Not long ago, I read a Los Angeles Times article saying 20% of Americans suffered from mental illness in 2010. The article ended with a warning: “…we need to continue efforts to monitor levels of mental illness in the United States in order to effectively prevent this important public health problem and its negative impact on total health.” The story did define what was meant by “mental illness.” Do I have to keep an eye on every fifth guy in the Post Office line?
Not necessarily.
The Times’ source was a January 19 report by SAMSHA, the Substance Abuse and Mental Services Administration, which said 45.9 million Americans suffered from mental illness in 2010. Their definition of mental illness is, “a diagnosable mental, behavioral, or emotional disorder (excluding developmental and substance use disorders)” in the DSM-IV, the 4th edition of The Diagnostic and Statistical Manual of Mental Disorders (1994).
Here’s how the DSM works: there are numerous schools of psychotherapy that differ in their approach to treating different disorders, but all have agreed to agree on the definitions of those disorders. One of my psych professors insisted that the DSM says more about our cultural “norms” than about the health of the population. For instance, in 1987, homosexuality was dropped from the list of disorders. Prior to 1987, gays and lesbians were “mentally ill.” After that, they were not.
Anyone who visits a psychotherapist and wants to submit an insurance claim will receive one of these diagnoses, most commonly, “Anxiety,” or “Adjustment Disorder.” This fits the vast numbers of clients who are able to cope with life, but seek help with problems at work or problems at home or issues of self-actualization. The SAMSHA report gave no mention of efforts to factor in the seriousness of the diagnosis. There is no way to know how many of the 45.9 million Americans who are “mentally ill” suffer from anxiety vs. schizophrenia.
To the best of my knowledge, the rise of “insanity” coincided with the Industrial Revolution. The US Census first noted the incidence of “idiocy/insanity” in 1840. By 1880, there were seven types of insanity: mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy.
According to my psych professor, the DSM grew out of a research collaboration between the American Psychiatric Association (APA) and the US military between the world wars. Soldiers in WWI suffered high rates of shell shock. The military sought screening methods for those who would hold up in combat. Although the screens later proved not to have the predictive power hoped for, the DSM came from this research. In other words, our current definition of sanity is based the attributes of a good combat soldier.
Voices were raised in protest, almost from the start, notably by Thomas Szasz in The Myth of Mental Illness (1961) and a 1973 article by David Rosenham, “On Being Sane in Insane Places.”
I am not trying to minimize the suffering of those with mental afflictions that cause them to harm themselves or others. First, I am questioning a report that excludes all forms of substance abuse from its definition of “mental illness.” I also question defining “anxiety” as “mental illness,” when anyone who was paying attention in 2010 felt anxious.
I have often been struck, since I studied psychology, that our concept of sanity, modeled on the good soldier, also defines the “productive” member of our consumer culture. It brings to mind a favorite line from a poem by Theodore Roethke: What’s madness but nobility of soul at odds with circumstance?:
In a Dark Time
In a dark time, the eye begins to see,
I meet my shadow in the deepening shade;
I hear my echo in the echoing wood–
A lord of nature weeping to a tree,
I live between the heron and the wren,
Beasts of the hill and serpents of the den.
What’s madness but nobility of soul
At odds with circumstance? The day’s on fire!
I know the purity of pure despair,
My shadow pinned against a sweating wall,
That place among the rocks–is it a cave,
Or winding path? The edge is what I have.
A steady storm of correspondences!
A night flowing with birds, a ragged moon,
And in broad day the midnight come again!
A man goes far to find out what he is–
Death of the self in a long, tearless night,
All natural shapes blazing unnatural light.
Dark,dark my light, and darker my desire.
My soul, like some heat-maddened summer fly,
Keeps buzzing at the sill. Which I is I?
A fallen man, I climb out of my fear.
The mind enters itself, and God the mind,
And one is One, free in the tearing wind.
– Theodore Roethke
The First Gates 
During my Abnormal Psychology class, we spent a good portion of time explaining why the DSM was essentially broken. The first problem is that it is entirely culturally based. One of the best examples of this is Dissociative Identity Disorder (more commonly known as having Multiple Personalities). DID, while rare to begin with in the US, is practically never found in countries outside of the US, which has led many people to question if it’s an actual condition, if it is culturally bound, or (for some cynics) if people simply try to rely upon it to be absolved of guilt from a crime.
My favorite discussion from that class involved the condition called Cyclothymic Disorder. It’s a mood disorder where the primary symptoms are mood swings where the person ranges from hypomanic highs (happy and excited, but to a lesser degree than a manic episode) and dysthymic lows (depressed episodes, but to a lesser degree than a major depressive episode). The day we discussed that I remember walking up to my teacher and asking her “Isn’t that life?” We have times where we’re happy, and times where we’re sad, and apparently if you rotate between the two you have a personality disorder.
I’m in no way trying to minimize the effect of those who truly do suffer from a mental illness. But if you’re just going off of the DSM, then 20% is far too low of an estimate. I think that every single person in the country could probably be diagnosed with at least one condition in the DSM if they were to go to a therapist looking for help in their life. The biggest problem with the DSM is that it doesn’t operate on a scale, it operates on a checklist. And as long as it operates on a checklist, you’re going to find studies that show a very high percentage of people suffering from mental illnesses.
(On a side note, my teachers spoke about how the DSM 5 was probably going to shift to a scale model rather than the checklist model. A quick check online shows that it should be released in May of 2013.)
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Thanks for your extensive reply, Adam. Two other points come to mind.
I remember once hearing a former prison warden say that probably 85% of those incarcerated were there for crimes done (1) under the influence of drugs or alcohol, or (2) to get drugs or alcohol. Now that was more than ten years go, but to leave that off the list seems like a major oversight.
The other point isn’t so much about diagnosis, but how much of our treatment these days may be broken. At a writer’s club meeting, I met a psychiatrist who had written a book on the dangers of our pharmacological treatment models. Not surprisingly, he had not been able to publish his book through traditional routes and was looking to publish an ebook. I have not run into him again so I don’t know how that was going, but I think of him every time I hear a TV commercial for anti-depressants with a warning that “it may cause thoughts of suicide.” I always wonder if I’ve heard that right, and the answer is always yes.
Anyway, thanks for your comment!
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One of the points of my textbook for that class dealt with the multiple causation of mental disorders, as well as how multiple treatment methods can (and should) be used. Our society has developed too much of a dependence upon prescription medication for everything from headaches to weight loss to insomnia. In most of the cases where these are used there are alternative methods, but they generally involve something more difficult than “complaining to my doctor and getting a pill.”
There’s also a large discussion about whether or not anti-depressants actually work. Most of the anti-depressants on the market are SSRI’s (selective serotonin re-uptake inhibitors) and in many cases are not terribly effective. The biggest problem with this is that when someone is depressed for an extended amount of time, they’re not going to schedule an appointment with a psychologist or psychiatrist, but with their family doctor. Since it’s highly unlikely that their family doctor has studied mental disorders, the first thing they’re going to is prescribe an SSRI anti-depressant. SSRI’s work best to treat depression when combined with therapy and regular consultation, a regular doctor doesn’t have the time to give these to every patient, so they just give them the pills and tell them to check back in 3 months.
There have been some studies showing that anti-depressants don’t really work any better than placebo, but these are often pushed into the background by pharmaceutical companies who are chasing the almighty dollar.
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Anti-depressants are certainly one of the most questionable meds. Another is drugging children – usually boys – for ADHD.
I saw a great documentary on PBS the other night on Geronimo. When he was of grade school age, he and the other boys of his band learned to run – as in run all day, covering miles of distance. In hunting cultures, running alongside their fathers was “school” for boys for millennia. Similarly, up until the start of the 19th century, most boys “schooling” in agrarian communities involved following their father behind the plow or guarding the herds.
Asking young boys to sit all is a brand new wrinkle in terms of genetic time. It’s a fact that the world has changed, and very few people make a living by running these days, but you’d think there might be an alternative to pumping them full of drugs to help them sit still
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Fascinating post and comments. I’m particularly interested in this last comment about “school” for boys. My grandson would have done well along side Geronimo.
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