Bruce M Z Cohen questions the large-scale increase in diagnoses of mental illness.
As shocking as it is fascinating, few would disagree that we are facing a global epidemic of mental disease. That’s what the statistics tell us: 450 million people currently affected globally with such a condition, 1 in 4 in the UK and the US. This situation is increasing year on year. In the US, the number of adults with a debilitating mental illness has risen six-fold in the past fifty years. In that time, the number of identified psychiatric disorders has more than tripled, from 106 to 374. So is the world becoming madder? Many of the current explanations offered by mental health professionals, social epidemiologists, health scientists, neurobiologists, and anthropologists claim it is, yet my research suggests we may be looking for the answer in the wrong place.
No one wants to talk about the elephant in the room here, which is the ongoing problems in identifying what mental illness actually is. The recent example of the American Psychiatric Association’s (APA) fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) illustrates this point. The DSM is the most important medical manual on mental disease produced today; it is a reflection of the current knowledge on mental illness. By bringing this evidence together, the DSM is meant to tell us what mental illness is, what causes it, what forms it can take, and how it can be treated. However, the DSM committee responsible for producing the DSM-5 came to the disturbing conclusion that, firstly, the causation of mental disorder remains unknown (for example, there is no useful biological marker or genetic test that has yet been identified) and, secondly, that psychiatrists cannot distinguish between mentally healthy and mentally sick people, meaning that mental health professionals have so far failed to define their own area of expertise in any scientifically rigorous manner. And of course, without an accurate identification of disease, a medical discipline cannot claim proof of causation or evidence of successful treatment, and they certainly cannot predict future cases of that disease.
My recent book, Psychiatric Hegemony: A Marxist Theory of Mental Illness, outlines this evidence in detail. It is part of my ongoing research into the historical and contemporary production and proliferation of mental illness diagnoses, treatment options, and professional practices. The logic for my research focus is pretty obvious. We have witnessed an incredible increase in the classification of people with a disease that has not yet been adequately defined by the classifiers. That leads us to question what political, social, economic, and cultural forces produce such classifications and who benefits from this form of medicalisation of human behaviour. Frankly, it should be the duty of all scientists within the mental health field that, in good conscience and putting the needs of the public first, they engage with these crucial questions.
The first stage of my research has been to survey historical constructions of diagnostic categories by the psychiatric profession, identifying any underlying societal patterns which brought them into being as well as (in some cases) accounting for their disappearance from mental health work. My results illustrate the temporality of mental illness diagnoses in the nineteenth and twentieth centuries as they changed with the prevailing norms and values of society at that time. The diagnosis of ‘masturbatory insanity’, for example, was a popular classification among the psychiatrists of Victorian Britain, a society in which masturbation was associated with idleness, particularly among working class men. Castration was one suggested ‘cure’ for such an affliction.
In contrast, the diagnosis of ‘hysteria’ was most commonly applied to women, particularly those considered to have sympathies with the suffrage movement at the end of nineteenth century. Psychiatrists theorised women as prisoners of their biology; if they ventured beyond the domestic sphere and followed ‘unfeminine pursuits’ such as education or employment, they were considered as vulnerable to hysteria. The diagnosis did not disappear from psychiatric work but actually remains in the DSM-5 as ‘histrionic personality disorder’. What I’ve concluded from my research is that psychiatric classifications tend to reflect a conservative morality and serve particular political purposes in managing deviant populations within society – this is most obviously illustrated with the DSM classification of homosexuality as a mental illness until 1973.
The findings from this historical research have subsequently informed the second part of my project which consisted of a textual analysis of the each edition of the DSM. If psychiatry reflects dominant norms and values of our society, then they should be reflected in the mental illness classifications constructed by the APA in the DSM. What my research found was a growing use of terms associated with work, school, and the home, and phrasings that emphasised productivity (in this case the problems associated with being unproductive). What we see over time in the DSM is the diagnoses speaking more specifically to our problems of living in neoliberal society. As an example, the symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) in the DSM-5 – such as forgetting or losing homework, failing to complete assigned tasks in the workplace, poor time-management, and so on – quite clearly denote the requirements for more productive and efficient students and workers.
While my current findings show no evidence of a world getting madder, they do demonstrate a more effective system of mental illness labelling which has aided expansion beyond the asylum and been a great success for those associated with the ‘business of mental health’, including pharmaceutical companies, psychiatric professionals, insurance companies, and therapeutic enterprises. In the next phase of my research, I am hoping to perform fieldwork with mental health professionals themselves to understand how they justify their practices in the absence of scientific progress in the area. Understanding how mental health professionals rationalise their work is crucial in helping us make sense of how the credibility of this phantom global epidemic is maintained on a day-to-day level.
Bruce Cohen is a Senior Lecturer in Sociology at the University of Auckland. His books include Mental Health User Narratives: New Perspectives on Illness and Recovery, Being Cultural and the Routledge International Handbook of Critical Mental Health.