The Epidemic of Mental Illness: Why?
The New York Review of Books, June 23, 2011
Edited by Andy Ross
It seems that Americans are in the midst of a raging epidemic of mental
illness. A large survey of randomly selected adults, sponsored by the
National Institute of Mental Health and conducted between 2001 and 2003,
found that 46 percent met criteria established by the American Psychiatric
Association for having had at least one mental illness within four broad
categories at some time in their lives.
Most psychiatrists treat only
with drugs. The shift to psychoactive drugs as the dominant mode of
treatment coincides with the emergence over the past four decades of the
theory that mental illness is caused primarily by chemical imbalances in the
brain that can be corrected by specific drugs. Drugs to treat psychosis are
the top-selling class of drugs in the United States.
prevalence of mental illness really that high?
Irving Kirsch is a
psychologist at the University of Hull in the UK. He asks whether
antidepressants work. When he began, his main interest was in the effects of
placebos. Placebos were three times as effective as no treatment.
Antidepressants were only marginally better than placebos. He analyzed data
from 42 trials of six drugs. Overall, placebos were 82 percent as effective
as the drugs. The average difference between drug and placebo was clinically
meaningless. The results were unimpressive for all six drugs. In trials
using an active placebo, there was no difference between the antidepressant
and the active placebo.
Robert Whitaker a journalist and previously
the author of a history of the treatment of mental illness. He considers
that most psychoactive drugs are not only ineffective but harmful. Even as
drug treatment for mental illness has skyrocketed, so has the prevalence of
the conditions treated. Psychoactive drugs disturb neurotransmitter
function, even if that was not the cause of the illness in the first place.
With long-term use, the brainís compensatory efforts begin to fail. Whitaker
sees an epidemic of brain dysfunction caused by the widespread use of
antipsychotics with serious side effects.
The theory that mental
illness is caused by a chemical imbalance in the brain had its genesis
shortly after psychoactive drugs were introduced in the 1950s. The drugs
treated psychosis, anxiety, and depression. They were derived from drugs for
treating infections, and were found only serendipitously to alter the mental
state. Over the next decade, researchers found that the new drugs affected
the levels of certain chemicals in the brain. The theory arose that the
cause of mental illness is an abnormality in the brainís concentration of
these chemicals that is specifically countered by the appropriate drug. That
was a great leap in logic.
But if psychoactive drugs are useless, why
are they so widely prescribed by psychiatrists?
AR Because the psychiatrists are
following the paradigm expressed by Joseph LeDoux in the 2002 NYAS
conference that I reported
The Illusions of Psychiatry
By Marcia Angell
The New York Review of Books, July 14, 2011
Edited by Andy Ross
The American Psychiatric Association's Diagnostic and Statistical Manual of
Mental Disorders (DSM), often referred to as the bible of psychiatry, is now
heading for its fifth edition.
Leon Eisenberg wrote that American
psychiatry in the late twentieth century moved from brainlessness to
mindlessness. Before psychoactive drugs were introduced, the profession had
little interest in the physical brain. But with their introduction the focus
shifted. Psychiatrists began to refer to themselves as
psychopharmacologists. By embracing the biological model of mental illness
and the use of psychoactive drugs to treat it, psychiatry was able to
identify itself as a scientific discipline along with the rest of the
The APA was then working on the third edition of
the DSM, which provides diagnostic criteria for all mental disorders. When
DSM-III was published in 1980, it contained 265 diagnoses (up from
182 in the previous edition), and it came into nearly universal use. Its
main goal was to bring consistency to psychiatric diagnosis. Each diagnosis
was defined by a list of symptoms, with numerical thresholds.
only did the DSM become the bible of psychiatry, but like the real Bible, it
depended a lot on something akin to revelation. There are no citations of
scientific studies to support its decisions. The current version, the
DSM-IV-TR (text revised), dates from 2000 and contains 365 diagnoses. The
DSM-IV sold over a million copies.
The pharmaceutical industry was
quick to see the advantages of forming an alliance with the psychiatric
profession. About a fifth of APA funding now comes from drug companies, who
are eager to win over key opinion leaders (KOLs) in the profession. Of the
170 contributors to the DSM-IV-TR, almost all of whom would be described as
KOLs, 95 had financial ties to drug companies.
The fifth revision of
the DSM is scheduled to be published in 2013.
Americans should be
concerned about the astonishing rise in the diagnosis and treatment of
mental illness in children. These children are often treated with drugs that
have serious side effects. We need to stop thinking of psychoactive drugs as
the best treatment for mental illness or emotional distress. Both
psychotherapy and exercise have been shown to be as effective as drugs for
depression. We need to rethink the care of troubled children. Here the
problem is often troubled families in troubled circumstances. We need to do
better. Above all, we should do no harm.
LA Review of Books, August 2012
All We Have to Fear: Psychiatry's Transformation of Natural Anxieties into
By Allan V. Horwitz and Jerome C. Wakefield
In 1980, the American Psychiatric Association published the third edition of
the Diagnostic and Statistical Manual of the American Psychiatric
Association, DSM 3. DSM 5 is due for release in 2013. DSM categories were
assembled through votes and compromise. The effect over the decades has been
to enlarge the numbers of ordinary people labeled mentally unstable.
Psychiatrists use simplistic diagnoses and loose criteria to transform
normal problems into diseases. Thirty years ago they said less than 1 in 20
of Americans had an anxiety disorder, now they say 1 in 2 do. They call
depression the common cold of psychiatry and diagnose hugely more cases of
ADHD, juvenile bipolar disorder, autism, social phobia, PTSD, SAD, and a
variety of other disorders. Psychiatry has lost its way.
By Jerome Groopman
The New York Review of Books, June 2013
Edited by Andy Ross
Temple Grandin is a professor of animal science at Colorado State
University, a successful businesswoman, and one of our most astute
interpreters of autism. The first signs that she was autistic began at six
months of age. Observing that she lacked speech and demonstrated violent and
obsessive behaviors, her mother took her to a neurologist, then sought out
suitable settings and schools for the girl.
Grandin has reached a
high level of sophistication about herself and the science of autism. Her
observations will assist not only fellow autistics and families with
affected members but also researchers and physicians seeking to better
understand the condition. As she counsels families whose children behave in
trying ways, she is concerned about the affixation of labels and generic
The labels are devised by the expert committees that issue
the Diagnostic and Statistical Manual of Mental Disorders (DSM).
DSM 4, a diagnosis of autism depended on three criteria:
1 Impairment in
2 Impairment in social communication
repetitive, and stereotyped patterns of behavior, interests, and activities
In DSM 5 it depends on two:
1 Persistent deficits in social
communication and social interaction
2 Restricted, repetitive patterns of
behavior, interests, or activities
Previously undiagnosed Aspies or
high-functioning autistics who meet only the first of the two new criteria
will be diagnosed with social communication disorder. Grandin: "Which is,
basically, autism without the repetitive behaviors and fixated interests.
Which is, basically, rubbish."
These diagnoses overlook the typical
Aspie who lives in an unsympathetic world. Aspies must learn how to respect
certain social imperatives, but they need forgiving and flexible
Reductio Ad Absurdum
By Ian Hacking
London Review of Books, 8 August 2013
Edited by Andy Ross
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,
replaces DSM-IV, which appeared in 1994. Everyone in North America who hopes
their health insurance will cover or defray the cost of treatment for their
mental illness must first receive a diagnosis that bears a DSM numerical
The DSM presents itself as a manual for clinicians. Hence it
came as a bombshell when, a week before DSM-5 was published, US National
Institute for Mental Health head Thomas Insel announced that the NIMH was
going to abandon the DSM because it dealt only with symptoms. He wanted
The DSM is a living, organic creature. About a thousand
individuals served as work group advisors. Many thousands of students,
technicians, secretaries and so on must also have been involved. This
enterprise is fully supported by the immense American Psychiatric
Association, with its 36,000 members.
The classification of mental
illnesses is not at all like the classification of animals, vegetables, or
minerals. Perhaps the DSM will be regarded as a reductio ad absurdum of the
botanical project in the field of insanity. The DSM does not represent the
nature or reality of the varieties of mental illness.
Book of Lamentations
By Sam Kriss
The New Inquiry, October 2013
Edited by Andy Ross
A dystopian novel need not be a novel. The Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM-5) by the American Psychiatric
Association is a brilliantly realized satire, at turns luridly absurd,
chillingly perceptive, and profoundly disturbing.
Here we have an
encyclopedia of madness, containing everything that can possibly be wrong
with a human being. The novel begins with a lengthy account of the system of
classifications used, with its various strains of madness arranged solely in
terms of the behaviors exhibited. This is a recurring theme in the novel,
while any consideration of the mind itself is entirely absent. The
classifications follow a stately progression, rising from the infernal pit
of the body and its weaknesses through our purgatorial interactions with the
outside world and finally arriving in the heavens of our libidinal selves.
What is being told is a story.
This is a story without any of the
elements that are traditionally held to constitute a setting or a plot. A
few characters make an appearance, but they are nameless, spectral shapes
that wander in and out of view as the story progresses, briefly embodying
their various illnesses before vanishing as quickly as they came.
Setting, plot, and characterization are woven into the form with
extraordinary subtlety. The setting of the novel is a conceptual landscape.
The prolog sets a scene of a profoundly bleak view of human beings; one in
which we hobble across an empty field, crippled by blind and mechanical
forces whose workings are entirely beyond any understanding.
would want to compile an exhaustive list of mental illnesses? This mad
project is clearly something that its authors are fixated on to an
unreasonable extent. In a retrospectively predictable ironic twist, this
precise tendency is outlined in the book itself.
The narrative voice
of the book affects a tone of clinical detachment, one in which drinking
coffee and paranoid schizophrenia can be discussed with the same flat tone.
Under the pretense of dispassion this voice embodies a whole raft of
terrifying preconceptions. Just like the neurological disorders that appear
at the start of the book, mental illnesses appear like lightning bolts, with
all their aura of divine randomness. At no point is there any sense that
madness might be socially informed, that the forms it takes might be a
reflection of the influences and pressures of the world that surrounds us.
DSM-5 seems to have no definition of happiness other than the absence of
suffering. Sections like those on the personality disorders offer a
terrifying glimpse of a futuristic system of repression, one in which
deviance is pathologized. For much of the novel, what the narrator of this
story is describing is its own solitude, but the real horror lies in the
world that could produce such a voice.
By Theodore Dalrymple
City Journal, December 2013
The American Psychiatric Association (APA)
Diagnostic and Statistical Manual of Mental Disorders is now in its fifth
edition (DSM-5). It fails to recognize that a description of behavior is not
the same as a medical diagnosis. No objective laboratory markers or
correlatives of psychiatric disorder exist. Yet the manual is destined to be
taken seriously by psychiatrists, insurers, and lawyers.
informs us that more than 1 in 7 people have a lifelong personality
disorder. Several undesirable characteristics must be present in an
individual for such a diagnosis. Either a mass outbreak of human nastiness
has occurred or the whole business of diagnosis is dubious or even
ridiculous. The DSM authors suffer from psychiatric nosology overvaluation