Mental Health Policy II Definitions, Epidemiology, Service Use and Access

Mental Health Policy II
Definitions, Epidemiology, Service Use and

Access
9/1/15 Week 2 1
Definitions, Epidemiology, Service Use and Access
The D.S.M. would do well to recognize that a broken heart is not a medical
condition, and that medication is ill-suited to repair some tears. Time does not
heal all wounds, closure is a fiction, and so too is the notion that God never
asks of us more than we can bear. Enduring the unbearable is sometimes
exactly what life asks of us.
But there is a sweetness even to the intensity of this pain I feel. It is the thing
that holds me still to my son. And yes, there is a balm even in the pain. I shall
let it go when it is time, without reference to the D.S.M., and without the aid of
a pill.
- Ted Gup fellow of the Edmond J. Safra Center for Ethics at Harvard
University writing on the loss of his son to a drug overdose and the
pathologizing of grief in the DSM 5. (NY Times, April 2013)
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 Nature versus nurture controversy…. Is mental illness

inherited, caused by stressful environmental conditions,
or an interaction of both?
 What are the implications for a person who is diagnosed

as having a “mental disease”? (A “schizophrenic”)
 How important are cultural determinants and social

determinants (poverty, racism, sexism)?
 Is the term “mental illness” even logical?
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1. Strictly speaking, disease or illness can affect only the body; hence, there can be no
mental illness.
2. “Mental illness” is a metaphor. Minds can be “sick” only in the sense that jokes are
“sick” or economies are “sick.”
3. Psychiatric diagnoses are stigmatizing labels, phrased to resemble medical

diagnoses and applied to persons whose behavior annoys or offends others.
4. Those who suffer from and complain of their own behavior are usually classified as
“neurotic”; those whose behavior makes others suffer, and about whom others
complain, are usually classified as “psychotic.”
5. 5. Mental illness is not something a person has, but is something he does or is.
Szasz, Thomas S. (2011-07-12). The Myth of Mental Illness: Foundations of a Theory of Personal
Conduct (p. 267). HarperCollins. Kindle Edition.
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Should we adopt a broad definition of disease that includes all the

following possibilities to understand the cause(s) of mental illness?
Disease: any condition that impairs normal functioning.

Types:
1) Pathogenic (common cold)
2) Deficiency (anemia)
3) Hereditary (Down’s Syndrome)
4) Physiological--malfunction of body organ (“chemical imbalance”)
asthma-lungs
diabetes-pancreas
addiction, schizophrenia, bipolar disorder-brain
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Fundamental changes in brain help

“explain” continued drug use and relapse.
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…the fact that addiction is associated with neurobiological changes is not, in itself, proof
that the addict is unable to choose.
Robert Downey Jr. was once a poster boy for drug excess. “It’s like I have a loaded gun
in my mouth and my finger’s on the trigger, and I like the taste of gunmetal,” he said. It
seemed only a matter of time before he would meet a horrible end. But Downey entered
rehab and decided to change his life. Why did Downey use drugs? Why did he decide to
stop and to remain clean and sober?
An examination of his brain, no matter how sophisticated the probe, could not tell us why
and perhaps never will.
The key problem with neurocentrism is that it devalues the importance of

psychological explanations and environmental factors, such as familial chaos,
stress, and widespread access to drugs, in sustaining addiction.
Satel, Sally; Lilienfeld, Scott O. (2013-05-16). Brainwashed: The Seductive Appeal of

Mindless Neuroscience . Basic Books. Kindle Edition.
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 Evidence does suggest an inherited component for

some disorders:
 Schizophrenia spectrum and other psychotic
disorders
 Bipolar disorder
 Major depressive disorder
 Borderline personality disorder
 ASP
 Alcoholism (stronger genetic link for men)
 But none are 100% heritable and the genetic component

is less clear for other disorders such as the phobias.
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 Other models of mental illness (all have modest support

but none can explain all mental illnesses):
 Psychosocial development (psychoanalytic
psychology; “schizophrenegenic mother”)
 Learning theory (at first, purely behavioral and then
cognitive behavioral implications)
 Social-stress (stressful conditions cause
psychological breakdowns particularly in pre-
disposed individuals – interaction idea)
 Labeling theory – (deviant behaviors labeled as
illness, mental illness as a social construct – Szasz)
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Alas, we have reviewed dozens of definitions of mental disorder (and helped to

write the one in DSM-IV) and must admit that none have much practical value
(Wakefield 1992, Wakefield & First 2003).
Historically, conditions have become mental disorders by accretion and practical

necessity, not because they met some independent set of abstract and
operationalized definitional criteria. Indeed, the concept of mental disorder is so
amorphous, protean, and heterogeneous that it inherently defies definition—
creating a hole at the center of psychiatric classification.
The common themes in the definition of mental disorder are distress, disability,
dyscontrol, and dysfunction but these are very imprecise and nonspecific
markers with little practical value.
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10
As one illustration, it has become crystal clear that there is no one prototype
“schizophrenia” waiting to be explained with one incisive and sweeping
biological model. Instead, a painful process of promising false starts has taught
us there is no single gene, or small subset of genes, to account for
schizophrenia.
… schizophrenia is rather a group of disorders, or perhaps better, a mob. There

may eventually turn out to be 20 or 50 or 200 kinds of schizophrenia, and its
definitions are necessarily arbitrary constructs. There is no clear right way to
diagnose this gang or even much agreement on what the validators should be
and how they should be applied.
(Frances and Widiger paper, no longer assigned)
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Pragmatic concerns must play so central a role because the DSM is an official
system of classification that has a huge (perhaps excessive) influence on how
everything works in the mental health world: who gets diagnosed, how they are
treated, who pays for it, whether disability is appropriate, and whether someone
can be involuntarily committed, released from legal responsibility, or sue for
damages.
Fads in diagnosis come and go and have been with us as long as there has
been psychiatry. The fads meet a deeply felt need to explain, or at least to label,
what would otherwise be unexplainable human suffering and deviance. In
recent years the pace has picked up, with false epidemics coming in bunches
that involve an ever-increasing proportion of the population. We are now in the
midst of at least four such epidemics: autism, attention deficit, childhood bipolar
disorder, and paraphilia not otherwise specified.
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History of the DSM
• 1952 – First edition

• 1968 – Second Edition DSM-II – only 136 pages
• 1980 – DSM-III published after work had begun in 1974
• 1987 – Publication of DSM-III-R after APA appointed a work group to
revise and correct DSM-III
• 1994 – Publication of DSM-IV
• 2000 – Publication of DSM-IV-Text Revision
• 2013 – Publication of DSM-5
See Blashfield, Keeley et al. (2014) on syllabus.
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 Prevalences studies of national scope were not done prior to the

1980s.
 Psychiatry was dominated by psychoanalytic/psychodynamic

thinking as embodied in DSM-1 and DSM-2, which focused on
etiological understanding and not symptoms or classifications.
 Administering a structured survey to thousands of people using lay

interviewers was not possible with DSM-2 because the specific
criteria for a given disorder were not available in DSM-2.
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• DSM-III was a radical departure from DSM-2

• Removed focus from etiology to symptoms and classification
and increased number of diagnoses.
• Coordinated with development of ICD-9.
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 DSM-5 continues the trend. It is 947 pages long and has over 500
diagnostic conditions.
 Use of the DSM-5 could result in higher estimated rates of mental

illness as it requires fewer symptoms for shorter durations to meet
diagnostic thresholds.
 The abandonment of the Roman numeral (e.g., III, IV) was

intentional with the goal being more frequent revisions as scientific
findings emerge. The revisions will be labeled 5.1, 5.2. etc.
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 Per Mayes and Horwitz, and Blashfield et al.:

 The basic transformation in the DSM-III was its development and use of
a model that equated visible and measurable symptoms with the
presence of diseases.
 This symptom-based model allowed psychiatry to develop a

standardized system of measurement.
 Such a standardized system benefited numerous interests. It allowed

research-oriented psychiatrists (“neo-Kraepelinians”), a small but highly
influential group in the profession, to measure mental illness in reliable
and reproducible ways.
 It also helped silence the critics of the previous system, who claimed
that mental illnesses could not be defined in any objective way (e.g.,
Szaz – but he maintained his criticism).
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 Per Mayes and Horwitz:

 For clinicians, the new diagnostic system legitimized claims to be
treating real diseases and, most importantly, allowed them to obtain
reimbursement from third party insurers.
 Because the manual defined illnesses solely through symptoms without

regard to causes, it was theory-neutral and could be used by clinicians
of all theoretical persuasions.
 The symptom-based manual also met the needs of pharmaceutical

companies to have specific diseases for their products to treat.
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 DSM-III came about, in part, as a result of many pressures on the

psychiatric profession:
 Psychiatry’s marginal status within the medical profession
 Increasing reluctance of insurance companies and the government to

reimburse long-term talk therapy
 The need to treat formerly institutionalized seriously mentally ill

persons in the community, the growing influence of medication
treatments
 Growing professional threat from non-physicians such as clinical

psychologists, counselors, and social workers.
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 The confluence of these pressures led to a new DSM that fundamentally

redefined what mental disorders were and how they should be identified,
diagnosed, and treated.
 “By intent and careful plan the developers of DSM-III sought to bring about
a revolution in how mental health professionals thought about and practiced
psychiatric diagnosis. On many levels, the revolution succeeded remarkably
well” (Kirk & Kutchins, 1992, p. 11).
 American psychiatry in the late twentieth century moved from a state of

“brainlessness” to one of “mindlessness.”
 What is of particular interest to social scientists is the extent to which

politics and the underlying economics of psychiatric practice permeated the
DSM-III’s creation.
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In short, a powerful quartet of voices came together during the 1980’s

eager to inform the public that mental disorders were brain diseases.
• Pharmaceutical companies provided the financial muscle (69% of the DSM-

5 study group contributors had/have direct ties to the pharmaceutical
industry).
• The APA and psychiatrists at top medical schools conferred intellectual

legitimacy upon the enterprise.
• The NIMH [National Institute of Mental Health] put the government’s stamp
of approval on the story.
• NAMI provided moral authority.
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 With the medicalization of psychiatry came an increased emphasis on

pharmacology rather than talk therapy.
 DSM-III standardized the diagnostic classification scheme for mental

illnesses and disorders but did not include treatment guidelines.
 By virtue of its Kraepelinian orientation, however, it allowed pharmaceutical

companies to market their products for a growing number of specific,
symptom-based disease entities (Healy, 1997).
 The DSM-III unintentionally positioned psychopharmacology on a growth

trajectory that various institutions—insurance companies, managed care
organizations, pharmaceutical companies, and the government—propelled
significantly in subsequent years as they responded to the DSM-III’s new
diagnostic guidelines and research incentives.
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 The DSM-III allowed for research on the prevalence of disorders because it

provided specific criteria for assessing a disorder.
 The criteria could be coded into questions on a survey form that could be
administered by trained non-professionals (lay interviewers).
 The first survey form was the Diagnostic Interview Schedule (DIS) used in the
ECA study.
 Currently, the Composite International Diagnostic Interview (CIDI) is the

instrument in current use in the WHO and NCS-R studies… NESARC uses
another instrument (AUDADIS).
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The assumptions underlying the symptom-oriented focus of the DSM-III (and

every version of the DSM since that time) has had some problematic
implications:
 Although the main purpose of the introduction of a separate axis for

personality disorders (Axis II) in DSM–III was to stimulate research on
personality disorders, many researchers subsequently made the implicit
assumption that Axis I and Axis II are independent. Moreover, Axis II
disorders were considered less important or severe. This issue no longer
applies to the DSM-5 since the axial system has been abandoned.
 Much research on DSM has been inspired by another implicit assumption

that each disorder has its own relatively unique etiology and that one
therefore also can and should develop a relatively specific treatment for
each disorder. This assumption has led to recent conflicts between the APA
and NIMH, which has developed its own independent set of criteria.
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 Most treatment studies and treatment guidelines have focused on the efficacy
and effectiveness of disorder– specific treatments, and not on the effect of a
particular treatment for different disorders or particular aspects of treatment
processes.
 Studies on gene–environment correlations strongly suggest that individuals

vulnerable to depression in part create their own (stressful) environments and
there is high comorbidity between depression and Axis II disorders, particularly
dependent, borderline, and obsessive-compulsive personality disorder, making it
highly unlikely that depression and personality disorders are independent
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 Multi-comorbidity is an issue generally with our current diagnostic systems.
 Research has consistently shown that comorbidity between depression, anxiety

and other Axis I disorders is the rule rather than the exception, arguing against
the assumption that depression and other disorders are relatively distinct.
 Epidemiologic and clinical studies have shown extremely high rates of

comorbidities among the disorders, undermining the hypothesis that the
syndromes represent distinct etiologies. (Dohrenwend’s g?)
 Widespread use of “NOS” because the original diagnostic criteria for each
diagnosis were too narrow (to improve reliability). They do not reflect the messy
clinical reality. NOS has been eliminated in DSM-5 and replaced with “other
specified” and “unspecified”.
 Patients with symptoms that straddled diagnoses such as “schizoaffective

disorder”.
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• The converse of the multi-comorbidity issue is that people with the same
diagnosis can be very heterogeneous because of the mix and match set of
symptoms necessary for diagnosis:
Like essentially all heterogeneous, polygenic illnesses, psychiatric disorders are

poorly captured as categories (which assume significant discontinuities between
‘well’ and ‘ill’ conditions and between any two disorders). DSM categories have
the bizarre property of being both too broad (in the sense that they identify
remarkably heterogeneous populations) and too narrow (in the sense that, given
the large number of arbitrary DSM diagnostic silos, many if not most patients
with a single DSM diagnosis actually qualify for two or more.)
(Casey, B. et al., (2013). DSM-5 and RDoC: progress in psychiatry research?

Neuroscience, 14, 810-814)
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 It became necessary in the 1970s to facilitate diagnostic agreement among

clinicians, scientists and regulatory authorities given the need to match patients
with newly emerging pharmacologic treatments…
 While it is true that no system based entirely on clinical description can match
the levels of diagnostic agreement made possible by objective medical tests,
there were no good alternatives for psychiatry when DSM-III was published in
the 1980s. Indeed, even today objective tests and biomarkers for mental
disorders remain research goals rather than clinical tools.
 The DSM-III-R and DSM-IV revisions remained close to the DSM-III approach,
in part because of the dearth of new scientific information. As a result, diagnosis
in the DSM-III, DSM-III-R, and DSM-IV are best understood as useful
placeholders, based on careful description, but not on deeper understandings.
 The use of symptom-based clusters as indicating diagnosis remains a

characteristic of the just-published DSM-5.
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The goal of this new manual, as with all previous editions, is to provide a common
language for describing psychopathology. While DSM has been described as a
“Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining
each. The strength of each of the editions of DSM has been “reliability” – each
edition has ensured that clinicians use the same terms in the same ways. The
weakness is its lack of validity. Unlike our definitions of ischemic heart disease,
lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters
of clinical symptoms, not any objective laboratory measure. In the rest of medicine,
this would be equivalent to creating diagnostic systems based on the nature of
chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common
in other areas of medicine, has been largely replaced in the past half century as we
have understood that symptoms alone rarely indicate the best choice of treatment.
Patients with mental disorders deserve better.
Thomas Insel – NIMH Director (April 2013)

http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml
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Insel walked this back within a week or so and issued a joint statement President of APA:
“The DSM-5 represents the best information currently available for clinical diagnosis of
mental disorders. Patients, families, and insurers can be confident that effective
treatments are available and that the DSM is the key resource for delivering the best
available care. The National Institute of Mental Health (NIMH) has not changed its
position on DSM-5.”
Nevertheless, NIMH has come out with its own set of criteria called the Research Domain
Criteria (RDoC). These criteria do not assume a diagnosis first but instead start with how
functioning is impaired in given domains:
“Rather than starting with an illness definition and seeking its neurobiological
underpinnings, RDoC begins with current understandings of behavior-brain relationships
and links them to clinical phenomena.”
http://www.nimh.nih.gov/research-priorities/rdoc/nimh-research-domain-criteria-
rdoc.shtml#toc_matrix
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 Major prevalence studies over the last 3 decades:
 Epidemiological Catchment Area Study (1980s)
 National Comorbidity Survey (1990s)
 National Comorbidity Survey - Replication (2000s)
 National Epidemiological Survey on Alcohol and Related Conditions

(NESARC) (2000s) – oversamples minorities; includes modules to
assess personality disorders; will be administered longitudinally to
track progression
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Major prevalence studies over the last 3 decades:
 National Survey on Drug Use and Health (annual; focuses on

substance use but also asks a limited number of questions about
mental health symptoms and treatment access).
 Two additional minority-specific psychiatric epidemiology studies

are linked to the NCS-R: the National Survey of African Americans
(NSAA) and the National Latino and Asian American Study
(NLAAS).
 WHO – World Mental Health Surveys (includes NCS-R in the US) in

31 countries.
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 Prevalence rates across studies vary with the ECA study generally
having the lowest rates
 All studies have yielded surprisingly high prevalence rates …..more

people have at least one lifetime DSM disorder than anyone
expected
 Per the NCS-R, the chance of having at least one DSM disorder in
your lifetime is close to 50%
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ECA NCS NCS-R

Affective Disorder 7.1% 11.1% 9.6%
Anxiety Disorder 13.1 18.7 18.2
Substance Use* 6.4 11.3 3.8
Any Disorder 19.5 23.4 26.2
*ECA estimate is for 6 month prevalence
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Rates across the 3 surveys vary but are difficult to compare because:
 Different diagnostic systems
 DSM-III (ECA)
 DSM-IIIR (NCS)
 DSM-IV (NCS-R)
 Different sampling strategies

 ECA was not a national sample (5 sites)
 NCS and NCS-R were national samples
 Change in instrumentation and protocol

 Better use of stem questions
 Computer assisted interviewing (reduces error)
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Other important findings from the NCS-R survey:
 The three most prevalent 12-month disorders found by the NCS-R were
specific phobia (9%), social phobia (7%), and major depressive disorder
(7%).
 The most prevalent 12-month disease classes are anxiety disorders (18%),
mood disorders (10%), impulse-control disorders (9%), and substance use
disorders (4%).
 The most prevalent lifetime disorders are anxiety disorders (29%), mood
disorders (21%), impulse-control disorders (25%), and substance use
disorders (15%).
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 The mental disorders with the highest proportion of seriously disabling 12-
month cases are: bipolar disorder (83%); drug dependence (57%); and
obsessive-compulsive disorder (51%).
 Impulse-control disorders, which have been neglected in most previous

epidemiological studies of adults, have a greater proportion at the serious
level than either anxiety disorders or substance use disorders.
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 Severity was strongly related to comorbidity; 9.6% of respondents with 1

diagnosis, 25.5% with 2 diagnoses, and 49.9% with 3 or more diagnoses
were classified as serious.
 Mental disorders are associated with a general pattern of disadvantaged

social status, including being female, unmarried, and having low
socioeconomic status.
 The finding that non-Hispanic black and Hispanic individuals have

significantly lower risk of disorders is inconsistent with this general pattern,
but the same relationship was found in the baseline NCS.
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 Many disorders start early, half of all lifetime cases start by 14 years
and three-fourths by 24 years. The age of onset varies by disorder:
 Median age of onset for anxiety disorders (11 yrs.)

 Median age of onset for impulse control disorders
(11 yrs.)
 Median age for substance use disorders (20 yrs.)
 Median age for mood disorders (30 yrs.)
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 Disorders that occur (have their onset) later in life are generally comorbid
(secondary) conditions.
 Mental disorders are distinct from chronic physical disorders because they
have their strongest foothold in youth, with substantially lower risk among
people who have matured out of the high-risk age range.
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A few words on substance use disorders (including alcohol use):

 Alcohol dependence is the most common substance use disorder by far
compared with any other drug
 The dependence rate on all other drugs combined is about half the
dependence rate on alcohol
 Those dependent on other drugs are usually also dependent on alcohol
(We will consider SUDs later on in the semester both as independent disorders
as well as very common co-occurring conditions with SMIs)
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NCS-R
Alcohol Abuse 13.2%

Alcohol Dependence 5.4
Drug Abuse 7.9

Drug Dependence 3.0
Any Substance Use Disorder 14.6
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There was a big problem with the NCS-R data and findings that likely reflect
the problems with the DSM (and ECA):
Are this many people really mentally ill in the US and in need of
treatment????
Implications:
26% (~60 million) of the United States population needs mental health
treatment in a given year?
46% (~135 million) of the United States population needs mental health
treatment in their lifetime?
A prospective study found that, by age 32, 50% of the general population had
qualified for an anxiety disorder, 40% for a depression, and 30% for alcohol
abuse or dependence (Moffitt et al. 2010). Imagine what the rates will be like
by the time these people hit age 50, or 65, or 80. In this brave new world
psychiatric overdiagnosis, few will get through life without a mental disorder.
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Because diagnoses have no real biological or neurological referrants, they are subject to
cultural influences and contexts. Important influences on diagnostic inflation include:
1. The widespread appeal of the DSM is in its clear definitions, which allow people to
diagnose themselves and family members.
2. It is fairly easy to meet criteria for one or another DSM diagnosis. The definitional
thresholds may be set too low.
3. The pharmaceutical industry has proven to be fairly unsuccessful in developing new

and improved medications. But it is wonderfully effective at marketing existing wares
and is an important engine in overdiagnosis and the spread of psychiatric epidemics.
4. Patient and family advocacy groups have played an important role in calling attention
to neglected needs; in lobbying for clinical, school, and research programs; and in
reducing stigma and promoting group and community. support.
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5. It is no accident that the recent epidemics have mostly occurred in the childhood
disorders. There are two contributing factors. The first is the push by drug companies
into this new market. The second is that the provision of special educational services
often requires that there be a DSM diagnosis.
6. The media feed off of and feed into the public interest in mental disorder. This
happens in two ways. Periodically, the media become obsessed with one or another
celebrity whose public meltdown seems related to a real or imagined mental disorder.
The mental disorder is then endlessly dissected by the media.
7. We live in a society that is perfectionistic in its expectations and intolerant of what

were previously considered to be normal and expectable distress and individual
differences.
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Maybe if we adjusted for severity, the numbers would make more sense (this is
what is meant by dimensionality in the Blashfield article)…. Criteria for severe
impairment in the NCS-R:
 Bipolar I or substance dependent with physiological dependence

(tolerance or withdrawal) or
 Making a suicide attempt and having any Axis I disorder or
 At least 2 areas of role functioning severely impaired or
 GAF score of 50 or lower (suicidal ideation, severe obsessions,

frequent shoplifting, no friends, unable to keep a job)
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 Criteria for moderate impairment in the NCS-R

 Substance dependent without physiological dependence or
 At least moderate impairment in any area of role functioning
 All other disorders classified as mild…
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NCS-R
Serious/Severe 7.7% (29.6)
Moderate 9.4 (35.7)
Mild 9.2 (34.9)
All 26.3%
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 So, viewed in this way, about 8% of the US adult population (18 years of
age or older) needs mental health treatment…
 This is still a large number - ~26 million people
 So the people with the most severe manifestations of the disorder get
treated right?
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 Yes and no… on the one hand, disorder severity is strongly related to
treatment …
 In the US, 52% of those with severe disorders, 34% of those with moderate,
22% of those with mild, and 8% of those with no disorder…
 Demand for treatment is related to severity, presumably mediated by

distress and impairment…
But….
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 Even though the proportion of non-cases in treatment is small (no

diagnosis!) the fact that noncases make up the majority of the population
means that noncases constitute a meaningful fraction of all people in
treatment…
 Either the majority or a near majority of people in treatment in each country

(WHO study) are either noncases or mild cases…
 AND… in developed countries (including the US) 35% to 50% of the serious
cases are untreated
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 Among those cases that do get treatment, at least half receive inadequate
care (even when “adequate” was defined as >= 2 visits to a treatment
provider…
 Only one-third of treatments meet minimal standards of adequacy based on

evidence-based treatment guidelines.
 People with SMI also get poorer medical care when they are able to access
it.
 Lower rates of treatment among racial and ethnic minorities, the elderly,
low-income, those with co-occurring substance abuse, and low education.
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 The proportion of NCS-R respondents who reported 12-month mental health

service use (17.9%) is higher than the value found a decade earlier in the
baseline NCS (13.3%) and the value found a decade before that in the
Epidemiologic Catchment Area Study (12.3%).
 The greatest part of this expansion occurred in the general medical sector.
General physicians often act as gatekeepers responsible for initiating mental
health treatments themselves and for deciding whom to triage for specialty care.
 Only a few patients treated in the GM sector receive minimally adequate care…
but presumably involve provider factors (eg, competing demands, inadequate
reimbursements for treating mental disorders, and less training and experience in
treating mental disorders) and patient factors (eg, worse compliance with
treatments than in MHS sectors).
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 System barriers that constrain reallocation:
 In US, decentralized system, limiting access to psychotherapists among

the middle class, does not translate into more care for the poor (not the
same pot of money or resources).
 Differences in perceived need despite objective severity drive

treatment.
 Differences in access associated with insurance coverage and financial

resources (is ACA changes this?).
 No obvious strategy (treating mild cases may prevent progression to

more severe disorders – ACA does emphasize prevention and parity).
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Question: What would you do to more rationally allocate

treatment? What system changes or policies would you
put in place?
9/1/15 Week 2 60
We will talk more about international comparisons, but based on NCS-R data
and comparable data collected in other countries…..
30
26.4 12-month prevalence – any disorder
25
20.5
20 18.4
17.8
16.9
14.9
15
12.2 12
10 9.1 9.2 8.8 9.1

8.2
4.7 4.3
5
0
ly i
bi
a ic
o
te
s
um ce ny ds ai
n in
e on ria pa
n na ha
x a i n a Ita la
n p a n e hi g
ol
um M
e St el
g
Fr
a
er
m
er S
U
kr
e ba N
ig J a C
han
d B h L
C
ni
t e G et S
U N
9/1/15 Week 2 61
 American culture with emphasis on independence

leads to more isolation and loneliness?
 Higher degree of stress?
 Concepts used to describe mental illness in English

do not translate to other cultures?
 More used to surveys and polls in this country and

hence greater openness?
9/1/15 Week 2 62
*****First Short Critique Due September 8th at 5:00PM. *****
Discuss attempts to define mental illness, including the DSM-5, controversial

issues with these definitions, and alternative ways in which we might define
mental illness. You can hone in on a single diagnosis such as Asperger’s, ADHD,
removal of the bereavement exclusion from Major Depression, etc. if you prefer.
9/1/15 Week 2 63

Mental Health Policy II Definitions, Epidemiology, Service Use and Access

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Mental Health Policy II

Definitions, Epidemiology, Service Use and

 Nature versus nurture controversy…. Is mental illness

 What are the implications for a person who is diagnosed

 How important are cultural determinants and social

 Is the term “mental illness” even logical?

3. Psychiatric diagnoses are stigmatizing labels, phrased to resemble medical

Should we adopt a broad definition of disease that includes all the

Disease: any condition that impairs normal functioning.

Fundamental changes in brain help

The key problem with neurocentrism is that it devalues the importance of

Satel, Sally; Lilienfeld, Scott O. (2013-05-16). Brainwashed: The Seductive Appeal of

 Evidence does suggest an inherited component for

 Major depressive disorder

 Borderline personality disorder

 Alcoholism (stronger genetic link for men)

 But none are 100% heritable and the genetic component

 Other models of mental illness (all have modest support

Alas, we have reviewed dozens of definitions of mental disorder (and helped to

Historically, conditions have become mental disorders by accretion and practical

… schizophrenia is rather a group of disorders, or perhaps better, a mob. There

(Frances and Widiger paper, no longer assigned)

History of the DSM

• 1952 – First edition

See Blashfield, Keeley et al. (2014) on syllabus.

 Prevalences studies of national scope were not done prior to the

 Psychiatry was dominated by psychoanalytic/psychodynamic

 Administering a structured survey to thousands of people using lay

• DSM-III was a radical departure from DSM-2

 Use of the DSM-5 could result in higher estimated rates of mental

 The abandonment of the Roman numeral (e.g., III, IV) was

 Per Mayes and Horwitz, and Blashfield et al.:

 This symptom-based model allowed psychiatry to develop a

 Such a standardized system benefited numerous interests. It allowed

 Per Mayes and Horwitz:

 Because the manual defined illnesses solely through symptoms without

 The symptom-based manual also met the needs of pharmaceutical

 DSM-III came about, in part, as a result of many pressures on the

 Psychiatry’s marginal status within the medical profession

 Increasing reluctance of insurance companies and the government to

 The need to treat formerly institutionalized seriously mentally ill

 Growing professional threat from non-physicians such as clinical

 The confluence of these pressures led to a new DSM that fundamentally

 American psychiatry in the late twentieth century moved from a state of

 What is of particular interest to social scientists is the extent to which

In short, a powerful quartet of voices came together during the 1980’s

• Pharmaceutical companies provided the financial muscle (69% of the DSM-

• The APA and psychiatrists at top medical schools conferred intellectual

• NAMI provided moral authority.

 With the medicalization of psychiatry came an increased emphasis on

 DSM-III standardized the diagnostic classification scheme for mental

 By virtue of its Kraepelinian orientation, however, it allowed pharmaceutical

 The DSM-III unintentionally positioned psychopharmacology on a growth

 The DSM-III allowed for research on the prevalence of disorders because it

 Currently, the Composite International Diagnostic Interview (CIDI) is the

The assumptions underlying the symptom-oriented focus of the DSM-III (and

 Although the main purpose of the introduction of a separate axis for

 Much research on DSM has been inspired by another implicit assumption

 Studies on gene–environment correlations strongly suggest that individuals

 Multi-comorbidity is an issue generally with our current diagnostic systems.

 Research has consistently shown that comorbidity between depression, anxiety

 Epidemiologic and clinical studies have shown extremely high rates of

 Patients with symptoms that straddled diagnoses such as “schizoaffective

First Short Critique Due September 8th at 5:00PM.