has expanded so much that many people in clinical trials may just have "problems with living". When I read reports of celebrities battling with depression I am often dumbfounded as to what their problem with living is! One striking example I came across was in relation to the singer songwriter Paul Simon who spent years in therapy because his problem with living was that he was too short and didn't have the singing voice he desired. A famous and highly respected artist with money to burn and he's depressed. That's nuts.😛 Today there are millions of people being diagnosed with depression because they are unhappy about some aspect of their life or qualities.
Pathological Expectations
Especially in the USA there is the irrational message we can all be successful, beautiful, and intelligent. If we aren't it is because we have failed in some way to fulfil our potential. Obviously many people do not understand the normal distribution in statistics and cannot perceive the obvious truth that only a few can be deemed successful or beautiful or intelligent or any combination thereof. Motivational speakers makes millions of dollars telling other people how they can be in the top 1% of success, beauty and intelligence but those paying thousands of dollars to hear such nonsense have obviously bought into the mythology that is so prevalent in modern societies.
Motivational speakers are selling snake oil and thankfully in recent years their popularity and influence has begun to wane. I hate Tony Robbins, I've always hated Tony Robbins. I was furious when I heard how at a conference a psychiatrist asked Robbins if he could help his psychotic patients and Robbins intoned something like "bring them unto me"! What a moron, psychosis is a very serious condition and anyone who think it is easily treated is a fool. For that remark alone Robbins should have been hauled off to goal for being a fraudster. At least then he could have the opportunity to prove his message by motivating all the prisoners not to beat him senseless.
Unrealistic expectations are encouraged in modern societies but studies indicate that people can be happy in living conditions many in modern societies would find intolerable. In an episode of The Simpsons featuring Lady Gaga Lisa asks her what is the secret to happiness. Lady Gaga replies, "Give up hope." How many people are experiencing depression because they are entertaining unrealistic expectations about their prospects in life? Comically the most recent editions of the DSM will even allow a diagnosis of depression in those grieving over the death of a loved one. Antidepressants will be prescribed, treatment will continue until the patient feels better and because grieving is almost always transitory the drug treatment will be deemed a success. That's nuts.
The Australian Data Quandaries
The diagnosis of depression and anxiety has spiked in recent years yet as the table illustrates rates of symptom presentation has remained unchanged. That is happening because more people are reporting their symptoms to doctors, mostly GPs, and hence the increase in prevalence being reported.
Keep in mind that the presence of symptoms does not equate to the presence of pathology. When people are asked about their symptoms there is the suggestion that they may well report symptoms because all of us feel down and\or anxious at various times.
The mainstream media likes to report crises but in this instance the journalists should have been more cautious. The above table, from an article in The Conversation, reflects findings in a study published in the Medical Journal of Australia which made a similiar argument and also documented a huge increase in the number of individuals on disability support pension for depression and anxiety.
The MJA article also mentions that the incidence of people being placed on the Disability Support Pension because of a depression\anxiety diagnosis has sharply risen. There is one recent change to mental health support which can explain both of these quandaries. The provision of a mental health support subsidy, which allows up to 10 psychology appointments, has opened the door to both increases. The use of these services has skyrocketed.
A GP diagnosis of depression\anxiety is not sufficient for Disability Support Pension purposes but a psychologist's diagnosis is sufficient. It is easy to fake or exaggerate the symptoms and many people reporting to psychologists want the diagnosis because the Disability Support Pension has huge benefits compared to the unemployment provisions. We should not be too harsh on people who choose this strategy because for many of them there is no prospect of employment and it is impossible to live long term on the unemployment benefit.
If the government adopted a more compassionate attitude towards the unemployed and increased the unemployment benefit the rate of diagnoses will decline. There are many studies highlighting how long term term unemployment is a big risk factor depression and how suicide rates rise during periods of high unemployment. The Australian Prime Minister Scott Morrison stated he wants a suicide rate of zero. That's ridiculous, will never happen, and the policies of his government are increasing the suicide rate but like most people Morrison believes suicide is fundamentally a mental health problem. That isn't entirely true, it may even be the case that 50% of all suicides have nothing to do with depression and given the vagaries surrounding a diagnosis of depression it is probably higher than 50%. Suicide is the ultimate solution for "problems with living".
Another big quandary is that despite the huge increases in psychiatric drug prescribing and mental health services the prevalence of anxiety and depression have not declined. Nor has the suicide rate declined. Have the huge amounts of public monies invested been because so many people have "problems with living" rather than genuine psychiatric disorders? The evidence indicates that is the case.
"Scripting" Depression
In Beyond Human Nature the philosopher Jesse Prinz states that the increasing diagnosis of depression might be arising because society is encouraging people to think they have depression. There is something to that argument. The article by the psychiatrist also suggests to me that she is scripting herself. While there is no clear diagnosis, and the symptoms don't quite match a particular pathology, she is convinced she "some form of mental illness" but can't determine what that form is. Her remarks remind me of "intern's syndrome", which happens to medical students because as they learn about symptoms they begin to think they demonstrate those symptoms.
Today we hear about the so called epidemics of depression and anxiety, of the huge increases in antidepressant prescribing, of how if we are experiencing any of the symptoms we must without delay seek help. Those messages are driving people and professional people to perceive psychiatric problems that in previous decades would often have been regarded as the travails of life rather than evidence of a psychiatric disorder. My suspicion is that the psychiatrist doesn't feel quite right but has no idea what feeling right should be like. Do any of us? Don't we often entertain the thought that if only this or that life would be right? I prefer the attitude of some Zen dude who stated, "If you can't find it where you're standing where do you expect to wander in search of it?"
Pot or Prozac
Prior to the World War 1 the very idea of illicit drug use did not exist. Problematic drug use did exist but drugs were not illegal. No doubt there was a substantial amount of self medication occurring. Why is that such a bad thing? Alcohol and tobacco are also used for means of self-medication but apparently that is not a bad thing simply because those are legal drugs even though their use is responsible for more violence and family breakdown(alcohol) and deaths(tobacco) than all illicit drugs combined.
The USA has an ongoing opioid epidemic. In Saving Normal the author states legal psychotropic drug abuse is now a bigger problem than illicit drug use. If only this was just about drug abuse. Unbeknown to many people there are a range of potentially serious pathological risks associated with the use of antidepressants and antipsychotics. It will take far too long to go into all the issues so some quick points:
- An often under-reported complication of SSRI drugs is "emotional bluntness". It is probably the most common "side effect". I actually think it is an effect which reduces the feeling of sadness hence the relief the patient experiences. However that comes at the cost of experiencing the full range of emotional expression.
- A number of antidepressants can induce dyslipidemia, hyperglycemia, obesity, leading to metabolic syndrome and potentially type 2 diabetes.
- Antipsychotics can also can also cause general metabolic dysfunction but much more worryingly have been demonstrated to causes brain shrinkage ranging from 9-11%. That has been demonstrated in both humans and macaque monkeys, the latter don't get schizophrenia and the relevant experiment was very well controlled. If marijuana was shown to induce that level of brain shrinkage it would be plastered over all the media but the findings regarded antipsychotics have largely gone unreported. Contrariwise there are literally thousands of studies suggesting the neuroprotective potential of THC, CBD, and cannflavins(flavanols found in cannabis). That is not an advertisement to blaze up because that benefit requires a very judicious imbibing of the compounds.
A Psychiatric About Face
Not Feeling Normal?
Don't worry about it. Normal is boring, normal people are less likely to be creative, intelligent, and change agents in the world. We need the freaks and eccentrics, we need the angry and the depressed, we need a huge variety of people in our society because otherwise it will lack innovation and the impetus for change. I often hear people extolling the values of modern society pointing to capitalism, property rights, rule of law, and democracy. All good things but a striking feature of modern societies is the rate of change, the ongoing cultural shifts which make defining modern culture a project in constant progress. Compare that to those who insist on preserving culture, something that is impossible for modern societies. The ever increasing tolerance of those who do not fit into the definitions of normal and psychologically health is a huge shift from previous cultures. Kerouac was onto something when he wrote ...
"The only people for me are the mad ones: mad to live, mad to talk all night long, who burn burn burn like fabulous roman candles in a New Jersey night sky."
Kerouac, On the Road.
Forget about those psychologists like Peterson and Kaufmann who want us to become better people where better is defined by their political and ethical positions, where questions are raised about those who do not clean their room or seek actualisation. The major difference between them and Tony Robbins is they use fancy words. Most clinical psychologists and psychiatrists acknowledge the eccentricity and varieties in human behavior and do not rush to pathologise those who are outliers. Nonetheless there clearly is a trend to increasingly finding pathologies like ADHD and oppositional defiant disorder, and autism. The diagnosis of ADHD often begins with a teacher evaluation! The rates of autism diagnosis have skyrocketed because the DSM changes since 2000 have greatly increased the rate of diagnosis because Asperger's is now diagnosed as autism. Asperger's should be a separate classification.
It is the systematic theorists, typically academics, religious leaders, and gurus, who wish to wrap up human behavior into some neat coherent logical structure and often fail to appreciate the need for diversity and rebellion, for quirkiness and eccentricity, for how important it is for a society to tolerate a wide expression of being human.
The psychiatrist in the lead article doesn't feel right, is convinced she has a psychopathology but can't define it. Perhaps she should heed the following.
Do I contradict myself? Very well, then I contradict myself, I am large, I contain multitudes.Man is most nearly himself when he is achieves the seriousness of a child at play.
Walt Whitman.Heraclitus.
Life is not a problem to be solved but a reality to be experienced.
Van Der Leeuw.
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