Jane McCredie: Doubts on mental illness epidemic

THE New York Review of Books isn’t necessarily where you expect to see a former editor-in-chief of the New England Journal of Medicine deliver a blistering critique of contemporary psychiatric practice.

But that is what Dr Marcia Angell, who now teaches at the Harvard Medical School, has done in a two-part review, concluding this week, of three new books that argue mental illness is over-diagnosed and over-medicated.

America, she writes, is in the midst of a “raging epidemic of mental illness”, at least as measured by numbers treated — a large random survey a decade ago found 46% of adults met American Psychiatric Association criteria for having had a mental illness at some point in their lives.

And that is one of the points where Dr Angell would take issue with the psychiatric profession, questioning what she would see as its constant broadening of diagnostic criteria that sees more and more people being drawn into the treatment net.

A counterargument could be that an increase in diagnosis is a good thing, at least to the extent that it represents a destigmatising of mental illness, greater awareness by clinicians and more willingness by people to seek help (whether that help is always available is another question).

Dr Angell, however, puts much of it down to what she calls the “baleful influence” of the pharmaceutical industry, which has an obvious interest in promoting medication for a growing raft of mental conditions.

She argues that, through relationships with key doctors and professional associations, support for patient advocacy groups and selective reporting of studies, the industry has built a lucrative business on some fairly shaky foundations.

Suggestions that SSRIs (selective serotonin reuptake inhibitors) may be little better than placebo in treating depression are not new, but Angell takes the argument further, questioning whether they offer any advantage at all.

The fact that the drugs perform slightly better than placebo in clinical trials could be due to an “enhanced placebo effect”, she writes, resulting from patients receiving the drug experiencing side effects they have been warned might occur and thus guessing they are in the active treatment arm.

Treating doctors swear by the drugs because they see genuine improvement in patients, but that could be a placebo effect too, she suggests.

The psychiatrist’s bible, the Diagnostic and statistical manual of mental disorders (DSM), also comes in for criticism, accused of being too cosy with the industry, overly willing to expand diagnoses and of not adequately referencing its recommendations.

Like the real Bible, it has depended a lot on “something akin to revelation”, Dr Angell writes.

The revised edition of the DSM-V, due out in 2013, is expected to broaden diagnoses further, including precursor conditions as well as wider definitions of some disorders.

Perhaps the most disturbing point Dr Angell raises is about the increasing medication of disadvantaged American children when their desperate parents are driven to seek a psychiatric diagnosis as a way of accessing health insurance or social security.

That, at least, is something we are spared here, but Dr Angell’s review does raise questions of relevance to Australia too.

There’s no doubt mental health has long been neglected in this country, with inadequate funding and access to treatment and support. And there’s little doubt too that many clinicians in the area would have their own criticisms of Dr Angell’s views (for one such critique see psychiatrist Professor Peter Kramer's recent article in the New York Times).

But is it worth considering whether the treatment of mental illness has become too reliant on medications of doubtful efficacy, neglecting other potentially useful approaches in the process?

Jane McCredie is a Sydney-based science and medicine writer.

Posted 11 July 2011

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