By Theory Possessed   /   Spring 2023   /    Notes & Comments

Mental Medicine

Are we living in an “emergent democracy of the sick”?

Joseph E. Davis

Eugenia Kozyr/Unsplash.

Should all adults under the age of sixty-five be routinely screened for anxiety? A draft recommendation issued last fall by the United States Preventive Services Task Force, a volunteer group appointed by a division of the US Department of Health and Human Services, concluded that screening is justified by the pertinent medical literature—and that it would provide “a moderate net benefit.” Although the task force technically is independent of the government, its recommendations carry significant weight for standards of care: Health insurers, for one, are often required by the Affordable Care Act to cover services the task force recommends.

Drawing public attention to specific medical issues is another function of the task force, and its new recommendation received wide and favorable coverage in the mainstream media. The reason should not surprise us. In our “emergent democracy of the sick,” to borrow a phrase from sociologist Philip Rieff, the idea that 30 percent of Americans have an anxiety disorder and that most cases go undetected and untreated seems obvious and uncontroversial. We lack sufficient awareness of the “crisis,” Dr. Lori Pbert, a task force member and the group’s spokesperson, told the press. Citing “barriers” to treatment, she called for greater access to mental health care and “more resources to be able to meet the demand” and beef up our “undersized mental health care workforce.” More disorder, more screening, more care: the familiar talking points, all dutifully repeated.

One of those taking a sharply different view was prominent psychiatrist Allen Frances. “Dangerously dumb” was his succinct verdict. Frances chaired the task force that prepared the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published in 1994, and he has since become a critic of what he has called “out-of-control” psychiatric diagnosis. In the space of a single tweet, he offered several reasons for his negative judgment. Routine screening, he argued, would lead to a great deal of misdiagnosing. Short screening instruments yield many false positive rates, and there is insufficient time for a proper diagnosis in a typical fifteen-minute primary care visit. As a result, even more people will be inappropriately put on psychoactive medications, and since therapists are already in short supply, the “great needs” of the severely ill will be further neglected.

The members of the Preventive Services Task Force, including Dr. Pbert, are not unaware of these issues, but they remain confident that wholesale screening for anxiety will produce a net benefit.

Whence that confidence?

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