Miércoles 29 de Junio de 2005, Ip nº 115

Who's Mentally Ill? Deciding Is Often All in the Mind
Por BENEDICT CAREY

THE release last week of a government-sponsored survey, the most comprehensive to date, suggests that more than half of Americans will develop a mental disorder in their lives.

The study was the third, beginning in 1984, to suggest a significant increase in mental illness since the middle of the 20th century, when estimates of lifetime prevalence ranged closer 20 or 30 percent.

But what does it mean when more than half of a society may suffer "mental illness"? Is it an indictment of modern life or a sign of greater willingness to deal openly with a once-taboo subject? Or is it another example of the American mania to give every problem a name, a set of symptoms and a treatment - a trend, medical historians say, accentuated by drug marketing to doctors and patients?

Changes in societies over time, and differences across cultures, make it extremely difficult to compare prevalence levels of mental illness, even today. Levels of depression in China were thought to be very low, for example, until the Harvard anthropologist Dr. Arthur Kleinman found in the 1980's that many Chinese did not think or talk about mood disorders the way Westerners do. They came to doctors or healers with physical complaints - dizziness, headaches and other pains that were treated as such, though in many cases they could be diagnosed as depression. A World Health Organization survey published in 2004 found that 2.5 percent of Chinese reported a mood disorder in the last year, compared with a rate of 9.6 percent in the United States.

In Japan, too, reported levels of depression tend to be low - just over 3 percent reported a mood disorder in the last year, in the W.H.O. survey - in part because of a culture of stoicism, said Dr. Laurence Kirmayer, director of social and transcultural psychiatry at McGill University in Montreal. Depression, after all, is not one symptom but many, and in Japan there is strong cultural taboo against repeated, vague complaints.

In addition, said Dr. Margaret Lock, a professor of social studies in medicine at McGill, Japanese doctors tend to be attentive to men's complaints of mood problems, and dismissive of women's. The result: depression rates are higher in men than in women, the reverse of the United States and much of Europe.

But more than anything, historians and medical anthropologists said, the rise in the incidence of mental illness in America over recent decades reflects cultural and political shifts. "People have not changed biologically in the past 100 years," Dr. Kirmayer said, "but the culture, our understanding of mental illness" has changed.

That evolving understanding can have implications for diagnoses. For example, in 1973, the American Psychiatric Association dropped homosexuality from its manual of mental disorders, amid a growing realization that no evidence linked homosexuality to any mental impairment. Overnight, an estimated four to five million "sick" people became well.

More common, however, is for psychiatrists to add conditions and syndromes: The association's first diagnostic manual, published in 1952, included some 60 disorders, while the current edition now has about 300, including everything from sexual arousal disorders to kleptomania to hyposomnia (oversleeping) and several shades of bipolar disorder.

"The idea has been not to expand the number of people with mental conditions but to develop a more fine-grained understanding of those who do," said Dr. Ronald Kessler, a professor of health care policy at Harvard Medical School and lead author of the latest mental health survey.

But if contemporary trends, whether scientific or commercial, can serve to expand the franchise of mental illness, the mores, biases and scientific ignorance of previous centuries did much to hide it.

In the 18th and 19th centuries, doctors had far fewer words for mental impairment - madness, hysteria, melancholia - and estimated its incidence at somewhere around 5 percent to 10 percent, as far as historians can determine.

In some communities, the mentally ill were tolerated as holy fools or village idiots. The city of Geel, in Belgium, was particularly enlightened. There, in the 18th and 19th centuries, lunatics "could walk the streets, engage in commerce, they would deliver food, carry milk, they were incorporated into the society and respected," said Dr. Theodore Millon, director of the Institute for Advanced Studies in Personology and Psychopathology in Coral Gables, Fla., and author of a recent history of psychiatry and psychology, "Masters of the Mind."

But Geel was exceptional. More typical, Dr. Millon said, was for people considered mad or uncontrollable to be confined, sometimes in homemade chambers called lock boxes. They were captive, uncounted, beyond any hope of treatment, their stories lost to history.

The behavior of millions of others who were merely troubled, rebellious or moody was often understood - and veiled - in religious terms, said Dr. Nancy Tomes, a professor of medical history at the State University of New York in Stony Brook.

Gamblers and drinkers, the excessively impulsive or rebellious, the sexually promiscuous (especially women) were considered sinners, deviants or possessed. Conversely, those who denied themselves food or comfort, or who prayed or performed ritual cleansing repeatedly, often struck others as especially pious, Dr. Tomes said.

As science gradually displaced religion in the industrializing countries through the 19th century, such behavior was increasingly seen in secular, diagnostic terms, historians said. Excessive fasting became anorexia; ritualized behavior was understood as compulsive, or obsessive-compulsive.

"In some ways this is the story of the past century, the medicalization of many behaviors that once were seen in an entirely religious context," Dr. Tomes said.

Beyond that, some experts are convinced that modern life in the West - especially urban life - is more stressful than in earlier periods, and that the increased numbers of illnesses in the psychiatric association's diagnostic manual is a reflection of that fact.

Dr. Millon, who has served on panels to write and revise the manual, tells the story of borderline personality disorder. In the late 1970's, he was among a small group of psychiatrists and psychoanalysts who settled on the term "borderline" to mean people who fell somewhere between neurotic and psychotic.

Some doctors in the room hated the term; others liked it; several said it was meaningless. But after hours of debate, reversals of opinion and bruised egos, the diagnosis was born: borderline personality disorder, to describe a needy, scattered, uncertain self, or personality.

Borderline is now one of the most popular diagnoses in psychiatry, an umbrella term that covers a multitude of symptoms that all seem to point to a similar problem.

"This is seems to me a kind of diagnosis for our age, this complex, changing, fluid society in which young people are not allowed to internalize a coherent picture of who they are," Dr. Millon said. "There are too many options, too many choices, and there's a sense of, 'I don't know who I am - am I angry, am I contrite, happy, sad?' It's the scattered confusion of modern society."


  15/06/2005. The New York Times.