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- jansenist_drugstore posted Oppression in Mental Health Diagnosis (10 posts)
- There has been plenty of well-written controversy about the five different iterations of the Diagnostic Statistical Manual of Mental Disorders (DSM), and the revisions in its most recent version, the DSM-V, have been especially criticized. On the one hand, diagnoses can provide opportunities for people to make meaning and sense of their experiences with emotional unwellness/mental illness, but on the other, the diagnostic procedure (and the research that backs it) is exploitative, oppressive and reductive.
Many people have already illustrated that, as a tool, the DSM is a means to generate serious revenue for pharmaceutical companies and its criminally-moneyed task force. There have been endless reports of financial conflicts of interest, hushed formations of various corporations, and millions of dollars poured into research that only seems to go toward swelling the salaries of the people developing the “empirical, evidence-based” diagnostic screening tools and treatments (1). A 2012 report shared that at least 70% of the scum on the DSM-V task force work as advocates and salespeople for pharmaceutical companies. A major problem with this is that 66% of mood disorders, 83% of psychotic disorders and 100% of sleep disorders in the manual call for drugs as an initial treatment plan (2, 3). An example of this is David Kupfer, the chairman of the task force, who is coincidentally the director of Minerva Neurosciences, a pharmaceutical/diagnostic company worth 309.9 million dollars, that develops screening measures and drug interventions for schizophrenia, depression, Parkinson’s, and so on.
Further, each time a diagnostic criteria is revised, it requires a new way to screen for it. For depression and anxiety disorders (currently two of the highest reported diagnoses), the diagnostic criteria has broadened with each edition of the manual. The result has been that the methods of diagnosis have also broadened to the point of sheer confusion, and are released quickly without too much validation or clarity, but with endless trust in the experts who determine what’s what (4, 5). The most common diagnostic method for Major Depressive Disorder in children is called the PHQ-9; for Generalized Anxiety Disorder, the standard screen for kids is the GAD-7. On the PHQ-9, you only have to score a 5/27 to be diagnosed (9 questions worth a max. of 3 points each), and the GAD-7 requires a score of 5/21 to be diagnosed (7 questions worth a max. of 3 points each). Sure, the diagnosis would be considered “mild” but the non-specialized, lazy general practitioner doing the assessment still believes that medications are the best treatment, often only because a pharma rep told them so. Also, the diagnosis can be made if the the child OR the parent OR the practitioner observe behaviors that yield positive endorsement to any of the questions. That means that pretty much anyone in a child’s life can decide which kid is depressed, which is anxious, and which is normal. This is a good explanation as to why the fuck there are 2,100,315 children on antidepressants, 1,194,805 children on antipsychotics, 1,445,509 children on anti-anxiety meds, and 3,655,472 children on ADHD meds (roughly 1 in 10 kids in total) in amerika as of 2017 (6). One of the major contributors to earlier editions of the DSM, R.L. Spitzer (now thankfully dead), infamously published extensive and heavily-funded research exploring the “efficacy” in “reparative 'conversion' therapy” (trying to change one’s sexual orientation from gay to straight), also happens to be one of the primary people that developed and profited from both of PHQ-9 and the GAD-7.
What I would like to address here is how these broadened diagnostic criteria have become a way to profile and oppress the poor, rather than successfully treat mental illness. There has been plenty of research that points to higher rates of mental disorder in low income areas, but not so much research as to how the ever-widening net of diagnostic methods are correlative to those results. It hardly needs to be said that people who are over-policed, underfed, under-served, socially oppressed and stereotyped, and cut off from tenable options for work, housing and opportunity experience lower quality of life than people who don’t need to think about struggles of daily living beyond being five minutes late for their SoulCycle class or running out of K-Cups faster than you can say “Alexa”. Previous research falls short of adequately capturing the relationship between income status and mental wellness in that it passes over contemporary cultural beliefs about behavior and the historical implications of standardized behavior, including the indirect symptomatization of poverty itself (7). This, to me, seems very different than attempting to make sense of the ways that our systems have completely deprived and destroyed entire communities from the outset.
Diagnosis is rooted in a belief in abnormality of behavior, thought processes, emotionality, etc. This would be somewhat acceptable if the criteria for mental and behavioral normalcy were identified in an ongoing, diverse, historically- and culturally-informed way, and if criteria were critiqued and adjusted based on the feedback of members of different income statuses, races, and cultures, but it could not be further away. Instead, what exists are long-standing, hatefully closed-off and reductive beliefs that normalcy, wellness and inherent human strengths = the behavior of the white upper class. These beliefs are continuously researched, funded, presented, and celebrated by the white upper class, and are subsequently taken as the golden standard for evaluating mental illness, so much so that most of the research that attempts to identify why there is a correlation between mental illness and poverty tends to haphazardly conclude that poverty causes mental illness. What this kind of research translates to in the real world of diagnosis is that poverty is mental illness. In the hospital that I work for, it is common for my colleagues to poke fun (behind closed doors, of course) at the behaviors and mentalities, even the word choices, of patients they know come from poor backgrounds/patients who are minorities. One (now-fired) supervisor particularly acknowledged/confessed diagnostic preconceptions just based on a person’s name if she thought it to be black. A 2011 study published by JAMA Psychiatric (edited by the above-mentioned David Kupfer), goes as far as saying that genetic patterning plays a role in mental health vis-a-vis income status. The author later makes one vague and hasty reference to genetic disposition in schizophrenia, but the reader is left to decide if the original meaning of genetic patterning is about xenophobic assumptions about racial genetics or neurological vulnerability. I took it to be the first, namely because the author originally described it as a hypothetical definition of “social selection” early in the article. Unsurprisingly, there is very scant research found regarding the differing treatment options across racial and ethnic differences, but one study reports that more white children receive mental health treatment than black/hispanic children, however attributes this almost exclusively to the reality that there just aren’t very many pediatric mental healthcare professionals serving low income neighborhoods (8). That said, the article also goes on to blame genetic differences based on race with adherence to treatment plans, which, for them, skew their data. Though, they admit that they are only hypothetically speculating when reporting this, and only cites one watery article related to different racial responses to medication for high blood pressure.
Moreover, understandings of what is considered standard, normal behavior arguably also increases fear and dread of being found to be abnormal, particularly for children. For under-served people, that distinction is already very clear as a result of media representation, gentrification, stereotypes, etc., and is further evidenced with the threat of conditions and diagnoses that they suddenly fall into because of the technocratic hierarchies of psychiatric medicine as a whole. ADHD diagnosis, the most commonly-diagnosed mental illness in children, is perhaps the most evident version of psychiatric imperialism: a 2015 study reporting on socioeconomic (SES) associations with ADHD reports that there are direct and indirect correlations between SES and ADHD, and that the lower the financial standing of a child’s family, the higher the probability that they will be diagnosed, while again, receiving less care overall (9). In upper-class families, many of the “symptomatic” behaviors that constitute an ADHD diagnosis have greater opportunity for creative/athletic supports like extracurriculars and educational support, while their poor counterparts are given messy and dangerous cocktails of medications, with frequent side-effects including stomach pain/nausea/vomiting, sleep disorder/insomnia, nervousness/intense fear, numbness/tingling, increased anxiety, weight loss, depression/suicidal ideation, irritability/aggression, absent-mindedness, facial tics, delayed growth/problems with childbirth and pregnancy, migraines, severe sedation, (........................................) in other words: a massive number of symptoms that are subsequently treated with other medications that continue to cause side-effects treated with other medications that cause a massive number of symptoms that are subsequently treated with other medications.
I believe that this standard of diagnosis transforms mental healthcare into a form of behavioral police force that punishes anyone who does not meet the standards of the profiteers who create the rules. Vague criteria and low-threshold for mental illness seriously blur the already-grey line of what is considered to be mental illness, especially for children in vulnerable circumstances. Simply put, the DSM does not and has never provided room to account for people of low SES or different cultural expectations of behavior and human well-being within amerika. Instead, it does and has always been a way to further exploit vulnerable populations by diminishing and quieting research that attempts to encourage multiplicity of thought and standard (see: index ratings of different medical journals). Additionally, many factors that prevent lower-income people from being fairly evaluated/treated (access to reliable transportation, reasonable health insurance, telephones and internet access, and time scarcity) have also shown to negatively influence provider perceptions of “adherence” to mental health plans, which results in bleak, lazy treatment options, discrimination of care in regards to scheduling priority and payment flexibility, and medication-first interventions. The DSM does not adequately take into account the challenges that impoverished people are forced to manage, yet makes it increasingly easy to reduce them even further into opportunity-deprived statistical entities. The DSM is not a successful attempt at a scientific language in classification, but rather one of quieting and isolating the alterity of the poor.
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