More people than ever are being diagnosed with cancer, dementia, hypertension, anxiety, autism, ADHD and the list goes on. Mental health diagnoses are growing at a rate we have not witnessed before: one in five children in the UK has a mental health diagnosis. Are we getting sicker or just getting better at recognising medical problems?
Suzanne O’Sulliavn isn’t sure. O’Sullivan is a neurologist with more than three decades of clinical experience behind her. She is the author of the award-winning It’s All in Your Head and in her latest book The Age of Diagnosis, she is asking tough, timely, sensitive and contentious questions. The thread that weaves through this provocative contemplation on modern medicine is this: are diagnoses doing more harm than good?
O’Sullivan tactfully grapples with the question about us getting sicker or getting better at recognising medical problems in a poised and skilful manner and offers a third possibility to account for the astonishing rise in diagnosis. She wonders whether borderline medical problems are becoming ironclad in diagnosis and if ordinary life experiences are being pathologised. Are bodily imperfections, sadness, social anxiety, normal life stage changes becoming “biologised” and are we “becoming victims of too much medicine and is it time to turn back the clock?”.
She refers to this phenomenon as “overmedicalisation”; where everyday ordinary human suffering, that is inherent and universal to the human condition, is given medical labels and turned into the “business of doctors”: like telling immature or socially anxious children that they have a neurodevelopmental brain disorder, for example.
O’Sullivan deftly describes another phenomenon called “diagnostic creep” as a process of over-diagnosis, where the dividing line between normal and abnormal slowly shifts so that over time people who were once considered healthy and normal are now drawn into the unhealthy and abnormal group.
It is unwise of course to consider “diagnostic creep” in the absence of a medical and wider societal culture that seems increasingly preoccupied by “missed diagnosis” and all that an apparent missed diagnosis unleashes for all those involved. O’Sullivan generously concludes that “Over diagnosis and over medicalisation usually arise out of good intentions, but also out of presumed truths that have not been tested”.
Many of us might assume that a diagnosis is definitive and impartial, derived in an empirical, scientific manner. O’Sullivan rattles this cage of impartial empiricism by claiming that most diagnoses are qualitative in nature: making them open to uncertainties, mistakes and exploitation. She describes diagnosis as a “clinical art”, which is inherently intuitive and heavily reliant on a doctor’s interpretation.
O’Sullivan also describes some of the wider non-scientific influences on diagnosis and what are now considered legitimate medical conditions. For example the term “neurodivergent” was actually coined by a sociologist and Long Covid is a diagnosis developed from patient activism, beginning as a hashtag on social media.
Adopting a bold and counterintuitive position concerning the benefits of early diagnosis is further testament to O’Sullivan’s independence of thought and capacity to question received wisdom. She claims that warning people of future disease that cannot be changed may rob them of their healthy years. O’Sullivan asserts that over-detection is happening where new technologies and increasingly sensitive screening programmes are used to detect milder forms of disease earlier until people are undergoing treatment they never really needed.
An accurate diagnosis can for many people be a lifesaver: physically and psychologically. It can transform the trajectory of an illness, can diminish the burden of loneliness and isolation that living with an army of unexplained symptoms can inflict on an individual. A diagnosis can also be a passport to health and social care services that otherwise would be denied to the individual and their dependents. Regrettably, this dependency on a diagnosis for health and social care services is in itself an issue of paramount importance that does not receive the interrogation it warrants by O’Sullivan.
Nonetheless O’Sullivan is raising a timely, sensitive and contentious question: are diagnoses doing more harm than good? This question provokes widespread reactivity across the patient advocacy groups and the medical establishment divide.
O’Sullivan does not shy away from uncomfortable questions. She digs deeper and asks a moral question, a question that blurs the dichotomous line between liberal and conservative approaches to public expenditure. By widening the criteria for a medical condition are we diverting resources away from those most in need, from those on the most severe end of the spectrum? She does not attempt to offer simple answers to complex problems, and this to my mind is further testament to her integrity.
This is a brave, considered, provocative and absorbing read, further testament to O’Sullivan’s skills as a very fine science communicator. O’Sullivan is addressing issues that most of us will have encountered, many of us wondered about, and some of us quietly questioned. She is addressing contentious issues surrounded by heavily vested interest groups on all sides with rigour, humanity and great clarity and does all of this from inside the tent: she is a medical doctor with a long career at the clinical coalface. This to my mind enhances the legitimacy, credibility and urgency of the questions she raises.
Alastair Santhouse is a consultant neuropsychiatrist at the Maudsley Hospital in London and a fellow of both the Royal College of Psychiatrists and the Royal College of Physicians. He is asking whether we have gone too far with medical diagnosis, and in doing so are we attempting to hollow out the rich complexity and contradictions that are inherent in being human?
Santhouse, like O’Sullivan, is raising concerns about the record levels of mental illness rates and the resulting public health crisis that cannot continue to be ignored. However, he is not calling for an immediate increase in mental health budgets, or rapid access to psychiatric services. He is instead calling for a radical rethink of mental health and more importantly what the jurisdiction of mainstream psychiatry should be.
In No More Normal, Mental Health in an Age of Over-Diagnosis, Santhouse attempts to unpack the upstream causes and consequences of burgeoning diagnosis of mental illness. He does this through a provocative, accessible and engaging reflection on the cultural moment that we are living through; the flattening of hierarchies, the democratisation of knowledge and the consumerisation of healthcare.
Santhouse critiques the resulting cultural backdrop, fuelled in no small part by the persistent wellness industry, which extols that personal happiness, multilevel life fulfilment and contentment are legitimate expectations and an entitlement as a 21st-century people. If we are falling short in our perceived quota of personal happiness, professional success, fulfilling relationships, work-life balance and contentment, are we really unwell or abnormal?
Santhouse asserts that at the heart of such a cultural backdrop is a radical alteration of what we consider to be “normal” and that the concept of “normal” is shifting. In such a context, low mood is turning into depression, an upsetting experience is turning into a trauma, and everyday worry and anticipation are turning into anxiety. He says of this: “Antidepressants cannot treat the weight of the 21st century and its inequalities, nor can they treat thwarted ambition or messy, unfulfilled loves”.
According to Santhouse, psychiatric categorisation has left the consultation room and entered the public arena and this has influenced the climate in which mental health and illness are thought about and experienced. Santhouse makes the point that this is not an entirely unwelcome development: it reflects the lessening of stigma associated with mental health, and suggests a more mature and compassionate, progressive and kinder society.
However, Santhouse suggests such a climate has two significant downsides: it inadvertently medicalises the trials and tribulations inherent in human existence and it also has significant resource implications. Calling out the impact of the de-stigmatisation and democratisation of mental health is to my mind an abiding strength of this book. Santhouse is naming this powerful cultural phenomenon of which we are both beneficiaries and victims.
At the heart of No More Normal is the uncomfortable moral question: does the cultural shift in our understanding of mental health and the democratisation of mental health result in serious mental health difficulties such as schizophrenia and bipolar disorder being overlooked in the “avalanche of new mental health concerns and by medicalising everyday experiences”? This moral conundrum is one we cannot continue to shy away from. The consequences are too numerous and too painful to ignore.
I have reservations about Santhouse’s reliance on the word normal. There are painful legacy issues that surround the word. To some extent the topics under Santhouse’s microscope are a reaction to the historical use and implications of the word normal by dominant social groups down through the centuries. For many victims of such a tyranny of normal, the word itself understandably elicits suspicion and fear.
In the final chapter Santhouse, with great humility and tenderness, offers something of an answer to the many questions raised. He deals with grief being subject to medical reductionism: the medicalisation of grief being an example of the spiritual, ephemeral aspects of human life that are being subjected to the intrusions of diagnostically bureaucratic classification into everyday life. He concludes that “the involvement of psychiatry in grief feels largely unnecessary from a practical point of view, but also more fundamentally. To grieve the loss of someone you have known and loved is a normal response.”
This encapsulates the issue that Santhouse circles throughout this book: mainstream psychiatry is at a crossroads and needs to make a choice concerning its jurisdiction. He unpacks some of this when describing the ever expanding lexicon of psychiatric diagnosis contained in the Diagnostic and Statistical Manual (DSM). The DSM is the text psychiatrists turn to when diagnosing mental health problems. The number of psychiatric diagnoses you can suffer from has quadrupled in the past 70 years.
This resonates with what Ireland’s former inspector of mental health services, consultant psychiatrist Patrick Devitt, has asserted. He called for mainstream psychiatry to focus on what he describes as the Big Five: schizophrenia, bipolar, severe depression, severe anxiety and severe personality disorders. The remaining trials and tribulations that make up the rich complexity and contradictions inherent in being human should not be the business of doctors.
Santhouse and O’Sullivan are asking important questions, their respective books are making a time-sensitive contribution to issues of immense public impact and interest. One area that deserves more attention from both authors is the role played by medical insurance in the burgeoning rate of diagnosis. In an insurance-driven medical landscape, both doctors and patients can be affected by the need for a formal diagnosis to ensure financial reimbursement for the provision of care. In part, this is an understandable omission, given that both authors are doctors working in publicly funded healthcare systems. However, they do not adequately address the role private insurance plays in overdiagnosis and in no more normal.
Paul D’Alton is a clinical psychologist and associate professor of psychology at UCD
