Mental health is big business — very big business. I know — I'm an active client of the industry.
Mental health thrives on a classification system spelt out in the Diagnostic and Statistical Manual, now in its fifth edition (DSM5). Unlike guides to diagnosis in other specialties, the DSM5 is completely focused on the symptoms experienced by the patient — two people could have a consultation with a psychiatrist and be diagnosed with precisely the same illness, irrespective of whether the underlying causes of their illness were poles apart.
As a handbook for clustering like symptoms with like symptoms, the DSM5 is unrivalled. As a manual that gives us insight into the etiology of specific mental illnesses the manual is severely underdone.
What is amazing is that few among the experts seem nonplussed about this. The DSM5, introduced earlier this year, is primarily a diagnostic tool to ensure that like is treated as like, at least when it comes to symptoms. This is a critical part of the legitimacy of the psychiatric profession — we can't have psychiatrists disagreeing all the time on what illness a patient suffers — as well as being the bible for determining the appropriate bounds of medicinal, speaking therapy and other interventions.
In the 1970s the DSM listed homosexuality as a mental illness — something that both much of the research community and all the gay community disagreed with. In the stroke of an editorial pen hundreds of thousands, perhaps millions, were cured by the declassification of homosexuality as an illness in the DSM. The DSM is a socially constructed manual, put together by those with a vested interest in mental health.
But what of the current DSM? Asperger's syndrome no longer exists, but is part of a spectrum of autism. Depression is expanded to include those down in the dumps for an extended time because of a death of a loved one. This is by and large good news for anyone who wants to match a client with a treatment — don't be too fazed by what is going on, simply look at the symptoms, get a classification and treat accordingly.
The truth is that our society is amazingly ignorant of the underlying causes of mental illness, and would seem not too interested in finding out more. I've been diagnosed with a major depressive disorder, melancholia — you can find it in the DSM. But my treating psychiatrist and I work together to find treatments — mostly drugs — to keep me in the realm of the sane. And it works about half of the time.
If the DSM came up with another name for my illness, I doubt that my consulting specialist would change course much. If pharmacological firms came up with a different treatment, that might be a different matter.
It is hard to get away from the idea that the DSM5 and its predecessors are driving the medical health agenda. They are the bible and the faithful shall follow accordingly. But better skilled physicians can take the DSM for what it is — a useful but limited taxonomy seeking to group like symptoms with like.
There are two paths out of this impasse. The first is to insist on a DSM based on more than symptoms, on the underlying causes of mental illness. Given the state of knowledge, this is not likely to happen in my lifetime. The second is to have medical practitioners use the DSM for what it is — a boy scout guide to psychiatric illness — and use their professional judgment to play around on the boundaries of what might and might not work as a treatment.
Sadly, GPs by and large are not trained in this field of endeavor. Most rely on the imparted wisdom of the DSM, while psychiatrists present a broad field of those who faithfully follow the DSM and others, like mine, who use it as a rough and ready guide before getting down to the serious business of trying to understand what is going on in my head that makes me fit a category in the DSM5.
My best guess is that the DSM will phase through versions 6, 7 and 8 at the minimum before etiology precedes symptoms as the defining characteristic of illness. In the meantime we can complain about the deficiencies of this diagnostic tool, or seek out and support those physicians who see the DSM for what it is — a ready reckoner to get the ball rolling, but not the last word on mental illness.
Michael Lockwood is an ex-senior public servant and consultant who has worked for state, federal and local governments. He is currently exploring a range of projects including other peoples's stories about depression. To find out more visit PortraitsInBlue.com. Michael thanks his colleague, Viv Read, for the support she gave him in drafting this article.
This week is Mental Health Week