Controversies in the Mental Health


The Habitual human behavior is directly linked to the multifaceted nature of mental health disciplines. There are lots of propositions and varied focus on how to recognize mental health and to create standards which identify symptoms and diagnose patients. Two proposed standards have roots in the development of medicine, psychiatry, and health statistics: the DSM and the ICD. What are these manuals, and why are they so controversial?

The Diagnostic and Statistical Manual of Mental Disorders

The Habitual human behavior is directly linked to the multifaceted nature of mental health disciplines. There are lots of propositions and varied focus on how to recognize mental health and to create standards which identify symptoms and diagnose patients

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) is a handbook published in 1994 by the American Psychiatry Association used to diagnose mental health disorders or illnesses. This book is primarily used in Western society - particularly the US, Canada, New Zealand, Australia, and some European countries - as a guide for diagnosing patients for health professionals. This publication is a polemic and widely discussed topic in mental health and related areas, with many professionals questioning its validity, purpose and applications.

Historical Development

The development of the DSM traces back from 1952, when the DSM-I was first published, containing about 106 classifications of mental health disorders. In 1968, the DSM-II was published. The first two editions were strongly influenced by a psychodynamic approach, which provides no particular contrast between the concepts of normality and abnormality. The DSM-II provided one of the most polemic diagnoses of the book's history, when it included homosexuality as a mental disorder. Such decision evoked various protests and it resulted in a plebiscite which decided to remove the diagnosis in 1973. In 1980, the first 'biomedically' modelled DSM was published: the DSM-III. The DSM-III created a clear distinction between normal and abnormal, resulting in a more defined criteria as to whether diagnose and treat a patient suffering from specific symptoms. In 1986 the DSM-III was reviewed and it evolved into the DSM-III-R. The DSM-IV, which is the current version of the book, was first launched in 1994. However, the most recent version is the revised DSM-IV-TR. The APA expects to launch the next edition of the DSM around 2010: the DSM-V.

Problems with the DSM-IV

The DSM has been widely criticized in the mental health community. The validity of the classification criteria used by the handbook has been discussed, particularly when defining normality, discussing culture-related mental health problems, and using a fixed set of characteristics for diagnosis. Criticizers of the APA's publication affirm that the major issues of the DSM-IV are: (a) the categories lack independence and are too heterogeneous (co-morbidity high, overlapping criteria for diagnosis); (b) aetiology is not considered (principles underlying categories are diverse); (c) there is low reliability (consistency) and low conceptual validity (correctness); (d) the classified disorders are mainly based on prevailing cultural view; (e) classification and labeling has potentially harmful consequences; (f) and there is the prevalence of political agendas represented by 'medicalising' life problems (marginalization of sections of society, drug companies, etc).

The International Statistical Classification of Diseases and Related Health Problems

The International Statistical Classification of Diseases and Related Health Problems is a handbook published by the World Health Organisation (WHO) and it embraces all types of diseases or illnesses, not only the mental health-related ones. The ICD was primarily "designed to promote international comparability in the collection, processing, classification, and presentation of morbidity and mortality statistics" (Wikipedia).

Historical Development

The development of the ICD traces back to the 1800's. In 1893, Jacques Bertillon (a French physician) created a system to report causes of death - system which was later adopted by several countries and organisations. In 1898 the APHA (American Public Health Association) recommended that the system should be revised every ten years in order to preserve its validity and application. The system was first reviewed version in 1900, and the next five versions followed in 1910, 1921, 1930, 1939 and 1949. In the sixth revision (1949) the classification expanded to two volumes, including morbidity and mortality conditions, and its title was officially renamed to The International Statistical Classification of Diseases, Injuries and Causes of Death (ICD). In this edition the World Health Organisation also became the responsible entity for the publications of the ICD. The next three revisions were published in 1958, 1968 and 1979. The current edition, the ICD-10, was published in 1999. The ICD is the most widely used statistical classification system in the world, and there are several modified version which are adapted to specific countries and type of data.

Problems of the ICD

For the purpose of mental health, the ICD does not offer the same level of specificity as the DSM. Similar to the DSM, the ICD's focus on recording statistical data, classifying symptoms and diseases, and creating comparable data across varied cultures can have a negative effect in its validity and application.

Manuals, Mental Health and Controversy

How do we define normality? This question has raised many other questions about the validity of such manuals, particularly the DSM-IV. The clinical approach towards all aspects of mental health, even cultural-related problems, is discussed by many mental health professionals as invalid because it attempts to label individuals based on a set of symptoms which could derive from various conditions. There is also the argument that the DSM-IV focuses only on the negative aspects of individual behaviour, failing to consider the positive aspects and therefore being unable to create a balance which would recognise the inexistence of a 'diagnosing' condition.

Such issues regarding normality, diversity and cultural labeling have also been recently discussed in the 'Meeting of Minds' and it is a common topic amongst behavioural professionals. Furthermore, there is a polemic discussion around the underlying economic benefits of maintaining the standards of both manuals. The DSM-IV is commonly used by doctors in order to provide a diagnosis, and some health insurance companies will only refund patients that can provide a numerical code based on the ICD and a written description derived from the DSM.

In the other hand, the historical development of both manuals has proved that they are responsive to the development of mental health disciplines and societal needs. Perhaps in the following decades or editions, they could experience improvements that would cater for the current issues which are discussed by professionals, or conversely the way by which mental health is managed today could be modified. The reality is that most of those questions are still without answers and which have to remain that mode in the foreseeable future.

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