June 14, 2005Snake Phobias, Moodiness and a Battle in PsychiatryBy BENEDICT CAREYA college student becomes so compulsive about cleaning his dorm room that his grades begin to slip. An executive living in New York has amortal fear of snakes but lives in Manhattan and rarely goes outside the city where he might encounter one. A computer technician, deeplyanxious around strangers, avoids social and company gatherings and is passed over for promotion.Are these people mentally ill?In a report released last week, researchers estimated that more than half of Americans would develop mental disorders in their lives, raisingquestions about where mental health ends and illness begins.In fact, psychiatrists have no good answer, and the boundary between mental illness and normal mental struggle has become a battle line dividingthe profession into two viscerally opposed camps.On one side are doctors who say that the definition of mental illness should be broad enough to include mild conditions, which can make peoplemiserable and often lead to more severe problems later.On the other are experts who say that the current definitions should be tightened to ensure that limited resources go to those who need them themost and to preserve the profession's credibility with a public that often scoffs at claims that large numbers of Americans have mental disorders.The question is not just philosophical: where psychiatrists draw the line may determine not only the willingness of insurers to pay for services, butthe future of research on moderate and mild mental disorders. Directly and indirectly, it will also shape the decisions of millions of people whoagonize over whether they or their loved ones are in need of help, merely eccentric or dealing with ordinary life struggles."This argument is heating up right now," said Dr. Darrel Regier, director of research at the American Psychiatric Association, "because we're inthe process of revising the diagnostic manual," the catalog of mental disorders on which research, treatment and the profession itself are based.The next edition of the manual is expected to appear in 2010 or 2011, "and there's going continued debate in the scientific community about whatthe cut-points of clinical disease are," Dr. Regier said.Psychiatrists have been searching for more than a century for some biological marker for mental disease, to little avail. Although there ispromising work in genetics and brain imaging, researchers are not likely to have anything resembling a blood test for a mental illness soon,leaving them with what they have always had: observations of behavior, and patients' answers to questions about how they feel and how severetheir condition is.Severity is at the core of the debate. Are slumps in mood bad enough to make someone miss work? Does anxiety over social situations disruptfriendships and play havoc with romantic relationships?Insurers have long incorporated severity measures in decisions about what to cover. Dr. Alex Rodriguez, chief medical officer for behavioralhealth at Magellan Health Services, the country's largest managed mental health insurer, said that Magellan used several standardized tests to ratehow much a problem is interfering with someone's life. The company is developing its own scale to track how well people function. "This is atool that would allow the therapist to monitor a patient's progress from session to session," he said.Although the current edition of the American Psychiatric Association's catalog of mental disorders includes severity as a part of diagnosis, someexperts say these measures are not tough or specific enough.Dr. Stuart Kirk, a professor of social welfare at the University of California, Los Angeles, who has been critical of the manual, gives examples ofwhat could, under the current diagnostic guidelines, qualify as a substance abuse disorder: a college student who every month or so drinks toomuch beer on Sunday night and misses his chemistry class at 8 a.m. Monday, lowering his grade; or a middle-aged professional who smokes ajoint now and then drives to a restaurant, risking arrest."Although perhaps representing bad judgment," Dr. Kirk wrote in an e-mail message, these cases "would not be seen by most people as validexamples of mental illness, and they shouldn't be because they represent no underlying, internal, pathological mental state."Separating the heavies from the lightweights - by asking, say, "Did you ever go to a doctor for your problem, or talk to anyone about it?" - has asignificant effect on who counts as mentally impaired.After researchers reported in a large national survey in 1994 that 30 percent of Americans adults had a mental illness in the past year, Dr. Regierand others reanalyzed the data, taking into account whether people had reported their mental troubles to a therapist or friend, had receivedtreatment or had taken other actions.They found that the number of people who qualified for a diagnosis of mental illness in the previous year plunged to 20 percent over all; rates ofsome disorders dropped by a third to half.But limiting the count to those who have taken action does not give an accurate picture of the extent of illness, argue other researchers, who havebeen sharply critical of efforts to drive down prevalence estimates.Dr. Robert Spitzer, a professor of psychiatry at Columbia University and the principal architect of the third edition of the diagnostic manual,wrote in a letter to The Archives of Psychiatry, "Many physical disorders are often transient and mild and may not require treatment (e.g. acuteviral infections or low back syndrome). It would be absurd to recognize such conditions only when treatment was indicated."He added, "Let us not revise diagnostic criteria that help us make clinically valid standard diagnoses in order to make community prevalence dataeasier to justify to a skeptical public."Dr. Ronald Kessler, a professor of health care policy at Harvard and the lead author of the 1994 survey and the nationwide survey released lastweek, said squeezing diagnoses so that many mild cases drop out could blind the profession to a group of people it should be paying moreattention to, not less."We know that there are prodromes, states that put people at higher risk, like hypertension for heart disease, which doctors treat," he said. "Youcan call these milder mental conditions what you want, and you may decide to treat them or not, but if you don't identify them they fall off