(Page 2 of 4)
All they could do, Hyman thought, was continue creating and refining concepts that would then be mistaken for real disease entities, further trapping psychiatry in its epistemic prison. Until someone figured out how to fashion an escape plan, Hyman didn’t think there was much point to another revision. After all, you don’t remodel a house when the foundation is infested with termites.
Mirin didn’t fight back—mostly, he says, because he didn’t disagree. “The DSM was a system based on descriptive criteria influenced by experts in the field,” Mirin tells me. “They had lots of opinions, but these couldn’t necessarily be validated. It’s one thing to guess and another to biopsy a tumor or to measure an enzyme.”
Even so, as much as America’s leading psychiatrists knew the DSM was flawed, they didn’t have anything to replace it with. “I realized that it got me nowhere to criticize the DSM because that did not offer a constructive alternative,” Hyman tells me. “In fact, given the way the DSM had controlled the imagination of scientists, there was little information with which to see beyond it.”
Hyman may have been anguishing about psychiatry’s predicament, but Mirin wasn’t losing any sleep over the fact that his profession was stuck guessing about categories that didn’t really exist. “I don’t recall feeling particularly tortured about it,” he says. “The DSM was essential to being paid for treatment. Without its methodology, payers would see mental illnesses as figments of a provider’s imagination.” It was also essential to the APA’s finances. After all, Mirin tells me, “coming down the mountain with the Ten Commandments sure sells a lot of books.”
Too Much Mental Illness
In 2002 Congress was considering a bill requiring insurers to pay for mental health care at the same level as other medical services, across the entire range of DSM-IV diagnoses. Parity, as this mandate was called, had been implemented in a handful of states, often only for mental disorders considered by insurers to be biological in origin, such as schizophrenia and bipolar disorder.
President George W. Bush endorsed the bill, but it seemed likely to sink into the mud of the legislative process, in part, Mirin thought, because The Washington Post—“the hometown paper of every member of Congress,” as he puts it—had twice come out against parity. Mirin took it upon himself to convince the Post to change its mind.
Mirin arrived on September 2, 2002, expecting an hour with a single editor, and was pleasantly surprised to find six editors and a reporter willing to give him nearly 90 minutes of back and forth. The journalists did their best to torment Mirin with the discrepancy between the DSM’s authority and the science behind it, asking questions, as people present at the meeting recalled, such as “How do you diagnose mental illness?” and “How do you tell if it’s real?” and “Do you have a science base like the rest of medicine does?”
Mirin brought with him an expert on diagnostic questions named Darrel Regier, whom he had recently hired to head up the APA’s research arm, the American Psychiatric Institute for Research and Education. Mirin had recruited Regier from the NIMH, where he had risen to the rank of vice admiral in the Public Health Service. Regier, an epidemiologist as well as a psychiatrist, had been measuring the levels of mental illness in the population since the earliest days of DSM-III. And what he had seen didn’t inspire confidence.
As the head of the NIMH’s Epidemiological Catchment Area (ECA) team, Regier supervised a group of researchers who, starting in 1980, fanned out across five U.S. cities armed with a questionnaire keyed to the diagnostic criteria in DSM-III. They asked 20,000 people, selected to reflect the general population, about their worries and their sadness, about whether they heard voices, about how they slept and ate. They tabulated the results and in 1984 began to release them in a series of journal articles.
The findings were stunning. In any given year, more than 20 percent of Americans qualified for a DSM-III diagnosis. Nearly one-third of the population—80 million people, according to the 1990 census—would have a mental illness during their lifetimes. And the sick among us were really sick. Sixty percent of those diagnosed with a mental illness had a comorbid disorder, meaning they qualified for at least two diagnoses. Ninety-one percent of people with schizophrenia had at least one other diagnosis, as did 75 percent of people with a depressive disorder. Fifteen percent had three or more diseases. More than half the people with a drug-related diagnosis, such as cannabis abuse, also had at least one more diagnosis.
Even more alarming, only 19 percent of the afflicted had sought help for their troubles, a number that dropped to 13 percent in the cases where only one diagnosis was warranted. It seemed that America had an enormous but undiagnosed and untreated public health problem whose effects on productivity, family life, and the body politic were unfathomable.
This potential fivefold increase in the size of the market for psychiatry wasn’t so much an embarrassment of riches as a plain old embarrassment. Even accounting for the fact that epidemiological studies, in which researchers go out looking for trouble, almost always yield bigger numbers than studies that rely on numbers gleaned from doctors’ offices and hospitals, the results beggared imagination. They also cast doubt on the DSM itself. The questions had to be asked: Was the problem in the minds of the people or in the methods of the doctors? Did the DSM-III make it too easy to turn people’s everyday troubles into disease?
Two decades after his research, Regier thinks the answers are all too clear. “We just don’t have good thresholds for identifying what we would consider mental disorders,” he told me in 2010.
Persuading the Post