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Sunday, May 26, 2013
Perhaps largely as a result of the most recent mass shooting, at Sandy Hook Elementary School, we are seeing a welcome debate in the media on the issue of mental illness.
This sensitive, almost taboo, subject seems to have reached critical mass in terms of how it is diagnosed, treated and paid for. Those of us who have experienced “the system” have a completely different view from those who have not.
This opinion is to offer one insider’s perspective as it relates to the current debate, particularly with respect to the Diagnostic and Statistical Manual of Mental Disorders, the DSM.
On May 14, National Public Radio journalist Diane Rehm had Drs. Allen Francis and David Kupfer as guests on her show. Both men have participated in determining and defining mental disorders for the DSM. Francis is of the opinion that the DSM has contributed to the over-diagnosis of some mental disorders, particularly attention deficit disorder, autism and bipolar disorder. (As a clarification, mental disorder and mental illness refer to the same thing. The medical establishment prefers the former while the rest of us tend to employ the latter.)
With respect to health insurance as it applies to mental illness, the only way for patients to qualify for coverage is for their condition to be mentioned in the DSM. A byproduct of this requirement is that someone with health insurance is far more likely to be diagnosed and treated than someone who has no insurance.
A troublesome extension of this is the incentive for doctors to make diagnoses based on coverage rather than on the actual mental condition of the patient. In other words, there may be a certain degree of fudging, particularly within the context of a hospital admission.
We are constantly assured by doctors and mental health advocates that mental disorders are just like any other medical disease such as diabetes or cancer. Kupfer used this argument on Rehm’s show.
This appears to have the dual purpose of boosting the credibility of psychiatric medicine and de-stigmatizing mental illness. No matter how well-intentioned the comparison may be, it just isn’t accurate. A telling sign that physical and mental ailments are not equivalent is the fact that mental illness is referred to as a disorder, not a disease.
There is no biological test or brain scan that can be done to determine mental illness. The “chemical imbalance” explanation for mood disorders such as depression or bipolar, for example, has been around more than 50 years.
It remains only a hypothesis, however, because no meaningful relationship has been established between levels of neurochemicals and quality of mood. The “mental illness is biologically based” argument is compelling and lends credibility but has proven, so far, remarkably elusive to scientific inquiry and verification.
In terms of mental health, the current system is set up to maximize profit-taking rather than responsible and accurate diagnoses. Doctors are forced to see a high volume of patients to make their practice worthwhile. They are subject to a “standard of care” protocol that puts pressure on them to prescribe medication. Pharmaceutical companies market to doctors extremely aggressively. As a result, it is highly unlikely that someone who consults a psychiatrist will leave the office without a prescription for psychotropic drugs.
From an early age, we are taught to respect and follow doctor’s orders. We are likely to believe what we are told, often without questioning the diagnosis or treatment no matter how serious or life-altering it may be. Moreover, doctors are encouraged by pharmaceutical companies and drug reps to downplay all negative side effects of medications, particularly with respect to mental illness.
I think Francis’ observation that “the wrong people are overtreated while the right people are under-treated” should be taken very seriously. It certainly resonated with me as I had already determined myself to be in the former category.
There will be no simple solutions to this difficult problem. What we are now experiencing is the product of increasingly questionable diagnosis and treatment practices that have accumulated during the last 60 years.
The medication paradigm appears to have contributed to increased incidence of mental illness. The current diagnosis trend is economically unsustainable. We need less volume, more accuracy and better treatment.
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