Reflection Paper: Diagnosis and Treatment in Mental Health, a cynical perspective

Over Diagnosis and Iatrogenic harm in Mental Illness
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The prevalence of mental disorders in Canada is growing and is becoming a public concern but the majority of people who satisfy the diagnostic criteria for mental illness do not access the appropriate treatment. In Canada 1 out of 5 people experience a mental disorder in their lifetime and evidence demonstrates that the number of people who meet the diagnostic criteria for mental illness is increasing. This raises a number of questions in regard to the diagnosis and treatment of this mental illness in the society. It is with no doubt that ineffective and harmful healthcare practices are not new, but the rate of over diagnosis and overtreatment has grown exponentially. This raises a number of questions in the whole healthcare system in the society. The first question that arises is what guides professional decision making in the diagnosis of mental disorders and does the professional codes and ethics contributed to this “over-diagnosis?” Medical practitioners have revised their guiding principles but still over-diagnosis remains raising the question “were this trend of over-diagnosis existing long before?
I am convinced that the concerns of over diagnosis and iatrogenic harm in mental disorders need to be addressed. However, I view them to be entirely separate and complex issues from the DSM V spectrum and the reliance of various mental disorders as a gauge of satisfying the quality of diagnosis (Corcoran & Walsh, 2010). I do believe that it is the quality of diagnoses (having the ability to translate diagnostic criteria to symptoms in an accurate manner) that affects “over diagnosis” and not the awareness levels of the patients. Inaccurate translation leads to labelling and medicalizing conditions that do not need any medicines. Medicalization in itself is wrong because at this point the medicine institution has overstepped its limits. Misinterpretation of symptoms can be attributed to DSM due to its general classification of disorders making physician wrongly recognize a condition as a medical problem. This demonstrates inadequacy in the identification of underlying causes of the condition resulting in physicians taking inadequate measures in eliminating the problem. DSM V focuses on medicalization rather than on identifying alternate solutions to the problem resulting in the issues of over diagnosing and iatrogenic harm (Hoffman, 2016). Parens puts this into a clear perspective by saying:
…as medicine focuses on changing individual’s bodies to reduce suffering, its increasing influence steals attention and resources away from changing the social structures and expectations that can produce such suffering in the first place. The idea is that, for example, rather than changing the bodies of shy people with drugs, we could change our expectations of how people have in novel situations; again, doing so, would exemplify the virtue of learning to affirm natural variation. Further, changing social expectations would be fairer to individuals, who instead of changing their bodies to better fit dominant norms, could, again, be affirmed in their norm challenging variation” (Parens, 2013 p. 30).
Based on this context, overdiagnosis is caused by inadequate responses to conditions due to unnecessary clinical interventions that consist of various health risks. Over diagnosis has a significant impact to certain aspects of patients’ lives and communities which have no direct relation to health. Criticizing over diagnosis and labelling of conditions appears to be a difficult task due to the broad and holistic definition of health. If indeed health is as it is defined by World Health Organization which defines it as “a state of complete, physical, mental and social well-being” (Callahan, 1973) then all aspects of one’s collective life can be considered to be a health problem. This definition of health supports the objectives of medicine demonstrating that medicine has the potentials of not only giving good lives to individuals but also making them healthy. This model of medicine is what DSM V has been based and the result is over diagnosis and iatrogenic harm to patients with mental health disorders. This problem of medicine framework has been well explained by Daniel Callahan who states
Association of health and general well-being as a positive ideal, has given rise to a variety of evils. Among them are the cultural tendency to define social problems, from war to crime in the streets as “health” problems; the blurring of lines of responsibility between and among the professions, and between the medical profession and the political order; the implicit denial of human freedom which results when failures to achieve social well-being are defined as forms of “sickness,” somehow to be treated by medical means (1973, p.78).
Over-diagnosis has been defined as “…when people without symptoms are diagnosed with a disease that ultimately will not cause them symptoms or early death” and is used to refer to “… the related problems of over-medicalization and subsequent overtreatment, diagnosis creep, shifting thresholds and disease mongering.”
First, when someone mentions “over diagnosing”, the first question that comes to my mind is “how can one know that he is ‘over-diagnosing’ a disorder and what understanding do we have about this disorder and what is its prevalence in the society?” The second question that I ask is “how can we be accurate about the disorder being diagnosed and the one being ‘over-diagnosed’?” The factors contributing to overdiagnosis are well discussed. The rapid technological advancements have allowed the detection of disorders at their earlier stages. With well intentions, medical practitioners make decisions to lower the treatments and interventions so that the asymptomatic population receives diagnosis or disease labels. This ideology is supported by the fear of not following the legal framework and the performance indicators that encourage extensive work. This process has resulted in an intentional evolution of a culture that supports individual-oriented decision making. All this is evident due to inadequate challenges to the narratives of the benefits that arise from early detection and treatments which are difficult to identify for the professionals as well as public.
This disease labelling has significant harm to individuals whose quantification has proved to be difficult. However, this is obvious in false-positive diagnoses of certain conditions such as dementia. Patients are put through harmful treatments, both mild and fatal, where resources are largely wasted; this harm can be termed as iatrogenic harm (harm caused to patients during the treatment process) (Caplan & Caplan, 2013). This may be in the form of anxieties and other uncertainties caused to patients due to medical practitioner’s failure to provide them with essential information in regard to their diagnosis, treatment, effects of the medications or unnecessary treatment.
An example that can be considered in this analysis is the diagnosis and treatment of attention deficit disorder commonly referred to as attention deficit hyperactivity disorder (ADHD). In a study to examine the attention ADHD and its treatments was receiving due to the increasing prevalence of children being diagnosed with ADHD, the National Institutes of Health established that one of the problems was inconsistent diagnosing, which is also a growing concern in the mental health disorders spectrum.
Analysing this question has led to contradictory results which demonstrate that in one side, there is over-diagnosis of even common mental disorders such a bipolar, but there is a large number of individuals with the disorder but have never been diagnosed – demonstrating inconsistence in bipolar diagnosis. The diagnosis of bipolar disorder should be accurately be done because it has a clear criteria and overlaps with few disorders. In their study in Rhode Island, Zimmerman et al. (2008), examined 700 subjects to determine whether bipolar is being over-diagnosed. Their results established that...