A recent study calculated that mental disorders topped the most costly conditions tied to health in the U.S., with total spending in 2013 reaching $201 billion. Published last month in Health Affairs, the study spurred reflection on how we define mental health and whether the parameters set by organizations such as the World Health Organization and American Psychiatric Association are overly broad, in ways helping to fuel overspending and overtreatment.
Mental health is an integral and essential component of health, but it is also notoriously difficult to define narrowly or universally. The WHO constitution aims to avoid controversy by putting the matter at its broadest: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” It defines mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”
On the basis of this capacious definition, with its emphasis on self-realization, stress-management, and optimal functioning, the organization signals that “the promotion, protection and restoration of mental health” should be “regarded as a vital concern of individuals, communities and societies throughout the world.” With the best intentions and an admirable focus on social justice and inclusion, the WHO stipulates that it is “vital to not only protect and promote the mental well-being of its citizens, but also address the needs of persons with defined mental disorders.”
Using a similar model and emphasis, the APA allowed the number of mental disorders officially recognized nationwide to almost double in just 26 years (1968-1994, with the publication of DSM-IV)—an expansion and a pace that exists “nowhere else in the history of medicine,” as David Healy noted in The Antidepressant Era (175). The organization’s second edition of its Diagnostic and Statistical Manual of Mental Disorders (1968) even included, under the category “Conditions without Manifest Psychiatric Disorder and Non-Specific Conditions,” “308: No Mental Disorder” (DSM-II, 13). A diagnosis for the undiagnosed or, simply, the not-yet diagnosable.
As anyone following the now-global debate about overdiagnosis, overmedication, and overtreatment could point out, however, overly broad definitions of mental disorders are very much part of the problem, leading to such recent (and alas predictable) findings that antidepressants, to take just one class of medication, are now widely prescribed for migraines, ADHD, menopause, and even digestive issues. Only last week, the FDA had to block a drug-maker from trying to market its antidepressant for “foggy thinking.” Meanwhile, to link to broader issues of health and medication, the nation is reeling from an opioid epidemic, fueled in part by aggressive—and illegal—marketing efforts that led to 245 million prescriptions for that and similar medication being filled in 2014 alone, an outcome, according to Bloomberg News, that created more than 2 million addicts nationwide today and continues to result in more than 20,000 deaths each year.
This clearly isn’t what the WHO has in mind when it declares, “There is a growing body of evidence demonstrating both the efficacy and cost-effectiveness of key interventions for priority mental disorders in countries at different levels of economic development.” Nevertheless, as others have observed, the idea that mental health could be held to a standard of “complete physical, mental and social well-being” makes overtreatment not just difficult to rule out, but all-but inevitable, given both the emphasis placed on optimal functioning and the desire by drug makers to assure that they have a range of products able to assist in just such functioning.
In “Toward a new definition of mental health,” published last summer in World Psychiatry, a group of European psychiatrists took issue with the WHO’s emphasis, pointing out that “people in good mental health are often sad, unwell, angry or unhappy, and this is part of a fully lived life for a human being.” Despite this truism, they continued, “mental health has been often conceptualized as a purely positive affect, marked by feelings of happiness and sense of mastery over the environment.”
Influenced heavily by “hedonic and eudaimonic traditions, which champion [respectively] positive emotions and excellence in functioning,” the WHO definition of mental health, according to the European group, “risks excluding most adolescents, many of whom are somewhat shy, those who fight against perceived injustice and inequalities or are discouraged from doing so after years of useless efforts, as well as migrants and minorities experiencing rejection and discrimination.”
They offer instead the following corrective:
Mental health is a dynamic state of internal equilibrium which enables individuals to use their abilities in harmony with universal values of society. Basic cognitive and social skills; ability to recognize, express and modulate one's own emotions, as well as empathize with others; flexibility and ability to cope with adverse life events and function in social roles; and harmonious relationship between body and mind represent important components of mental health which contribute, to varying degrees, to the state of internal equilibrium.
Certainly, this proposed revision avoids undue (and unrealistic) emphasis on positivity, as well as the occlusion of “negative” components of subjectivity that are, they note, unavoidable elements of being human. The revised definition is also sufficiently flexible to accommodate “the many challenging life situations in which well-being may even be unhealthy: most people would consider as mentally unhealthy an individual experiencing a state of well-being while killing several persons during a war action, and would regard as healthy a person feeling desperate after being fired from his/her job in a situation in which occupational opportunities are scarce.”
Yet the focus on “internal equilibrium,” “harmony with universal values of society,” and “harmonious relationship between body and mind” jettisons more than a century of psychoanalytic thought and clinical practice regarding the sheer impossibility of maintaining any of these elements without difficulty or duress. To mention just the most obvious treatise on this, Freud’s Civilization and Its Discontents (1929), the point made over and again about the difficulty—at times, undesirability—of that “harmony” with ostensibly “universal values of society” is that the ensuing malaise in each of us is structural rather than individually symptomatic. In this respect, Freud overturned a powerful, often coercive, and sometimes unethical insistence that individuals should always sacrifice and adapt their behavior for the greater good.
Written shortly before he was forced to flee Vienna because of National Socialism and its support for genocide, before more than a decade of totalitarianism and warfare devastated Europe, the Soviet Union, and parts of Asia, Freud’s still-relevant treatise captures as well how elusive our ability to forge—and maintain—“harmony with universal values” remains. Meanwhile, The Ego and the Id, his earlier study from 1923, serves as a cautionary reminder to those who would downplay the conflict arising from internal psychical divisions, which, again, are seen as structural consequences of selfhood—ones that can be so adversarial that Freud likens them to the ferocity of war.
The point is not to replace one form of idealism (consistent positive functioning) with another (equilibrium and internal/external harmony). Both are over the long-term unrealistic, unsustainable, and in different ways likely to heighten rather than reduce stress, to say nothing of overtreatment and ballooning healthcare costs. Mental health is of course much more than the absence of abnormality. But to equate it with harmony, equilibrium, and optimal positivity is to fall prey to another trap. In its idealism about psychical functioning, this revised focus is destined to increase the very suffering of those it is seeking to assist.