Opinion — 14 June 2012

More and more Australians are being diagnosed with a mental illness. Are we pathologising normal states of mind, or are we really getting sicker? Jill Stark reports.

ANDREW Tierney was a quiet, introverted teenager. Socially awkward and prone to prolonged periods of sadness, he struggled to make friends. At the time, he thought it was a normal part of growing up. Looking back, the 51-year-old sees it differently.

“I think I’ve gone through bouts of depression my whole life and just not realised it. Anything to do with mental illness was frowned upon when I was a kid. ‘You can’t have problems, just get over it,’ was the attitude,” he says.

Diagnosed with clinical depression after a suicide attempt six years ago, he now believes that might have been prevented if he had had more support as a teenager. And it may have helped him see the warning signs in his son, Terry, who tried to take his own life at 14 after the death of his best friend in a car accident.

In the 1970s, Andrew’s behaviour was dismissed as “teen angst”, while Terry’s troubles were diagnosed as a mental health problem. He has since recovered after being prescribed antidepressants by a doctor and after receiving counselling from headspace, the national youth mental health foundation.

The difference between the experiences of Andrew and Terry is that Terry, 19, lives in an Australia where the spotlight on mental illness has never shone more brightly.

The figures say that one in five of us will experience a mental disorder in any given year, and almost half will be afflicted in our lifetimes. But as the focus on mental health intensifies, there is growing disquiet, much of it within the psychiatric profession, that in the push to raise awareness and reduce stigma, the pendulum may have swung too far in the opposite direction.

While the spotlight has helped reduce suicide rates and encouraged people like Andrew and Terry to seek help, some fear the diagnostic bar is being set so low that normal human behaviour, sadness and personality quirks are being classified as medical conditions. They argue that this shift will spark false epidemics of psychiatric disorders and lead to more people being unnecessarily medicated.

“It’s been to psychiatry’s advantage to talk up these higher numbers. We know that governments are not going to be interested in doing something about a trivial or very rare condition,” says Gordon Parker, scientia professor of psychiatry at the University of New South Wales and founder of the Black Dog Institute. “The figure that one in five will have an episode of depression is very evocative, and certainly makes a point that these mood disorders are common and that we should do something about them. But is it valid? Almost certainly no.”

Central to Parker’s concerns is the rise of psychiatric drug use. In 2009-10, more than 13 million Medicare-subsidised prescriptions were written for antidepressants, an average increase of 1.3 per cent a year since 2005-06. Anti-psychotics have also increased to 2.6 million prescriptions a year, up 9.6 per cent over the same period. A recent analysis, showing these powerful drugs are being given to people aged over 67 at twice the rate they’re prescribed to younger people, has led experts to worry they are being used as a way to control behaviour in elderly dementia patients rather than as a therapeutic measure.

The broadening definition of mental illness has been a boon for the pharmaceutical industry, with the global psychiatric drug market now worth $80 billion a year, and tipped to climb to $88 billion by 2015.

It’s a long way from the 1950s, when the world’s first antidepressant, imipramine, was discovered and manufacturer Geigy worried there weren’t enough depressed people for it to generate a profit.

Many mental health experts argue that these drugs have helped save lives and that advances in treatment mean more serious illnesses such as catatonia and severe forms of schizophrenia are rarely seen today.

However, rising economic pressures and the psychological burden of chronic “lifestyle” diseases such as type 2 diabetes and obesity have created new triggers for mental distress, which can be treated like any physical ailment, with appropriate therapies.

“Our society’s changed, we’re busier than ever before, more women are working, workplaces are more stressful and expectations on workers are higher than they were in decades past. That has taken a significant toll on mental health,” says Kate Carnell, chief executive of national depression initiative beyondblue.

So all of this raises the question: are we any more mentally ill than we once were? Or has medicine simply blurred the boundaries between normality and disease?

Mental illness in Australia has only been recorded in a population-wide way in the past 10 to 15 years, making comparisons with previous generations problematic.

Going by British and American studies, which show exponential increases in mental disorders over the past 50 years (particularly depression and anxiety), researchers extrapolate that it’s likely to be similar in Australia.

The most commonly referenced modern-day snapshot is the Australian Bureau of Statistics’ 2007 National Survey of Mental Health and Wellbeing, which found that one in five people aged 16 to 85 had experienced a mental disorder in the 12 months prior to the survey, marginally up from the 18 per cent recorded in the 1997 survey.

A further 25 per cent in this age bracket had been diagnosed with a mental disorder in their lifetime. All up, that’s 45 per cent, or more than 7.2 million Australians, who meet the criteria for a diagnosable mental illness.

It’s an alarming number that has been used as a call to arms. The Gillard government last year invested a record $2.2 billion in mental health services _ almost a quarter of it into youth programs such as headspace, founded by former Australian of the Year Professor Pat McGorry, who frequently quotes figures from the 2007 survey showing one in four (26 per cent) of 16 to 24-year-olds will suffer a mental disorder in any given year.

Arguably, without McGorry’s impassioned lobbying, mental health would still be in the shadows, but Parker warns that the figures don’t tell the whole story.

“I suspect that 90 per cent of the suggested increase in prevalence we are seeing for mood disorders like depression is due to the lowering of the bar for diagnoses and destigmatisation, making more people come forward with lower levels of severity who in the old days would have soldiered on,” he says. “The risk now is of including normal states of sadness and depressed mood as diseases and thus pathologising normal reactions to abnormal situations . .

The downsides are people get misdiagnosed and given medication that’s inappropriate and may have significant side effects.”

The 2007 survey grouped respondents into three categories: 14 per cent of people were found to have anxiety disorders such as post-traumatic stress disorder and panic disorder; 6 per cent had mood disorders, which includes conditions like depression and bipolar syndrome; while 5 per cent had experienced substance abuse disorders including “harmful alcohol use”. Using these criteria, critics claim, a binge drinker could arguably be counted as mentally ill.

The survey also classified low levels of depressed mood for relatively short periods as a depressive episode.

McGorry acknowledges the need for better data, but denies prevalence rates have been exaggerated. He points out that services are facing unprecedented demand and two-thirds of people with mental health problems still go untreated.

“Some people just want to put their head in the sand and dismiss mental ill-health as the ‘worried well’, that they should just draw on their own resilience and only seek help if things get really, really severe. But when the person’s becoming disabled, they’ve got a right to seek help. It doesn’t mean that they should be immediately channelled into the serious mental illness category and given medication, but they do deserve an assessment and non-stigmatising help,” he says.

Nobody denies the burden of mental illness is substantial. In 2010, more Australians died from suicide (2361) than on our roads (1368). Mental disorders are responsible for one in four new disability claims, and cost 4 per cent of the nation’s gross domestic product.

But diagnosing psychiatric problems is an inexact science. Barbara Hocking, executive director of SANE Australia, says that unlike physical conditions such as cancer or heart disease, there are no clear biomarkers for mental illness that can be picked up by diagnostic screening such as X-rays, brain scans or blood tests.

This, she says, means mental illnesses are more likely to be misdiagnosed than other health problems. At the opposite end of the spectrum, it can lead to under-treatment, with people often reaching a crisis point before they receive support.

“We see it time and time again in the early stages when you’re told, ‘No, you’re not sick enough, go away’, which is counter to everything that happens in any other health area,” Hocking says. “The rule of thumb we always use is if whatever you’re experiencing is bad enough to stop you doing what you need to do in your day, if it stops you getting out of bed to make the kids’ lunches before they go to school, if it stops you getting to work and doing the things you usually enjoy, then it’s worth getting help.”

At the heart of the debate is the changing definition of mental illness and the contentious document that is used globally to diagnose disorders. The Diagnostic and Statistical Manual of Mental Disorders (DSM), produced by the American Psychiatric Association, has grown from a 130-page booklet of around 60 broad illnesses in its first edition in 1952 to a 900-page tome listing more than 300 disorders.

A draft of its fifth edition, due to be published next May, proposes a range of new disorders and drops the diagnostic threshold for many existing conditions. It has caused an international outcry, with 51 health groups including the American Counselling Association, the American

Psychological Association and the British Psychological Society calling for an independent review.

The draft document has also sparked a bitter divide within the psychiatric community, with the debate as much about the ideological future of the profession as about the nature of mental illness.

The most strident critic of DSM-5, American psychiatrist Allen Frances, who developed the previous edition in 1994, has called it a “dangerous public health experiment” that would inappropriately inflict the “mental disorder” label on millions of people now considered normal.

Among the proposed conditions are “disruptive mood dysregulation disorder”, which could turn children’s tantrums into an illness, and “mild neurocognitive disorder”, which could see the natural forgetfulness of age become a treatable disease. Criminal behaviour such as rape could be redefined as mental illness, with “paraphilic coercive disorder” (or arousal from sexual coercion) being considered a new condition.

It will also be easier for a boisterous child to meet the diagnosis for attention deficit hyperactivity disorder (ADHD), as the number of symptoms needed to meet the diagnosis has been halved. There has already been a global epidemic of the condition since it was added to the DSM in 1987.

It follows a trend that has seen diagnostic categories expand with every new edition. Most notably, while once depression was broadly divided into two types _ melancholic depression, which was seen as a disease and had no obvious cause, and reactive depression, sparked by stressful life events _ DSM-3, released in 1980, essentially created one condition that varies by severity. Thus, critics argue, the bar was lowered, and mild or moderate sadness was lumped into the same category as what was once considered clinical depression.

Based on the DSM, GPs use a checklist of symptoms and behaviours to arrive at a diagnosis of mild, moderate or severe depression. It’s a blunt instrument that on its own does not consider personality type or differentiate between transient unhappiness triggered by personal circumstances such as marriage difficulties or job loss, and depressive illness with a biological root.

This “checklist” diagnosis, says Parker, and the notion all forms of depression respond to medication, has led time-poor GPs, who prescribe 85 per cent of all psychiatric drugs in Australia, to reach for the prescription pad rather than delve more deeply into a patient’s problem.

“I’ve treated a perfectionistic school teacher who had been at the school for 30 years and he was publicly demeaned by the headmaster and he felt invalidated. A week later he went to a GP and was put on an antidepressant. He was referred to us 18 months later when he’d had 22 differing medications and two courses of electroconvulsive therapy. His depression was no better; in fact, it was worse. He would have been in a much better place if the headmaster had prescribed him an apology,” Parker says.

Chris Tanti, chief executive of headspace, concedes over-prescribing is a concern, but says those experiencing “normal” human anguish can become gravely ill and should be treated.

“People can be catatonic, they won’t talk for months because they lose their spouse. I think about that as a serious problem. Yes, the DSM does create a paradigm that has its limitations but what’s the absence of that? The absence of that is chaos.”

Parker favours a screening program for mood disorders that is less about symptom severity and more about the fundamental nature of the problem. He’s developed a detailed online assessment program, which patients can fill in on their own time, with the results then sent to their GP. This, he says, removes some of the problems of “six-minute medicine”.

For Andrew Tierney, labels are irrelevant. He’s just thankful his son got the help he needed before it was too late. And he wonders how different things may have been if his own teenage problems had not been dismissed as trivialities.

“What might seem insignificant to us can be huge for a kid, like a break-up or being picked on. The public perception needs to change to recognise that these kids have got problems. We need to give them help instead of saying, ‘You’re not sick’, and then two weeks later the child’s dead and we’re saying, ‘I don’t know why it’s happened’.”

¦For help or information, call Suicide Helpline Victoria on 1300 651 252, Lifeline on 131 114 or visit headspace.org.au

Written by Jill Stark

As first appeared in Sunday Age, 10 June 2012

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