The Magazine

A Nation of Crazy People?

From the June 27, 2005 issue: Overestimating mental illness in America.

Jun 27, 2005, Vol. 10, No. 39 • By PAUL R. MCHUGH
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DSM-IV makes no attempt to classify mental symptoms or complaints by cause. As a result, it mingles serious and impairing conditions with other forms of mental distress in one hopeless and scientifically indigestible stew. When this diagnostic method is employed for a census of mental disorders in the citizenry, it ominously exaggerates the incidence and the nature of mental troubles. It leaves the public wondering: If more than 50 percent of Americans have at some point been mentally "impaired," what constitutes a "normal" mental life?

Another way of stating the problem is that DSM-IV is the medical counterpart of a naturalist's field guide--say, Roger Tory Peterson's Field Guide to the Birds. To develop his guide, Peterson asked expert bird watchers what features of shape, coloring, voice, and range they used to distinguish one warbler from another, and he arranged his guidebook accordingly. As a result, bird watchers became more precise in the terms they used to describe what they saw. But as Peterson noted, amateurs relying on the way birds look often confuse varieties with separate species, while ornithologists turn to biology to make more fundamental distinctions.

Similarly, clinical psychiatrists in 1980 wanted to find a way to apply their diagnostic terms consistently. With DSM-IV, they agreed on which symptoms they would use as criteria for each diagnosis, and thus increased their diagnostic consistency. But the best clinicians apply DSM-IV diagnostic terms only after they have fully examined the patient and come to see these symptoms in context. They do not simply run down a checklist of symptoms, count them up, and attach a diagnosis, as did the technicians from Harvard.

Psychiatrists are right now rewriting the diagnostic manual. I believe they will move closer to internal medicine, classifying patients according to what has provoked their symptoms rather than according to the symptoms alone. Only then will scientific and epidemiologic studies in psychiatry improve.

In the meantime, while scientists are working to lift psychiatry beyond the level of a field guide, epidemiologists should stop expending time and money repeating surveys that purport to measure the prevalence of psychiatric disorders but instead only mislead and alarm the public. They should spend their efforts in more productive areas of psychiatric research.

They might, for example, start following people over time, as cohorts with particular life circumstances: They might consider the long-term performance of children with particular classroom-identified dispositions or children exposed to various forms of deprivation or trauma early in life, seeking to discover how these people manage the hurdles they face and which vulnerabilities to mental problems and which resiliencies they manifest in later life. Epidemiologists should attend to studies where patients with particular characteristics--such as temperament, upbringing, or stress--are compared with nonpatients with similar characteristics (so called case-control studies) testing whether these characteristics provoke, protect against, or are incidental to the patients' mental unrest or illness. They should enhance cross-cultural knowledge of how mental impairment, as opposed to mental distress, is expressed by people of differing cultures and exactly what measures help to prevent or treat the case examples.

Analytic studies like these could accomplish much more than descriptive surveys that do little in the long run but exasperate the public and make ephemeral headlines. Along the way, with these more specific studies we would likely discover not that the majority of people are impaired but just how remarkably resilient most of us are and what distinct and wonderful assets most people bring to life. To conduct more of the same kind of empty surveys as are now being done is, I'm afraid, a little crazy--with crazy defined as doing the same thing again and again and expecting a different result.

Paul McHugh is a university distinguished service professor of psychiatry and behavioral science at the Johns Hopkins School of Medicine and former psychiatrist in chief of the Johns Hopkins Hospital.