There have been significant changes over the past twenty years in the manner in which our society responds to labeling in the mental health field. Using psychiatric diagnoses to “label” individuals used to be thought of as “bad”. Today, it seems that everyone, including health professionals, students, parents and administrators, is pushing for individuals to be given diagnoses. It is crucial to understand the influences behind this change in how we think about emotional difficulties, and to be able to use diagnoses appropriately.
One positive influence has been the efforts to reduce the stigma associated with mental illness and seeking professional help. In universities across North America, increasing numbers of students are requesting mental health aid, and part of this is due to the deceased stigma in acknowledging emotional difficulties. The Canadian Senate Task Force on Mental Health has targeted the de-stigmatizing of mental illness as crucial in the promotion of mental health services in Canada. It is crucial to differentiate between de-stigmatizing serious mental illness, and the inadvertent or intentional promotion of emotional distress as illness.
A basic misunderstanding of the Diagnostic and Statistical Manual of Mental Disorders (DSM) has led to misuse of diagnoses. The DSM is a manual of descriptive diagnoses that is meant to be used as a guide, and does not, for the most part, indicate actual disease entities. In its introduction the DSM states “The specific diagnostic criteria included are meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion”. Unfortunately, in most medical schools across Canada, psychiatry is presently being taught by a predominantly biological approach that assumes DSM diagnoses to be actual biological disease entities. The assumption that a group of symptoms implies etiology leads to limited understanding of complex issues and thus to simplistic treatment plans.
The managed care insurance system in the United States has had a major impact on the use of diagnoses, treatment and research. Managed care companies will only pay for psychological aid if there is an Axis 1 diagnoses. These companies are more likely to reimburse practitioners if there is a more severe diagnosis or multiple diagnoses. Thus, the diagnosis of an Adjustment Disorder is often not sufficient for the practitioner to receive payment for more than an initial assessment. Only a very limited number of therapy sessions are usually covered, while prescribing medication is encouraged and with some companies will be the only treatment that will be recognized. This has led to research to support either shortened forms of therapy or medication use. Practitioners then begin believing in the forms of assessment and treatment to which they are coerced to adhere. This has led to the “see a symptom, give a pill” form of treatment that has become increasingly evident, especially in students coming from the United States.
The pharmaceutical industry has also played a large role in promoting psychiatric diagnoses. Marketing by these companies advocates the idea of “depression” being an illness. Depressed moods are common, and can describe a range of both normal emotional states, and multiple different disorders. Yet many publications and marketing approaches talk about depression as if it is a singular, biological entity. The pharmaceutical industry also actively promotes new diagnoses, such as Social Anxiety Disorder, in their greedy search for new markets and new off label indications for medications. This is one aspect of this industry changing their marketing strategy from marketing treatment for diseases to marketing lifestyles. It is evident from drug company ads that the emphasis has been on convincing the population that medications will result in improved lifestyles regardless of whether one has an illness or not. The pharmaceutical industry has been very active in trying to “educate” the populace, with special emphasis on college students, such as with Wyeth’s Depression in College: Real World, Real Life, Real Issues initiative. Programs such as Depression Screening Day or Ulifeline receive major support from the pharmaceutical industry and promote the idea of “depression” as being a mental illness. While these programs may have some value, the distortions that they promote in treating emotional states as diseases can undermine an individual’s emotional development. In recent years, Bipolar Disorder has become the new fad diagnosis. This is especially troubling for the adolescent and young adult population where mood swings are common. It is not unusual these days to see a young person with somewhat unstable moods arriving at University with multiple diagnoses on three or four psychiatric medications. Most of the time, these diagnoses are unjustified. In these students, often any time they feel anything more intense, they begin to panic. When calling home feeling upset, the first question they are asked is “Are you taking your medication?” Many young people are feeling increasingly alienated from their own emotional states, as they, and their families become influenced by the emotion as disease model. Students experiencing a normal range of emotions may feel anxious about feeling anxious or depressed about feeling depressed. This intolerance of affect in our society can be crippling for a developing adolescent.
Psychiatric diagnoses can be valuable in attempting to understand and treat student populations. Diagnoses give a common language with which professionals can talk to other colleagues about emotional states. They provide guidelines for assessment and treatment. Understanding diagnostic criteria can lead one to know when one may have to explore more deeply with a patient, or allow more time for recovery. Differentiating between an acute disturbance and a longstanding personality problem is crucial in knowing what can be expected in response to treatment. This builds confidence in the treating practitioner and the client. If certain problems are known to take time to resolve, comprehensive treatment plans are easier to implement, and clients can feel reassured with their progress. It needs to be recognized that most individuals do not fit completely into any diagnostic category. This implies that we are dealing with individuals with complex emotional lives, who deserve individualized attention. It does not mean that we should be making multiple diagnoses to fit all the person’s symptoms. The chances are when one sees an individual who has been given more than one diagnosis, that all the diagnoses have been poorly evaluated. Diagnoses should be used to help understand the individual, and not to stick them with a label that then drives the treatment. The focus in the university setting needs to remain with the welfare of the individual student. Diagnoses should not be used to relieve practitioners’ own anxiety or to deal with risk management issues. Despite pressures from outside influences, university student services can remain a domain where the student, and not the diagnosis or the system, remains the priority.
Norman Hoffman, M.D., F.R.C.P.C