The Mental Health Crisis Crisis
We are in the midst of a mental health crisis—crisis. It’s hard to know where to begin when I find myself in a field with only a few sturdy anchors, surrounded by swirling tides of folk wisdom, social fads, and a vigorous anti-establishment ethos.
The ramifications of this swirling tide of conflicting and diluted information are vast. However, what tends to weigh on me most is its confrontation with me in my day-to-day work. Take, for example, a fairly typical intake these days: a client informs me they are seeking ADHD treatment. Adderall, always Adderall and nothing less. When I tactfully ask, “How do you know you have ADHD?” the response almost invariably involves either an online checklist, the client confidently telling me that they “meet DSM criteria”, or simply, “Because I can’t pay attention.” At that point, I face the now familiar but no less daunting task of condensing 80 years of mental health history into a 25-minute conversation explaining why they likely don’t have ADHD. (And inevitable also these days how their thrice daily marijuana use is probably not helping their “ADHD”).
The DSM…
The Diagnostic and Statistical Manual of Mental Disorders, the “bible of psychiatry” now in its 5th edition, serves as the chief index of all conceivable mental health ailments. It was never meant to hold the sway with which it’s used today. After all, It would seem obvious that one’s mental health clinician would opt for an approach that isn’t a mere checklist of criteria that if used in exclusivity could essentially remove the need for our broader profession permanently. Fill out the questionnaire, “meet criteria”, and a pill gets spit out of a vending machine. Ever see the commercial for Hims?—we’re basically already there. Some insist the DSM plays a minuscule role in their day to day aside from billing and coding purposes—fine. But recognize that our entire field has DSM weaved into it like a thread in a quilt. This system of diagnosing mental illness determines what clinicians are reasonably expected to assess in reference to. That system then also necessarily determines FDA approval categories for therapeutics, and then by extension guides research into future treatments. Imagine that! The system of assessment, diagnosis, treatment, and research is built on a foundation of dubious scientific validity. Thomas Insel M.D., the former head of the NIMH, publicly addressed this state of affairs in 2013 when he announced that the NIMH under his watch would cease funding for any research that was rooted in DSM constructs, acknowledging the way that the DSM has hampered scientific progress for the past forty years, “While DSM has been described as a 'Bible' for the field, it is, at best, a dictionary, creating (emphasis added) a set of labels and defining each… Patients with mental disorders deserve better.”
As a psychiatric nurse, I have an advantage—nursing care for the mentally ill has a history stretching back centuries, giving me a wealth of history and wisdom to draw upon from my professions trailblazing forbearers. Furthermore, it wasn’t my profession that wrote the darn thing, and believe me, we nurses have our own problems to sort out—but we all are nevertheless required to accept this document at face value. The system reinforces this mentality as diagnostic inflation goes unchecked, driven by our ever-popular fee-for-service model—where the more services rendered, the more the “provider” can bill for, and the more money is made. Imagine walking into an urgent care with the flu, only to walk out with four separate diagnoses: sore throat disorder, fever disorder, headache disorder, and cough disorder—each with its own medication and ICD code. This is the current state of fee-for-service mental health treatment. My average patient arrives with four separate diagnoses and at least as many prescriptions. Their previous provider seemingly assumed the medications would sort out who does what and how not to overlap with one another once they all meet for brunch in the patient’s prefrontal cortex.
Are there any adults in the room?
For decades, the American Psychiatric Association has been urged to reform the DSM-based diagnostic system and loosen its grip on mental health policies. Yet, calls for change even within modern DSM committees are met with rigid resistance—a mentality dating back to the publication of DSM-III in 1980 that sought to consolidate mental health treatment and policy away from the three other official mental health professions at the time (Psychiatric Nursing, Psychology, and Psychiatric Social Work) into the auspices and control of the American Psychiatric Association. That dramatic shift led to the carving up of broad diagnostic concepts into smaller, operationally defined entities, which were then packaged and marketed as entirely separate diseases—something the pharmaceutical industry eagerly capitalized on and continues to until this day.
A Depressing Example
A brief look into the history of psychiatric diagnosis reveals that "major depressive disorder", a headlining hit these days, as we know it is not a valid diagnosis in and of itself. It was a construct developed for DSM III for purely pragmatic reasons—to help clinicians share a common psychiatric language when discussing mood disorders. But the initiated clinician, who, like me, winces at the daily bombardment about how the rates of depression are skyrocketing, knows that, before 1980 what we now call "major depressive disorder" was composed of at least three entirely distinct illnesses—each as different from one another as cataracts are from fungal infections are from arthritis. And just as these conditions differ, so too should their treatments. Instead, today’s approach risks exacerbating one form of depression while attempting to treat another as it reinforces a system that prioritizes communicative pragmatism over scientific validity. Due to this lack of diagnostic validity and non-willingness to revert back to a science-based system, you could essentially be receiving antifungal agents for your cataracts*.
Of the roughly 300 diagnostic entities in the latest version of the DSM, maybe 25 have any scientific validity beyond being a mere clinical picture (I’m looking at you, Prolonged Grief Disorder). That means about 90% (actually 95.2% according to one prolific researcher) of the DSM lacks a meaningful scientific foundation and does not meet the standards we demand of other medical diagnoses.
This chronic confusion has led us to where we find ourselves today—over-diagnosed, over-medicated, and losing sight of what it means to mindfully experience life as it was meant to be lived—“life on life’s terms”. Historically, such confusion breeds backlash and rebellion: think of the rise of Scientology or the anti-psychiatry movement. The result? Patients either receive treatments that make them worse or receive no treatment at all. Either way, they’ll likely still end up in my office at some point swearing that marijuana is the only thing that helps them.
How we got here is knowable, the way forward is attainable.
I humbly suggest that the first step to truly understanding this mental health crisis—assuming we regard it as noble work—is to commit to a certain amount of vulnerability and openness toward the possibility that the road we’ve been led down no longer serves us. Embracing practice philosophies and theoretical frameworks that get out of the problem and into the solution is the first step. We can freely admit what we don’t know. And it is certainly okay to acknowledge the pitfalls and darker chapters of mental health history—corporal punishment of asylum patients, psychosurgery, countless others—and recognize where we have gone wrong. All while avoiding throwing the baby out with the bath water and risk the “tear the whole system down!” fallacy as its natural follow-up question begs a more nuanced and urgent approach from us, “and replace it with what, exactly?!”.
I wasn’t sure how to end this article, as this story is far from over, so I’ll conclude with two things: one piece of advice and one quote. The advice is merely a starting point; where this conversation goes from here will take up at least another 5 articles, but at least it’s a starting point to get the wheels turning. The quote, as simple as it is, has been a guiding light for me both personally and professionally.
Advice: If you are a victim of being overmedicated and yet feel uncared for, you may need an alternate approach.
Quote: If nothing changes, nothing changes.
Ari Daniels is a Psychiatric Nurse Practitioner licensed in NY and NJ
*Major Depressive Disorder is an amalgamation of at least three separate illnesses: Involutional Melancholia (aka Melancholic Depression), the depressive pole of Manic-Depressive Illness, and Neurotic Depression. These three conditions exhibit different ages of onset, lifetime courses of illness, and genetic predispositions—truly three distinct illnesses that each respond to different classes of medications given their heterogeneity. Giving the wrong medication to the wrong type of Depression can yield no response at best and catastrophic effects at worst.
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