by James Davies / The Times of London
Published at 12:01AM, May 6 2013
Even worse, he argues, is that psychiatry is making millions of people dependent on drugs they don’t need
In March 2011 a group of scientists undertook a comprehensive study on nearly one million Canadian schoolchildren. What they did was look at the medical diagnoses that all these children had received within the period of one year.
The children were between the ages of 6 and 12, and the scientists were particularly interested in how many of them had been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). Once the calculations were conducted and the results came in, the scientists were initially baffled by what they found:
the precise month in which a child was born played a significant role in determining whether they would be diagnosed with ADHD.
As odd as this may sound, the figures published in the Canadian Medical Association Journal are plain to see.
The line that charts the monthly diagnostic rates, rather than resembling a mountain range that peaks and dips from month to month, instead moves steadily and diagonally upwards from January to the end of December.
To translate this into numerical terms, we find that 5.7 per cent of all boys born in January were diagnosed, compared with 5.9 per cent born in February and 6 per cent born in March. After that, the monthly rates rise incrementally until boys born at the end of the year are 30 per cent more likely to be diagnosed than boys born at the start.
If this figure seems startling to you, then just consider the female diagnostic rates: girls born at the year’s end in December are 70 per cent more likely to be diagnosed with ADHD than girls born in January. So what’s going on here?
The clue to unravelling this puzzle has nothing to do with birth signs or weather patterns or cosmic shifts in the lunar calendar. It rather has to do with the simple fact that children in the same year at school can be almost a full year apart in actual age. This is because children with birthdays just before the cut-off date for entering school will be younger than classmates born at earlier times of the year.
So in Canada, for example, children born at the beginning of the year are 11 months older than classmates born at the end of the year. This means that January children have a full 11 months’ developmental advantage over their December peers. (In Britain, the equivalent birth months would be September and August, because the school year begins in September.) And an 11-month gap at that age represents an enormous difference in terms of mental and emotional maturity.
Because I was keen to find out more about the implications of this study, I interviewed Dr Richard Morrow, one of its lead researchers.
“Well, the most important thing we noticed,” Morrow said candidly, “is that the younger kids in the classroom were far more likely to be diagnosed with ADHD because their relative immaturity was being mistaken for symptoms of ADHD.”
The relative immaturity of the younger children was, in effect, being wrongly recast as psychiatric pathology. “And this clearly explained for us”, continued Morrow, “why the younger you are in your class the more likely you are to be diagnosed with this condition. And this is happening not just in Canada, because we found that wherever similar studies have been conducted (eg, the US and Sweden) they have reached the same results — the younger you are in your class the more likely you’ll get the diagnosis — it’s a pretty wide phenomenon.”
The reason why Morrow’s research is so important to us is because it provides a clear example of what is known as medicalisation — namely, the process by which more and more of our human characteristics are seen as needing medical explanation and treatment. Now, while in the Canadian study it’s clear that the effects of medicalisation can be deleterious, this is obviously not the case in all instances — indeed medicalisation, at best, has often been a force for good. For example, it was right to use medicine to tackle biological conditions such as Huntington’s disease or epilepsy that were once unhelpfully understood as religious problems (to be healed only by prayer or church attendance).
And yet there are forms of medicalisation that are clearly unhelpful, that invasively spread medical authority where it was never designed to go. For instance, “problems” such as low achievement, certain kinds of truancy or underperformance have attracted medical diagnoses and intervention in our children, as have many normal reactions to the demands of adult life that are labelled as “stress disorders”, to be biologically explained and pharmacologically treated.
The issue of medicalisation is so crucial, because it concerns where the very limits of medical intervention should be drawn. At what point does medicalisation begin to undermine the health of a population? At what point does it begin to turn what should be a matter for spiritual, philosophical or political understanding and action into an issue to be managed by medicine alone?
This question has particular relevance for psychiatry. For psychiatry, as we will soon see, has been accused more often than any other medical specialism of incorrectly medicalising our normal actions and responses. The question for us right now, then, is to what extent this accusation is true.
The DSM — or, to use its full title, the Diagnostic and Statistical Manual of Mental Disorders — is produced by the American Psychiatric Association (APA) to standardise diagnoses of psychiatric conditions. It is the bible of the psychiatric profession across the world and a book of supreme importance, because it decides what does and doesn’t constitute a psychiatric disorder. The chairman of the latest edition, DSM-IV, which will be replaced by DSM-V this month, is a psychiatrist called Dr Allen Frances.
When I interviewed Dr Frances in May 2012, his DSM-IV was still being used and sold around the world. Apart from one minor revision in 2000, the manual he published in 1994 has for two decades shaped research and practice within the global psychiatric community.
What I wanted to know from Dr Frances, therefore, was whether, with the benefit of hindsight, he felt his DSM-IV taskforce had made any mistakes. In short, did his manual unleash any unintended negative consequences that he now regrets? “Well, the first thing I have to say about that,” answered Dr Frances confidently, “is that DSM-IV was a remarkably unambitious and modest effort to stabilise psychiatric diagnosis, and not to create new problems. This meant keeping the introduction of new disorders to an absolute minimum.”
What Dr Frances meant was that his taskforce added only eight new disorders to the main manual. And this is indeed a modest amount considering his predecessor Dr Robert Spitzer had introduced around 80. Yet, from another standpoint, this claim to modesty is somewhat wobbly — it ignores that Dr Frances included an additional 30 disorders for “further study” in the appendix, and that he subdivided many existing disorders. So if we include these appendix disorders and subdivisions (all of which patients can be diagnosed with), Dr Frances actually expanded the DSM from 292 to 374 disorders.
“We added a bipolar II,” Dr Frances told me. “We also added Asperger’s disorder (this was to cover people who didn’t have full-blown autism, but who had considerable problems with symptoms), and finally we added ADHD (for people who had attention issues coupled with hyperactivity).
And, well, these decisions helped promote three false epidemics in psychiatry.”
Trying to sound unfazed, I asked Dr Frances to clarify what he meant by three false epidemics.
“Well, I mean we now have a rate of autism that is 20 times what it was 15 years ago. By adding bipolar II, we also doubled the ratio of bipolar versus unipolar depression, and that’s resulted in lots more use of antipsychotic and mood stabiliser drugs. We also have rates of ADHD that have tripled, partly because new drug treatments were released that were aggressively marketed. So every decision you make has a trade-off, and you can’t assume the way you write the DSM will be the way it’ll be used. There will be so many pressures to use it in ways that will increase drug sales, increase school services, increase disability services and so forth.”
At this point in our interview I could not help but recall the Canadian schoolchildren, all of whom had been diagnosed with ADHD. Was the creator of the modern ADHD category now admitting that potentially millions of children just like them (not to mention the adults) were being wrongly diagnosed with this and other mental health conditions?
I put the question to him directly: “So are you saying that the way the DSM is being used has led to the medicalisation of a number of people who really don’t warrant their diagnoses?”
“Exactly.”
“Can you put a figure on how many people have been wrongly medicalised?”
“There is no right answer to who should be diagnosed. There is no gold standard for psychiatric diagnosis.
So it’s impossible to know for sure, but when the diagnosis rates triple over the course of 15 years, my assumption is that medicalisation is going on.”
Once in a while when conducting interviews you hear a confession that hits like a thunderclap. And this for me was one of those moments. Here was the creator of DSM-IV admitting that many new disorders they included actually helped trigger the unnecessary medicalisation and medication of potentially millions of people.
© James Davies 2013. Extracted from Cracked: Why Psychiatry Is Doing More Harm Than Good, published by Icon on Thursday. It is available from the Times Bookshop for £9.89 (RRP £10.99), free p&p, on 0845 2712134; thetimes.co.uk/bookshop
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