The Times - Over-diagnosis in the mental health sector

20th August 2024, David A Rew, Consultant Surgeon

Sir, Matthew Parris has hit the nail on the head with his condemnation of synthetic mental health diagnoses, but he underestimates their societal impact and costs. Few claims in the medico-legal industry are seemingly now complete without the obligatory statement of mental trauma for personal injury or clinical error, however minor and self-limiting the consequences of those events.

The cost of processing these inflationary claims is borne by many others in the wider community, including the taxpayer through the NHS and the vehicle owner through inflated motor insurance premiums.

David Rew
Consultant General Surgeon, Southampton Hospitals

Background

The possible over-diagnosis of mental health conditions which were previously unknown to society are of increasing concern, particularly as yet another adverse outcome of the Covid Pandemic and Lockdown. Other letters on this matter on 20^th August were as follows:

Letter 1.

Sir, Matthew Parris has noticed a real problem (“Mental health industry is cheating the public”, Aug 19). There is a deeper problem in medicine in that modern medicine has thrown all its energy into providing panaceas to people. This works in reaction to the presence of an illness and its symptoms. The problem with this view is that it sees health as the outcome of medical treatment. Hence you need to be treated to get better. And to get treatment you must have a symptom as an entry ticket. In other words, the system draws people and symptoms into itself. There is no balancing view of how to live life positively, in a way that promotes personal, social and environmental flourishing, and in such a way that the illnesses and symptoms do not emerge in the first place. What is called health promotion is really fear-filled, irritable disease avoidance. We are going round and round on a symptom-diagnosis-treatment loop that is gaining a momentum of its own, so Parris is right to question this process.

Dr Peter Davies
GP, Halifax, W Yorks

Letter 2.

Sir, Many of us who trained in the disciplines of psychiatry will agree with Matthew Parris that the “worried well”, and those who support them by recently coined labelling and talking therapies, have distorted the priorities of the nation’s health and social security budgets.

Worse, all too many tragic events have shown that mental hospital and expert aftercare treatment resources for patients who are truly mentally ill, notably those who are chronically disabled by schizophrenia and manic disorders, are inadequate in quantity and quality.

One has every sympathy for people burdened by unhappiness, frustration, disappointment and personal distress, but their interests are not honestly served by reinforcing their belief that such emotional feelings are symptoms of mental ill health. Those who receive payment for counselling and advice have a duty to differentiate between their own and their clients’ interests.

Richard Lingham
Former member, Mental Health Review Tribunal; Truro

The original article by Matthew Parris on Monday 19^th August 2024 was as follows:

Mental health industry is cheating the public

Diagnosis has gone beyond science - ADHD, PTSD or clinical depression are just words, sanctified by common usage

Among the courses most in demand among aspirant undergraduates this year, psychology leads the march to become the most popular degree course in Britain. Employment prospects in the fields of therapy and counselling are expanding rapidly alongside an ever-increasing public interest in mental health, psychiatric diagnosis and the problems of those believed to be neuro-divergent.

Neuro-divergence has become a bandwagon, so overladen as to devalue cruelly the plight of the much smaller numbers of adults and children whose sometimes grave mental difficulties struggle for definition amid the careless use of words and phrases such as autistic, clinically depressed, attention deficit hyperactivity disorder (ADHD) and bipolar. You now hear people talking about these things in pubs and coffee shops.

The bible of this branch of medicine, published in the United States is Diagnostic and Statistical Manual of Mental Disorders (DSM). The first edition in 1952 listed and described 106 disorders (including, at the time, homosexuality). In this century the fifth edition of the manual was published, which listed more than 400 mental disorders.

In its reach into our popular culture, “mental health” is an exploding branch of the discipline it believes itself to be a part of: medical science. Read Dr Lucy Johnstone’s Psychiatric Diagnosis (to whose argument and explanation I am indebted) for an understanding of a veritable spasm of interest, attention and claimed scientific expertise in the field.

But is psychiatry (the study of diagnosis and treatment) a science at all? Does psychology (the study of the mind, and behaviour) deserve the name of science? These questions matter as government struggles for ways of pushing, pulling or nudging our fellow citizens back into work. More than nine million of us are now “economically inactive” - choosing not to work.

Many within this inactive cohort include mental health disorders in their claim for a personal independence payment (PIP, a substantially enhanced welfare benefit). Such maladies, having no visible physical symptoms are almost impossible to disprove. You can learn online how best to pitch your claim.

As numbers of such people swell, so does the number of therapists and counsellors who cater for them; so does the frequency with which journalists write about mental health issues, and so do the online sites for self-diagnosis in an ever-widening range of mental disorders. And so, naturally, do the calls for more government funding for mental health treatment within the NHS.

The situation is spinning, like DSM-5, out of control. There exists a mutually-reinforcing relationship between the clients of any branch of medicine and the practitioners employed to treat them. And because both need to believe, a second mutually-reinforcing relationship arises between therapists and the supposed theory that underwrites therapy. Just as surely as (when my grandmother was born) the patients, the leech-doctors and the professional blood-letters depended on theoretical phlebotomy: the hypothesis that illnesses were caused by an excess of blood, or bad blood.

Where then is science’s theory of the mind, and mental disorder? In Middlemarch George Eliot refers to “the serene light of science”. The light of science is anything but serene. Adam Smith’s “invisible hand” of supply and demand applies to university faculties, research funding and the public appetite for explanation and “cure”, as directly as it applies to the manufacture and supply of biscuits. And by creating, through a system of state benefits paying extra to the mentally unwell, the state has inadvertently created a consumer demand for psychiatric diagnosis.

Ministers know the system is being gamed and will say so in private. But they flinch from sounding uncaring, and confine themselves to nudging claimants to seek treatment. And all that does is validate further the supposed science behind the therapy.

Proper science provides acid tests for its own validity. Does the theory, when applied, reliably predict outcomes? Proper therapy is driven by results. Can the success of treatments for physical ailments be measured? Yes. But where are the results for therapies in the field of mental health? It’s difficult. How could we employ placebos? How could we devise “control” groups to see if the treated do better than the untreated?

In an attempt at scientific methodology, a study asked a number of therapists individually and separately to diagnose the same patient, without comparing notes. Their diagnoses differed wildly.

You can, of course, ask patients whether a therapy has helped, but they will always be inclined to say yes. Anecdotally we suspect counselling can sometimes help, but a shoulder to cry on so often does - be it a priest’s, an analyst’s, a shaman’s or any good listener’s. This is not science.

How about drugs? It’s important here to clear up a widespread misconception. So far, we have no drugs that target particular disorders or “cure” them. We have chemical coshes that sedate the whole person; and we have stimulants such as Ritalin that can clarify and give focus.

We have alcohol, which can suppress inhibitions; and we have hallucinogens. All are mind-altering. But neuroscience (a real and developing discipline) has yet to determine whether any part of the brain can be identified as “causing” any mental disorder, or “treated” by chemical means. Big pharma once invested a lot of money in this attempt, but without results.

It follows that ADHD, autism, PTSD or clinical depression are really only words, sanctified only by common usage, not science, and used across a vast range of human feelings, attributes and behaviours, corralling them into groups that may at least outwardly seem to have something in common, but may have little to do with each other, or share any identifiable cause. We once used descriptions such as “fever”, “hysterics”, and “nervous breakdown” in the same way.

There’s nothing wrong in trying to be a science, trying to posit a theory of the mind, trying to map “mental disorder” or trying out different treatments. But that is where we’re at: in the very low foothills of anything approaching a scientific discipline.

The mental health industry is cheating a gullible public, hungry for diagnosis, explanation and a set of named disorders, by pretending to a status it should not be claiming. And hard-squeezed NHS funding should follow results, not the 21st-century equivalent of witch doctors. Until we can measure, we should not believe.