Mental illness in college students: Overdiagnosed

The New York Times ran an article in December about the declining mental health of college students. The focus of the article was actually on how difficult it is for understaffed counseling centers to cope, but the problem was framed with some disturbing statistics: “44 percent [of students] in counseling have severe psychological disorders, up from 16 percent in 2000, and 24 percent are on psychiatric medication, up from 17 percent a decade ago.”

The article offered two possible explanations for these statistics: More students are able to attend college because effective psychiatric medicine is available and/or counselors are now better at recognizing a serious illness than they used to be.

Experts say the trend is partly linked to effective psychotropic drugs (Wellbutrin for depression, Adderall for attention disorder, Abilify for bipolar disorder) that have allowed students to attend college who otherwise might not have functioned in a campus setting.

There is also greater awareness of traumas scarcely recognized a generation ago and a willingness to seek help for those problems, including bulimia, self-cutting and childhood sexual abuse.

Low symptom criteria, DTC advertising, too many drug reps

I wrote about this in December and was skeptical, especially about the first explanation. Allen Frances – head of the task force that created the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and a vocal critic of the upcoming DSM-5 – now offers a third, more plausible explanation: Overdiagnosis. (emphasis added)

The sudden exploding rate of “severe” psychiatric illness on campus is most likely caused by overdiagnosis– not by a decline in the mental health of the college students. … In retrospect, it seems clear that the severity and duration requirements [of symptoms] included in DSM-IV were set too low, particularly in the criteria sets that define the milder forms of the depressive, anxiety, and attention deficit disorders. These border upon, and are difficult to distinguish from, the commonly encountered and expectable everyday aches, pains, sufferings, and performance problems that are an inherent part of college life. Not all difficulty is disorder.

Direct-to-consumer advertising, designed to convince viewers they have an illness that can be medicated, plus the huge sums of money drug companies spend encouraging doctors to write prescriptions, also contribute to overdiagnosis. The result is not without negative consequences.

Medication prescribed for milder conditions has little superiority over placebo and adds the risks of side effects and complications. Then there is the stigma of having a psychiatric disorder, its possible impact on job and marital prospects, and in getting insurance. To say nothing about the way a falsely diagnosed student sees himself at a crucial moment of identity formation– the reduction in the sense of personal efficacy, resilience, and responsibility. Finally, the ready availability of stimulant drugs used to treat attention deficit disorder has encouraged the growth on college campuses of a large secondary illegal market, supplying pills for recreation and performance enhancement

As Frances concludes, human beings don’t change all that rapidly. It’s medical diagnoses that are subject to fashion, fads, and the manipulation of market forces.

Resources:

Image: The Mirror

Allen Frances, Are College Students Getting Sicker? No, Diagnoses Change Faster Than People, Psychiatric Times, January 11, 2011

Trip Gabriel, Mental Health Needs Seen Growing at Colleges, The New York Times, December 29, 2010