June 14, 2005
Snake Phobias, Moodiness and a Battle in Psychiatry
By BENEDICT CAREY

A college student becomes so compulsive about cleaning his dorm room that
his grades begin to slip. An executive living in New York has a mortal fear
of snakes but lives in Manhattan and rarely goes outside the city where he
might encounter one. A computer technician, deeply anxious around
strangers,
avoids social and company gatherings and is passed over for promotion.

Are these people mentally ill?

In a report released last week, researchers estimated that more than half
of
Americans would develop mental disorders in their lives, raising questions
about where mental health ends and illness begins.

In fact, psychiatrists have no good answer, and the boundary between mental
illness and normal mental struggle has become a battle line dividing the
profession into two viscerally opposed camps.

On one side are doctors who say that the definition of mental illness
should
be broad enough to include mild conditions, which can make people miserable
and often lead to more severe problems later.

On the other are experts who say that the current definitions should be
tightened to ensure that limited resources go to those who need them the
most and to preserve the profession's credibility with a public that often
scoffs at claims that large numbers of Americans have mental disorders.

The question is not just philosophical: where psychiatrists draw the line
may determine not only the willingness of insurers to pay for services, but
the future of research on moderate and mild mental disorders. Directly and
indirectly, it will also shape the decisions of millions of people who
agonize over whether they or their loved ones are in need of help, merely
eccentric or dealing with ordinary life struggles.

"This argument is heating up right now," said Dr. Darrel Regier, director
of
research at the American Psychiatric Association, "because we're in the
process of revising the diagnostic manual," the catalog of mental disorders
on which research, treatment and the profession itself are based.

The next edition of the manual is expected to appear in 2010 or 2011, "and
there's going continued debate in the scientific community about what the
cut-points of clinical disease are," Dr. Regier said.

Psychiatrists have been searching for more than a century for some
biological marker for mental disease, to little avail. Although there is
promising work in genetics and brain imaging, researchers are not likely to
have anything resembling a blood test for a mental illness soon, leaving
them with what they have always had: observations of behavior, and
patients'
answers to questions about how they feel and how severe their condition is.

Severity is at the core of the debate. Are slumps in mood bad enough to
make
someone miss work? Does anxiety over social situations disrupt friendships
and play havoc with romantic relationships?

Insurers have long incorporated severity measures in decisions about what
to
cover. Dr. Alex Rodriguez, chief medical officer for behavioral health at
Magellan Health Services, the country's largest managed mental health
insurer, said that Magellan used several standardized tests to rate how
much
a problem is interfering with someone's life. The company is developing its
own scale to track how well people function. "This is a tool that would
allow the therapist to monitor a patient's progress from session to
session," he said.

Although the current edition of the American Psychiatric Association's
catalog of mental disorders includes severity as a part of diagnosis, some
experts say these measures are not tough or specific enough.

Dr. Stuart Kirk, a professor of social welfare at the University of
California, Los Angeles, who has been critical of the manual, gives
examples
of what could, under the current diagnostic guidelines, qualify as a
substance abuse disorder: a college student who every month or so drinks
too
much beer on Sunday night and misses his chemistry class at 8 a.m. Monday,
lowering his grade; or a middle-aged professional who smokes a joint now
and
then drives to a restaurant, risking arrest.

"Although perhaps representing bad judgment," Dr. Kirk wrote in an e-mail
message, these cases "would not be seen by most people as valid examples of
mental illness, and they shouldn't be because they represent no underlying,
internal, pathological mental state."

Separating the heavies from the lightweights - by asking, say, "Did you
ever
go to a doctor for your problem, or talk to anyone about it?" - has a
significant effect on who counts as mentally impaired.

After researchers reported in a large national survey in 1994 that 30
percent of Americans adults had a mental illness in the past year, Dr.
Regier and others reanalyzed the data, taking into account whether people
had reported their mental troubles to a therapist or friend, had received
treatment or had taken other actions.

They found that the number of people who qualified for a diagnosis of
mental
illness in the previous year plunged to 20 percent over all; rates of some
disorders dropped by a third to half.

But limiting the count to those who have taken action does not give an
accurate picture of the extent of illness, argue other researchers, who
have
been sharply critical of efforts to drive down prevalence estimates.

Dr. Robert Spitzer, a professor of psychiatry at Columbia University and
the
principal architect of the third edition of the diagnostic manual, wrote in
a letter to The Archives of Psychiatry, "Many physical disorders are often
transient and mild and may not require treatment (e.g. acute viral
infections or low back syndrome). It would be absurd to recognize such
conditions only when treatment was indicated."

He added, "Let us not revise diagnostic criteria that help us make
clinically valid standard diagnoses in order to make community prevalence
data easier to justify to a skeptical public."

Dr. Ronald Kessler, a professor of health care policy at Harvard and the
lead author of the 1994 survey and the nationwide survey released last
week,
said squeezing diagnoses so that many mild cases drop out could blind the
profession to a group of people it should be paying more attention to, not
less.

"We know that there are prodromes, states that put people at higher risk,
like hypertension for heart disease, which doctors treat," he said. "You
can
call these milder mental conditions what you want, and you may decide to
treat them or not, but if you don't identify them they fall off the radar,
and you don't know much of anything about them."

In the survey released last week, Dr. Kessler and his colleagues found that
half of disorders started by age 14, and three-quarters by age 24. "These
are people who may show up at age 25 or later as depressed alcoholics,
maybe
they're in trouble with the law, they've lost relationships, and from my
perspective we need to go upstream and find out what's happening before
they
become so desperate," Dr. Kessler said.

One condition whose estimated prevalence has bounced around like a
Ping-Pong
ball in this debate is social phobia, extreme anxiety over social
situations. In a 1984 survey, investigators identified social phobia
primarily by asking about excessive fear of speaking in public. They found
a
one-year prevalence rate of 1.7 percent.

But psychiatrists soon concluded that other kinds of fears, including a
fear
of eating in public or using public restrooms, were variations of social
phobia. When, in 1994, these and others questions were included, the
prevalence rate rose to 7.4 percent.

Dr. Regier re-evaluated the data using a different criterion for severity
and found a much lower rate: 3.2 percent. Last week, Dr. Kessler reported a
rate of 6.8 percent.

"You can see why people have a hard time believing these numbers because
they change so much depending on how you look at the data," said Dr. David
Mechanic, director of the Institute for Health, Health Care Policy and
Aging
Research at Rutgers University.

Yet the cutoff points for disease severity have real effects on the lives
of
people like Paul Pusateri, 48, a Baltimore business analyst.

Mr. Pusateri said he was outgoing through college but then had a panic
attack in his mid-20's, as he was preparing to give a speech. He managed to
build a career and family despite surges of anxiety before speeches and
meetings. But finally, more than two decades after the first symptoms, he
reached a point where he dreaded even small or one-on-one meetings with
familiar co-workers.

"It's very bizarre; the only way I can describe the feeling is, Imagine
walking down the street at dusk having someone put a gun in your face and
threaten to kill you - having that absolute terror before a routine work
meeting," he said.

Mr. Pusateri said that, perhaps unconsciously, he applied severity criteria
to his own growing mental struggles. He may have set the bar too high: only
when he began badly mangling presentations at work, and then dreaded going
in at all, did he tell his wife that he felt he was in trouble. His wife
had
watched a therapist talk about social phobia on television, and soon he was
getting help.

He considers himself lucky to have found a diagnosis at all, not to mention
a therapist. "I was desperate by the time I did anything about it, I saw
that my livelihood was at stake," he said.

Yet by all outside appearances, and by some strict definitions, he might
not
have qualified as having a disorder until he took some action.

In the coming years, Dr. Regier's office will be responsible for clarifying
the thresholds of disease for the next diagnostic manual, to somehow
identify difficult cases like this one, while remaining credible to
insurers
and to the public at large.

After a prolonged controversy last year over the use of antidepressants in
children, most experts say the last thing psychiatry needs now is for this
process to turn into a public fight over who is sick and who is not.

But this fight may be hard to avoid. The two sides are far apart, debates
over the diagnostic manual are traditionally contentious and despite
increasing openness about mental illness the public tends to be skeptical
of
any prevalence numbers over a few percent.

"That's the problem," said Dr. Regier, "people hear these higher prevalence
rates and they immediately start thinking about severe, disabling
schizophrenia. But we know these surveys include a lot of mild cases, and
we
need to ask, How significant are these?"

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