On Psychiatric Overdiagnosis

Consternation and derision greeted the recent Archives of General Psychiatry study that suggested that large numbers of American college students have mental disorders. Every once in a while psychiatrists like to assert that a large proportion of the population needs nothing so urgently as, well, to see a psychiatrist as soon as possible, and it gets everyone in an uproar. Psychoanalysts used to be good at this, but it works just as well for the DSM system. Rather than quibble over numbers, I have a few general comments.

Psychiatrists seem to have the idea that they are the ultimate arbiters of diagnosis. They aren't; the society in which they practice is. Now, psychiatrists do have more expertise than the average person on the street when it comes to mental functioning, but some wisdom is not the same as omniscience. The psychiatric profession--explicitly via the DSM, implicitly via aggregrated clinical habits--submits proposals as to what should constitute mental disorder. However, it is the society at large, contingent upon public attitudes and financial resources, that ultimately decides what the purview of psychiatry will be.

The analogy that comes to mind is the distinction between military tactics and defense policy. As the famous quote goes, war is too important to trust to the generals. In the case of democracy at least, a society decides (by virtue of the government it elects) the general kind of defense policy it will pursue. The military is entrusted with the mission of carrying out those military goals. But the military does not set defense policy--in a democracy at least. To be sure, military personnel have opinions about defense matters that, due to their expertise, should be given particular attention, but they do not have the final say.

To stretch the metaphor to a breaking point, the problem is that the "war on mental illness" (would that be like the "war on drugs" or the "war on terror?") is not a coordinated campaign, but rather comprises endlessly complicated guerrilla tactics carried on in many thousands of consulting rooms. Psychiatrists have their "marching orders," a plan of what is to be accomplished and what is or is not appropriate in carrying out that plan, in the form of, say, FDA recommendations, the DSM, and the nebulous concept of "standard of care," but due to professional privilege it is easy for psychiatrists to become vigilantes. They become so sure of their power and, granted, so honestly aggressive toward "the enemy" (mental disorder, recall, not the patient), that they exceed appropriate bounds. When psychiatrists try to be Batman, things go awry.

When a soldier or even a general becomes insubordinate or even undermines the mission in subtler ways, he can be removed. When individual psychiatrists commit malpractice, of course, they can be removed in a way too. But there is no easy feedback system for influencing the profession as a whole when it has strayed too far. Economics can accomplish this, and did so when society essentially decided that it could not pay for long-term psychoanalysis for anyone who wanted it.

Psychiatry, like the Republican Party, may be venturing farther into the wilderness. Criticism of diagnostic and prescribing trends, along with high-profile pharma cases rocking academic psychiatry, has put the profession out of step with "mainstream America." Psychiatry needs to understand that while people at all ages have varying degrees of mood instability and impulse control, not everyone wants to classify these differences along a diagnostic spectrum. People want to have the freedom to be odd or even imprudent even if it may do them harm; they want the freedom to screw up without having to see a psychiatrist. Lack of "awareness" and "access" can be real issues, but when psychiatrists focus on them excessively they can lose sight of the fact that some people just do not desire their services. Psychiatry seems to think, "If only they knew us better, they would like us--what's not to like?" Hmm.

For the foreseeable future there will be enough truly unambiguous psychopathology to keep the profession plenty busy without having to go stir up diagnoses. None of what I've written is meant to romanticize very real depression, bipolar disorder, schizophrenia, and yes, personality disorder and substance abuse, for which psychiatry is alas, quite necessary. But overall mainstream psychiatry is looking a lot like the party of Delay, Bush, McCain, and Palin. Let's see, whom else can I offend?