In March 2011, a doctor by the name of Richard Morrow conducted a broad study of one million Canadian schoolchildren, observing the medical diagnoses that all children received within a period of one year. He specifically studied those children between the ages of six and 12 who had been diagnosed with ADHD. He found that the boys who were born at the end of the calendar year were 30% more likely to be diagnosed with ADHD than boys who were born at the beginning of the year. For girls, those born in December were 70% more likely to be diagnosed than those born in January(1). What could be the reason for this?
The answer is simpler than you think. Children in the same year at school have the potential to be almost an entire year apart in their physical age. Which means that girls born in January have 11 months’ advantage in their development over the girls born in December. An 11 month gap at this age in a child’s life equates to a huge difference in mental and emotional maturity.
What Morrow discovered is that younger children in the same academic year were more likely to be diagnosed with ADHD due to their relative developmental differences in maturity, which were being mistaken for symptoms of ADHD. This is but one example of the negative implications of the medicalization phenomenon in the way we categorize and diagnose mental illness.
Medicalization is defined by when a human experience is diagnosed pathological in origin and therefore treated as a medical condition. It’s a topic I’ve chosen to delve into first as it sets the stage for many of the obstacles associated with diagnosing, preventing, and treating mental illness.
Psychiatry has been accused more often than any other medical specialization of incorrectly medicalizing the human condition. The concern with mental illness is that it is traditionally assessed based on symptoms alone, and without first analyzing the possible causes of such, which may be due to someone’s upbringing as a child, to their current workplace and career stressors, or to abrupt, yet very real and poignant, traumatic events.
Diagnosis based on symptoms can be highly problematic. A catalyst of medicalization is the bible of psychiatry: The DSM. The Diagnostic and Statistical Manual of Mental Disorders is used by psychiatrists to diagnose mental health disorders in both adults and children. The latest version, theDSM-5, was published in 2013 by the American Psychiatric Association. An entire book can be written on the history, validity, and overall impact of this manual in the field of modern psychiatry (and indeed many books have been produced on this topic), but in the context of this article it’s important to know that the DSM plays a huge role in shaping our perception of mental illness.
The New York City-based psychiatrist Robert Spitzer, an instrumental voice in the development of the DSM, accurately summarized the problem, “We made estimates of prevalence of mental disorders totally descriptively, without considering that many of these conditions might be normal reactions which are not really disorders.” (2) Which means that Spitzer and the other authors of the DSM cared less about the contextual factors that would contribute to a person’s relative unhappiness and anxiety, and instead favored analyzing the physical symptoms of a particular disorder without regard to the notion that these reactions may in fact be normal, human reactions to difficult life situations.
Take, for example one of the depressive disorders currently listed in the DSM-5: major depressive disorder. For context, the full list in the category of depressive disorders are: disruptive mood dysregulation disorder, major depressive disorder (including major depressive episode), persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorder, and unspecified depressive disorder. In the DSM-5, to be diagnosed with major depressive disorder, you have to have at least five of the following symptoms in the same two-week period (and at least one of the symptoms must be diminished interest/pleasure or depressed mood):
- Depressed mood: For children and adolescents, this can also be an irritable mood
- Diminished interest or loss of pleasure in almost all activities
- Significant weight change or appetite disturbance: For children, this can be failure to achieve expected weight gain
- Sleep disturbance (insomnia or hypersomnia)
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness
- Diminished ability to think or concentrate; indecisiveness
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide
If you can check off five of these bullet points at this very moment, you report having experienced similar feelings for the past 20 days, and then you proceed to a psychiatrist for a 20 minute evaluation, you would likely be diagnosed with major depressive disorder and given a prescription for antidepressants.
That’s all it takes. What is not counted is your life circumstances, many of which may not be in top shape right now. You may have gotten fired from your job, abruptly experienced a loss of a dear friend, or you might be lonely and overwhelmed by having moved to a new city far away from home. Or it could be a combination of the three, or any other concoction of the harsh realities of being an adult human in 2018.
In the DSM-5, the exclusion of bereavement from major depressive disorder was eliminated. Experiencing grief for an extended period of time is no longer considered a normal behavior. This means that your natural feelings of deep sadness, loss, sleeplessness, crying, the inability to concentrate, tiredness, and low appetite after suffering a traumatic loss now warrants the diagnosis of depression if these symptoms continue for more than two weeks. I am just going to let this sit for a moment.
Someone dies, you are sad about it, and you’re now mentally ill.
Ignoring everyday human suffering and mental and emotional development is at the heart of the medicalisation issue. From a seven-year boy in Canada who, by virtue of their November birth month, has been mistakenly diagnosed with ADHD to a 32 year-old woman who, while mourning the recent death of her parent, is labeled as having a significant depressive disorder, we see the range of assumptions that the field of psychiatry that the DSM makes and in doing so, contributes to a harmful over-medicalisation of Western society. Are we really all suffering from a pathological mental disease, or are we being told that having human negative feelings are so wrong that they warrant us going down the rabbit hole to a world of medication, social discrimination, and possible isolation from our community as a consequence of extra-special treatment?
At what point does medicalization harm the overall state of “wellness” or “illness” in society? How can we better use such tools as the DSM to more accurately diagnose people who seek help from the medical community? And is medicalization the root cause of the over-prescription of medications to treat mental disorders, or are there other factors to be considered?
(This article originally appeared on Medium)
(1). Richard L Morrow, “Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children,”CMAJ 2012 Apr 17; 184(7): 755–762.
(2). James Davies, Cracked: How Psychiatry is Doing More Harm than Good, (UK, Icon Books, 2013), 47.