The redefinition of mental health

What's happened?

The American Psychiatric Association (APA) is revising its manual on diagnosing mental health. The new edition is known as DSM-5. Because mental illness has no physical markers, the manual attempts to define characteristics that patients share. The guidelines are used by most mental health professionals in America, the world's largest health market, to select treatment. It's a staple of America's $700bn-a-year health insurance industry, as several insurers will only pay for treatment if the disease is diagnosed by the guidelines.

Is there a problem with this?

More than 11,000 people have signed a petition against the update. Industry bodies, including the British Psychological Association and sub groups within the APA, criticise it. Concerns are that it will increase the number of people judged to be mentally ill.

DSM-5 introduces five new categories. It also lowers the threshold for diagnosing existing problems, such as attention deficit hyperactivity disorder (ADHD). "Many people who are shy, bereaved, eccentric, or have unconventional romantic lives will suddenly find themselves labelled as mentally ill," says Peter Kinderman, head of Liverpool University's Institute of Psychology. Campaigners also fear new diagnoses for sex abusers could allow offenders to escape prison sentences.

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This is all part of a wider trend. APA-registered classifications rose from 59 in 1917 to around 350 by 1994, mainly due to improved diagnoses.

But critics claim pressure from drug firms has played a part more patients mean more customers. Classifications make it easier to get insurers to pay for drugs. Close links between the APA and drugmakers have come under scrutiny. Big pharma's representatives sit on the APA's board and many of its members receive funding from pharmaceutical companies.

Members, including president Alan Schatzberg, were forced to relinquish duties after it emerged they concealed how much money drug firms gave them for research. Others held shares in firms producing new psychiatric drugs. Over half the APA's yearly $12m income comes from big pharma, while 56% of the DSM-5 panel have financial ties with drug firms.

So changes are necessary?

Allen Frances, who edited the 2000 update, says panel members are not "drug company shills", but that they don't realise that the manual is often "misused in actual practice". DSM-5 members called the proposals "hypotheses to be tested and disproved if the evidence isn't found to support them", making it more a mass experiment.

The APA also admitted that "a lot of this hasn't been tested as well as we would like". A previous panel member complained that "diagnoses were developed by majority vote on the level we would use to choose a restaurant".

How powerful is big pharma?

The US Senate Finance Committee found consistent systematic abuses, with academics receiving secret payments to write complimentary reviews of new drugs. Yet this hasn't solved the problem, says Dr Thomas Insel, head of the US National Institute of Mental Health. Doctors, who receive conference invitations, speaking fees and free drugs, must break away from pharma's "culture of influence".

Since 2008, at least 15 firms have paid $6.5bn to settle accusations of marketing fraud. Johnson & Johnson recently paid out $743m to settle various lawsuits over its anti-psychotic drug Risperdal. American companies also influence consumers through marketing (see below), funding front groups' that claim to represent consumers.

How widespread is the use of psychiatric drugs?

One World Health Organisation (WHO) study found that 48% of the US population would fall under one of the DSM-4 categories at some point in their life. DSM-4 proposals that children who challenge parents could have "oppositional defiant disorder" led to a proliferation of paediatric drugs. Bubble-gum-flavoured pills for childhood ADHD helped the medication sales hit $7.42bn in 2010 from $4.05bn in 2006.

Since the DSM-4 revision American use of anti-depressants has risen by more than 400%. In 2011, 20% of citizens took a psychiatric drug and prescription drug overdose became the leading cause of accidental death.

Is this just in America?

Outside the US, mental health professionals consult WHO's International Classification of Diseases. APA's US dominance means British and European institutions use its guidelines. So the definitions it settles on will influence the world. DSM-5's first draft awaits feedback and the manual should be implemented in 2013.

The child drugmarket

One of the most worrying elements in the rise of prescription drugs has been the increase in drug use among children. The three major psychiatric illnesses of the past 15 years bipolarism, autism and ADHD affect children. Companies have not had to develop new drugs to treat these conditions, but often just repackaged existing ones for adults.

The marketing push was boosted in 1999 when pharmaceutical firms were allowed to advertise drugs directly to consumers in the US. Big pharma spent $4.5bn on consumer advertising in 2010, including branding toy building blocks in paediatricians' waiting rooms with the names of drugs.

The campaign has been successful. Around 4% of US children now take prescribed drugs, helping to make anti-psychotics a blockbuster, generating $15bn in annual revenue.