Examine social factors to explain rise in diagnoses of mental disorders

Their conclusions, which appear in the latest issue of the journal Health Affairs, comes ahead of the May release of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a comprehensive guide that sets the classification, diagnosis, and treatment of mental disorders across the United States and the world.

The study included researchers from New York University, Columbia University, the University of California, Berkeley, and Rutgers University.

In their analysis and commentary, the authors argue that the forthcoming DSM-5, which is used by all psychiatrists, psychologists, and mental health workers in the U.S., has missed crucial population-level and social determinants of mental health disorders and their diagnosis. As a result, the DSM may be mischaracterizing the rates of certain afflictions.

"If we are to believe current reports, there are 12 times more children with Attention Deficit Hyperactivity Disorder (ADHD) in the U.S. than in Europe, and within the U.S., there are almost 50 percent more children with ADHD today than a decade ago, according to DSM," observes the article's lead author, Helena Hansen, MD, PhD, an assistant professor of anthropology at NYU and an assistant professor of psychiatry at NYU Langone Medical Center. "My colleagues and I wanted to know if there was something else behind this."

"To explore this, we assembled a group of population health experts to identify the best way to explain the rise in these diagnoses. And what we found was that the clinical authorities in psychiatry who revise the DSM are unable to take into account other forces that drive the diagnosis of mental disorders."

To address this matter, the researchers posed three possible causes of the rise in diagnoses that are not currently accounted for in revisions of the DSM:

* Is there a change in the environment causing an actual increase in the mental health problem? For example, have the pressures of standardized testing in the U.S. caused ADHD symptoms?

* Are the diagnostic criteria applied differently depending on the institutional and social environment? For instance, do the increasing numbers of children diagnosed with ADHD reflect pharmaceutical company promotion of ADHD awareness and ADHD medications among school teachers and parents? Among low income children, do diagnoses reflect their effort to qualify for disability benefits in the wake of welfare reform?

* Are the diagnostic criteria written in a way that includes people who do not have a disorder? For example, do the criteria for ADHD of excessive running, climbing, and talkativeness describe a high level of energy that should be expected among children?

The researchers also propose an independent review of these factors.

"To sort out which these three factors causes differences in the diagnosis of a mental disorder over time and place, we need a review body that acts independently of the authors of the DSM and that is composed of experts on population health and the social factors driving mental health," says Hansen. "Using the example of ADHD, the review body might look at the number of children diagnosed under different educational and welfare policies -- and before and after pharmaceutical promotions. It might also examine how changes to the criteria for ADHD in each revision of the DSM affect the number of children given the diagnosis."

"By charging experts with independent review of the best available research on population and social variation in the diagnosis of mental disorders, we can identify unconsidered but powerful causes of diagnosis and inform future revisions of the DSM."

The analysis, which was supported by the Robert Wood Johnson Health and Society Scholars Program, will appear in the May issue of Health Affairs.