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Is the Validity of Psychiatric Diagnosis Being Overemphasized?

The WHO World Health Report (2001, p. x) states that ‘[w]e know that mental disorders are the outcome of a combination of factors, and that they have a physical basis in the brain. We know they can affect everyone, everywhere’. Yet critical psychiatrists, such as Joanna Moncrieff, point out that in fact there is ‘no convincing evidence that psychiatric disorders or symptoms are caused by a chemical imbalance’ within people’s brains (2009, p. 101). Moncrieff (2009) makes a distinction between ‘disease-centred’ and ‘drug- centred’ models for the action of psychotropic medications. The ‘disease- centred’ model suggests that the medications work by directly addressing the biological mechanisms that give rise to the mental disorder. On the other hand, ‘drug-centred’ models propose that psychotropic medications act by inducing abnormal or altered mental states. She points out that there is little evidence to support the former. Furthermore, there is much research that questions the validity and reliability of certain mental disorders, particularly the schizophrenia label (Boyle 1990/2002; Bentall 1990, 2003)—a diagnosis that some feel should be abolished altogether rather than exported globally (Hammersley and McLaughlin n.d.). Bentall’s (1990) criticisms regarding the diagnosis of ‘schizophrenia’ include the following: [1]

These are issues that have also been identified with other forms of psychiatric diagnosis. Indeed, the US National Institute for Mental Health has opted to move away from using the Diagnostic and Statistical Manual approach (advocated by the American Psychiatric Association) and the International Classification of Disease approach (advocated by the WHO) for psychiatric diagnosis because ‘the boundaries of these categories have not been predictive of treatment response. And, perhaps most important, these categories, based upon presenting signs and symptoms, may not capture fundamental underlying mechanisms of dysfunction’ (Insel et al. 2010, p. 748).

Such issues have led many critical psychiatrists, as well as mental health service users and survivors, and other professionals and researchers, for example, some psychologists (often but not solely based in HICs), to increasingly call to abolish psychiatric diagnostic systems, and/or to call for a paradigm change within psychiatry, based on evidence that, in summary, psychiatric diagnoses are not valid, do not aid treatment decisions, impose Western beliefs about mental distress on other cultures (Bracken et al. 2012; Timimi 2011, online), may increase stigma (Angermeyer and Matschinger 2005; Read et al. 2006), and are sites of institutional racism for ethnic minorities in many HICs (Fernando 2010). Despite these critiques, mental health services in HICs continue to operate primarily within the parameters of these problematic biomedical diagnoses and forms of treatment.

In spite of the concerns regarding the validity and reliability of psychiatric diagnoses, the mhGAP initiative highlights a range of priority psychiatric diagnoses that services should be scaled up to address—including schizophrenia. Reflecting on the tensions that can exist in applying mental health diagnostic criteria in LMIC settings, Dr Rosco Kasujja (a clinical psychologist in Kampala, Uganda) states that

There are so many conditions that are specific to Uganda or other LMICs. However, I was trained only to use the DSM-IV, and hence my assessment may be inappropriate or irrelevant. Is the client coming to me to be relieved of distress or just to get a label? Such is the extent of distortions surrounding diagnostics, whereby practitioners spend more time trying to find a label than finding the best way to help the client feel better. (Kasujja 2014, p. 4)

There is a further concern that the portrayal of mental distress as biological may be ideological in that it enables a sidestepping of critique of the deleterious effects of social arrangements and systemic inequality, overlooks the complexity of lived experience, and potentially serves the financial interests of the pharmaceutical industry (Kirmayer 2006; Shukla et al. 2012). A key issue then in framing distress as biomedical lies in implications for treatment, which currently tend to be dominated by medication.

Is a Preoccupation with Eliminating Symptoms of Illness Obscuring Understanding About What Constitutes 'Positive Outcomes' for Individuals Experiencing Mental Health Difficulties?

Global Mental Health (GMH) has been likened to a moral crusade that is seeking to respond to ‘a failure of humanity’ (Kleinman 2009, p. 603). Patel et al. (2006, p. 1312) call for a move beyond the ‘scientific evidence base’ of particular treatments (which are taken as well established) and push the ‘moral case’, claiming that ‘it is unethical to deny effective, acceptable, and affordable treatment to millions of persons suffering from treatable disorders’. The denial of effective and sometimes life-saving treatments in LMICs is a serious concern that has played out particularly around communicable diseases, such as HIV/AIDS, and is often linked to intellectual property rights and the pharmaceutical industry’s pursuit of profits (Shah 2006; Soldatic and Biyanwila 2010). While the WHO and MGMH’s promotion of medications as first-line treatment for many mental disorders may be a topic of debate, particularly in terms of benefits that this might serve the pharmaceutical industry, it should be noted that some proponents have argued that psychotropic medication should be exempted from patenting in order to reduce costs (Patel et al. 2006).

Casting GMH as a moral concern has created a context in which there is an imperative for people to act, and for this action to be taken quickly: according to the Lancet Global Mental Health Group (2007, p. 370), ‘the time to act is now’. However, this urgency for action is not universally welcomed by people working in LMICs as it may lead to little consultation with local peoples and to resources being spent on the development of services that are neither appropriate nor effective (Kasujja 2014).

Yet what if the scientific evidence contains evidence that the treatment (often psychotropic medication) being scaled up is not always effective, acceptable, or affordable? What if evidence points to the use of this medication as sometimes ineffective, or at worst, harmful? When examining the evidence base for the use of psychotropic medication, a number of issues come to light. First, little is known about how psychotropic drugs actually work (Moncrieff 2009); and some trials (particularly for anti-depressants) have found that drug-placebo differences are not statistically significant (Kirsch 2009). Second, there is a growing body of research that points to the harm caused by long-term use of some psychiatric medications (Breggin 2008; Luhrmann 2007; Whitaker 2010). For example, antipsychotic medications have been found to contribute to increased morbidity (metabolic disorders and cardiovascular conditions) and risk of premature mortality linked to sudden cardiac death (Alvarez-Jiminez et al. 2008; Ray et al. 2009; Weinmann et al. 2009). In trials of anti-depressants, significant adverse effects have been found, including increased risk of suicide (Healy 2006). Furthermore, a number of psychiatric drugs, and particularly the psycho-stimulants often prescribed to children, are highly addictive (Timimi 2002).

Third, there is a lack of clear consensus among mental health professionals and people with mental health difficulties themselves about what constitutes a ‘positive outcome’ from such difficulties (White 2013; White et al. 2016). Traditionally, psychiatry has been concerned with eradicating symptoms of mental illness. However, it is important to appreciate that clinical symptoms do not necessarily improve in parallel with social or functional aspects of service users’ presentation (Liberman et al. 2002). Evidence suggests that individuals who discontinued their medication following a first episode of psychosis at seven-year follow-up had more than double the chance of achieving functional recovery (i.e. 40 vs. 18%) (Wunderink et al. 2013). In line with these findings, Morrison et al. (2012) have called for greater patient choice in decisions being made about whether antipsychotic medication is required to facilitate recovery from psychosis.

In recent times, conceptualizations of outcome from mental health difficulties have been extended, from a narrow focus on symptom remission alone to a broader interest in individuals’ subjectively appraised levels of functioning (White et al. 2016). Consistent with this approach, the WHO has adopted a specific focus on ‘mental health’ rather than simply focusing on trying to treat mental illness. According to the Mental Health Action Plan 2013—2020 (WHO 2013), mental health is ‘conceptualized as a state of wellbeing in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’ (WHO 2013).

Fourth, when attempts have been made to measure outcomes for people diagnosed with schizophrenia across cultures (in terms of relief of psychiatric symptoms and social recovery), outcomes in ‘developing’ countries have been found to be better. These findings were reported by WHO’s major studies: the International Pilot Study for Schizophrenia, the Determinants of Serious Mental Disorders (DOS-MED), and the International Study of

Schizophrenia (WHO 1973, 1975, 1979; Jablensky and Sartorius 2008). Despite flaws in its methodology (Fernando 2014), it would seem that the context for recovery from what may be called ‘serious mental illness’ may well have been better in India and Nigeria than it was in ‘developed’ countries at that time. Halliburton (2004) suggests this may have been due in part to the availability and plurality of indigenous systems of healing.

Lastly, evidence suggests that focusing on treatment of symptoms of mental illness by use of psychotropic medication may also have harmful effects on a community by potentially discrediting indigenous forms of healing, and foreclosing interventions and analysis that examine contextual and socio-economic contributors to distress (Read 2012; Jain and Jadhav 2009; Mills 2014b). These issues will be discussed in more detail in subsequent sections.

  • [1] Service users’ presentations do not fall into discrete types of psychiatricdisorder as is commonly assumed. 2. Service users experience a mixture of symptoms of schizophrenia and nonschizophrenia symptoms. 3. There is no clear distinction between symptoms of schizophrenia and normal functioning. 4. A diagnosis of schizophrenia does not predict outcome or response totreatment.
 
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