narrower way, to refer to how problems in living not previously approached in a medical manner can be treated as if they were illnesses. There are a number of ways in which this can happen in psychiatric diagnostic manuals such as the DSM:
The use of overly broad categories: If diagnostic categories are overly broad and use definitions that leave lots of room for subjective judgement, then some clinicians may apply a given diagnosis more than other clinicians. For example, the broad categories in DSM-I and DSM-II led to the problems found in the US–UK study of schizophrenia diagnosis, as discussed in Section 2.1.
Ignoring normal rates in the general population: In order to decide whether an experience is abnormal, manual developers should survey the general population, since many of us experience mild forms of symptoms which often resolve themselves. For example, in the past, delusions (false and unusual beliefs) have been considered a clear indication of schizophrenia; however, they are much more common in the general population than previously thought. A study of 7000 people in the Netherlands found that 12 per cent had delusions but significant problems were experienced in only 3.3 per cent of these cases (van Os et al., 2000).
Reduced thresholds: If the duration, intensity or number of symptoms required for a diagnosis is reduced, then more people will be diagnosed with that disorder. Prior to DSM-5, for example, clinicians were prevented from diagnosing major depressive disorder if the person had recently been bereaved, because of the risk of pathologising a normal grief response. DSM-5 removed this exclusion, raising concerns that rates of both diagnosis and antidepressant prescriptions would increase.
‘Disease mongering’: This occurs when new disorders are proposed for experiences that had not previously been considered a mental health problem. For instance, DSM-IV introduced ‘premenstrual dysphoric disorder’ (PMDD) as an example of a ‘depressive disorder not otherwise specified’. This referred to ‘markedly depressed mood’, ‘marked anxiety’, ‘marked affective lability’, and ‘decreased interest in usual activities’ associated with a woman’s menstrual cycle (APA, 1994, p. 350). In DSM-5, PMDD is a formal subcategory of depressive disorders. Several researchers and activists have argued that the category pathologises a common experience for many women (Ebeling, 2011). Moreover, it means that women may be inappropriately given antidepressant medication, with all its concomitant side effects.
Recent decades have seen substantial rises in the rates of certain diagnoses, such as attentional deficit hyperactivity disorder and depression, along with the prescription of associated medications such as Ritalin and antidepressants, respectively. There are lots of factors which appear to drive medicalisation: mental health awareness campaigns; the media; government policies (e.g. moves to offer medication and other treatments for mild problems as a preventative measure); advocacy groups campaigning for problems to be seen as illnesses; changing social norms; and the desire of the public for a technical fix to problems in living. Pharmaceutical companies are a key influence and, in their adverts to consumers in the US, they often include checklists of symptoms (mirroring DSM criteria) and recommendations to visit a doctor for assessment if a person experiences those symptoms (Ebeling, 2011).
Since medication is a common treatment for many psychiatric diagnoses, any changes in diagnostic manuals have the potential to increase or decrease the market for pharmaceutical companies’ products. Ebeling (2011, p. 827) discusses the way in which the pharmaceutical company which produced the antidepressant Prozac ‘heavily influenced the codification of PMDD as a disease state’ by funding research in this area by a psychiatrist member of the DSM-IV PMDD work group. It relabelled the antidepressant Prozac as ‘Sarafem’ and sold it as a specific treatment for PMDD (Ebeling, 2011). Chapter 17 will discuss the controversial influence of the pharmaceutical industry on research into the effectiveness of antidepressants.
Activity 4.1: The pros and cons of medicalising mental health
Allow about 10 minutes
In the Introduction, you considered two opposing views on the medicalisation of mental health. Now that you have worked through most of the chapter, try to list a few reasons why some people might consider medicalisation to be a helpful approach to mental health, and a few reasons why others might consider it unhelpful. Only move on to the activity discussion once you have compiled your list.
Discussion
Those outlining the advantages of medicalisation might note that it:
quickly and efficiently enables access to medical treatments
can increase the reliability of diagnoses through its use of rigid categories
provides clear, succinct categories that can be tested and modified.
Those outlining the drawbacks might note that it:
restricts the ability to explore contextual and individual factors
can reduce the validity of diagnosis, particularly as new disorders might be proposed for experiences not previously regarded as mental health problems
can result in overly broad diagnostic categories
can lead to the prescription of unnecessary medication.
5.3 The continuing impact of the DSM
The DSM continues to have a significant impact on research. Additionally, although the NIMH appears to be distancing itself from the DSM, many other research funding bodies continue to fund studies based on its diagnostic categories. This has an impact on clinical practice: in the UK, the National Institute for Health and Care Excellence publishes clinical guidelines on particular ‘conditions’ which draw on research findings using ICD and DSM categories.
Mental health services are increasingly organised by diagnostic categories. The high levels of comorbidity (a medical term used to denote when two or more conditions co-occur) that arise when categories such as those of the DSM are used can create problems; to which service should a person with a diagnosis of both depression and personality disorder be referred, for instance? There is an increasing proliferation of diagnosis-specific adaptations of therapies, such as cognitive behavioural therapy (CBT) for psychosis, CBT for anxiety, and so on. The use of diagnosis by health insurers and the NHS can cause a range of dilemmas. What if a clinician thinks that a person needs help but their problems do not map easily on to diagnostic categories? What if someone does not wish to receive a diagnosis? What if a professional feels that the use of diagnosis is pathologising? How can couple and family therapists record their work using a system that provides categories only for individuals?
The debate about DSM-5 has again prompted questions about how we understand mental health and the role of social norms. The reliability problem has returned, while diagnosis has expanded further into everyday life. Rates of diagnosis and medication for some problems have increased. This has led to questions being raised about the influence of the pharmaceutical industry. Diagnostic manuals such as the DSM continue to have an impact on both research and mental health services.
Conclusion
Psychiatric diagnosis involves the application of a medical framework to problems in living. By comparing people’s reported problems against the criteria found in diagnostic manuals such as the DSM, the closest-matching diagnostic category or categories can be identified. This chapter has explored whether a medical framework can appropriately be applied to mental health. It has also examined the process of
