2013 : WHAT *SHOULD* WE BE WORRIED ABOUT?

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Professor of Psychiatry, Member of the Duke Institute of Brain Sciences
Are We Homogenizing The Global View Of A Normal Mind?

Should we worry about the consequences of exporting America's view of an unhealthy mind to the rest of the world?

Biologists estimate there may be 1.5-5 million subspecies of fungi, though only 5% are currently categorized. To outsiders, it may appear that America's classification of mental disorders is not too different. At the turn of the century, psychiatric disorders were mostly categorized into neuroses and psychoses. In 1952, DSM-I, the first version of the psychiatric diagnostic bible, formally expanded this to 106 conditions.

DSM-II in 1968 had 182 conditions, DSM-III in 1980 had 265 conditions, and DSM-IV in 1994 had 297. DSM V is expected to be released later this year and will have many changes including an unknown number of new conditions. Today, somewhere around 40 million Americans are thought to be suffering from a mental illness. In 1975, only about 25% of psychiatric patients received a prescription but today almost 100% do and many receive multiple drugs. The use of these drugs has spread so rapidly that levels of common antidepressants, like Prozac, have been detected in the US public water supply.

Two key studies from the 1970s illustrate some of subjectivity underlying our psychiatric diagnoses. In 1973 Rosenham described an experiment in which eight healthy people who briefly simulated fake auditory hallucinations and went for psychiatric evaluations, were all hospitalized (for an average of 19 days) and forced to agree to take antipsychotic drugs before their release. This by itself is not surprising since doctors tend to trust patient's description of symptoms. But what was revealing, was the second part of this experiment when a psychiatric hospital challenged Rosenhan to repeat this again with its facility and Rosenhan agreed. In the subsequent weeks, the hospital's psychiatrist identified 19 (of 193) presenting patients as potential pseudopatients, when in fact Rosenhan had sent no one to the hospital!

In another study in 1971, 146 American psychiatrists and 205 British psychiatrists were asked to watch videotapes of patients. In one case with hysterical paralysis of one arm, mood swings and alcohol abuse, 69% of Americans diagnosed this as schizophrenia but only 2% of British did so.

Despite the DSM having been developed by many of the world's leading minds with the best of intentions, the dilemmas illustrated by these studies remain a challenge even today: overlapping criteria of many disorders, wide symptoms fluctuations, spontaneous remission of symptoms, subjective thresholds for severity and duration, and diagnostic variations even among Anglo-Saxon cultures.

DSM III and IV with its translations into multiple languages, resulted in the globalization of these American diagnostic criteria, even though they were never intended as a cross-cultural export. Large numbers of foreign psychiatrists who attended the American Psychiatric Association's annual meeting began to implement these ideas in their native countries. Western pharmaceutical companies seeking new markets in emerging countries were quick to follow with large scale campaigns marketing their new pills for newly classified mental disorders without fully appreciating the cross-cultural variations. Rates of American defined psychiatric disorders are rising in many countries including emerging nations.

In his insightful book, Crazy Like Us, Ethan Watters raises the worry that by exporting an American view of mental disorders, as solid scientific entities treatable by trusted pharmaceuticals, we may be inadvertently increasing the spread of such diseases. We assume people react the same way around the world to stress as we do. We assume that mental illness manifests the same way around the world as it does in the US. We assume our methods and pills are the better ways to manage mental illnesses than local and traditional methods. But are these assumptions correct?

Suffering and sadness in many Asian cultures has been traditionally seen as part of process of spiritual growth and resilience. People in other cultures react to stress differently than we do. Even severe illnesses such as schizophrenia may manifest differently outside the US due to cultural adaptations or social support. For example, a landmark WHO study of 1379 patients from 10 countries showed that two-year outcomes of first episode schizophrenics were much better for the patients in the poor countries than in the US, despite a higher proportion of American patients on medications.

In my own travels to India, it's obvious to see these trends in full bloom. As the Asian psyche becomes more Americanized, people from Bombay to Beijing are increasingly turning to pills for stress, insomnia, and depression. Is this the best direction for the entire world to follow?