What Should We Be Worried About?

ARE WE HOMOGENIZING THE GLOBAL VIEW OF A NORMAL MIND?

P. MURALI DORAISWAMY

Professor of psychiatry, Duke University Medical Center; member, Duke Institute for Brain Sciences

Should we worry about the consequences of exporting America’s view of an unhealthy mind to the rest of the world?

Biologists estimate that there may be between 1.5 million and 5 million subspecies of fungi, though only 5 percent (of the lower estimate) are currently categorized. To outsiders, it may appear that America’s classification of mental disorders is not too different. At the turn of the century, psychiatric disorders were mostly categorized into neuroses and psychoses. In 1952, the first version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the psychiatric diagnostic bible, formally expanded this to 106 conditions. DSM-II, published in 1968, listed 182 conditions; DSM-III (1980) listed 265 conditions; and DSM-IV (1994) listed 297. DSM-V is expected to be released later this year and will have many changes, including an unknown number of new conditions. Today, around 40 million Americans are thought to be suffering from a mental illness. In 1975, only about 25 percent of psychiatric patients received a prescription, but today almost all do, and many receive multiple drugs. The use of these drugs has spread so rapidly that levels of common antidepressants, such as Prozac, have been detected in the U.S. public water supply.

Two key studies from the 1970s illustrate some of the subjectivity underlying our psychiatric diagnoses. In 1973, David Rosenhan described an experiment in which eight healthy people who simulated fake auditory hallucinations and went for psychiatric evaluations were all hospitalized (for an average of nineteen days) and forced to agree to take antipsychotic drugs before their release. This by itself is not surprising, since doctors tend to trust patients’ description of symptoms. But what was revealing was the second part of the experiment, in which a psychiatric hospital challenged Rosenhan to repeat it using its facility and Rosenhan agreed. In the subsequent weeks, the hospital’s psychiatrist identified 19 (of 193) presenting patients as potential pseudopatients, when in fact Rosenhan had sent no one to the hospital at all.

In another study, in 1971, 146 American psychiatrists and 205 British psychiatrists were asked to watch videotapes of patients. In one case, involving hysterical paralysis of one arm, mood swings, and alcohol abuse, 69 percent of the Americans diagnosed schizophrenia but only 2 percent of the British did so.

Despite the DSM having been developed by many of the world’s leading minds with the best of intentions, the dilemmas illustrated by these studies remain a challenge: overlapping criteria of many disorders, wide symptom fluctuations, spontaneous remission of symptoms, subjective thresholds for severity and duration, and diagnostic variations even among Anglo-Saxon cultures.

DSM-III and IV, with their translation into multiple languages, resulted in the globalization of these American diagnostic criteria, even though they were never intended as a crosscultural export. Many foreign psychiatrists who attended the American Psychiatric Association’s annual meeting began implementing these ideas in their native countries. Western pharmaceutical companies seeking new markets in emerging countries were quick to follow with large-scale campaigns marketing their new pills for newly classified mental disorders, without fully appreciating the crosscultural variations. Rates of U.S.-defined psychiatric disorders are rising in many countries, including emerging nations.

In his insightful book Crazy Like Us: The Globalization of the American Psyche, Ethan Watters raises the worry that by exporting an American view of mental disorders as solid scientific entities treatable by trusted pharmaceuticals, we may be inadvertently increasing the spread of such diseases. We assume that people around the world react the same way to stress as we do. We assume that mental illness around the world manifests the same way as it does in the U.S. We assume that our methods and pills are better ways to manage mental illnesses than local and traditional methods. But are these assumptions correct?

Suffering and sadness in many Asian cultures has traditionally been seen as part of a process of spiritual growth and resilience. People in other cultures react to stress differently from us. Even severe illnesses such as schizophrenia may manifest differently outside the U.S., due to cultural adaptations or degrees of social support. For example, a landmark World Health Organization study of 1,379 patients from ten countries showed that two-year outcomes of first-episode schizophrenics were much better for the patients in the poor countries than in the U.S., despite a higher proportion of American patients on medications. In my own travels to India, I have seen these trends in full bloom. As the Asian psyche becomes more Americanized, people from Bombay to Beijing are increasingly turning to pills for stress, insomnia, and depression. Is this the best direction for the entire world to follow?