Although there are varying opinions about the personality traits and characteristics that taken together constitute optimal mental health, historically it has been somewhat easier to define and identify mental illness—deviations from, or the absence of, mental health. Within the broad diagnosis of mental illness, there is more consensus about the origins, nature, and symptoms of mental disorders—serious, and often long-term conditions in which changes in cognition (thinking), behavior, or mood impair functioning—than exists about mental health problems—shorter term, less intense conditions that often resolve spontaneously, without treatment.
Because many mental health disorders are identified by primary-care physicians (general practitioners, family practitioners, internists, and pediatricians), the World Health Organization (WHO) developed educational materials and guidelines to assist practitioners in general medical settings—as opposed to psychiatric or other mental health settings—to assess and treat the mental health problems and disorders of patients in their care. The guidelines describe an assessment interview as a series of screening questions for which predominantly positive answers suggest the patient has an "identified mental disorder," or a "subthreshold disorder"—the patient responds positively to many questions but not enough to fulfill the diagnostic criteria for a disorder as defined by the WHO's tenth revision of the International Classification of Diseases (ICD-10), the European guide for diagnosis of mental disorders. In North America the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; Washington, DC: American Psychiatric Association, 2000) is used for the same purpose as the ICD-10. Practitioners are encouraged to ask open-ended questions that encourage patients to freely express their emotions, assure confidentiality, to acknowledge patients' responses, and to closely observe their body language and tones of voice.
Changing Criteria for Mental Illness
There are many controversies in mental health diagnosis, beginning with the definitions and classification of mental illnesses. Which criteria distinguish conditions as mental illness rather than normal variations in thinking and behavior? Should conditions such as attention deficit hyperactivity disorder (ADHD) be classified as learning problems or mental disorders? Should practitioners distinguish between neurological conditions that cause brain dysfunction and cognitive impairment such as Alzheimer's disease and mental illness involving brain dysfunction such as depression that may result from an imbalance of chemicals in the brain?
DSM-IV, as mentioned above, is the authoritative encyclopedia of diagnostic criteria for mental disorders. This definitive guide, which expands upon the ICD-10, is the most widely used psychiatric reference in the world and catalogs more than three hundred mental disorders. Table 3.1 lists the major classifications of mental disorders contained in the DSM-IV.
An examination of past versions of the DSM reveals that the definitions of mental illnesses have changed
TABLE 3.1
Major diagnostic classes of mental disorders (DSM-IV)
Disorders usually first diagnosed in infancy, childhood, or adolescence
Delerium, dementia, and amnestic and other cognitive disorders
Mental disorders due to a general medical condition
Substance-related disorders
Schizophrenia and other psychotic disorders
Mood disorders
Anxiety disorders
Somatoform disorders
Factitious disorders
Dissociative disorders
Sexual and gender identity disorders
Eating disorders
Sleep disorders
Impulse-control disorders
Adjustment disorders
Personality disorders
SOURCE: "Table 2-5. Major Diagnostic Classes of Mental Disorders (DSM-IV)," in Mental Health: A Report of the Surgeon General, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, with NIH, 1999, http://www.surgeongeneral.gov/library/mentalhealth/chapter2/sec2.html (accessed January 18, 2006)
dramatically from one edition to another. Persons diagnosed with a specific mental disorder based on diagnostic criteria in one edition might no longer be considered mentally ill according to the next edition. Critics of the DSM, which has expanded more than tenfold since its inception, claim that diseases are added arbitrarily by the American Psychiatric Association (APA) and that while some entries represent changing ideas about mental health and illness, others are politically motivated. For example, homosexuality was once considered a mental illness, but today, largely in response to changing societal attitudes, it is no longer termed an illness.
Skeptics also question the sharp increase in the number of diagnoses and the number of Americans receiving these diagnoses. Does the increasing number of diagnoses reflect rapid advances in mental health diagnostic techniques? Have mental health professionals simply improved their diagnostic skills? Are the stresses of twenty-first-century life precipitating an epidemic of mental illness in the United States? Or are mental health professionals—psychiatrists, psychologists, clinical social workers, marriage and family therapists, and other mental health practitioners—simply labeling more behaviors and aspects of everyday life as pathological (diseased)?
Further, there is dissent even within the mental health field about diagnosis that is rooted in the ongoing debate about the origins of mental illness. After taking into account all of the relevant medical research, Mental Health: A Report of the Surgeon General (1999, http://www.surgeongeneral.gov/library/mentalhealth/home.html) concluded that for most mental illnesses there is no demonstrable physiological cause. This means there is no laboratory test, imaging study (x-ray, magnetic resonance imaging, or positron emission tomography), or abnormality in brain tissue that has been definitively identified as causing mental illness. The majority of persons suffering from mental illness apparently have normal brains, and those with abnormal brain structure or function are diagnosed with neurological disorders rather than mental illnesses.
Finally, there are those who view mental illness as a social condition rather than one requiring medical diagnosis. They observe that even the Surgeon General's report, which favors biological explanations of the origin, diagnosis, and treatment of mental illness, concedes that mental health is poorly understood and defined differently across cultures. If mental health and illness are rooted in cultural mores and values, then they are likely socioeconomic and political in origin. The proponents of societal causes of mental illness contend that if mental illness is in part defined as functional impairment, and during the course of their lives perhaps half the U.S. population will be impaired (according to the National Institute of Mental Health [NIMH], 2006, http://www.nimh.nih.gov/publicat/numbers.cfm), then perhaps it is not the individual who is ailing, but the society. This theory is supported by the fact that the WHO, in their World Health Report (2001, http://www.who.int/whr/2001/en/), estimates that 25% of individuals will be diagnosed with mental illness in developed and developing countries, half of the proportion of the American population estimated to be at risk.
Despite the challenges of diagnosing metal illnesses, there is consensus that early diagnosis is vital because untreated psychiatric disorders can produce more frequent and more severe episodes, are more likely to become resistant to treatment, and may lead to the development of co-occurring mental illnesses. NIMH cites research revealing that while about 80% of all people in the United States with a mental disorder eventually do seek treatment, there are personal and public health consequences that result from long delays in seeking and receiving treatment. Untreated mental disorders are associated with school failure, teenage childbearing, unstable employment, marital instability, and violence ("Mental Illness Exacts Heavy Toll, Beginning in Youth," NIMH, June 6, 2005, http://www.nimh.nih.gov/press/mentalhealthstats.cfm).
Projective Testing Techniques
Most diagnoses of mental illness are made on the basis of symptoms reported by the patient, the practitioner's observations, and the use of designated guidelines or criteria for distinguishing between disorders and establishing diagnoses. There are, however, additional diagnostic tests practitioners may perform to confirm diagnoses. Projective tests are thought to provide insight into clients' unconscious minds and have been used to characterize and describe symptoms, as well as to detect physical abuse, sexual abuse, and child abuse. They include the Rorschach test, Thematic Apperception Test (TAT), human figure drawings, and the Washington University Sentence Completion Test. There is widespread agreement that projective tests should be just one component of a comprehensive diagnostic study and that results from the tests should be integrated with history and interview information, because test results should be weighted only when they are consistent with other data.
There has been harsh criticism of projective tests during recent years, with detractors detailing their shortcomings, concluding that they lack a scientific underpinning and produce exaggerated estimates of pathology. In an effort to address this controversy, Howard Garb and his colleagues analyzed the efficacy of a variety of projective tests and reported their findings in "Effective Use of Projective Techniques in Clinical Practice: Let the Data Help with Selection and Interpretation" (Professional Psychology: Research and Practice, vol. 33, no. 5, October 2002).
The investigators concluded that for making diagnoses, psychologists should rely primarily on interview and history information, but that results from psychological tests, including self-report personality inventories and projective techniques, may be helpful. They advised psychologists that they were likely to be "on safer ground when they use projective techniques as an aid for exploration in psychotherapy rather than as an assessment device."
Further, the investigators exhorted psychologists to rely heavily on history and interview data to predict behavior. They recommended that to evaluate psychiatric symptoms and personality traits, practitioners should depend on interview and history information, self-report personality inventories, and, in selected instances, projective tests. Although evaluation of symptoms and personality traits are ostensibly the ideal task for projective techniques, the investigators found that findings derived from Rorschach, TAT, and human figure drawings have not been independently and consistently replicated.
Automated and Online Diagnostic Testing
There are other diagnostic tests and case-finding instruments—tools practitioners may employ to screen for and identify persons suffering from mental illness. Jonathan Shedler and his colleagues from Harvard Medical School and the Clinical Research Unit of Kaiser Permanente in Colorado evaluated the utility and validity of Quick PsychoDiagnostics (QPD) Panel, an automated mental health test. They reported their findings in "Practical Mental Health Assessment in Primary Care: Validity and Utility of the Quick PsychoDiagnostics Panel" (Journal of Family Practice, vol. 49, no. 7, July 2000).
QPD was designed to meet the needs of primary-care physicians who do not have sufficient time to administer even brief diagnostic tests. The test combines features of an inventory and a structured interview and screens for nine frequently occurring psychiatric disorders and requires no physician time to administer or score. Patients respond to a core set of fifty-nine questions and, when responses suggest a possible psychiatric disorder, the test offers pointed questions that, like a structured interview, probe in depth. Although the test contains more than two hundred diagnostic questions, patients see and respond to a customized, relevant subset of them. Scoring is performed electronically.
The investigators evaluated validity by correlating QPD Panel scores to the Structured Clinical Interview for DSM-IV (SCID) and established mental health measures. They assessed utility, in terms of acceptability to physicians and patients, by administering satisfaction surveys to both groups. The researchers concluded that the QPD Panel is a valid mental health assessment tool with the capacity to diagnose a range of common psychiatric disorders. They deemed it practical for routine use in busy primary-care practices and observed that "routine screening would benefit the many patients who currently go undiagnosed and untreated."
Even if computerized diagnostic capabilities are imperfect and unproved, University of Pittsburgh Department of Psychiatry researcher Howard Garb suggested that computer programs will become more prominent in mental health practice in "Computers Will Become Increasingly Important for Psychological Assessment: Not That There's Anything Wrong with That!" (Psychological Assessment, vol. 12, no. 1, March 2000). Garb contended that computers would be widely used for psychological assessment because mental health professionals are not good at some judgment tasks and that the use of computers to make judgments might prevent problems associated with clinicians' judgments. He concluded, "Using computers to make judgments and decisions in personality assessment can lead to dramatically improved reliability, a decrease in the occurrence of biases, and an overall increase in validity and utility."
Tom Buchanan from the University of Westminster Department of Psychology described the strengths and weaknesses of Internet-mediated, or online, psychological assessment in "Online Assessment: Desirable or Dangerous?" (Professional Psychology: Research and Practice, vol. 33, no. 2, April 2002). Buchanan cited the strengths of online personality testing as allowing more people to complete them than would otherwise be possible. It enables persons who were previously unable to do so, because of distance or time constraints, to access mental health services. (Those who favor online therapy or counseling make the same arguments.) There also is the possibility that people may be more candid when completing tests online and willing to disclose more information about themselves to computers than to other people.
Weaknesses of Web-based assessment include computer anxiety that may affect participants' responses and the observation that online respondents tend to report higher levels of negative affect than those who complete conventional paper questionnaires. Mental health researchers wonder whether online respondents are simply more inclined to self-disclosure or whether they are actually a more depressed group. There are also professional and ethical concerns such as the likelihood of well-meaning but untrained individuals who offer tests and opinions about a range of psychological conditions. One concern is the consequences of providing already troubled individuals with information that might be potentially distressing. Without appropriate follow-up or counseling, delivering such sensitive and potentially emotionally charged information is ethically and professionally unacceptable.
Other potential problems center on the technology itself. Interruptions in connectivity may interfere with the assessment process. This is especially true when assessment is performed live during a videoconferencing session. Further, without the use of a secure server and encrypted communications, electronic communications may be intercepted by a third party. Buchanan concluded that "online clinical tests are both desirable and dangerous. There is clearly great potential, but a lot of work must be done before this potential is realized. Only time and extensive research can tell us whether these instruments will become a useful tool in behavioral telehealth contexts."
User Comments Add a comment…