(Asylum Magazine) – The new Diagnostic & Statistical Manual (DSM5) is soon due to be published. DSM is the modern ‘bible’ for diagnosis in psychiatry. Yet there is little or no evidence to support the idea that the categories used in DSM are either based on sound science or clinically helpful. So I decided earlier this year that it was time to start a campaign.
I’ve called it: ‘No More Psychiatric Labels’. My arguments are mainly empirical, based on a review of the evidence. I thought it was important to demonstrate that it is the science that tells us that the system of psychiatric diagnostic is a bad idea. In summary, my review found that:
• Psychiatric diagnoses are neither reliable nor valid.
• Using psychiatric diagnosis does not aid treatment decisions.
• Long-term prognosis for mental health problems has got worse over the years.
• The use of psychiatric diagnosis increases stigma.
• Psychiatric diagnosis imposes Western beliefs about mental distress on other cultures.
• Alternative evidence-based models for organizing effective mental health care are available.
Validity refers to whether a particular diagnosis has a meaningful correspondence with something that exists objectively in the real, ‘natural’ world. For example, that the term ‘depression’ applies to a psychological and/or physiological process that can actually be identified, and that a similar process occurs in people all over the world afflicted with the condition.
The failure of scientific research to reveal any specific biological abnormality to identify a psychiatric diagnosis – or for that matter any physiological or psychological marker – is well recognised. Unlike the rest of medicine, which has developed diagnostic systems based on testable theories about the causes of illness, psychiatric diagnoses have established themselves simply through the voting rights of boards of psychiatrists who decide amongst themselves when a new diagnostic category is to be created.
In psychiatry, diagnoses are descriptions of sets of behaviours that often go together. By itself, a psychiatric diagnosis cannot tell you about the cause, the meaning, or the best treatment.
Even the descriptions of behaviours that make up the criteria for psychiatric diagnoses have large crossovers between them. For example, ‘distractibility’ can be found in diagnoses such as ADHD, anxiety, depression, and autism, as can aggression, difficulties with making peer relationships, and agitation. This problem flows from the fact that the basis for the categories are only symptoms (behaviours) and not signs (real, measurable organic differences).
If, as seems likely, our diagnoses do not reflect real differences in our biology, then there is always the potential for harm if we use them as if they tell us something about causes.
The frequency with which patients are given more than one diagnosis illustrates the lack of clarity around what a diagnosis means or represents. Widespread co-morbidity (i.e. giving a person more than one diagnosis simultaneously) indicates basic deficiencies in the understanding of the ‘natural boundaries’ of even the most severe forms of mental distress. The main diagnosis an individual receives often changes, and this happens by means of a subjective judgement rather than a scientific test. That is to say, the change occurs due to a different belief on behalf of the doctor doing the diagnosing rather than as a result of a new test, for example.
And so, when a clinician claims that a patient is clinically depressed, or has ADHD, or has bipolar disorder, or whatever, not only is he trying to turn something based on subjective opinion into something that appears scientific, but he are also reifying the event – turning something subjective into something ‘concrete’. This causes a kind of ‘tunnel vision’ where the psychiatric diagnostic version of events becomes the dominant story and alternative ways of viewing the situation are pushed to one side. Hence, if someone believes ADHD is a ‘real’ disorder that exists in the brain and is potentially lifelong, that person – and those who know them – may come to act according to this belief. This is to create a pessimistic self-fulfilling prophecy.
‘Reliability’ refers to the extent to which clinicians can agree on the same diagnoses when independently assessing a series of patients. Research concerning the reliability of major diagnostic categories gives results ranging from pure chance to perfect agreement, but studies in clinical settings show particularly poor reliability. In itself, this indicates that psychiatric diagnoses are not valid, since one needs to be able consistently to agree on who should be included as a ‘case’ in any particular category before one can start to examine whether the description has validity.
There is also a poor correspondence between levels of impairment and having the required number of symptoms for many psychiatric diagnoses. Thus, many people below the threshold for a diagnosis actually have higher levels of impairment than those above. Conversely, many people who reach the cut-off for a positive diagnosis may actually have relatively low levels of impairment.
Using psychiatric diagnosis does not aid treatment decisions
Matching diagnosis with a specific treatment has no statistically significant effect (whether for a specific drug or a specific psychotherapy). A positive outcome for treatment of psychiatric disorders is most strongly related to factors other than treatment, such as social circumstances. For example, when a person receives treatment, the strongest association for improvement is with ‘developing a good therapeutic relationship with the clinician’.
Many psychiatric drug treatments (as with psychological treatments) rely more on these ‘non-specific factors’, such as the quality of the relationship between the professional and the service user, than disease-specific therapeutic effects. For example, it is generally assumed that drugs marketed as antidepressants ‘correct a chemical imbalance’. However, the placebo effect is much more important than any pharmacological effects. (The placebo effect occurs when a person reports a positive effect even though they have been given a simulated treatment, e.g. a sugar pill rather than an active one.)
Several reviews comparing the results of different trials have concluded that most of the benefits from ‘antidepressants’ can be explained by the placebo effect, with only a small effect attributed to the drug – a small amount, moreover, that is unlikely to be clinically significant for the great majority of patients. Studies investigating the degree to which non-technical factors (such as the therapeutic relationship) affect outcome have found that, whether with psychoactive drug treatment or not, these factors are far more influential than the treatment model used.
The long-term prognosis for mental health problems has got worse
Over the past half century, and unlike the rest of medicine, no overall improvement in long-term mental health outcomes has been achieved by the richer, industrialised countries. However, some studies do suggest that mental health in the West is getting worse. Compared to a few decades ago, more people are being given diagnoses such as chronic schizophrenia. This is particularly so for young people, more of whom are nowadays labelled with a long-term disability because of a mental condition than ever before. Rates of psychiatric drug prescriptions for young people have been rising year-on-year without any accompanying evidence that their long-term mental health outcomes are improving.
The use of psychiatric diagnosis increases stigma
Surveys of public attitudes toward mental illness have found an increase in Western countries in the number of people who believe that mental illnesses are ‘an illness like any other’ which is caused by biological abnormalities in the brain. However, a large number of studies have found that attributing mental health problems to biology is associated with negative public attitudes such as a belief that patients are unpredictable and dangerous, and an associated fear of them and a wish to keep them at a distance. It seems that the ‘medical model’ diagnostic approach has a significantly negative impact which causes an increase in stigma rather than a reduction.
Diagnosis imposes Western beliefs about mental distress on other cultures
Countries around the world are being encouraged to adopt Western beliefs and to recognise diagnoses like ADHD, depression and schizophrenia. This is called ‘psychiatric literacy’. However, as already indicated, outcomes – particularly for the more severe mental health problems – have been consistently better in developing countries than developed ones. In the process of encouraging the adoption of Western psychiatric models, we not only imply that those cultures that are slow to take up these ideas are ‘backward’ but we may also undermine effective local practices and distract attention from factors that do make a difference to mental health, such as economic ones. For example, several international studies conclude that the greater the disparity between rich and poor in any society, the poorer the mental health.
Psychiatric manuals and their categories have been popularised over the last fifty years, and diagnoses are regularly discussed in the media. As a result, it is widely argued that a significant proportion of the population suffers from mental illness, that this is a global issue, that this amounts to a significant economic burden, and that there is a strong case for investing in improved mechanisms of detection and treatment. However, there is little evidence to support the idea that popularising mental health diagnoses and convincing policy makers of the need to diagnose and treat more people does actually benefit mental health.
There have been a variety of campaigns in order to increase rates of diagnosis and treatment. For example, in the early 1990s the UK’s Royal College of Psychiatrists and Royal College of General Practitioners launched their campaign ‘Defeat Depression’. This was intended to raise public awareness of depression, reduce stigma, train general practitioners in recognition and treatment, and make specialist advice and support more readily available. Unfortunately, evaluations following the campaign failed to detect any significant improvements in clinical outcomes. However, the campaign did result in a rapid increase in the prescription of antidepressants and an accompanying increase in the medicalisation of unhappiness and distress.
Unlike other areas of public health, mental health in those societies with the most developed services appears to be the poorest. In such societies ‘epidemics’ of psychiatric diagnoses – for example, ADHD, autism, depression, bipolar disorder – have only emerged and become popularised in recent years. Whilst there are complex political, social and cultural reasons for these ‘epidemics’, they are encouraged by the emergence and popularisation of new diagnostic categories which then change our ideas about the nature of distress and what it is to be a person.
Alternative evidence-based models for organising effective mental health care are available
We already know about many of the factors associated with a greater likelihood of developing a mental health problem. These include emotional or psychological trauma (particularly early childhood trauma), adversity, poverty, lifestyle, and family functioning.
In addition, rating levels of impairment and distress would provide a much more accurate and less stigmatising way of categorising mental health problems than using psychiatric labels.
The message from research into treatment outcomes is that mental health services can improve them, but not by using diagnostic categories so as to choose treatment models. Rather, it is important to concentrate instead on developing meaningful relationships with service users, ones that fully include them in decision making.
Furthermore, we know that the biggest impact on outcomes derives from factors external to treatment, such as a person’s social circumstances and levels of support. This means that services need to learn how to work with the lived reality that people experience, not simply with ‘the space between the ears’.
Developing the knowledge base and services in these ways would give mental health services and practitioners a better chance of improving the lives of those they work with. It would also help to break long-standing barriers between mental health services and the rest of medicine by allowing the development of paradigms that are evidence-based and which properly incorporate an understanding of how physical and mental well-being are closely related to each other. Such non-diagnostic-based paradigms could then help patients, whether they present with physically unexplained symptoms, serious distress or psychosis, without needing to label them ‘mentally ill’.
Sami Timimi is a consultant child and adolescent psychiatrist and Director of Medical Education at Lincolnshire Partnership Foundation Trust. He writes from a critical psychiatry perspective and has published many articles and books including A Straight Talking Introduction to Children’s Mental Health Problems and most recently The Myth of Autism: Medicalising Men’s and Boys’ Social and Emotional Competence. He is a founder member of the International Critical Psychiatry Network.