Yesterday, a story on stuff.co.nz looked at the increase in the number of New Zealand children being diagnosed with anxiety. There has been a significant increase in mental health diagnoses, particularly under the heading of “anxiety.” The story shared concerns and analysis of the increase, quoting two University Professors who explained factors behind the increases (including the Christchurch earthquakes and the economic downturn), and – alternately – the view of a suicide prevention advocate who “slammed the results as bad science.”
The suicide prevention advocate – Maria Bradshaw, the founder of “Casper” – attacked the New Zealand Before School Checks which are meant to pick up potential mental health (and other health) problems in preschoolers. However these checks only pick up potential issues, they don’t diagnose them, so I’m not convinced they are relevant fodder for condemnation. If there is a problem here, it’s going to surely be with those who do the diagnosing, and with the actual Diagnostic Manuals; either a child has a condition or they do not. If a check system is identifying children who would had previously gone undiagnosed – and thereby without corresponding supports and interventions – I don’t think it’s best to target the check system itself.
Bradshaw’s critique doesn’t rest there though. She is worried that the “definition of normal” has become too narrowed. That once normal behaviour – such as tantrums and lack of concentration – are now getting labels. Those labels are sometimes accompanied too by drugs, for example there have been significant recent increases in mood-stabilising drugs and antidepressants prescribed for children under five years old.
I hold some of these concerns myself, particularly around the prescription of mood altering drugs to very young children. I think it important though to take into account what the professors quoted in the story also said, about the likelihood that children remain under-diagnosed and many would benefit from a confirmed diagnoses who simply have not been assessed yet. What we may be seeing now rather than a “huge increase” of cases, is a growing awareness and recognition of cases that were always there. There are other excellent points made by the professors too, that you can read for yourself in the story. This post of mine is primarily concerned about a particular statement by Bradshaw.
The statement is one that I find misleading, dismissive, and perpetuates an erroneous view of the general public about the reality and importance of mental health issues:
“These are not medical things. It’s not like working out if your child has diabetes or not. That’s science, but this is not.”
The statement shocked me, coming from the head of a suicide prevention centre, so I went to their website, where I found some other concerning views being promoted. I found attacks on any use of antidepressants, which they backed by a 2008 meta-analysis. However, a simple search revealed that there was another, more recent meta-analysis performed in 2010 that reached a somewhat different finding: “For patients with very severe depression, the benefit of medications over placebo is substantial.” The Casper site also doesn’t bother with a 2012 systematic review that reached the conclusion “the combination of psychotherapy and antidepressants for depression may provide a slight advantage whereas antidepressants alone and psychotherapy alone are not significantly different from alternative therapies or active intervention controls.” Basically, it appears to be some cheery-picked results, to suit an agenda.
What agenda could a suicide prevention group have in this area, and how might it impact on Bradshaw’s views of modern mental health? The founder sadly lost her child to suicide after the child had been put on antidepressants. (That sad fact is why I was hesitant to write and share this post, but she advocates open dialogues around tough topics, and I mean her no personal ill will in writing this, so share this I shall.) The rest of the website much follows the theme of being against modern treatments for a variety of conditions, including being against vaccinations in general: “vaccines cause illness… not cure it. More toxic chemicals pushed by big pharma corps.” The attacks on modern pharmaceutical companies extends to dismissing studies associated with funding from such companies (as backed up by this study on 11 German Journals, for instance). (I know many of my readers are already familiar with the arguments around the relevance of funding to outcomes, and the point of sharing methods and being able to independently replicate results, so I won’t go further into that at this point, I’m just bringing this up as relevant background to the how the group views modern ailments and treatments.)
I like many of the objectives the suicide prevention groups wants to achieve, including talking openly about the circumstances and reality of suicide, but I am less sympathetic to using it as a platform to attack a much broader and unconnected range of mental health conditions, and in general as an attack on modern medicine’s evidence-based attempts to tackle these issues. Which brings me back to Bradshaw’s statement about what is medical, what is science, and what is “not.”
The simple fact is that there are many conditions we now know to be medical, that were once just loosely grouped symptoms without a name. There are also many conditions that we once didn’t have the ability to recognise with objective tests, because we hadn’t developed the medical equipment to do so yet. Furthermore there are some medical conditions that we once dismissed as just “part of life” or “part of the human condition” – including disabilities and old age issues – that we can now successfully treat and thereby improve life quality for the affected individuals.
The fact that we don’t have all the answers yet, and can’t find the exact spot in the brain or the body that causes the problem, doesn’t mean something isn’t medical and certainly does not mean it isn’t science. In fact it is the very nature of science to observe and experiment and trial, and yes even make errors. In that scientific process it may become clear that there is nothing abnormal going on, that the condition is just an extension of a normal human experience for instance. Or that what we thought was condition X, is really a variation on condition Y. The conditions being added to the new Diagnostic Manual, and already in existing Diagnostic Manuals, are an expression of that ongoing process. Just like autism was once considered to be childhood schizophrenia, and later split into five groupings, and now will become one main grouping under an umbrella term as of 2013. Each is part of step informed by science and experiments and trial and error, the process is not static. Nor do conditions that were once in such Manuals always remain classified as “mental conditions,” neither do mental conditions always sit apart from known and identifiable medical conditions.
It is too easy, too dismissive, to say that various conditions are part of normal life and are expressions of growing psychologizing of normality. That in itself overlooks that a diagnosis requires strongly and persistently abnormal behaviours to even qualify for a diagnosis. It is too easy to read off the title of a condition and judge it without reading through the requirements. For example, again taken from the Casper site, in an attack on mental health services, they write this: “…while the most common diagnosis was ‘other’ which includes labels such as factitious disorder (making up symptoms), social anxiety disorder (shyness) and things like not being able to sleep after drinking coffee!“, clearly dismissing the named conditions as a bit of a joke. Yet even just looking at SAD, it can only be diagnosed when it severely interfers with daily functioning or is causing signficant distress, and when other medical conditions that might be causing the symptoms have been ruled out.
This actually goes to another attack the Casper site makes on mental health conditions. They argue for an alternative approach to mental health, where a physical health assessment should be done first to rule out other causes of the emotions and symptoms at issue. However, from my own experiences and from experiences with my own son, this is exactly what already happens, and it is even expressly written into many conditions in the Manual as part of the diagnostic process; ruling out alternative causes of the issues is itself already part of the process.
Which brings me back to the correct target. If we are concerned that certain conditions shouldn’t be in mental health Manuals, and that “normal” is becoming too pathologised, and that “abnormal” is getting treated with drugs (particularly in young children), then I think we should be having an open discussion about each of those concerns, instead of lumping them together into an attack on mental health and on modern medicine.
Lumping them together in this way – attacking mental health categories and belittling their reality and their titles as if it’s all a joke – only serves to further stigmatize a group of both adults and children who are in need of help, some of them in need of very serious help that can only be received after a confirmed diagnosis. When someone says that “it’s not medical, it’s not science” because of the symptoms used as part of the diagnosis process, they’re ignoring all the science and medical work being done in the field, and the reality that there is huge cross-over between medical and mental health issues. And again, are just (as I see it) heaping ridicule and derision on a group of people who are already treated as unwanted outcasts.
In summary, I do think we need to look at these issues, no doubt. But I think it needs to be done in a way that places the attention and the attacks (if attacks are needed) on the right targets, which appear to be the Manuals themselves and specialists who may be misapplying the Manuals. I think we need to be very careful not to ridicule, stigmatize or belittle the children who have received the diagnoses, or to dismiss and laugh at the concerns of their parents. We need to keep in mind that there is a huge and overwhelming percentage of children who do not ever even come close to receiving any type of mental illness diagnosis; “normal” still exists, even if it does seem to have shrunk somewhat. We need to be aware too that the growth we’re seeing may simply be the outcome of better awareness and that very many children are benefitting from the increased support and interventions they then receive following a diagnosis.
There are many factors at play here. It’s complicated. It’s scientific investigation at work, trying to find the answers and weed out the errors. It may not be tidy, it may not get it right straight away, but it will keep searching and reorganising as we shift closer to the truth. Because this is science.
If you’re interested in reading more on the nature of truth and science, you may be interested in my post called “Law, Science, Burdens of Proof, and Contextual Truth.“