Citation: The PLOS Medicine Editors (2013) The Paradox of Mental Health: Over-Treatment and Under-Recognition. PLoS Med 10(5): e1001456. doi:10.1371/journal.pmed.1001456
Published: May 28, 2013
Copyright: © 2013 PLoS Medicine Editors. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The authors are each paid a salary by the Public Library of Science, and they wrote this editorial during their salaried time.
Competing interests: The authors' individual competing interests are at http://www.plosmedicine.org/static/editorsInterests.action. PLOS is funded partly through manuscript publication charges, but the PLOS Medicine Editors are paid a fixed salary (their salary is not linked to the number of papers published in the journal).
Abbreviations: ADHD, attention deficit hyperactivity disorders; LMIC, low- and middle-income country
Provenance: Written by editorial staff; not externally peer reviewed.
Among all the conditions in the world of health, mental health occupies a unique and paradoxical place.
On the one hand is over-treatment and over-medicalization of mental health issues, often fueled by a pharmaceutical industry interested in the broadening of the boundaries of “illness” and in the creation of more and wider diagnostic categories and thus markets for “selling sickness.” On the other hand exists profound under-recognition of the suffering and breadth of mental health issues affecting millions of people across geographies, which is a global problem.
As a journal, PLOS Medicine has covered both sides of the mental health “coin,” and we continue to make mental health in general a priority area. We recognize that the whole of the field of mental health research is relatively underdeveloped, and that a particular scarcity of clinical trials exists from outside high-income settings and for non-drug interventions. As a result, we also support efforts to improve capacity in mental health research whilst committing to the publication of the state of the art in research and commentary ,.
Over-treatment, especially when it results from “disease mongering,” is a persistent and troubling issue. The harms of over-treatment arise from situations where normal life experiences (such as menopause, shyness, grief, etc.) are deemed illnesses  or when diseases are “created” from mild problems and symptoms (such as restless legs syndrome or female sexual dysfunction) ,. In both situations, people become patients, and their problems are deemed to need medical treatment when they may not need it or could be harmed by it, or when nonmedical options are available. Over-diagnosis and over-treatment have been shown for a range of human conditions , but this phenomenon as it relates to mental health is particularly powerful . For example, the widespread over-diagnosis of conditions such as bipolar disorder, autism spectrum disorder, and attention deficit hyperactivity disorders (ADHD), especially among children, is now being documented—the US Centers for Disease Control recently estimated that 6.4 million children aged 4 to 17 had received an ADHD diagnosis at some point in their lives (amounting to 11% of all US children)—a 41% increase in the last decade that has been met with alarm and concern by many doctors and parents . Two thirds of these children are said to be on medication for the condition. Recent Canadian data  reaffirm the concerns with excessive labeling of normal child behavior as pathological. Over-diagnosis in mental health risks unnecessary tests and treatment, the stigma associated with being labeled mentally ill, and the considerable costs of testing, treatment, and wasting resources that could be better utilized elsewhere ,.
The recent DSM-5 process is a lightning rod for these concerns: this month's update of the psychiatric diagnostic manual has been widely criticized for continuing the tradition of broadening diagnostic categories and adding new conditions that redefine more people as having mental illness and in need of pharmaceutical treatment ,. That decisions about DSM-5 categories are made by experts with financial ties to the industry that benefits most from a widened patient population ,, is particularly worrying.
In perhaps the most dedicated venue for discussions of this topic, the Selling Sickness conferences (http://www.sellingsickness.com), which PLOS Medicine has been instrumental in shaping, have brought together academic researchers, medical reformers, consumer advocates, and health journalists with shared interests in examining the problem of disease mongering and developing strategies and coalitions for change. The inaugural conference in 2006 coincided with our launch of the PLOS Medicine Disease Mongering Collection (http://bit.ly/18i6j6h) that to this day remains astonishingly relevant. In February 2013 we participated again, this time in a roundtable on the role of the medical media where we outlined our responsibility as editors to avoid the spin in published articles and the journal's press releases that can fuel hype about new disease categories and treatment ; we also highlighted another important role of journals in fighting disease mongering: to require that all clinical trials be registered and data be reported and shared, so that the full picture of the benefits and harms of tested interventions can be seen (see, for example, http://www.alltrials.net). The conference's Call to Action petition (http://sellingsickness.com/final-statement/) is available for readers to view and sign. Later in 2013, two comrade conferences, PharmedOut (http://www.pharmedout.org/) and Avoiding Overdiagnosis (http://www.preventingoverdiagnosis.net/), will continue the conversation about both the extent and the prevention of over-diagnosis, and will undoubtedly provide new insights into the problems associated with over-treatment of mental health.
Equally important, however, is the vast under-recognition of mental health conditions, especially in the developing world. This neglect has occurred at multiple levels including at the national level, where many countries have failed to establish adequate mental health policy. At the level of global health agendas, mental health was essentially ignored in the Millennium Development Goal program and failed to elevate to prominence at the recent United Nations special assembly on non-communicable disease.
As many others have noted –, this neglect makes little sense: more than 13% of the global burden of disease is attributable to neuropsychiatric disorders, and over 70% of this burden lies in low- and middle-income countries (LMICs). Almost a quarter of the world's disability burden is now attributable to mental and behavioral disorders (including depression, anxiety, Alzheimer disease, and schizophrenia) . And yet mental health has failed thus far to receive the political priority and international funding commensurate with its global toll . There are signs this tide is shifting, and several prominent groups and organizations are working to raise the profile of global mental health. PLOS Medicine has provided a forum for that effort over the last few years, publishing packages of care for mental health disorders in LMICs  and an ongoing series on mental health interventions in practice . And this week we conclude a five-part series that sets out an agenda for integrating mental health care into primary care, maternal health, non-communicable disease, and HIV interventions in the developing world . All of these analyses were done by researchers free of financial links to manufacturers with a stake in expanded markets, thus providing the necessary independent opinion.
In addition, we've recently published high-quality research on a range of topics within mental health that contributes to improved clinical practice, policy, and action. This includes definitive evidence on the long-term health consequences of sexual abuse  and trafficking , a genome-wide analysis establishing the limited ability of genetic data to predict antidepressant response , and a meta-analysis reporting the relative benefits and harms of adjunctive antipsychotic medications in depression . These studies add to a growing evidence base, and signal a growing recognition of the importance of mental health.
Still, our understanding of all aspects of mental health is relatively underdeveloped. As others have acknowledged ,, the research base for over-diagnosis and harm from over-treatment remains limited, and so the new initiatives and calls for action are welcomed. So too is growing recognition and research on genuine mental health issues and the best ways to address and prevent mental health problems, especially in terms of policy and human rights action and in a global context. To the extent that these two areas (over-treatment on one hand, under-recognition on the other hand) represent the paradox of mental health, where's the balance point? We don't have all the answers, but as a journal we reaffirm our commitment to publishing rigorous, insightful research and commentary on the breadth of issues around global mental health, and we welcome continued debate on the challenges this paradox represents. The largest challenge may be to recognize and prioritize mental health globally—with the requisite political visibility, funding, research, and attention—without reducing it to an object for disease mongering, pathologizing, and harmful over-treatment.
Wrote the first draft of the manuscript: JC. Contributed to the writing of the manuscript: JC PS MW LC AR. ICMJE criteria for authorship read and met: JC PS MW LC AR. Agree with manuscript results and conclusions: JC PS MW LC AR.
- 1. The PLOS Medicine Editors (2012) Addressing Global Disparities in the Burden of Noncommunicable Diseases: Call for Papers. PLoS Med 9(12): e1001360 doi:10.1371/journal.pmed.1001360.
- 2. Patel V, Jenkins R, Lund C (2012) the PLoS Medicine Editors (2012) Putting Evidence into Practice: The PLoS Medicine Series on Global Mental Health Practice. PLoS Med 9(5): e1001226 doi:10.1371/journal.pmed.1001226.
- 3. Moynihan R, Doust J, Henry D (2012) Preventing overdiagnosis: how to stop harming the healthy. BMJ 344: e3502. doi: 10.1136/bmj.e3502
- 4. Woloshin S, Schwartz LM (2006) Giving Legs to Restless Legs: A Case Study of How the Media Helps Make People Sick. PLoS Med 3(4): e170 doi:10.1371/journal.pmed.0030170.
- 5. Tiefer L (2006) Female Sexual Dysfunction: A Case Study of Disease Mongering and Activist Resistance. PLoS Med 3(4): e178 doi:10.1371/journal.pmed.0030178.
- 6. Angell M (14 July 2011) The Illusions of Psychiatry. The New York Review of Books. Available: http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry/?pagination=false. Accessed 27 March 2012.
- 7. Schwarz A, Cohen S (1 April 2013) A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise. The New York Times. Available: http://www.nytimes.com/2013/04/01/health/more-diagnoses-of-hyperactivity-causing-concern.html. Accessed 6 May 2013.
- 8. Morrow R, Garland E, Wright J, Maclure M, Taylor S, et al. (2012) Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children. CMAJ 184: 755–762. doi: 10.1503/cmaj.111619
- 9. Rosenberg RS (12 April 2013) Abnormal Is the New Normal: Why will half of the U.S. population have a diagnosable mental disorder? Slate Magazine. Available: http://www.slate.com/articles/health_and_science/medical_examiner/2013/04/diagnostic_and_statistical_manual_fifth_edition_why_will_half_the_u_s_population.html. Accessed 6 May 2013.
- 10. Crocker L (11 April 2013) DSM-V: Hoarding, Binge Eating & More New Mental-Disorder Diagnoses. The Daily Beast. Available: http://www.thedailybeast.com/articles/2013/04/11/dsm-v-hoarding-binge-eating-more-new-mental-disorder-diagnoses.html. Accessed 6 May 2013.
- 11. Cosgrove L, Krimsky S (2012) A Comparison of DSM-IV and DSM-5 Panel Members' Financial Associations with Industry: A Pernicious Problem Persists. PLoS Med 9(3): e1001190 doi:10.1371/journal.pmed.1001190.
- 12. The PLoS Medicine Editors (2012) Does Conflict of Interest Disclosure Worsen Bias? PLoS Med 9(4): e1001210 doi:10.1371/journal.pmed.1001210.
- 13. Yavchitz A, Boutron I, Bafeta A, Marroun I, Charles P, et al. (2012) Misrepresentation of Randomized Controlled Trials in Press Releases and News Coverage: A Cohort Study. PLoS Med 9(9): e1001308 doi:10.1371/journal.pmed.1001308.
- 14. Tomlinson M, Lund C (2012) Why Does Mental Health Not Get the Attention It Deserves? An Application of the Shiffman and Smith Framework. PLoS Med 9(2): e1001178 doi:10.1371/journal.pmed.1001178.
- 15. Bass JK, Bornemann TH, Burkey M, Chehil S, Chen L, et al. (2012) A United Nations General Assembly Special Session for Mental, Neurological, and Substance Use Disorders: The Time Has Come. PLoS Med 9(1): e1001159 doi:10.1371/journal.pmed.1001159.
- 16. Collins PY, Patel V, Joestl SS, March D, Insel TR, et al. (2011) Grand challenges in global mental health. Nature 475: 27–30. doi: 10.1038/475027a
- 17. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, et al. (2012) Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 380: 2197–2223. doi: 10.1016/S0140-6736(12)61689-4
- 18. Patel V, Thornicroft G (2009) Packages of care for mental, neurological, and substance use disorders in low- and middle-income countries: PLoS Medicine series. PLoS Med 6: e1000160 doi:10.1371/journal.pmed.1000160.
- 19. Patel V, Belkin GS, Chockalingam A, Cooper J, Saxena S, et al. (2013) Integrating Mental Health Services into Priority Health Care Platforms: Addressing a Grand Challenge in Global Mental Health. PLoS Med 10(5): e1001448 doi:10.1371/journal.pmed.1001448.
- 20. Norman RE, Byambaa M, De R, Butchart A, Scott J, et al. (2012) The Long-Term Health Consequences of Child Physical Abuse, Emotional Abuse, and Neglect: A Systematic Review and Meta-Analysis. PLoS Med 9(11): e1001349 doi:10.1371/journal.pmed.1001349.
- 21. Oram S, Stöckl H, Busza J, Howard LM, Zimmerman C (2012) Prevalence and Risk of Violence and the Physical, Mental, and Sexual Health Problems Associated with Human Trafficking: Systematic Review. PLoS Med 9(5): e1001224 doi:10.1371/journal.pmed.1001224.
- 22. Tansey KE, Guipponi M, Perroud N, Bondolfi G, Domenici E, et al. (2012) Genetic Predictors of Response to Serotonergic and Noradrenergic Antidepressants in Major Depressive Disorder: A Genome-Wide Analysis of Individual-Level Data and a Meta-Analysis. PLoS Med 9(10): e1001326 doi:10.1371/journal.pmed.1001326.
- 23. Spielmans GI, Berman MI, Linardatos E, Rosenlicht NZ, Perry A, et al. (2013) Adjunctive Atypical Antipsychotic Treatment for Major Depressive Disorder: A Meta-Analysis of Depression, Quality of Life, and Safety Outcomes. PLoS Med 10(3): e1001403 doi:10.1371/journal.pmed.1001403.
- 24. Moynihan R, Henry D (2006) The Fight against Disease Mongering: Generating Knowledge for Action. PLoS Med 3(4): e191 doi:10.1371/journal.pmed.0030191.