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Commentary: Do you really have a mental disorder? Or are you just going through a tough time?

SINGAPORE: The topic of mental health has gained significant visibility in recent years, encouraging more open dialogue and demanding greater attention from healthcare systems worldwide. This increased awareness is undoubtedly a positive step towards destigmatising mental health, but it also brings forth an important question: Are we over-medicalising mental health symptoms?

Mental health disorders have a long history of being viewed through various lenses, from moral defects to supernatural explanations like demonic possession and witchcraft. It was not until the late 18th century that the first asylums were established, marking a shift toward a more medical approach to mental health.

Unfortunately, these asylums were more about isolating the mentally ill from society rather than treating their conditions​​. Even when there were “treatments” (such as bloodletting and rotational therapy), they were often barbaric, inhumane and ineffective.

A significant shift occurred with the advent of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in the 1950s. It aimed to classify mental health disorders based on clinical symptoms and other specific criteria, providing a standardised framework for diagnosis and collaboration among mental health professionals. The latest edition, DSM-5-TR, was published in 2022.

While the DSM has been instrumental in guiding clinicians worldwide, it has also been blamed for contributing to the over-medicalisation of mental health. The expanding diagnostic criteria have also faced significant criticism for potentially leading to over-diagnosis and for contributing to the medicalisation of normal human experiences and distress, like sadness.

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DEPRESSION – A DISORDER OR JUST A NORMAL REACTION?

Using “depression” as an example, the definition of major depressive disorder (MDD) in the DSM-5-TR includes experiencing a depressed mood most of the day, nearly every day, for at least two weeks.

By setting a relatively short time frame of two weeks, the concern is that normal, albeit intense, periods of sadness may be pathologised. The controversy was further fuelled by the removal of the “bereavement exclusion” in a previous edition of the DSM.

Critics argue that this change could lead to overdiagnosis of depression in people experiencing normal grief shortly after a significant loss. This could lead to the over-medicalisation of normal emotional experiences, and in turn, the unnecessary treatment, stigma and neglect of the social, cultural and psychological contexts in which these emotions occur.

ROLE OF DR GOOGLE

Mental health in Singapore, especially among youths, has worsened. A study by the National University of Singapore in April showed that one in 10 teenagers in Singapore suffers from at least one mental health disorder. The research also showed that youths are increasingly turning to digital media as a source of self-therapy.

Separately, data from the National Population Health Survey 2022 showed that 25.3 per cent of Singapore residents aged 18 to 29 suffered from poor mental health last year. This is an increase from 21.5 per cent in 2020. Overall, 17 per cent of Singapore residents faced mental health issues last year, up from 13.4 per cent in 2020.

As mental health literacy continues to grow, so too has the trend of self-diagnosis. The vast wealth of information available on the internet empowers individuals to educate themselves about mental health conditions, including their symptoms and available treatments.

This can provide a sense of relief and validation, as individuals gain a framework for understanding their distressing experiences which might otherwise feel overwhelming. It offers a path towards treatment and can initiate critical conversations about mental health. This is not a bad thing.

We just have to bear in mind its potential for pitfalls. Misinterpretation of symptoms, the over-pathologising of normal emotional responses and confirmation bias can lead to inaccurate self-diagnoses, which in turn can result in unnecessary anxiety, delayed professional help, or inappropriate self-treatment. 

Simultaneously, individuals may begin to perceive their emotional, psychological and behavioural responses only through a medical lens. While this can offer a form of validation and a structured approach to treatment, it can also potentially serve as a form of avoidance. By attributing all responses solely to an illness, individuals might inadvertently evade acknowledging and addressing challenging life circumstances or personal behaviour patterns.

It can become tempting, and seemingly easier, to blame a disorder for one’s actions or feelings, rather than confront the underlying issues that may be at play.

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CHICKEN OR EGG?

The relationship between the rise of digital mental health platforms and the medicalisation of emotional, psychological and behavioural responses, is a “chicken or egg” scenario. Both phenomena have evolved in parallel, raising the question: Which one is driving the other?

As conditions like depression, anxiety and ADHD have come to be seen more as medical disorders rather than personal flaws or moral weaknesses, the landscape of treatment has expanded significantly.

This expansion, in turn, has provided fertile ground for the rise of digital health platforms. Tech innovators have seized the opportunity, developing myriad apps and websites that offer self-screening for mental health conditions.

But has the rise of digital mental health platforms inadvertently encouraged a culture where everyday emotional fluctuations are seen through the lens of pathology? With these tools at our fingertips, the line between normal psychological variation and mental health disorder can blur.

The medicalisation of mental health may have set the stage for these platforms to emerge, but their prevalence may also be driving further medicalisation. Like the chicken and the egg, it’s hard to determine which came first, or indeed, which is the main driver of the other. What is clear is that these two phenomena have become intertwined in our modern understanding and approach to mental health.

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STRIKING A BALANCE

In the complex discussion on the over-medicalisation of mental health issues, it’s imperative to underline that the challenge lies in striking a nuanced balance.

On one hand, we must be cautious about over-pathologising normal emotional experiences, which could lead to unnecessary medical treatments and stigmas. On the other hand, it’s vital to not under-recognise or trivialise mental health issues that require professional intervention.

Everyone has a role to play in fostering a balanced, compassionate approach to mental health. Individuals, family members, friends and society at large contribute to the mental health landscape by recognising signs of distress, offering emotional support and encouraging professional consultation when needed. These collective efforts can significantly improve the quality of life for those navigating mental health challenges, steering them toward appropriate avenues for diagnosis and treatment.

Importantly, professional help does not automatically imply pharmacological treatment. The bio-psycho-social-spiritual model advocates for a more holistic approach to mental health care, one that encompasses not just biological but also psychological, social and spiritual dimensions of well-being.

This rounded model offers an array of interventions that can be tailored to the individual’s needs, from psychotherapy and lifestyle changes to social support and spiritual guidance. Medication becomes just one of the options, to be used when appropriate and in conjunction with other forms of intervention.

In Singapore, the newly launched National Mental Health and Well-being Strategy seems to adopt a balanced approach, providing a four-tiered model that tailors mental health services to the individual’s severity of needs. From community-led mental health promotion and peer support at the lowest tier, to specialised clinical interventions at the highest, the model offers a diverse range of care options. This design potentially minimises the risk of over-medicalisation by providing alternative paths for treatment and support, thus aligning well with the multi-dimensional approach of the bio-psycho-social-spiritual model.

Striking the right balance in mental health care is indeed a delicate task, fraught with potential pitfalls at either extreme. However, it’s a crucial endeavour for constructing a healthcare system and society that recognises, supports and nurtures the mental well-being of all its members, whatever their needs may be.

Given the multi-faceted nature of mental health, it’s important that we continue to adapt and refine our approaches, guided by ongoing research, societal changes and the lived experiences of those we aim to help.

Dr Jared Ng is Senior Consultant and Medical Director at Connections MindHealth. He was previously chief of the department of emergency and crisis care at the Institute of Mental Health.

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