After reading Robert Whitaker’s “Anatomy of an Epidemic” and doing some reflection on his arguments I thought I could provide some ideas on factors that might have played a role on this “increased prevalence of mental illness.” I am writing this letter with the intention of enriching the open debate on this issue and provide a different perspective.
- Decreased stigma: In general, it is believed that due to stigma of mental illness, still, as opposed to other medical specialties, mentally distressed people do not seek help regarding their issues. Over the last few decades, much emphasis has been made to prevent this to happen. Probably after the expansion of psychoanalysis, psychiatry started to reach a wider population, the so-called “well-worried.”
- Romanticization of mental illness: After Vincent Van Gogh, who is believed to have suffered from bipolar disorder, a link between “being mad and being a genius” was established. Today, artists create a “persona” that help them market their products. Experts in bipolar disorder believe that creativity is a sign of bipolarity and recently some researchers have proposed that many of the most influential writers, artists and politicians including Beethoven, Churchill, Hemingway and even Freud had bipolar disorder.
- Pathologizing the normal: In general, psychiatrists err on the side that a patient coming to our office already have some kind of psychiatric disorder and our role is to figure out which one. Many of our patients come with transitory normal life emotional crises and may end up diagnosed with depressive disorders or other mental disorders. Encouraging health and providing support is an underutilized therapeutic weapon.
- Assuming chronicity: Classically, mental illness has been thought to be chronic and irreversible. This belief is still rooted in most of the clinicians, even in the younger ones. However, there is more evidence, that some psychiatric disturbances are acute and reversible and even severe mental illness like schizophrenia may improve over the years.
- The comorbidity crisis: For every symptom there is a psychiatric disorder and a psychiatric drug. Often, one patient receives polypharmacological treatment for the several different psychiatric disorders. In general we all would benefit from re-reading the classical authors in the field that spent so much time describing the psychopathology of the psychiatric illnesses. A new symptom does not mean a new psychiatric disorder and a new drug is not always the answer.
- Widening the criteria for psychiatric disorders: Since selecting patients with the current DSM-IV criteria is not helping much to advance in the understanding of the pathophisiology of mental illness, for research purposes, some scientists propose a different way of recruiting people for their studies. More recently, it has been proposed that patients can be selected from a spectrum of psychiatric traits rather than choosing only those who meet full criteria. This will probably help understand better the etiology of psychiatric diseases. In the other hand, for patient care, widening the criteria would result in an obvious increase of prevalence of psychiatric disorders. This already happened with depression but is happening now with bipolar and autistic spectrum disorder. This could result in the pathologization of what used to be normal.
- The pharmaceutical companies: They have certainly spent a good deal of money in the marketing of their products rather than in the research of new medicines. I am under the impression that part of their marketing is focused on pushing psychiatrists to diagnose patients with severe mental illness. A patient diagnosed with bipolar disorder in general receive more medicines than a patient diagnosed with depression. This is good for their revenue. Usually they come with studies indicating that bipolar disorder is today underdiagnosed and that if we miss the diagnosis our patients may commit suicide. Pharmaceutical representatives encourage physicians to prescribe antipsychotics in order to prevent that.
- The drug-centered paradigm of care: In order to prescribe any medicine of any kind, a diagnosis is required. Despite targeting a wide population, in the psychoanalytic era, psychiatrists used to treat neurotic symptoms rather than mental illness. Less often psychiatric diagnoses were made as compared with the more recent psychopharmacological model.
- The reimbursement of the medical visits: Insurance companies required also a psychiatric diagnosis for reimbursement. Despite being some years in these system I still not understand it well, but I am under the subjective impression that some milder forms of psychiatric disorders, such as dysthymic disorder or adjustment disorder give more problems for reimbursement purposes. This might influence in an increased number of severe mental illness diagnoses. To prevent this, the psychiatrist should be reimbursed by the time he or she spends with the patient rather than the complexity of the patient’s disease. A capitated system of reimbursement might help prevent this as well.
- The media: The impact of the media in the incidence of psychiatric disorders have been widely studied. Several Hollywood actors and other musicians with substance dependence claim to have bipolar disorder. Today, in T.V., ADHD and bipolar disorder and common topics. As a result, may psychologically distressed individuals may identify with the symptoms and come to the psychiatric office reporting a history of the symptoms they have seen on TV, the paper or hear through friends. The cultural component in our field, cannot be forgotten. In the past, many patients were diagnosed with other conditions such as multiple personality disorder that were treated with psychoanalysis.
- Social help: As compared to other European countries. In the U.S.A. the easier way for poor people to get help is through disability. Mental rather than physical illness is an easier way to get financial support.
In general most psychiatrists I have met would rather have more time to spend with their patients and do the psychotherapy part rather than refer our patients to other mental health providers. In general, the system is always looking for a way to save more money, even if this means to decrease the quality of care. I am under the impression that more people, especially the younger clinicians are not happy with the drug-centered paradigm of care and the “15 minute med-check” medical visits. I am under the subjective impression that over the last 2-3 years, the pendulum is shifting to a more well balanced biopsychosocial model of patient care, wishful thinking? Hope not!
Fernando Espi Forcen, M.D., is a child psychiatry fellow at the University of Chicago.
