Do the majority of Australians really have a mental disorder?
Separating mental illness from normal human stress and anxiety seems lost in ever-loosening psychiatric definitions.
It’s a staggering statistic: in the last census, close to half of all Australians reported they had experienced a mental health disorder in their lifetime.
The enormous prevalence of mental distress is reflected in astronomical rates of prescription of psychotropic drugs. One in seven Australians is taking an antidepressant; 3.2 million prescriptions for stimulant medications for ADHD were given to almost half a million Australians in 2022; and a burgeoning new frontier in radical drug therapy using MDMA (ecstasy), psilocybin mushrooms and ketamine for depression are on the ascendancy with the support of regulators.
The nation’s peak mental health charities and suicide prevention bodies pour their dollars into awareness campaigns to destigmatise depression and mood disorders, pushing messages of originally worthy intention that now have become platitudes, such as RUOK? For anyone who has experienced the acute end of a mental health condition, the question on bad days could be answered in a millisecond with one word: no. And what then? Multidisciplinary services for those with complex mental health needs are critically overloaded and underfunded. Suicide remains the most common cause of death among people aged 15 to 44, the national rate of suicide having reduced not at all despite the creation of national bodies specifically tasked with slashing it.
It was devastating to read in the last edition of The Weekend Australian Magazine schizophrenia sufferer Sandy Jeffs’ account of public hospital psychiatric wards as “places of utmost, unspeakable torment”. Wards often placed at the back of a general hospital where the carpet ends and the linoleum starts. Wards whose bathrooms are awful and inferior to the rest of the hospital for no good apparent safety reason. In emergency departments, non-violent patients experiencing psychosis and its associated acute fear lie in catatonic states. Paralysed by drugs, sometimes unable to move, they’re nevertheless policed and often manhandled by security guards, at the worst moment in their lives.
This is the reality of acute mental illness such as schizophrenia and bipolar disorder. Yet this is not part of our national conversation or the subject of self-confessionals on social media. Instead, efforts to reduce stigma largely are focused on garden variety depression, anxiety and ADHD.
As Jeffs wrote, mental health juggernaut Beyond Blue has played a prominent role in normalising depression and anxiety, using celebrities as ambassadors to market hope and recovery. “Their PR has been so effective that everyone can relate to their message,” she says. “In the wake of endless media coverage, people are pathologising and self-diagnosing their sadness and anxiety as depression and seeking psychiatric treatment.” Yet few but those who have experienced it comprehend the extraordinary torment of the schizophrenia or bipolar sufferer who grapples in daily life or in midnight hours with intrusive thoughts that construct a parallel, delusional reality, and the sheer force of mental effort and will it takes to maintain equilibrium.
As Jeffs says, there is no Beyond Blue for them, and very little understanding.
Without a doubt, depression and conditions affecting those with mood disorders can be crippling, stressful for families, at times life-threatening, and medication can be a vital part of the solution.
But there’s also no doubt that a proportion of people diagnosed with these mental health conditions have been subject to diagnostic criteria that have been steadily loosened across time, resulting in the widespread prescription of powerful psychotropic medications. These individuals sometimes are signed up to a lifetime of overmedicalisation without true medical justification. There are flow-on implications for the diagnosis craze in identity politics and culture, with myriad social media influencers positioning themselves as poster children for various mental health pathologies.
“There is a fuzzy boundary separating those people who have what can be considered normal variation in such things as levels of activity and attentiveness, and those who are considered to have a mental disorder,” psychiatrist and Duke University emeritus professor Allen Frances tells Inquirer.
“I think the issue is that psychiatry as a field is subject to fads and fashions. And whenever any diagnosis becomes popular as advertised, the prevalence of these conditions seems to be recorded at much higher rates than previously were believed. Drugs become a panacea.”
The genesis of modern Western society’s enormous take-up of psychiatric drugs began almost 30 years ago, in the pharma mecca of the US. Frances was in the unique position of contemplating the seismic consequences for diagnosis and pharmaceutical prescribing as an author of psychiatry’s diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders. Frances co-authored the DSM-IV, published in 1994. His team at that time took an exceedingly cautious approach despite much pressure to loosen categories of diagnosis.
“We were very concerned in doing DSM-IV that the psychiatric diagnoses were already expanding and capturing many people who might better be considered to have problems of everyday life rather than mental disorders,” Frances says.
One of only two categories of diagnosis they did alter was ADHD to better capture girls with less hyperactivity and more inattentiveness. It was a conservative change but it was enough to open the door to what became a huge marketing opportunity for drug companies.
“What happened was that the drug companies developed and got patent rights to essentially old drugs, old stimulant drugs that had been used for ADHD,” Frances says. “In the previous 30 years these drugs were very inexpensive in their original forms. And the drug companies slightly changed the formulations and got new patents so the drugs could then be made quite expensive. This gave them the money and the motive to widely publicise ADHD.”
At a similar time in history, drug companies were simultaneously pushing the now-debunked serotonin theory of depression and heavily marketing the world’s first selective serotonin reuptake inhibitor drug, Prozac, as the solution to chemically imbalanced broken brains. The serotonin theory still holds sway in medicine today despite being disproven. Doctors funded to the hilt by pharma embraced the movement, and the era of mass antidepressant prescribing – now at its zenith – had begun.
The early marketing campaigns in the US of psychotropic drugs have been more successful than pharmaceutical companies could have imagined. Not only were they successful in themselves in raising medication prescribing to high levels, the phenomenon of overdiagnosis has now expanded to one of self-diagnosis via social media, morphing into somewhat of a cultural phenomenon with mental pathology internalised at the level of the individual, strongly linked to identity as those struggling with all manner of mental challenge and life stressors in a complex world seek explanation or collective affirmation, clinging to some promised certainty or proffered solution to the difficulty of managing human distress or problematic patterns of concentration and mood.
Psychiatry has been the compliant shepherd of this trend, with successive loosening of diagnostic criteria in subsequent editions of the DSM that has made it easier and easier for virtually anyone to fit into any number of categories of mental illness.
Frances has been vocal in his criticism of these trends from the time that the DSM-V was published in 2013. The DSM-VI has gone even further in expanding the ease of diagnosis.
“What’s happened in the last 20 to 25 years has been the widespread use of medications, some of which were previously considered more substances of abuse, with the benefits of the use of these medications being exaggerated and the risks being largely neglected,” he says. “There’s a kind of societal push to find a medication panacea for many problems that previously would have been conceived of as within the range of the normal difficulties of everyday life.”
There is now a mainstream push in psychiatry to deprescribe antidepressants as it becomes clear the risks of the drugs outweigh the benefits for a large number of people, with many struggling with extreme withdrawal symptoms when trying to get off them. The extraordinarily low efficacy rates of the drugs are under increased scrutiny. The process is forcing a reckoning in psychiatry that challenges the fundamental notion of mental illness itself and the way diagnosis and pathology can engender a sense of victimhood in individuals.
Australian Mark Horowitz, a clinical research fellow in psychiatry at University College London, has a PhD in the neurobiology of depression and is an author of the recent Maudsley Deprescribing Guidelines focused on SSRIs, among other psychotropic drugs. “I think one central issue is that people have been taught that normal means comfortable,” Horowitz says. “But life is full of ups and downs, and feeling anxious or depressed is often part of that.
“By the age of 45, 86 per cent of people meet formal diagnostic criteria for a mental illness, and most of that is anxiety and depression. It is not possible for there to be something chemically wrong with the brains of almost three-quarters of the public.
“We become stressed, depressed and anxious when our emotional needs are not met and when stressors placed upon us overwhelm our abilities to cope. The research is very clear that depression follows stressful life events: the more the number of events, the greater the risk. This is despite prominent psychiatrists misleading the public by saying it is the other way around.
“If we understand that our moods are responses to what is happening in our lives, then the solutions are to be found in helping to solve those problems or creating circumstances where these problems are less likely. For issues that are determined by social circumstances, solutions are often political or broader: addressing inequality, poverty, inadequate housing makes our society less depressogenic.”
There is good evidence that the diagnosis of neurodiversity can sometimes amount to shifting social problems on to individuals and branding it pathology, Frances says. “There’s absolutely compelling evidence that the diagnosis of ADHD is being applied carelessly to kids who should not be getting a diagnosis and should not be treated with stimulant medication,” he says. “The evidence for this comes from a number of different countries and many millions, maybe over 10 million, children all around the world, that the best predictor of an ADHD is a child’s birthday.
“What this means is that the youngest kid in a school class is almost twice as likely, particularly boys, to get the diagnosis as the oldest kid in the class. The way you can account for this is that immaturity is being misdiagnosed as mental disorder and treated with medication. The snowball of overdiagnosis and overtreatment with stimulant medication is taking on additional size from other forces.
“School classes are often chaotic and disruptive kids in the class can make a difficult situation seem impossible. So teachers have been inculcated to deal with educational problems in the classroom by identifying the least mature kid in the class, the one most likely to be disruptive, and suggesting this child has ADHD. This basically turns an educational problem of controlling a classroom into a mental health problem, and localises it in one kid.”
The Covid-19 pandemic arguably has supercharged such a trend in adults as people struggling to cope with the fear and uncertainty the virus unleashed, and the way it up-ended ordinary routines, by identifying in popular culture and on social media with adult ADHD sufferers who described the way stimulant drugs brought a sense of order and focus to their stressed and scattered brains. The issue has received much attention, but those hit hard by the pandemic in an acute pathological sense, suffering extreme mental distress or trying to cope with the onset of serious psychiatric illness amid critically overloaded health services and a near-total absence of community-level mental health support structures, are the forgotten people.
“The cruel paradox is that when we overtreat and overdiagnose people with milder conditions, we’re usually not doing them a favour, we’re often giving them a medication that won’t be helpful and they may end up experiencing the stigma of a diagnosis,” Frances says. “The risk-benefit ratio of diagnosing and treating these people with medications is often very, very narrow.
“At the same time, the risks and benefits are very unevenly balanced for the severely ill where the benefits of diagnosing and treating are obvious. And the risks pale in comparison with the benefits, but that’s the population we neglect.
“It’s these people who most desperately need diagnosis when the diagnosis can be most reliably made, because there’s a bright line between severe illness and normality to people who may wind up in mental health wards, in prison or homeless, who have terrible problems when they’re neglected by society. These people get lost in the shuffle when resources and attention is directed to much milder problems.”
