Magazine article Clinical Psychiatry News

Findings of Survey on Mental Illness: 'Nonsense'

Magazine article Clinical Psychiatry News

Findings of Survey on Mental Illness: 'Nonsense'

Article excerpt

The recent survey showing that almost half of Americans meet DSM criteria for a mental illness at some point in their lives raises questions about the way in which mental illnesses are classified. In fact, experts such as Paul R. McHugh, M.D., have compared the DSM to a "naturalist's field guide with the advantages and disadvantages of such" (JAMA 2005;293:2526-8).

Do such statistics showing psychiatric disorders to be widespread in this country ring true for you? Is the DSM too broad?

'Mild' Disorders Important

We're asking the wrong question. We don't ask how many people have a physical disorder. If we did, we'd have to decide whether we should include mild problems such as a cold or a sprained ankle. And we'd probably come up with a high prevalence within a given year.

Some argue that the solution to the high prevalence rates of mental illness is to raise the threshold. That way, only people with marked distress or impairment in general functioning would be considered to have a mental disorder. However, just as it would not make much sense to do a survey of people with low back syndrome and then only include the people who were unable to go to work, only including people with a severe mental disorder in a survey of mental disorders wouldn't make sense, either.

Since the DSM-III, clinicians have diagnosed an individual who comes to them for help by asking themselves whether the patient fits criteria for one or more disorders. Unfortunately, we don't have biologic markers that can validate psychiatric diagnoses. Some people say that we should not revise the DSM until we have those kinds of markers. But I think that if we did that, we would be waiting a long time.

Robert Spitzer, M.D.

New York

Delineating Disorder From Normality

Issues of prevalence concern epidemiologists and policy makers more than psychiatrists. Most people who walk into our offices are self-identified as having a mental disorder. The situation is different in large nationwide surveys in which investigators interview people to determine whether they have sufficient psychiatric symptoms to qualify as a psychiatric "case" and are thus faced with the problem of how to delineate disorder from normality.

Unlike many medical conditions, symptoms of mental illness are often not apparent. Also, people are reluctant to talk to others about having psychiatric symptoms. As a result, prevalence rates reported by surveys appear to be out of line with people's common sense notion that mental disorders are not common.

Since psychiatric "caseness" in epidemiologic studies is determined by whether or not the subject's symptoms meet criteria for a DSM disorder, critics blame the DSM for these inflated prevalence figures. Most of the diagnostic thresholds in the DSM are based not on empiric data, but on expert consensus. The DSM-IV added what has come to be known as the "clinical significance criterion," which requires that the "disturbance causes clinically significant distress or impairment in one or more areas of functioning." The ability to make such distinctions hinges on clinical judgment. Nonclinicians doing surveys may find it difficult to apply such distinctions.

Until we develop standards for objectively determining the threshold for psychiatric "caseness," the best we can probably hope for is empirically based diagnostic cut points that reflect risk for harm (as is done with thresholds for hypertension).

Michael B. First, M.D.

New York

Clinical Significance Criterion Matters

The issue is not whether the DSM is too broad, but, rather, how well our current survey methods translate the DSM into prevalence rates.

The challenge is to determine who has symptoms that are clinically significant, that is, have actual psychopathology in need of treatment. The criteria used in the DSM-IV clearly affect prevalence rates. …

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