The Surgeon General's Unkindest Cut - David Satcher's Mental Health: A Report of the Surgeon General critiqued - Critical Essay

USA Today (Society for the Advancement of Education), Nov, 2000 by Richard E. Vatz

David Satcher's report on mental health "onstensibly science-based, is simply filled with nonscientific and unvalidated data."

SECRETARY of Health and Human Services Donna Shalala called David Satcher's Mental Health: A Report of the Surgeon General the "first Surgeon General's report on mental health," implying that it will be an annual accounting. Let us hope that future versions will be less subjective and more rigorous.

The report is, simply put, invalid, misleading, and dangerously consequential. As is true of most mental health position papers, the conclusions are not the result of valid, scientific research findings. For example, the elimination in 1973 of most homosexuality from psychiatry's Diagnostic and Statistical Manual of Mental Disorders (DSM) was the consequence not of medical research, but of political struggles in the field of psychiatry. The claims in the current report--that about one in five Americans, or 53,000,000, are mentally ill and that approximately one-half of all Americans suffer mental illness during their lifetime--are neither scientific nor new.

In the early 1990s, the National Institute of Mental Health made precisely the same claims. The statistics came from surveys by "lay interviewers." Along with the American Psychiatric Association, the NIMH recommended in the ill-fated 1993 Clinton health care plan that Americans should be insured for 30 outpatient psychiatric visits a year, followed ultimately by unlimited psychiatric psychotherapy sessions. With even 30, this would have meant that, if all 52,000,000 took advantage of the plan, there would be about 1,500,000,000 psychiatric sessions a year paid for by insurance. The true "Therapeutic Society" would have been born.

If the recommendations and claims of the Surgeon General's report were taken seriously, it would also mean that mental illness would become the most common chronic disease in America, surpassing, for example, according to the latest Statistical Abstract of the United States, arthritis, affecting 32,663,000, and hypertension, suffered by 29,954,000.

Psychiatrist Kay Redfield Jamison inadvertently put her finger on the problem of current public debates on mental illness in a Dec. 17, 1999, letter to The New York Times when she wrote, "The science underlying the numbers and treatments in the surgeon's report... is reliable and replicable." What she doesn't--cannot--claim is that the numbers are valid.

Psychiatry utilizes reliability of psychiatric disorders (testing to see if diagnosticians agree on what psychiatric disease patients suffer from) in the place of a search for validity (ascertaining whether diagnosis measures what it claims to measure). This has been pointed out repeatedly over the years by psychiatric critic Thomas Szasz of the State University of New York Health Science Center and has been argued even by the more establishment-oriented Paul McHugh of Johns Hopkins University in an article in the December 1999 Commentary. In it, he additionally points out:

* We are witnessing a proliferation of new, nonorganic, bogus psychiatric disorders.

* In psychiatry, as opposed to somatic medicine, the symptom is the disease, rather than a sign of it, leading to overblown estimates of the incidence of mental illness.

* The changing of behaviors by psychotropic drugs ("Everyone is more attentive when on Ritalin") affects anyone who takes them and cannot be used validly as indicative of psychiatric disorders.

The report contains some striking anomalies, such as the inclusion of Alzheimer's disease as a mental disorder. Alzheimer's is a degenerative disease with a specific pathology involving neurofibrillary tangles and amyloid deposition that causes progressive irreversible memory loss and other neurological dysfunction. The hallmark of mental illnesses is the lack of specific pathological referents. Alzhelmet's disease is clearly a neurological disorder, perhaps included to give apparent validity to less neurologically evident mental disorders. In fact, in the immediately preceding diagnostic manual, DSM-III-R, one finds this sentence, which is missing from DSM-IV: "It should be noted that Alzheimer's disease is itself a physical disorder, and therefore is not included in this manual of mental disorders...."

Mental Health: A Report of the Surgeon General, ostensibly science-based, is simply filled with nonscientific and unvalidated data. The gravamen of the report is that menial health should not be viewed as "separate and unequal" to general health, and that there should be public support for the long-standing goal of "parity" for mental illness, the insuring of mental illnesses on an equal basis with all physical illnesses.

The report claims--twice in the "Executive Summary"--to yield a "single, explicit recommendation: to seek help if you have a mental health problem or think you have ,symptoms of a mental disorder [emphasis in original]." It then says that a variety of treatments or helping sources will suffice, but that "personal preference may influence" whether a person utilizes "talk therapy" or "medications." Could anyone imagine such starkly different, equally recommended consumer choices with real disease?