We’re All Mad Here

One of my favorite movies of all time is ‘As Good as It Gets,’ which stars Jack Nicholson as a grumpy, obsessive-compulsive writer. In one classic scene, he tells his neighbor’s housekeeper to “sell crazy someplace else, we’re all stocked up here.”

This will soon be true, at least for most Americans. There are plenty of crazy people out there: Aurora shooter James Holmes, Philly abortion doc Kermit Gosnell, and the individual who bombed this week’s Boston Marathon. But the ranks of the mentally ill will soon expand dramatically.

The belief that we’re all a little bit nuts is nothing new. In the 1865 novel ‘Alice in Wonderland,’ the Cheshire Cat tells Alice, “We’re all mad here. I’m mad. You’re mad.” Come the summer of 2013, this will indeed be the case. Over 50% of Americans will, under new diagnostic and treatment guidelines, suffer from some sort of mental disorder in their lifetime.

In May, the American Psychiatric Association is scheduled to release the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Often called the ‘psychiatric bible,’ the DSM provides a set of standard criteria for determining whether or not someone is suffering from a mental illness.

The DSM is widely used in the mental health community. Clinicians use it to diagnose patients. Insurance companies use it to determine whether they will pay for treatment. Pharmaceutical companies use it to set drug prices and plan marketing strategies. Policy makers use it to make decisions about which mental health programs to fund and who is eligible to receive government assistance. Lawyers and judges use it to determine if a criminal can be held responsible for his crimes or whether a mother should be granted custody of her kids.

Obviously, there is a strong incentive on the part of many stakeholders to make the DSM as broad as possible. For example, physicians want to get paid for seeing patients, but often can’t if the patient doesn’t have a recognized illness. Similarly, drug companies want to convince patients that they have a treatable condition so that they will pester their doctors for a prescription.

So, while only 5% of Americans will have a severe mental illness in a particular year, under the DSM-V nearly a quarter of us will have a treatable disorder at any given time.  Half of us will need treatment at some point in our lives. That’s a lot of doctors to see and a lot of pills to take.

Are we really any crazier than we were a generation ago? Perhaps. Some reliable studies suggest that the incidence of conditions like anxiety, neuroticism and narcissism have increased over the past couple of decades. However, much of the increase in disease prevalence can be explained away.

We’ve also gotten a lot better at detecting mental illness, with doctors more aware of the signs and symptoms of common illnesses like depression, attention deficit hyperactivity disorder, or substance abuse. Increased awareness leads to increased diagnosis. In addition, while there is still considerable stigma and shame associated with mental illness, it has decreased in recent years. People suffering from psychiatric disorders are more likely to seek treatment and to be open about their illness. These are good things.

But what worries me is that the DSM-V also classified conditions that are physical not psychological in nature – such as caffeine withdrawal and obstructive sleep apnea – as diagnosable mental illnesses. It also drops Asperger’s as a separate disorder, lumping it in with other autism spectrum conditions. Soon, people living with Asperger’s will have a new diagnosis, which will affect both treatment and their ability to receive services.

Moreover, we will soon be pathologizing behaviors that would, in the past, be seen as quirky but not necessarily unhealthy. For instance, the DSM-V will include paraphilias – atypical sexual interests like bondage or sadomasochism – as diagnosable conditions. What is for some a natural albeit unusual expression of human sexuality could now affect child custody, employment and insurability decisions.

No wonder then that some prominent physicians have described the forthcoming release of the DSM-V as, “a sad day for psychiatry”. Diagnosing and treating mental illness is a challenge, but it’s a challenge that the American Psychiatric Association’s new guidelines fail to meet. The only thing that these guidelines do is to make us all a little bit crazy.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on April 18, 2013. It is also available on the WAMC website.]


About Sean Philpott-Jones

A public health researcher and ethicist by training, Sean holds advanced degrees in microbiology, medical anthropology, and bioethics. He is currently Chair of the Bioethics Department at Clarkson University's Capital Region Campus and Director of the Bioethics Program of Clarkson University-Icahn School of Medicine at Mount Sinai, and Director of two Fogarty-funded programs to provide research ethics education in Eastern Europe and in the Caribbean Basin. Until his term expired in August 2012, he served as Chair of the US Environmental Protection Agency’s Human Studies Review Board, an advisory panel that reviews the scientific and ethical aspects of research involving human participants submitted to the EPA for regulatory purposes.
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2 Responses to We’re All Mad Here

  1. Bonnie Steinbock says:

    Why does something need to be considered an illness to get access to treatment that would help alleviate suffering? Grief in the face of life’s tragedies need not be pathological for therapy, both talking therapy and medication, to be helpful. But the problem of reimbursement for mental health practitioners runs up against the concern of many that we are over-medicalizing normal behavior. In my view, the real question is not, is the behavior an indication of disease, but rather, what interventions would be useful to the individual, and is the condition something that the rest of us should be willing to help pay for? That question is not necessarily answered by the disease/normal dichotomy.

    • I don’t disagree. One concern I have is how the ‘disease/normal’ dichotomy changes how we as a society view normal behavior. Perhaps the DSM-V pathologizes grief in order to ensure that physicians and therapists can be reimbursed, for example, but could this lead to bereaved individuals viewing a normal psychological and emotional response as somehow abnormal?

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