How Economic Factors Influence the Prevalence, Assessment, and Treatment of Mental Illness

Michelle Barton

December 5, 2016

Psychology 461: Psychological Assessment

Dr. Jason Doiron

University of Prince Edward Island

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Mental illness is commonly understood as an individual, and increasingly physiological,

problem. It is rarely situated in a political, economic or historical context. Nancy Scheper-

Hughes describes this as “a technical practice for ‘rationalizing’ human misery and for

containing it to safe quarters, keeping it ‘in its place,’ and so cutting off its potential for

generating an active critique” (Scheper-Hughes, 1994). The body is perceived as the site of dis-

ease, but Scheper-Hughes argues that the body can also offer a critique of “social dis-ease” and

that illness “can contain the elements necessary for critique and liberation.” Unfortunately, the

current trend in clinical psychology is to focus intensely on individual behaviours, symptoms,

and neurobiological causes. How the practice of psychology and psychiatry might be

transformed by researchers and clinicians paying as much attention to the broader social

context of mental illness as they give to individual behaviours and symptoms is yet to be seen.

This paper seeks to explore some of the economic factors contributing to this narrowing

of the assessment process in mental illness. It will also explore how financial interests are

contributing to the definition and “invention” of mental illnesses and influencing treatment

options. As we will see, when those responsible for defining mental illnesses also have a

financial stake in those definitions, the public is left in a very vulnerable position.

The Challenge of Defining Abnormality

One of the challenges in defining psychiatric disorders is that there are no natural

boundaries between what is normal and what is abnormal. There are no objective tests for

verifying or falsifying mental illnesses. What is considered appropriate behaviour in one setting

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may be considered inappropriate or pathological in another. Ultimately, what qualifies as a

disorder is heavily influenced by social norms and cultural practices.

Psychologists and psychiatrists often use psychological tests to measure how much of a

specific construct—such as depression or ADHD—an individual is experiencing. On norm-

referenced tests an individual’s score is interpreted in reference to a norm group that is

representative of the population for whom the test is intended. The distribution of scores

received by the norm group determines what is considered normal and what is considered

atypical.

But what happens if the majority of the population, the norm group, is dysfunctional? In

this case, creating group “norms” would serve to normalize pathological traits. The Scottish

psychiatrist R.D. Laing famously theorized that alienation—the condition of being “out of one’s

mind”—is the condition of the normal man. He goes on to say that “the ‘normally’ alienated

person, by reason of the fact that he acts more or less like everyone else, is taken to be sane”

(Laing, 1967). On the extreme end, the consequences of a socially reinforced pathology may be

evident in the brutal and often lethal acts by delinquent gangs, war, genocide, and ethnic

cleansing. However, when such behaviour is sanctioned by the majority of the population, or by

those with the greatest amount of power and influence, it is not considered pathological.

According to critical social theory, abnormality and deviance is defined by the people and

institutions in power.

More recently and in a similar vein, British psychologist Ian Parker criticized psychology

for normalizing conditions of social alienation and working to reproduce existing conditions and

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power relations (Parker, 2007). Not only is the individual enmeshed within a social-political

framework, but so too are the psychological constructs and clinical practices by which the

individual is assessed and treated. Ignoring social alienation and the structural violence that

harms or disadvantages individuals leads to assessment procedures that identify and treat

consequences rather than causes. In the past, it was the religious authorities who had the most

influence on how the mentally ill were perceived and treated. The current power structure that

dominates mental health research and clinical practices is capitalism. Economic inequality

impacts the prevalence of mental illness, and financial interests guide the direction and

outcomes of research as well as assessment practices, diagnostic parameters, and treatment

options.

Mental Illness and Economic Inequality

There is evidence that many mental illnesses—such as schizophrenia—correlate

positively with a lower socio-economic status. One reasonable explanation for the social-class

gradient is the social drift hypothesis, which posits that people with the greatest risk of

developing mental illness drift into low-status occupations and poorer neighbourhoods. Early

research into schizophrenia certainly appears to support this theory (Goldberg & Morrison,

1963). More recent research has focused on the increased stress associated with lower-class

living as a risk factor for developing schizophrenia (Berry& Cirulli, 2016).

Interestingly, in developing nations the prevalence of schizophrenia is higher among

upper-class, better-educated individuals (Warner & de Girolamo, 1995). This suggests class-

related differences may be related to the development of schizophrenia in ways that are not

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yet fully understood. A 2004 World Health Organization survey of mental illness shows that the

prevalence of DSM-IV disorders is highest in industrialized countries with significant income

inequality. Countries with higher standards of living coupled with lower levels of income

inequality due to strong social policy had the lowest rates of mental illness (World Health

Organization, 2004).

How mental illness affects and is affected by socio-economic factors is poorly

understood and seldom addressed. Despite a general awareness that socio-economic status

influences mental health, clinicians place little to no importance on a person’s financial income,

personal history, social capital, level of education, or experience of stigmatization, when

assessing and treating mental illness. The nature of the illness is conceptualized as essentially

individual and the treatment of choice is predominantly pharmacological.

The Bio-Bio-Bio Model

In 2005, Steven S. Sharfstein, the then-president of the American Psychiatric Association

(APA), addressed the “extraordinary presence of the pharmaceutical industry throughout the

scientific programs and on the exhibit floor” during the APA’s annual meeting (Sharfstein, 2005).

He acknowledged that the interests of Big Pharma and psychiatry are often not aligned, and

that there is much concern regarding the over-medicalization of mental disorders. Even more

troubling, the influence of Big Pharma has contributed to a reduction of the biopsychosocial

model to a bio-bio-bio model, in which psychiatric conditions are considered to be biological in

nature and broader social and personal realities are ignored. Michel Foucault described this

dehumanizing separation of the individual’s body from a total personhood as “the medical

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gaze” (Foucault, 1973). This practice of depersonalization and the narrowing of inquiry to

biological and behavioural determinants situates the problem within the individual’s body and

contributes to the overuse of medications. The person is regarded as being maladjusted or

anatomically defective, while the social, political and economic structures that shaped the

problem remain hidden.

The quality of hiddenness is not limited to the individual with the problem; it is also a

part of the current neoliberal capitalist system of healthcare that forces healthcare

professionals to work at a frantic pace and favour the quick-fix of pharmaceuticals. Taking

adequate time to understand their patients and addressing the multiple and complex root

causes of dysfunction would potentially put their job or clinic in jeopardy. In a recent Canadian

study, clinicians identified professional time constraints as the most significant barrier to

providing psychotherapy (Hadjipavlou, Hernandez, & Ogrodniczuk, 2015). Consequently, well-

meaning clinicians inadvertently blame their patients for their suffering by focusing on genetic

or lifestyle factors without assessing the broader social context in which these vulnerabilities

and behaviours develop. The simplicity and efficiency of assigning diagnostic labels and writing

prescriptions has stripped mental illness of its social, political, historical, and economic context.

Using Checklists to Classify Disorders

To quickly and efficiently assess psychological constructs, checklists and questionnaires

have become increasingly more popular. They are often meant to provide a simple, brief way to

screen for disorders but they are also increasingly used as diagnostic proxy. These types of

assessments limit the scope of assessment and further reduce an illness to a cluster of

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symptoms and behaviours stripping away any contextual factors that may be contributing to

the construct in question. There is also an increased risk of over- or under-diagnosing of

disorders depending on the test-taker’s attitude and interpretation of the test items. Although

checklists and questionnaires can serve as beneficial screening or supplementary tools,

clinicians should guard themselves against the increasingly streamlined process of assessing

and diagnosing mental illness. According to the Canadian Mental Health Association (CMHA),

one in five Canadians will be diagnosed with a mental illness in their lifetime (“Fast Facts About

Mental Illness,” 2016). With such a high percentage of individuals being diagnosed with mental

illness the reliability and the validity of the DSM has come into question.

The Ever-Increasing Number of Mental Disorders

In 1883 Emil Kräpelin (1856–1926), a German psychiatrist, published a classification

system for psychological disorders, paving the way for the first Diagnostic and Statistical

Manual (DSM) published by the American Psychiatric Association (APA) in 1952. The DSM-I

listed 106 disorders which were referred to as “reactions.” Each subsequent edition of the DSM

had an increasing number of disorders. The DSM-IV, published in 1994, described 297

disorders. Due to criticism about the ever-increasing number of disorders, the DSM-5 did not

increase the total number of disorders. However, it did add new diagnoses. The DSM-5

achieved the appearance of having fewer disorders while increasing the number of diagnosable

conditions by reclassifying previous listed disorders as “subtypes” of another disorder.

In addition to concern regarding the quantity of disorders being defined, there is also a

growing concern about the inclusion and medicalization of ordinary personality traits, such as

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shyness, which was introduced in the DSM-5. In his 1872 discourse on blushing, Charles Darwin

considered shyness an adaptive trait. Unfortunately, the present-day American ethos devalues

shyness in favour of the quick-wit, confidence, and leadership qualities associated with

extraversion. How labeling shyness as a mental disorder will come to be utilized in clinical

practice and what impact it will have on the individual is yet to be seen, but it certainly spurred

an important conversation about psychiatry’s scientific claims-making and what psychologist

Arthur Houts describes as the “social invention” of disorders (Houts, 2002).

A Financial Conflict of Interest

The “social invention” of disorders is a critical issue for psychology considering the close

relationship between those who write the DSM and the pharmaceutical industry. Sixty-nine

percent of the DSM-5 task force and 56% of panel members had financial ties to the

pharmaceutical industry (Cosgrove & Krimsky, 20012). This represents a 21% increase over the

number of DSM-IV task members with such ties. The panels that had the most conflicts of

interest were also the panels for which pharmaceuticals are the first-line of intervention. One

hundred percent of the Sleep/Wake Disorders panel members had financial ties to the

pharmaceutical industry as did 83% of those on the panel for Psychotic Disorders and 67% of

the Mood Disorders panel.

Although the current APA disclosure policy does not require panel members to identify

the specific nature of their financial ties, independent research by Cosgrove & Krimsky

identified at least 21 of the 141 panel members as members of drug companies’ speakers

bureaus or advisory boards. Additionally, APA’s disclosure policy does not require panel

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members to disclose unrestricted research grants they receive from industry. These grants are

not considered a financial conflict of interest. However, Cosgrove & Kimsky argue that these

grants may create an “obligation to reciprocate” or invoke a bias. Currently, panel members can

receive US 10,000 per year from industry and have up to US 50,000 invested in stock holdings in

pharmaceutical companies. Psychiatrists not involved in the DSM have been known to receive

as much as millions of dollars in speaking and consulting fees from pharmaceutical companies

for the promotion of their product (Angell, 2009).

In addition to having representatives involved in DSM revisions, the pharmaceutical

industry also spends billions of dollars to promote their products in the media—such as drug

commercials and the “Stop the Stigma of Mental Illness” campaign that was launched by the

National Alliance on Mental Illness (NAMI) but sponsored by Big Pharma—and lobbying the

government to influence legislation. According to the Centre for Public Integrity, the industry

spent more than $880 million lobbying and campaigning in the US from 2006 to 2015 (“Pharma

Lobbying,” 2016), more than any other industry and eight times the amount spent by the

formidable gun lobbyists. Additionally, millions of dollars are donated every year to federal

candidates and political parties.

Pharmaceutical companies also invest heavily in psychiatric research, providing the

capital required to conduct clinical trials. This type of sponsorship has increased significantly in

recent decades raising the question of funding bias and leading to a close examination of the

relationship between the drug industry and clinical research. One study examined the drug

outcomes of 542 clinical studies and compared their sponsorship source (Kelly et al., 2006).

Seventy-eight percent of studies sponsored by drug manufactures resulted in a favourable

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outcome. This was significantly higher than the 48% of favourable outcomes in studies without

industry sponsorship and the 28% of favourable outcomes in studies sponsored by a

competitor. This is a major concern, as these biases not only influence medical literature but

also inform evidence-based medicine (De Vries & Lemmens, 2006). In addition to the strong

bias in favour of industry funded research, the limited amount of public funding for non-

pharmaceutical psychological treatment research further reduces the body of innovative

psychological science.

These conflicts of interests between private enterprise and public health jeopardize the

integrity of academic and practical psychology and psychiatry. The financial muscle of the

pharmaceutical industry has established a stronghold on the profession that cannot be

eliminated without significant reforms. Until the profession demonstrates a willingness to wean

itself from industry money, pharmaceutical companies will remain actively involved in both

defining mental disorders and funding research to promote pharmacotherapy.

Conclusion

There exists within society power structures that seek monetary gain from those who

suffer with mental illness. These structures have a vested interest in how mental illness is

researched, diagnosed, and treated. They also have a vested interest in not investigating the

socio-political and economic factors that contribute to social alienation and subsequent illness.

These factors remain hidden while the biological factors that can be addressed with

pharmacological treatment are overemphasized.

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A thorough mental assessment should be rooted in the biopsychosocial model of health,

one that addresses social determinants of health as well as biological and psychological factors,

which, arguably, occur downstream. For researchers, identifying the relationships between

social worlds and private suffering could lead to social policy changes and even a paradigm shift

within the field of psychology. Rather than locating the illness within the individual and trying to

“fix” him or her, the individual illness may be understood as a symptom of a broader social

disorder that is affecting vast numbers of the population with various expressions.

By ignoring or paying lip-service to the social conditions that lead to our alienation and

subsequent disorders, and by trusting that psychological research and treatments are unbiased

and apolitical, we are blindly and uncritically supporting those who have a financial interest in

keeping us ill.

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References

Angell, Marcia. (2009). Drug Companies & Doctors: A Story of Corruption. Retrieved from:

http://www.nybooks.com/articles/2009/01/15/drug-companies-doctorsa-story-of-

corruption/

Berry, A., & Cirulli, F. (2016). Toward a diathesis-stress model of schizophrenia in a

neurodevelopmental perspective. In M. V. Pletnikov, J. Waddington, M. V. Pletnikov, J.

Waddington (Eds.) , Modeling the psychopathological dimensions of schizophrenia: From

molecules to behavior (pp. 209-224). San Diego, CA, US: Elsevier Academic Press.

doi:10.1016/B978-0-12-800981-9.00013-4

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

Darwin, C. (1872). Self-Attention, Shame, Shyness, Modesty; Blushing, The Expression of the

Emotions in Man and Animals. New York: D. Appleton & Company.

De Vries, R., & Lemmens, T. (2006). The social and cultural shaping of medical evidence: Case

studies from pharmaceutical research and obstetric science. Social Science & Medicine,

62(11), 2694-2706. doi:10.1016/j.socscimed.2005.11.026

Fast Facts About Mental Illness. (2016). Retrieved from: http://www.cmha.ca/media/fast-facts-

about-mental-illness/#.WEXiaPkrLIU

Foucault, M. (1973). The birth of the clinic : an archaeology of medical perception. New York :

Pantheon Books, 1973.

Goldberg, E.M. and Morrison, S.L. (1963). Schizophrenia and social class. British Journal of

Psychiatry, 109:785–802

Barton/13

Hadjipavlou, G., Hernandez, C. S., & Ogrodniczuk, J. S. (2015). Psychotherapy in contemporary

psychiatric practice. The Canadian Journal Of Psychiatry / La Revue Canadienne De

Psychiatrie, 60(6), 294-300.

Houts, A. C. (2002). Discovery, invention, and the expansion of the modern Diagnostic and

Statistical Manuals of Mental Disorders. In L. E. Beutler, M. L. Malik, L. E. Beutler, M. L.

Malik (Eds.) , Rethinking the DSM: A psychological perspective (pp. 17-65). Washington,

DC, US: American Psychological Association. doi:10.1037/10456-002

Kelly, R. J., Cohen, L. J., Semple, R. J., Bialer, P., Lau, A., Bodenheimer, A., & Galynker, I. I. (2006).

Relationship between drug company funding and outcomes of clinical psychiatric

research. Psychological Medicine, 36(11), 1647-1656. doi:10.1017/S0033291706008567

Laing, R. D. (1967). The politics of experience, and, the bird of paradise. Harmondsworth:

Penguin.

Parker, I. (2007). Revolution in Psychology: Alienation to Emancipation. London: Pluto Press

Pharma lobbying held deep influence over opioid policies. (2016) Retrieved from

https://www.publicintegrity.org/2016/09/18/20203/pharma-lobbying-held-deep-

influence-over-opioids-policies

Scheper-Hughes, Nancy. (1994). The Rebel Body: The Subversive Meaning of Illness. Traditional

Acupuncture Society Journal, 10:3-10

Sharfstein, Steven S. (2005, Aug 19). Big Pharma and American Psychiatry: The Good, the Bad,

and the Ugly. Retrieved from

http://psychnews.psychiatryonline.org/doi/full/10.1176/pn.40.16.00400003

Barton/14

Sismondo, S. (2008). How pharmaceutical industry funding affects trial outcomes: Causal

structures and responses. Social Science & Medicine, 66(9), 1909-1914.

doi:10.1016/j.socscimed.2008.01.010

Warner, R. and de Girolamo, G. (1995). Epidemiology of Mental Health and Psychosocial

Problems: Schizophrenia, Geneva: World Health Organization, Chapter 3.

World Health Organization. (2004). Prevalence, Severity, and Unmet Need for Treatment of

Mental Disorders. JAMA: Journal of the American Medical Association, 291(21), 2581-

2590. doi:10.1001/jama.291.21.2581