POSTED ON JUNE 4, 2008:
Questioning the answers to mental illness
"While there is an uptrend, it's a postive uptrend, because it means more people are getting help for illness," said Davis.
Are rates of mental illness on the rise or are recent numbers just an effort to raise profits?
If the endless stream of news headlines during the last several years is to be believed, mental illness diagnoses of all kinds are apparently on the rise in the United States among most demographic groups.
"Bipolar Illness Soars as a Diagnosis for the Young," read a headline in the New York Times last September.
"Rise in childhood mental illness is perplexing," read a recent headline in the Seattle Post-Intelligencer.
"Rate of Mental Illness is 'Staggering,'" read a WebMD Medical News report from 2004.
"Anxiety Rising on U.S. College Campuses: More students seeking help for OCD, PTSD, other woes, survey finds," read a HealthDay News headline in February.
The survey referenced in that report is like many of its kind, reporting an increasing prevalence of mental illness on college campuses beyond the rate at which schools can treat them.
Virginia Tech shooter Cho Seung-Hui was referenced as a "worst case scenario" example in a Medical News Today report last April.
"As the numbers of American college students with mental illness rise, counseling centers throughout the country are finding it harder and harder to cope. This is exacerbated by a maze of privacy and students' rights legislation which limit what officials are able to do to help," read the lead.
The latest National Comorbidity Survey Replication in 2005, which is conducted every 10 years, found that fully half of all Americans will develop a mental illness at some point in their lives.
While the nation at-large seems to be less mentally healthy than in previous generations, that observation is sparking a wide range of questions and explanations among experts and laypeople.
Some wonder what's changed about our culture and way of life to bring about so much sickness of the mind.
Others, though, suggest those illnesses have likely been there all along, but advances in treatment, screening and public awareness have only recently brought them to light.
Still others, however, argue that much of our "mental illness" today is largely a "diagnosis in search of an illness," and that our modern culture of highly commercialized medicine and easily accessible quick fixes to life's basic problems has created a pervasive illusion of widespread mental illness.
Diagnosis, Treatment and the American Way
A local mental health spokesperson, for one, said those high numbers aren't necessarily a bad thing.
"While there is an uptrend, it's a positive uptrend, because it means more people are getting help for illness," said Paul G. Davis, director of advocacy for the Mental Health Association in Tulsa.
Davis explained that the number of mentally ill people isn't necessarily increasing, only the number of people diagnosed as such.
"We're getting better information to them and their doctors are better able to diagnose the illness," he said.
Ron Kessler, PhD, an epidemiologist in the Department of Health Care Policy at Harvard Medical School, echoed Davis' comments.
Kessler was one of the leaders in the aforementioned National Comorbidity Survey Replication, as well as other government-backed trend surveys on the subject.
"There's actually an enormous number of people who meet the criteria for mental illness, and they've been there for years and they haven't gotten any treatment," he told UTW.
"It used to be that only one out of four of them have gotten treatment, and now we're at the point where almost one out of two of them are getting treatment, so they're saying, 'My God! Look at this explosion! It's an epidemic!'" Kessler said.
"But they've been there all along and they're coming out of the woodwork now," he added.
The epidemiologist explained that the rise of direct-to-consumer advertising, coupled with the lowering of the negative public perception attached to mental illness, are opening doors for people to seek treatment.
"The stigma's going down and there's these advertisements to people in women's magazines: 'If your kid has ADHD, come get help.' Things like that. People are becoming more aware of problems and they're becoming less embarrassed about getting treatment," Kessler said.
Some of Kessler's comments, however, inadvertently or otherwise, could be taken to suggest that the "increased awareness" might have a lot to do with drug companies' bottom line.
"There's more people being diagnosed with it, but the question is, 'What's going on?' and one of the things that's going on is the drug companies now have medications that are approved and they're running around to doctors saying 'Look for this, look for this!'" Kessler said.
"Obviously, the drug companies are out there, beating the drums, trying to get people to do it . . . So people are coming in and saying, 'I think my kid, who I want to get into Harvard, has bipolar disorder. Give him a pill,'" Kessler also said.
His comments bring to mind a front-page New York Times article from 2005, entitled, "Gimme an Rx! Cheerleaders Pep Up Drug Sales."
"Anyone who has seen the parade of sales representatives through a doctor's waiting room has probably noticed that they are frequently female and invariably good looking. Less recognized is the fact that a good many are recruited from the cheerleading ranks," wrote NYT reporter, Stephanie Saul.
"Known for their athleticism, postage-stamp skirts and persuasive enthusiasm, cheerleaders have many qualities the drug industry looks for in its sales force," she continued, reporting that pharmaceutical companies regularly recruit sales reps from college cheerleading squads, regardless of degree majors.
"There's a saying that you'll never meet an ugly drug rep," Saul quoted Dr. Thomas Carli of the University of Michigan, who has actively campaigned to limit drug reps' access to hospital hallways.
"Dr. Carli . . . said that seduction appeared to be a deliberate industry strategy. And with research showing that pharmaceutical sales representatives influence prescribing habits, the industry sales methods are drawing criticism," the Times reported.
The article focused on sales of all medications without singling out antidepressants or prescriptions for other mental illnesses, but Kessler was asked if that kind of aggressive marketing for those drugs might be influencing psychiatrists to diagnose more people, as well as influencing more people to seek those diagnoses.
"I think the people out there running drug companies want to create a market," he answered, but denied that their creation of that market has led to an over-diagnosis of mental illnesses.
"Direct-to-consumer advertising increased dramatically in the 1990s, so people are much more likely to say, 'Yes I think I have depression,' and they're much more likely to get treatment," Kessler said.
He explained that the National Comorbidity study was conducted just before the advent of direct-to-consumer advertising, and the replication was done a decade later.
Within that period, Kessler explained, there was no difference in the proportion of the population classified as having an illness, but there was a doubling of the number of people getting treatment.
He said the actual number of mentally ill people has not increased since the 1980s.
"To the best of our reckoning, it looks like the mental health of the American population did get worse between the end of World War II and the early 1980s, and it's stayed pretty flat since then," he said.
To critics of the ongoing upsurge in mental illness diagnoses, 1980 was an important year--but more on that to follow.
So, why did the collective mental health of the United States decline over those three decades? Is there something about our modern way of life that taxes our mental health?
"It's either that, or genes have changed, and genes don't change that quickly. It could be toxic exposures, too. There are people who have these theories about different mental illnesses, you know, coming from (substances) in plastic bottles and things, and getting various viruses and stuff like that," Kessler initially answered.
"It's definitely something about the environment. It's not about our genes. But the environment is a very broad thing. Is it the decay of the American family? Is it about the meaning of life? We don't know," he added.
The reason Kessler and other mental health professionals don't know the cause, he said, is that they don't have "a real good fix" on whether it's true that the change has taken place.
He said data related to mental illness is comparatively "flakier" than that related to other types of sickness.
"And 'flaky' is a scientific term meaning 'unreliable,'" he jokingly clarified. "It's not like cancer where, if you die, they can do an autopsy and see that it was cancer."
Also, data-gathering methods in the 1950s weren't what they are today, and have since been refined to be more concrete and detailed, he explained.
But, even with improvements in research methods, he said data related to mental illness is still somewhat "fuzzy," since it relies on researchers, clinicians and patients to make certain judgment calls.
Regarding the Comorbidity study he helped lead, Kessler said, "I think it probably is the case that 50 percent of the population has [had] what the American Psychiatric Association would call a 'mental illness' at some time in their life."
"Now, the question is, 'Is the APA trying to increase the income of its members by calling things illnesses that are not really illnesses?'" he added.
This reporter only barely hinted at that question, but Kessler has apparently been at this for a while, so he saw it coming.
Making Matters Worse?
Plenty of others are asking that very question, and they're not limited to just Tom Cruise and other devotees of L. Ron Hubbard, either (and no--this reporter is not a Scientologist, if anyone out there is wondering).
For instance, Allan V. Horwitz, PhD, a medical sociologist and professor at Rutgers University (also not a Scientologist), has written several books and articles exploring that very question.
In his 2002 book, "Creating Mental Illness," Horwitz argues that current notions of "mental illness" as disease only fit a limited number of serious psychological conditions, and that most conditions currently regarded as "mental illness" are either social constructions, normal reactions to stressful social circumstances, like a romantic breakup or the loss of a job (or, in Oklahoma, the Sooners losing to the Longhorns), or are forms of socially-supported deviant behavior.
He co-authored another book with a similar premise, published last year, entitled, "Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder."
Horwitz's co-author was Jerome C. Wakefield, PhD, University Professor and Professor of Social Work at New York University, and a former professor at the University of Chicago, Columbia University and Rutgers University.
"While depressive disorder certainly exists and can be a devastating condition warranting medical attention, the apparent epidemic in fact reflects the way the psychiatric profession has understood and reclassified normal human sadness as largely an abnormal experience," the back-of-the-book description reads.
The book criticizes the practice of diagnosing depression on the basis of symptoms--a "fundamentally flawed" system, according to the authors, because it "fails to take into account the context in which the symptoms occur."
Horwitz and Wakefield emphasize the importance of distinguishing between abnormal reactions resulting from internal dysfunction and normal sadness resulting from circumstances.
But, they contend that the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) makes their reasoning an impossible distinction to make, since the journal establishes a symptom-based system of diagnosis.
"Indeed, it is this very mistake that lies at the root of the presumed epidemic of major depression in our midst," they wrote.
The current edition of the DSM was released in 1980, it bears pointing out, which is when Kessler said the last major increase in actual mental illness occurred.
In answer to the anticipated inquiry, "Is the APA trying to increase the income of its members by calling things illnesses that are not really illnesses?", Kessler touched on the DSM and its role in the explosion of mental illness diagnoses. "That's a legitimate question, and there's a lot of controversy about that right now, because they're now going through another revision of their diagnostic system, and they're having all these group meetings about how they're going to change things and where they're going to draw the lines. It's, you know--'Science by Committee.' They're voting to decide what to do," he said.
"But, given what the definitions are right now, it's pretty clear that half the population has one of those things at some time in their life," he added.
However, Kessler was asked, Can most of those conditions rightly be called "mental illness"?
As an example, he was asked about his testimony to the U.S. Senate Subcommittee on Disaster Recovery last November, in which he said depression was on the increase in Gulf Coast communities, two years after Hurricane Katrina.
Wouldn't past generations understand that as just a normal response to the hard knocks of life? Isn't it a normal, healthy, human response to that kind of adversity, to be sad about it? How does that qualify as a "mental illness"?
His answer was to compare the damage done to the psyches of Gulf Coast residents to the damage done to a healthy elbow after it's struck by a baseball bat.
"I think it's understandable, if somebody hits your elbow with a baseball bat, you're going to have a broken elbow. That's a normal thing. But, you can still call it a problem. So, where do you draw the line to decide if something is a 'mental illness' or not is really a judgment call," Kessler said.
He noted that 90 percent of concentration camp survivors from World War II experienced symptoms of what today would be diagnosed as Post-Traumatic Stress Syndrome.
"Since it was 90 percent, you'd say, 'Well, it's normal.' In other words, a typical human being is going to have that. It's not something that's wrong with the organism. It's the typical reaction of the organism," the researcher explained.
Likewise, Kessler said there's a difference between "normal grief" and "pathological grief" in mourning a loved one.
"If your wife dies and over the course of a year you're in mourning, and you're sad and you don't go out and go bowling and you don't yuck it up and stuff like that," he said that's a normal state of grieving.
"But psychologists' feeling is that, after a year, if you still have decided you're never in your life going to do anything again, that's a problem. But, where that line is drawn is a judgment call," Kessler added.
And, since it is a judgment call, with direct-to-consumer advertising and the drug companies' drive to create a market for their medications, aren't there a lot of factors influencing that judgment beyond what's best for the patient?
"Most people, we've discovered, tend to wait an awful long time before they get the treatment. There's no great desire on the part of the people in the population to run off and say, 'I've got a mental illness,'" he answered.
"There are exceptions for some people who screw up their lives and they want to use that as an excuse, but by and large, you don't find people beating down doctors' doors because they want to get antidepressant medication because they think it's a hip thing to do.
"So, the concern a lot of people have about overmedication, particularly among adults, at least, is not really founded," Kessler added.
He pointed out that antidepressants don't get people high, unlike some other prescription drugs that are more prone to abuse, such as Valium.
I Can't Stand Snakes!
Kessler emphasized that, if anything, adults are probably under-diagnosed and under-treated for mental illness, and the opposite is probably true for children.
"There's a lot of concern that some kids are being overmedicated because their 'helicopter moms' sort of want them to be 'superkids,'" he said, adding that parents and teachers sometimes have a propensity to seek medication for a child's supposed Attention Deficit Hyperactivity Disorder as a substitute for good discipline and character development.
"There's some concern that inner city kids are being overmedicated with ADHD medication because, it's not really that they're ill, but they're problem kids, and the parents or the teachers don't want to deal with them, so they give them a pill," said Kessler.
He also conceded that there is the occasional grownup using the same tactic to escape adult responsibility.
"There are a lot of people who have a self-defeating attitude and a lot of people who are sort of, like, hustlers who figure they would rather not do anything and live on a little bit and sort of bounce around from one relative to another, and kind of think that's a better life," he added.
Which, he said, goes "back to that fuzzy thing of 'Do we want to call that an illness or not?'"
"I mean, they are probably depressed. They probably have low self-esteem. They probably are anxious and worried about whether they're going to succeed. They probably have bad attitudes and all kinds of stuff, and do you want to call that an illness or not, or do you want to call that 'malingering'? And I think there's a lot of malingering," said Kessler.
In those cases, "giving them a kick in the butt" is more effective than a pill, but a lot more work, too. Also, he said, everything that goes under the umbrella term of "mental illness" isn't necessarily serious, or even worthy of medical attention.
"We don't want to get hung up on this idea that physical illness is something you have, and mental illness is something you are," he said.
"There are 'hang nail'-kinds of things in the mental illness world, too, and a lot of those 50 percent have those kinds of things, too," Kessler explained.
He said, hypothetically, that if a national study found that 99.9 percent of the population would have a physical illness at some point, no one would be surprised, but "physical illness" encompasses everything from life-threatening cancer to the common cold.
But, Kessler said the stigma still attached to the term "mental illness" makes for more alarming, eye-catching headlines, which the media uses to trumpet studies like his that report high incidences of mental illness.
As for serious mental illness, though, he said studies, including the National Comorbidity Survey, agree that about 6-8 percent of the population has it, which has not increased significantly (not since the latest DSM's 1980 release, at least).
He pointed to issues like "adjustment disorder" or "shyness" as conditions included in some of the "mental illnesses" with which 50 percent of the nation's population will be afflicted.
It wasn't clear if he was speaking hypothetically, but Kessler said, as another example, he was afraid of dogs as a child, and his dog phobia made him nauseous whenever he was around dogs.
"That's the most common mental illness: phobias," he said.
So, technically speaking, Indiana Jones, with his fear of snakes, would be "mentally ill"?
"Absolutely. He met the criteria. And he still saved the damsel in distress," he answered.
"Somebody who gets depressed for two or three or four weeks--not when their mother dies, but because their team didn't win, I would think that's an overblown reaction, and considered clinical depression."
But doctor, this is Oklahoma. Do you still think it would be considered "overblown" here?
"That's right--you and your football," he laughed.
Kessler apparently thought this reporter was joking, and ignored the question, going on to say, "Or if they don't show up for work for a couple of days. That might be considered a minor depression."
Along with such "hang nail"-type mental illnesses, Kessler said some disorders are being created to classify behavioral patterns that don't fit neatly into existing categories.
"The clinicians are themselves confused about what to do with kids like that. They have words for it. They have a thing called, well, 'Oppositional Defiant Disorder,'" he said.
"Well, what the hell does that mean? That means the kid's a pain in the ass," Kessler added, explaining, "They won't do anything you want them to do, so they've got 'ODD.' They don't know how to treat it. There are these kids who, you say 'yes,' they say 'no.' It doesn't make any difference what you say, they'll say the opposite. The only thing you can do is say 'no,' to make them say 'yes.'"
So, as Horwitz and Wakefield argued, it sounds like much of what, in today's terms, is classified as a "mental illness" would have been seen as a character issue, or spiritual issue in past generations?
In answer, Kessler said, "There are some things where it's pretty clear, like if someone kills himself or if somebody's psychotic and they're hearing voices. That's an obvious illness," Kessler answered.
"Then they get sick with all this other stuff, that's just sort of problems with living, and the question is, is that an illness, or is that a character-trait sort of thing? And they don't know. If they're biological psychologists, they look for something biological, like a gene," he also said.
"Once you have a hammer, you go around looking for nails," he added.
While he seemed dismissive of diagnoses such as 'Oppositional Defiant Disorder,' he pointed out that studies have indicated a strong association between parents with ODD and kids who wind up having it, even kids who were adopted at birth and never met their biological parents.
"There is a genetic basis for this stuff. There is something inherited that makes people more likely to behave in certain ways," Kessler said.
He also noted that evidence suggests personality as a whole is largely influenced by genes.
"But, is anything biological necessarily a 'disease' to be treated? What about low IQ? Or athletic prowess, or lack thereof?" the researcher said.
"As we learn more and more about all this stuff, we bump into a whole bunch of complicated moral and philosophical questions," he added.
And, Kessler, noted, most of those questions weren't asked in previous generations, when conditions like "Oppositional Defiant Disorder" and "Attention Deficit Hyperactivity Disorder" were unheard of.
"Is it because the world was a simpler place? Maybe we were more worried about getting tuberculosis all of a sudden back then, or polio--when my mom was a kid, she said she had kids in her class walking around with crutches. We just don't see that any more, so now we're in this society where we worry about boutique things like feeling self-actualized," he said.
Kessler said research into other countries' mental health status suggests that many of the issues dealt with today in the United States are what Horwitz called "cultural constructions," or in Kessler's own words, "illnesses of affluence."
"When we do studies of other countries--Iraq or Lebanon or South Africa, and look at mental illness, we don't find as high rates of people there who say they're depressed. They're worried about different stuff. They don't have these existential issues, or worry about the meaning of life. They're just saying, 'Can I get enough food to eat?' They obviously have a worse life than we have, so it's fuzzy, I'm afraid," he said.
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