Categorical Rigidity And Static Assumptions In The Diagnosis Of "Mental Illness"

Conditions of psychic dysfunction are sometimes situational and temporary.

One of the biggest problems I have with modern psychology is that its definitions of mental pathology implicitly argue in favor of their permanence, as static conditions. Even in the absence of persisting crisis, once someone- anyone- is tagged by the medical establishment with labels like "bipolar" or "schizotypal", there’s a pronounced tendency to treat “the patient” as if suffering from an intractable disorder that can only be treated with blunt-force medication and occasional 20-minute checkups, not healed.

If every transient psychic crisis I had ever gone through (and some of them were more than momentary) or episode of bizarre behavior (I've had a few, although nothing that led to an arrest or an ER visit) had been flagged, subjected to intervention by medical authorities, and then defined and treated as evidence of severe mental illness, I might have bought into an uncomprehending outside narrative that incorrectly exaggerated the severity of my "condition" at the time, in line with the tacit prerogative of the therapeutic state:: the presumption of superior knowledge exercised AT the patient, viewing a an episode of dysfunction or protracted emotional distress as evidence of the static, intractable condition known as "severe mental illness.". And I might have been convinced of the lifelong permanence of a situation that was more properly handled as a storm to weather, as part of the challenge of becoming a more internally stable and resilient individual. Growing into adulthood can be difficult. I realize that some folks benefit from getting embedded long-term in an institutional framework of medical supervision; some of them practically require that level of intervention. But many of us do not.

In that regard, I view some of the conclusions of the 2021 SAMHSA Report on Substance Abuse and Mental Health with dismay. I'm terribly skeptical of some of the statistical findings, such as the SAMHSA estimate that 11.4% of 18-25 year old Americans fit their criteria for a diagnosis of "Serious Mental Illness." https://www.samhsa.gov/data/release/2021-national-survey-drug-use-and-health-nsduh-releases

Compare that with the 2017 SAMSHA report that appears roughly similar in outline form, and apparently relies on survey interpretation methodology that’s substantially similar: in 2017, 7.5% of 18-25 year olds were said to fit the description of “severely mentally ill.” The table (Figure 49) featuring that statistic also includes the annual estimates for the preceding nine years. going back to 2008. In 2008 the estimated percentage of “seriously mentally ill” 18-25 year olds was 3.8%; it actually dropped slightly in the following year, 2009, to 3.3%, before rising to 3.9% in 2010, returning to the 3.8% figure of 2008 in 2011, and then to 4.1% in 2012 and 4.2% in 2013; and then rising dramatically over the next four years to reach the estimate of 7.5%.

To review the 2017 and 2021 SAMSHA numbers: the incidence of “severe mental illness” in 18-25 year olds increased by 300% between 2011 and 2021. To repeat: according to SAMHSA, in the last ten years, the incidence of Serious Mental Illness in young adults tripled.

Is that so? Really? Is it actually the case that more than 1 in 9 American young adults are grappling with serious mental illness?

The problem here is that SAMHSA appears to contradict the guidelines of the American Psychological Association Guidelines for Psychiatric Evaluation (March 2020):

Psychologists understand that test instruments are not typically used as singular measures but rather are integrated with other standard measures as well as nonstandardized yet valuable data points (e.g., collateral interviews, behavioral checklists, paper review of prior documents). Tests and other measurement instruments can be cited in the technical manual for multiple uses. Psychologists remain aware that although their area of expertise may support use of a test for a particular purpose, other uses of the test may fall outside the psychologists’ scope of competence. Similarly, psychologists are advised that assessment is most comprehensive and accurate when multiple data points are used to arrive at a determination (e.g., diagnosis, recommendation, disposition), and as such they are encouraged to include all additive data sources in drawing conclusions, inferences, and decisions.

Integration of data. Psychologists seek the competency to integrate all data points and other form of findings in the writing or oral reporting of results. Multiple data points include but are not limited to standardized tests, clinical interview, collateral reporting, behavioral checklists, environmental context, and client variables. Integration of data points is a distinct skill from interpretation but results in interpretation and the formation of case conceptualization, which advances decision-making and initial formation of recommendations. The weighting of data points in the integration of data is a process that considers the cultural, ethnic, and other diversity variables that influence the context and interpretation of data points.

Interpretation. To accurately interpret findings, psychologists strive to understand the conceptual meaning of scores and the technical range of interpretation of any given set of individual scores (see Section 2 of these guidelines). Accurate interpretation is dependent on the psychologist’s ability to integrate multiple sources of data points. Insofar as primary sources of data can be inconsistent rendering a clear determination difficult, psychologists seek to develop the knowledge and skills to critically evaluate these apparent data inconsistencies and arrive at the most viable interpretation of the data that serves the purpose of the assessment accurately (Hopwood & Bornstein, 2014). Psychologists aspire to reflect accuracy in their interpretation of test and assessment instrument results and to carefully consider and control potential sources of error and/or bias, particularly when these errors may contribute to a diagnosis, recommendation, disposition, or other high-stakes decisions (e.g., custody, employment, guardianship determination, competence and decisional capacity, disability compensation, incarceration). In this regard, errors in reporting assessment results can include overinterpretation, inconsistent interpretation, selective interpretation, and/or other misinterpretations of results. Although sources of these errors can be attributable to lack of technical knowledge, the most common sources of bias effecting interpretation of psychological assessment data include distortions and subjective weighting errors based on preconceived beliefs, and/ or other intervening factors such as anchoring effects (i.e., overweighting initial data), attribution effects (i.e., favoring data from one source over another), and/or confirmation effects (i.e., selectively weighting data based on personally held beliefs). An excellent and thorough discussion of these and other biases effecting psychological assessment that affect accurate interpretability of multiple data can be found in Reynolds and Suzuki (2013).

The exclusive reliance on survey questionnaire responses in the SAMHSA reports presents a serious liability that undue credence is given to the significance of verbal responses by those under examination in the Mental Health portion of the survey. Thoughts and beliefs are not the same as acted-out behaviors. In particular, the opinions solicited to make determinations on Major Depressive Episodes (MDE) make use of a set of criteria that deserve a lot more skeptical scrutiny:

According to DSM-5, people are classified as having had an MDE⁸⁰ in their lifetime if they had at least five or more of nine symptoms nearly every day (except where noted) in the same 2-week period, where at least one of the symptoms is a depressed mood or loss of interest or pleasure in daily activities. These symptoms are as follows:

depressed mood most of the day;

markedly diminished interest or pleasure in all or almost all activities most of the day;

significant weight loss when not sick or dieting, or weight gain when not pregnant or growing, or decrease or increase in appetite;

insomnia or hypersomnia;

psychomotor agitation or retardation at a level observable by others;

fatigue or loss of energy;

feelings of worthlessness or excessive or inappropriate guilt;

diminished ability to think or concentrate or indecisiveness; and

recurrent thoughts of death or suicidality (i.e., recurrent suicidal ideation without a specific plan, making a specific plan, or making an attempt).

Even the behavioral dysfunctions included in the 9-item DSM-5 checklist don’t appear to indicate all that much mental pathology, in my experience and observation. People go through rough patches. Depressive episodes, I can grant credence to that. Major depressive episodes, not really.

(By contrast, most of the survey criteria in the “drug use” section of the SAMHSA reports are fairly unambiguous; either someone used x substance(s) with a given amount of frequency over the previous year, or they didn’t. That said, the SAMHSA report methodology appears to base their estimates of Substance Use Disorder on some awfully loose criteria. A topic for a different post…)

Here’s the methodology used for the 2021 SAMSHA report. It’s entirely about survey responses to questionnaires. 2021 Methodological Summary And Definitions | CBHSQ Data (samhsa.gov)

A CDC report used as one of the sources for the data set that concluded 1 in 9 18-25 year olds suffered from Severe Mental Illness alludes specifically to its own reliability problems:

The findings in this report are subject to at least four limitations. First, these data are based on self-report and were not confirmed by health professionals. Questions about mental health symptoms might be predictive of but do not necessarily reflect a clinical diagnosis… Symptoms of Anxiety or Depressive Disorder and Use of Mental Health Care Among Adults During the COVID-19 Pandemic — United States, August 2020–February 2021 | MMWR (cdc.gov)

So while it’s well-understood that survey self-report is inadequate to provide clinical diagnosis for individuals, the SAMHSA medical establishment bureaucracy has no such reservations about relying on that sort of data to provide an estimate of the mental health of the American population and some of its demographic subgroups. Even when their estimates indicate that the population of severely mentally ill young adults has increased by 300% in ten years- from 3.8%, to 11.4% of 18-to-25 year olds- it doesn’t seem to have crossed their desk that just possibly the researchers are engaged in a facile method of psychological evaluation that has led to rampant over-diagnosis.

More informally, it’s an indisputable fact that it’s become common practice in American social media culture for people to indulge in defining other individuals or groups as "mentally ill" based on criteria such as political belief (and partisan dogmatists of all stripes are fond of defining their opponents as various types of insane- as well as defining all dissenters from any of their views as adherents to whatever opposing ideology they deem to constitute The Enemy.) I’ve noticed that there's also a marked tendency for militant atheists and antitheists on social media to define all theists and/or adherents to any religion as "mentally ill." When the person making such a priori assumptions is a mental health professional- and I have no doubt that some of them are inclined toward such logically sloppy opinions, even though they should have been more well-trained- an awful lot of noisiness and inaccuracy can be introduced into the process of diagnosis and the course of treatment.

The psychology of mental dysfunction is in its infancy as a scholarly discipline within the paradigm of Western medicine. But it's quite possible that it's taken the wrong course from the outset, with its implicit insistence on "knowledge" as the power to define, and then control. I recall reading a book featuring a Native American tribal medicine man and his ideas on the human mind. The book was written by a Western-educated physician freshly out of medical school, newly arrived in the southwest US. The medicine man asked the Western physician the question "What is the mind?" The doctor had a hard time with his reply, stammering and demurring about the various paradigms of theorists and the experiments of neuroscientists, groping with language to explain the findings of Western medicine on the subject. And the Native American healer responded by saying "I can tell you what I know of the human mind in one sentence: the mind is mysterious."

That attitude of humility and open-minded curiosity comprises a much more productive method of approaching questions of mental health and mental pathology than the pretense of superior authority that’s implicitly granted by a medical diploma or therapy credential, in my view. The goal is to heal individuals, not sort them into categories- especially categories reified with static definitions, like “seriously mentally ill”. I realize that SAMHSA researchers might respond by explaining that their annual surveys are intended only to provide estimates of the number of Americans who would benefit from more robustly funded mental health services. To which I can only reply: “11.4% of Americans between the ages of 18 and 25- 3.8 million of them, in that age cohort alone- are seriously mentally ill? Really?”

To be clear: I disagree with the thesis of the late Thomas Szasz, M.D., that mental illness is a “myth.” That sounds extreme, to me; Szasz got carried away with that conclusion. However, I’ve noticed that it’s all too common for people to get carried away with their theories on all sorts of subjects. That doesn’t mean that they don’t have any valid insights to offer. And I think that Tom Szasz’s critique of modern institutional psychology- in particular, what Szasz refers to as the Therapeutic State, and its widespread default to the practice of what he refers to as Ceremonial Chemistry- has considerable merit. There isn’t anything more extreme about his assertions on that subject than there is about the widely accepted findings on the nature of institutional power and bureaucracy by sociological investigators like Max Weber, Jacques Ellul, and Thomas Kuhn. Tom Szasz is simply noting that such critiques of status quo institutional power and the sociology of knowledge possess a relevance that extends to the workings of the modern medical establishment- a relevance that’s especially noteworthy when viewing the ways that capital investment, economic reward, institutional power, private status considerations- and politics- exert undue pressures on the direction of professional mental health research and innovation, and on the approved practices for mental health patient treatments & therapies.

Mental health c.2023 is a field where allopathic medicine and neuroscience research is in its infancy; the treatment of first resort- psychopharmacological prescription- is overwhelmingly a matter of guesswork with a high quotient of error and ‘active placebo’ effect; and even the simplest aggregated measures of therapeutic success are difficult to assess. Furthermore, considerable uncertainty is present from the outset of a patient’s first encounter with the system, at the point of the initial evaluation and attempt at formal diagnosis. Because, as previously noted: the human mind is mysterious. Psychological evaluation bears very little similarity with a physical checkup and lab workup, which are able to provide some precise parameters to help determine a patient’s physical condition.

Western medicine owes its authoritative reputation to its ability to demonstrate its accuracy of diagnosis and efficacy of cure for a wide array of physical ailments, from outset to resolution. Human psychology- mental health- is not nearly as amenable to the sort of monitoring processes that document the prognosis of a patient afflicted with a physical malady. Obviously. Despite that indisputably profound difference, Western medicine has a bias for regarding mental health with the same paradigm that it applies to bodily health. I think the evidence shows that this default framing has a way of leading to a lot of problems, ranging from misdiagnosis and over-diagnosis to iatrogenic disease and iatrogenic exacerbation of the mental problems of the patient. I don’t know how to fix the situation; it’s a challenge that needs to be addressed by the courage and wisdom of leaders in the healing professions. But the first step is to realize that you have a problem- and the institutionally embedded career professionals who run the Substance Abuse and Mental Health Services Administration do not appear to have gotten that far yet.