World Mental Health Day: Another Missed Opportunity?

At the heart of the entire debate over mental health is the official World Health Organization (WHO) definition, adopted in 1948: “a state of complete well-being, and not merely the absence of disease.” That may fit physical disease, but it doesn’t really suit the realm of mental, nervous and emotional illness.

The WHO definition says that those who enjoy mental health also enjoy “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community.” Yet, as a moment’s reflection will tell us, there is no individual, industry, NGO or government that can ever realize such an open-ended aim.

If people are schooled to believe in the WHO’s vision, then demand for mental health is bound to be insatiable. In fact, demand has helped to drive up U.S. spending on mental disorders from $35 billion in 1996 to $58 billion in 2006, a faster rate of growth than costs for cancer or heart disease. Little wonder that critics call most mental health policy a “bottomless pit.”

We also need to discuss extensively the difference between bona fide mental disorders and the psychological and emotional highs and lows of everyday life. How do we distinguish between normal shyness and social anxiety disorder? Between understandable sadness and clinical depression? Between sensible vigilance and paranoid delusions? Between high standards of personal cleanliness and obsessive-compulsive disorder?

These are crucial questions in light of the diagnostic inflation that psychiatry has undergone in the last half century. The first edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM), published in 1952, listed 106 disorders. The most recent edition lists 365. Everyone except for the DSM’s most fervent defenders admits that society hasn’t gotten that much crazier.

It is not as if the boundaries between disease and wellness haven’t been discussed before. It’s just that throughout history, the debate has been dominated by interest groups with a stake in expanding the number of mental disorders.

In the past, that list has included governments, researchers, the courts, psychiatry itself, drug companies and third-party insurers — but recently even patient advocacy organizations such as the National Alliance on Mental Illness have avoided the topic of where normalcy ends and full-fledged mental illness begins.

Yet the WHO and most other health organizations continue to operate as if the chief barrier to mental health is the delivery of services, not the process of determining what is and is not a mental disease in the first place.

Another unsettling aspect of the WHO’s statements is the assumption that developing countries merely want and need more of what developed countries already have — that is, money and resources to spend on mental health care.

Yet viewing the issue of global mental health as simply a matter of wealth distribution skirts the more fundamental issue of what kind of mental health care other parts of the world need.

As Ethan Watters and others have argued, lately American psychiatry has been exporting its diagnoses and treatments to other cultures, “homogenizing how the world goes mad.” Depression, anorexia nervosa and post-traumatic stress disorders, for example, are being diagnosed more and more by developing-world practitioners.

This is all happening as if western-based psychiatry and the drugs it dispensed were a one-size-fits-all model for improving mental health. Like tracts of rain forests, the theories of entire cultures about the mysteries surrounding mental health are disappearing in the wake of psychiatric globalization.

Launching a major discussion about the key pillars of today’s mental health consensus should not become an exercise in psychiatry-bashing or any other form of blame game. Nor should we go to the other extreme of over-valuing other cultures’ approaches to mental health while rejecting the advances made by western medical science.

On the other hand, the time has certainly come for all stakeholders in mental health care — industry, government, taxpayers, the courts, patients and their families — to acknowledge the role they play in policymaking. The WHO’s Mental Health Day is a welcome opportunity to take stock of what progress has been made — and what we have lost in our search for sanity.

It’s an opportunity that should not be missed.