Medicalizing Distress, Ignoring Public Health Strategies

Abstract

Byline: P. Thangadurai, K. Jacob Psychiatry, which has medicalized many forms of human argues for individual treatments and interventions. It has blurred the disease-illness divide, subcategorized presentations, lowered the thresholds for diagnosis and introduced many new psychiatric disorders. Its phenomenological approach to diagnosis and classification employs symptom checklists and symptom counts sans context. The medicalization of distress is supported by the capitalistic project and the current political economy of health, fits in well with neoliberalism and allows the free market to expand its business interests. This essay contends that social and economic correlates of depression, anxiety and common mental disorders, despite robust evidence, are not emphasized. It argues that social and economic determinants of mental health demand public health and population-based strategies to prevent and manage common mental disorders in the community. Such approaches will impact a greater proportion of people than medical interventions. Depression and anxiety, standard psychiatric diagnoses, are part of our vocabulary and popular culture. However, these terms are employed to highlight idioms of distress, describe illness experience and to label diagnostic categories. Their widespread, flexible and interchangeable use has blurred the boundary between distress and disease. The disease halo has been inappropriately transferred to many forms of human suffering. The medicalization of distress has resulted in a focus on treating individuals. It has also resulted in ignoring the impact of social and economic stress on mental health resulting in very little emphasis on the need for and use of public health and population-based interventions. Psychiatric Context Psychiatry in the 1970's was struggling with unproven etiologies for mental illness and with poor diagnostic agreement among psychiatrists. The discipline adopted an atheoretical approach to diagnosis using operational criteria, [sup][1] that emphasized reliability and counted symptoms. It dismissed the relevance of context and environmental stress to diagnosis, as these require interpretation and reduce inter-rater reliability. [sup][1],[2] The creation and use of the suffix disorder for psychiatric categories sidestepped the disease-illness divide. The discipline also created a diagnostic label called depressive which attempted to identify people with more severe distress and clinical depression. [sup][1] It soon became the gold standard. The diagnosis of depression, when viewed through the biomedical lens, tends to suggest the disease, supposes brain etiology and pathogenesis, documents signs and symptoms, offers differential diagnoses, recommends pharmacological therapies and prognosticates about the course and outcome. However, psychiatric diagnoses pose many challenges. The lack of laboratory tests for diagnosis has forced psychiatrists to rely on features. The absence of pathognomonic symptoms has meant the use of syndromes for labeling and symptom checklists for diagnosis. The criteria essentially count symptoms with little regard for context. [sup][3] The recent increase in the number of psychiatric categories and the lowering of the threshold has resulted in a wide net, which medicalizes a variety of normal human responses to environmental stress. Epidemiological studies of depression also use diagnostic instruments, which do not evaluate stress and context and fail to identify short-term adjustment problems. [sup][2] The elastic concept of depression and the rigid application of the diagnostic hierarchy and criteria has resulted in the marginalization of short-term stress-related adjustment disorders in practice. Consequently, the hybrid category, major depressive disorder, identifies a heterogeneous group of people with melancholic depression (endogenous depression), those with chronic depression and with recent stressors (neurotic depression/dysthymia) and normal people under severe stress (adjustment disorders). …