Where has all the stigma gone?

75 There has been a dramatic increase in recent years in the number of people diagnosed with mental disorder. For example, in USA the NIMH estimates that, in any given year, 25% of the population has a diagnosable mental disorder. A prospective study found that, by age 32yrs, 50% of the general population had qualified for an anxiety disorder, 40% for depression and 30% for alcohol abuse or dependence. Fifty-one percent of boys and 49% of girls aged 13-19 have a mood, behaviour anxiety or substance abuse disorder. The World Health Organisation projects that by 2020 depression will be the second leading cause of worldwide disability. In South Africa psychiatric disorder has already knocked backache of its perch at the top of the disability log. It is of course possible that brain dysfunction has become more common. However, a few voices have dared to question the actual figures and even, heretically, the methodologies and tools of the epidemiological surveys from which they are derived. Other, persuasive possible reasons for the reported increases in psychiatric illness have been suggested. Here are a few: a. The boundaries of normality are shrinking and are very porous. Widespread traits, feelings and behaviours, which were previously regarded as well within a normal spectrum of the rich tapestry of life, or as normal reactions to life experiences and situations, now fulfill the criteria for psychiatric disorder in current psychiatric nosologies. This may become even more problematic under the influence of the emergent DSM V. b. Massive propaganda exercises have encouraged everyone to identify patients, work colleagues, friends and family members who may have unrecognised psychiatric disorder and need help. Undoubtedly many previously unrecognised patients have benefited from treatment in this new therapeutic atmosphere. Twenty-five years ago I was interrupted during a lecture to a group of non-psychiatric doctors. A surgeon, a gynaecologist and a general practitioner sitting together felt that they had to share aggressively with the audience that in all their years of practice they had never seen a case of this thing called " Depression ". They were suspicious of the psychiatric message of the time. This could never happen now, which is good. c. There has been an extraordinary increase in prescriptions for psychotropic drugs. The role of the main beneficiaries, the pharmaceutical industry, and its motives, in persuading us to participate in the expansion of diagnoses and prescribing has been questioned. Some …