The Sadness Epidemic

In reviewing All We Have to Fear by Allan Horwitz and Jerome Wakefield, Andrew Scull asks why diagnoses of so many mental illnesses are soaring:

They identify two problems: the psychiatric profession’s obsession with simplistic, symptom-based diagnoses, and the looseness of its criteria for defining mental states as pathology. All sorts of anxieties that are in reality part of the normal range of human emotion and experience have been transformed by professional sleight of hand into diseases. The upshot, they contend, is that whereas thirty years ago less than five percent of Americans were thought to suffer from an anxiety disorder, nowadays some widely cited epidemiological studies have decreed that as many as 50 percent of us do so. . . . 

This debate has broken out with renewed vigor over the development of the new diagnostic manual for American psychiatry, the DSM-V:

Three decades ago, the British psychiatrist Edward Hare and I engaged in a vigorous debate on this issue in the pages of the British Journal of Psychiatry. He argued that the growing number of lunatics in Victorian museums of madness were victims of a new viral disease, schizophrenia, and I countered that it was more probable that other factors were at work — namely, the amorphousness of nineteenth century definitions of madness, the decreasing willingness and ability of families to cope with difficult or impossible relations, and the eagerness of psychiatrists to enlarge their sphere of operations. Of more contemporary relevance, a range of commentators have noticed the explosive growth of depression as a diagnosis, to the point where it is now frequently termed ‘the common cold’ of psychiatry; the equally dramatic expansion in the number of children being diagnosed with ADHD; the appearance out of nowhere of juvenile bipolar disorder, which apparently became forty times as common between 1994 and 2004; the epidemic of autism, a formerly rare condition afflicting less than one in five hundred children in 1990, which has now mushroomed into a disease found in one in every ninety children. More than a few scholars have been tempted to attribute these seismic shifts not to any real alteration in the numbers of sufferers from these disorders, but to disease-mongering by the psychiatric profession and by Big Pharma, the multi-national pharmaceutical industry that obtains a huge fraction of its profits from the sale of drugs aimed at mental disorders of all sorts.

Among the most zealous critics of the expanding psychiatric empire have been two unlikely souls: Robert Spitzer, the principal architect of DSM III, and Allen Frances, who played a similarly large role in the construction of DSM IV. As the latest edition of that tome, the largest thus far and the most delayed, struggles to be born, those assembling it have been assaulted by Spitzer and Frances for creating a version built on hasty and unscientific foundations; they claim it pathologizes everyday features of normal human existence, and that, like its predecessors, it will create new epidemics of spurious psychiatric illness. Allen Frances, in particular, has taken to uttering frequent mea culpas, taking the blame for loosening the criteria for diagnosing autism in DSM IV, and thus, so he claims, sowing fear and mislabeling thousands and thousands of children.

My feeling is that it makes little difference whether we call mental problems diseases or not. The questions is, can we do anything to help people? If Ritalin helps restless kids make it through the school day, without doing some lasting harm to their brains, why not use it? If antidepressants help people that Andrew Scull thinks are just experiencing "normal sadness" get on with their lives, what's wrong with that? If there was a pill that helped everybody feel better, why not use it? (Doesn't alcohol play this role in some cultures?) I think the debate over these diagnostic criteria is a distraction from the real issue, which is whether the drugs actually help people, and whether they do long-term damage to the brain.