December 2010 Archives

The New York Times of Dec 19, 2010 carried an alarming story. It seems that during the past decade, college students have suddenly become much more mentally ill. The rate of severe psychiatric disorder among those seen in school counseling services used to be 16 percent -- now it has reached 44 percent. Ten years ago, 17 percent received psychiatric medicine -- now it is 24%. This "epidemic" of severe mental illness has overwhelmed the understaffed student health services around the country.

The article provides two causal theories. Perhaps the availability of highly effective psychiatric medicine allows youngsters with mental disorders to improve enough to go to college. Or perhaps counselors are recognizing serious illness that was previously hidden. 

No support is offered for either suggestion and there is a much more plausible third alternative. The sudden exploding rate of "severe" psychiatric illness on campus is most likely caused by over diagnosis -- not by a decline in the mental health of the college students. Psychiatric illness is elusive and difficult to define and there are no biologically based laboratory tests.

The presence or absence of any given mental disorder is determined by a checklist of symptoms that establishes thresholds that are necessarily fallible to some extent, and arbitrary. Requiring the presence of six symptoms rather than five (or a duration of four weeks rather than two) can dramatically change the rates of a disorder -- who gets diagnosed as ill, who is considered normal.

In retrospect, it seems clear that the severity and duration requirements included in DSM IV were set too low, particularly in the criteria sets that define the milder forms of the depressive, anxiety, and attention deficit disorders. These border upon, and are difficult to distinguish from, the commonly encountered and expectable everyday aches, pains, sufferings, and performance problems that are an inherent part of college life. Not all difficulty is disorder.

And it gets worse. Thirteen years ago, the drug companies lobbied successfully for the right to market their wares in massive direct-to-consumer advertising campaigns. Such profit-motivated skewing of public information about illness is rightly prohibited virtually everywhere else in the world. The primary strategy of the drug company "educational" pitch was to "sell the ill" in order to "move the pill." Attractive actors or celebrities would demonstrate just how easy and common it is to have an unrecognized and readily treatable psychiatric disorder. And the advertisement would usually end with the helpful entreaty to "ask your doctor."

The drug companies could feel comfortable that most doctors would be quick to the prescription pad in responding to patient questions and requests. They had already lavished physicians with industry-sponsored conferences, free trips and meals, free samples, biased research, and co-opted thought leaders. There was one drug salesperson for every seven doctors -- sometimes outnumbering the patients in waiting areas. Not surprisingly, diagnosis and medication sales have skyrocketed and profits have risen astronomically.

College students confront what will probably be the most stressful phase of their lives. It is no cinch all at once to have to leave home, enter a world of strangers, develop an independent sense of self, confront new temptations and challenges, and perform in a highly competitive academic environment. Many students experience (usually brief and self-limited) periods of sadness, worry, trouble concentrating, performance difficulties.

Psychiatric diagnosis and treatment can be enormously helpful for those who have severe and persistent symptoms. By all means, let's diagnose and medicate those students who really need it. But, the huge and sudden rate increases reported in the article (occurring simultaneously with the drug company marketing blitz) almost surely represent a medicalization of the expectable difficulties many students have in adjusting to college life. Student health services would do well to avoid premature diagnosis and the rush to prescription. Diagnose only those who are really ill, provide counseling and watchful waiting for the rest.

What are the costs of over-diagnosis and overly aggressive treatment? Medication prescribed for milder conditions has little superiority over placebo and adds the risks of side effects and complications. Then there is the stigma of having a psychiatric disorder, its possible impact on job and marital prospects, and in getting insurance. To say nothing about the way a falsely diagnosed student sees himself at a crucial moment of identity formation: the reduction in the sense of personal efficacy, resilience, and responsibility. Finally, the ready availability of stimulant drugs used to treat attention deficit disorder has encouraged the growth on college campuses of a large secondary illegal market, supplying pills for recreation and performance enhancement.

Human nature and psychiatric illness are pretty constant, but diagnostic labels are subject to fashion swings, wild fads, and market manipulation. Whenever there is an "epidemic" of psychiatric disorder, assume that it has been exaggerated and is likely to do more harm than good. 

1) The available scientific literature, though quite limited, does confirm that potential patients do exist who would meet the suggested criteria for this disorder.

2) Existing studies suggest a rate of at least 5 percent of the proposed diagnosis in the general population.

3) The rate could conceivably double (or more) if the diagnosis becomes official, is widely used in primary care,  and is targeted by drug company marketing.

4) There is no treatment with proven efficacy, but some people currently not diagnosed might benefit from existing treatment.

   
5) If included, the diagnosis will likely cause extensive false positive diagnosis of normals who will often receive unnecessary and potentially harmful and expensive treatment.

1) It is premature to include this diagnosis until much more research is available on its rate in the general population, the rate of false positive diagnosis, whether treatment helps, and what are its risks. 

2) New diagnoses must prove their safety and efficacy applying the same strict standards of evidentiary support that we would require before the introduction of a new drug (since the risks and benefits can be equivalent).

3) Patients not covered with a specific label can always be diagnosed and treated within the "Not Otherwise Specified" categories. 

4) Practical consequences are crucial in deciding whether a change should be made. The presence of a (skimpy) scientific literature indicating that patients with the proposed disorder can be found is insufficient to support its inclusion.   

5) The default position is a "do no harm" conservative noninclusion. Any change in DSM-5 that can possibly be misused will very likely be misused -- this is the clearest lesson of DSM-IV.

6) The education on how to use DSM-5 will be dominated and twisted by drug company marketing.

1) He knows from the literature and experience that such patients exist.

2) They need help.

3) It is irrelevant to his task to consider whether the inclusion of the proposed diagnosis in DSM-5 may lead to overdiagnosis and overtreatment. His job is simply to evaluate the available science.

4) Any potential misuse of DSM-5 is not his worry. It should be solved by education of the mental health clinicians.