Unlike a broken leg, mental health—and the lack thereof—is deeply complex. Mental states exist on a spectrum, often without clear biomarkers. Medical diagnoses frequently intertwine overlapping conditions, subjective assessments, and corporate influences. Neurodivergence reveals ethical dilemmas, diagnostic inflation, and a system largely guided by just two books. Can we do better?
The Full story

You are not awfully anxious or completely calm, but are typically somewhere in between and also always something else—say tired. All mental states exist on a spectrum. And the same is true for Autism Spectrum Disorder, Borderline Personality Disorder, Major Depressive Disorder, or any other mental state. There are millions of variations within each, and most are overlapping with others. This overlap is known as comorbidity. And it gets more complicated.
Complex origins of mental disorder

Unlike a broken leg, your mental health, or the lack thereof, has highly complex origins. Schizophrenia, for example, tends to run in families and might be mostly genetic. Anxiety can be the result of genetic traits, prenatal stress, childhood trauma, and random events.
Most mental disorders also lack clear biomarkers: biological factors are either too complex to identify or too expensive to analyze. This ambiguity is the very reason doctors came together to describe and classify all the atypical behaviors they saw. The creation of common labels was necessary for both psychiatrists and patients to understand what was going on, and talk to each other.
diagnostic manuals

And so, whenever psychiatrists in the United States and Australia see someone, they follow the guidelines of the Diagnostic and Statistical Manual, to assess and categorize their patients. The DSM is sold by the American Psychiatric Association. Doctors in the rest of the world also use the International Classification of Diseases to diagnose mental problems. The ICD is published by the World Health Organization.
Both publications greatly influence what clinicians and government officials consider normal, or abnormal behavior. For example, according to a previous version of the DSM, homosexuality was known as a sociopathic personality disturbance. After an update of the book in 1974, doctors could no longer officially consider it a mental disorder—even if they wanted to.
societal and medical influence

Politicians all around the world follow the book’s guidelines to understand who is mentally sick, who is not, and whether public health insurance, that we pay with our taxes, should cover treatments that include medication or pay for a therapy that doesn’t involve drugs.
And in the hands of doctors, the contents of these two manuals can determine whether a girl is considered “healthy”, even if she is not, or is prescribed mood stabilizers, even if she might not need them—which may happen considering that 1 in 10 teenage girls in the United States today take antidepressants.
subjective diagnosis

Now the lack of clear biological evidence is the reason why neither the DSM nor the ICD have introduced biological or genetic factors into their classifications. Psychiatrists hence mostly rely only on what they see with their own eyes, subjective self-reports, multiple-choice tests, and what family members tell them.
combination of comorbidities

The combination of comorbidities and the lack of clear evidence is a problem—there is no reliability. It is highly unlikely that even the best doctors could reliably identify one specific disorder among hundreds of options that tend to overlap, especially if they try to treat children who themselves have no idea what’s going on.
Consider autistic people who often start speaking at a later age and like routines because they need predictability. And kids with ADHD who have no problem speaking and crave excitement and novelty. A boy born with both could be bored by routines, but overwhelmed by novelty, and since he lacks the language to explain his feelings, he might be misdiagnosed with generalized anxiety disorder.
other challenges

On top of this already highly complex situation are four other challenges: criteria change over time, normal mental states may get pathologized, the list of disorders gets longer and longer, and the research on many conditions might have started off biased.
the DSM-5

The fifth and latest edition of the DSM was published in 2013. It contains 297 disorders, ten times the number of diagnoses that the project started with in 1917. Here are five examples of what changed and what didn’t.
diagnostic inflation

The criteria for autism, eating disorders, and depression were broadened. The new definitions, together with an increase in public awareness, and lifestyle changes could contribute to what’s known as diagnostic inflation. Data from health insurance claims of 41 million Americans shows that the diagnosis of major depression in 12 to 17-year-olds increased from 1.6% in 2013 to 2.6% in 2016—which means it became 63% more common.
autism redefined

The update combined Autism and Aspergers under what’s now known as Autism Spectrum Disorder [ASD]. The change made the diagnosis for many more likely, but about 1 in 3 who would have been diagnosed with Aspergers in 2013, don’t fall into the autism spectrum after the change. And yet, today 1 in 36 children in the US get diagnosed with ASD, up 400% from 20 years ago.
grief diagnosis

Grief after losing a loved one can, since the update, be diagnosed as Major Depression Disorder and be treated with medication. This pathologization of a normal state is highly controversial—perhaps we should be deeply saddened if we lose someone we love.
Disruptive mood dysregulation disorder

Disruptive Mood Dysregulation Disorder, which many parents know as temper tantrums or angry outbursts, was added. Psychiatrists who identify it in young children may now prescribe mood stabilizers, which in some cases can be the right treatment, but may have negative consequences—especially for those who don’t need them.
ADHD chanllenges

What did not change: ADHD, a condition that was studied originally only in boys, continues to include diagnostic criteria that do not suit girls or adults, both of whom may show different symptoms of it. As a result, women are often treated for conditions they do not have, such as bipolar disorder. At best, that’s just ineffective.
who benefits?

While many doctors relying on the new DSM do help a lot of real patients with real problems, we have to ask who else benefits. Or as the investor Charlie Munger, liked to say: “Show me the incentive and I will show you the outcome”.
The DSM is written, published, and sold by the American Psychiatric Association, a non-profit organization whose 30,000 plus members are the very doctors who use the book in their daily practice.
collaborative history

Since the middle of the last century, doctors and pharmaceuticals have been working together to deliver treatments for people suffering from schizophrenia, depression, and other mental health issues. After all, both psychiatrists and businessmen wanted to cure the same patients, albeit perhaps for different reasons.
After some success and the development of the first antidepressant in the 1950s, the relationship between the two grew ever more cozy leading to potential conflicts of interest.
pharmaceutical influences

In the 1970s some drug makers funded a political action committee to help the psychiatrists lobby the US Congress to pass laws that ensure more public funds are spent on the awareness, research, and treatment of mental health.
Pharmaceuticals also began sponsoring ghostwriting services and media training workshops, turning psychiatrists into renowned authors and speakers at the top medical schools around the world.
In 2008, a congressional investigation revealed that around 30% of the nonprofit’s annual budget was funded by the industry, primarily through advertising and medical education which often claimed that mental problems are the result of chemical imbalances one can fix with pills.
doctor connections

Even the content of the DSM, the very book used to diagnose and treat mental illnesses, appears to have been directly influenced by doctors, who not only cared for sick patients but also had incentives aligned with the businessmen who sell drugs.
A widely cited paper revealed that 69% of the doctors overseeing the DSM-5 had ties to pharmaceutical companies. In the subcommittee for sleep/wake disorders, a condition for which medication is the first-line treatment, 100% had financial ties to big drug makers—the global market for sleep disorder treatments is a $20 Billion industry and growing fast.
what do you think?

But you tell us! Since for certain conditions, drugs are critical. Is there a way to curb conflicts of interest between doctors and businessmen without killing expensive medical research projects that might bring us better treatments? And how do you feel about fixed guidelines used to treat conditions that are extremely complex to assess? Please share your thoughts in the comments below!
Sources
- Cosgrove, L., & Krimsky, S. (2012). A comparison of DSM-IV and DSM-5 panel members’ financial associations with industry: a pernicious problem persists.
- Diagnostic and Statistical Manual of Mental Disorders – Wikipedia.org
- American Psychiatric Association – Wikipedia.org
- Braslow, J. T., & Marder, S. R. (2019). History of psychopharmacology. Annual Review of Clinical Psychology, 15(1), 25-50.
- APA’s Vision, Mission, Values, and Goals – Psychiatry.org
- Ledford, H. (2012). Industry ties remain rife on panels for psychiatry manuals. Nature.
- Murphy D, Glaser K, Hayward H, et al. Crossing the divide: a longitudinal study of effective treatments for people with autism and attention deficit hyperactivity disorder across the lifespan. Southampton (UK): NIHR Journals Library; 2018 Jun. (Programme Grants for Applied Research, No. 6.2.) Chapter 17, Improving outcomes through better diagnosis: the effects of changes in DSM-V on clinical diagnosis.
- Health News and Articles – Bcbs.com
Dig deeper!
- Dr. Biderman, a child psychologist at Harvard University Medical School, received hundreds of thousands of dollars in consulting fees from AstraZeneca. Read more here.
- Get an unfiltered view of the income, expenses, and other details of the American Psychiatric Association.
- Visit official website of the American Psychiatric Association
- Read about the astounding increase in antidepressant use by Americans
- Read about the increase in sleep medication used.
- Read more about the scrutiny APA’s faces over drug industry ties (pay wall).
- Read about the trends in prescribing antipsychotic to children.
Classroom activity
Objective:
Students will analyze the complexity of mental health diagnosis and treatment by examining the history, challenges, and conflicts of interest in the field. They will discuss the implications of diagnostic inflation, the role of pharmaceuticals, and the ethical considerations in mental health care.
Materials Needed:
- Sprouts video on The Hard Truth About Mental Health.
- Excerpts from the script.
- Case studies illustrating diagnostic inflation, misdiagnosis, or ethical dilemmas in mental health care.
- Access to online resources or supplementary articles on mental health, the DSM, and conflicts of interest in psychiatry.
- Whiteboard or large post-it notes for group brainstorming.
Duration:
60 minutes
Steps:
- Introduction and Video Viewing (10 minutes):
- Introduce the topic by explaining the complexity of mental health diagnosis and the influence of the DSM and ICD.
- Show the video based on the script (approx. 7–8 minutes). Encourage students to take notes on key points that stand out to them.
- After the video, ask students to reflect on these questions:
- What surprised you most about the process of diagnosing mental health conditions?
- What ethical or practical dilemmas did the video highlight?
- Analysis of Causes and Impacts (15 minutes):
- Divide the class into four groups, each focusing on one of these themes:
- Theme 1: Diagnostic inflation and its possible origins (biological, awareness, criteria).
- Theme 2: The lack of clear biomarkers and the challenges of subjectivity in mental health diagnosis.
- Theme 3: The role of pharmaceutical companies and potential conflicts of interest.
- Theme 4: The impact of fixed diagnostic guidelines on diverse populations and conditions.
- Provide each group with excerpts from the script and case studies relevant to their theme.
- Groups discuss and answer:
- What are the key challenges or issues related to your theme?
- What are the potential consequences for patients, doctors, and society?
- What solutions or reforms could address these challenges?
- Divide the class into four groups, each focusing on one of these themes:
- Group Presentations and Connections (15 minutes):
- Each group presents their findings, focusing on:
- The key challenges and consequences of their assigned theme.
- Any solutions or reforms they propose.
- Facilitate a class discussion after each presentation, encouraging students to ask questions or connect ideas between themes.
- Each group presents their findings, focusing on:
- Class Debate: Ethics and Effectiveness in Mental Health Diagnosis (15 minutes):
- Divide students into two sides for a structured debate on the following questions:
- Question 1: Should the DSM and ICD continue to rely heavily on questionnaires instead of biomarkers for diagnoses?
- Question 2: Can we effectively curb conflicts of interest between pharmaceutical companies and psychiatrists without hindering medical innovation?
- Encourage students to use examples from the video, their group discussions, and their own experiences to support their arguments.
- Divide students into two sides for a structured debate on the following questions:
- Reflection and Sharing (5 minutes):
- Ask students to individually reflect on these prompts:
- What was the most surprising or thought-provoking thing you learned today?
- How do you think mental health care could be improved, given the challenges discussed?
- Allow a few students to share their reflections with the class.
- Ask students to individually reflect on these prompts:
Assessment:
- Evaluate students based on their engagement during group discussions, presentations, and debates.
- Assess their ability to critically analyze the script’s content and connect it to real-world implications.
- Encourage respectful and evidence-based arguments that demonstrate an understanding of the complexities in mental health care.
Collaborators
- Script: Jonas Koblin and Ludovico Saint Amour di Chanaz, PhD
- Cartoon artist: Pascal Gaggelli
- Producer: Selina Bador
- Voice artist: Matt Abbott
- Coloring: Nalin
- Editing: Peera Lertsukittipongsa
- Sound Design: Miguel Ojeda
- Publishing: Vijyada Songrienchai