National Nurses United

Mental Parity_Temp 11/24/09 6:54 PM Page 16 "This is a not a question of bad or good, but do we need to know more before we undertake such a massive intervention in our children's lives? " I think that with the false positives so high, this is not a good idea. the pharmaceutical industry has come to resemble the tail wagging the dog, seeking—and even manufacturing—disorder for which medications are heralded as the only cure. For all the advances in science, many critics of the current psychiatric paradigm would say the field has actually become more simplistic, where evaluations focus strictly on symptoms isolated from the larger context of an individual's life, and emotional difficulties find definition only through the lens of brain pathology. "It gets to the point that you wonder if it's worth it to treat 500 people unnecessarily to possibly save one life," said Lawrence Diller, a psychiatrist in Walnut Creek, Calif. The push for widespread psychiatric screenings— not just of teenagers, but the general public—has grown in recent years as pharmaceutical interests have increasingly come to dominate the mental health field. At the height of the antidepressant craze in the early 1990s, an organization called Screening for Mental Health, largely supported by Eli Lilly, the makers of Prozac, began sponsoring National Depression Screening Day. Last year, the event tested roughly 300,000 people on that single day alone. But by most accounts, the true dawning of the screening movement began in 2003, when a presidentially appointed panel of experts, many with strong ties to pharmaceutical companies, made an official policy recommendation that "every child should be screened for mental illness once in their youth in order to identify mental illness and prevent suicide." The next year President George W. Bush authorized $82 million to support the widespread screening of adolescents. The states of Illinois and Indiana have since mandated the screening of all children, while Massachusetts has passed a law requiring the testing of some 400,000 kids receiving Medicaid. But the psychiatric tests go far beyond young people: A federal bill has been approved by the House of Representatives, and is now before the Senate, calling for the mental screening of all new mothers for post-partum depression, after such a law was passed in New Jersey. Bills are currently making their way through both the House and Senate requiring the mental health testing of active members of the armed services as well as veterans. About 40 percent of individuals visiting primary care receive screening for depression and other behavioral problems, according to a 2004 study in Medical Care. These screening tests that are supposed to save lives, however, are notoriously unreliable, suggesting much higher rates of depression and other mental illness than actually occur in the population. Of 14,200 students tested by TeenScreen, the most widely used suicide screening tool, in 2003, roughly a quarter of them tested positiv e for "mental health problems," Laurie Flynn, the director, told a Congressional panel. Meanwhile, more objective studies, such as those cited by the recent U.S. Preventive Task Force report, peg the numbers at closer to 6 percent for adolescents, with the possibility of an individual suffer16 REGISTERED NURSE ing some type of depression over the course of a lifetime at no mor e than 20 percent. "When we live in a society that labels every mental disturbance as a disorder, we're putting curses on people," says Jerome Wakefield, a professor at New York University and the author, with Allan Horwitz, of The Loss of Sadness. "We're talking about a disorder in the brain, and if we're wrong about that, we should know." Wakefield does not object to widespread screenings on principle, more their limited criteria and the narrow range of responses to which they lead. The tests could be helpful, he says, if they asked more sophisticated questions that accounted for social circumstances and natural emotional responses. Instead, the questions spring almost entirely from the symptom-based approach of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV), a book that has virtually transformed the way we evaluate and treat mental illness. Departing from the therapeutic model that plumbed the psyche for the root causes of distress, the modern DSM, recast in 1980, has advanced the idea that disorder could be diagnosed with an empirically defined set of symptoms, and treated not on a couch, but with medicine. The premise dovetailed perfectly with a shift toward profit-driven efficiencies in managed care. Over the years, the number of disorders in the DSM has risen fr om 106 when it was first published in 1952 to 182 in the second edition published in 1968, to 265 disorders in the DSM-III, and has now grown to 294 in DSM-IV—many of the conditions included in dir ect response to medications available at the time. "If you have a treatment, you're more interested in getting the category in," Robert Spitzer, the chair of the DSM-III working group, told Christopher Lane in an interview for Shyness. "If you have no treatment for it, there's not as much pressure to put the thing in." The problem is that the DSM's criteria for defining this v ast and growing number of disorders are vague, often subjective, and fail to account for the circumstances of a patient's life. Someone may complain of apathy or sleeplessness, for example, and receive medication for depression, when he might simply be suffering from the ordinary stresses of the world, if not the inevitable grief of life ev ents such as divorce or the loss of a loved one. "Clinicians are just looking at the symptoms," says Barbara Williams, a retired psychiatric registered nurse formerly with Dominican Hospital in Santa Cruz, Calif. "The diagnoses are almost arbitrary." Bill Shryer, director of the Diablo Behavioral Clinic in Danville, Calif. calls the DSM approach "recipe card therapy," and far from finding comfort in the hard definitions of disorder, sees a real danger in following the book too literally. "You run the risk of double jeop ardy: the wrong diagnosis and the wrong treatment. People who use these guidelines are more likely to make a serious error." The criteria have also been shown to be unreliable in identifying the proper condition. A study, for example, in October 2008 of 100 patients with a primary diagnosis of major depr ession or bipolar disorder found that 26 percent actually had an anxiety disorder, according to a study by David J. Muzina and colleagues at the Cleveland Clinic Center for W W W. C A L N U R S E S . O R G OCTOBER 2009

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