Psychiatric Stigma and a 2018 Game Changer
Image: Game by John R Perry (CC0)
Synopsis: Mental health stigma exists. Many people fear labels or how they will be viewed if those labels are applied to them. It's a real concern, but things are getting better. Consider the 2018 changes at a national level in the US allowing for treatment of symptoms rather than classified psychiatric diagnoses. That's one step in the right direction. Mental health parity is the next step needed.
BY LEN LANTZ, MD / 1.2.2020; No. 2 / 6 min read
Disclaimer: Yes, I am a physician, but I’m not your doctor, and this article does not create a doctor-patient relationship. This article is for educational purposes and should not be seen as medical advice. You should consult with your physician before you rely on this information. This post might also contain affiliate links. Please click this LINK for the full disclaimer.
Why does mental health stigma exist?
I’ve been thinking a lot about what causes mental health stigma. One of the causes is simply that our society sees mental illness as different than physical illness. It’s crazy, really, because the brain is the most important organ of the body. But when it comes to talking about mental illness people feel unsettled.
Consider this: let’s say that you have asthma. You’re not labeled or shunned as an “asthmatic.” You are simply normal and asthma is a problem that you have to deal with. You can’t breathe well without your inhaler. But using your inhaler is not seen by others as a “crutch.” No one expects you to be able to change your asthma via willpower. And no one sees you as cognitively, emotionally or spiritually weak because you have asthma.
At the end of the day, there is not much stigma when it comes to having asthma. Contrast that to depression or attention deficit hyperactivity disorder (ADHD). Lots of ignorant people question whether depression or ADHD actually exists. They think that someone should be able to change their diet or thought patterns or show enough willpower so that they no longer have depression or ADHD. When a person has one of these conditions, they are told by others that they are using the medication as a “crutch” and therefore are weak or lazy.
I don’t see having a psychiatric diagnosis as being any different than any other medical diagnosis. People with mental health conditions are normal. The condition is simply a problem that they are responsible for dealing with. If you choose to use a psychiatric medication, it is not a “crutch.” Just like inhalers, psychiatric medications are tools. A tool is simply something that you use or don’t use. If you use it, you will probably get benefits but you may also get side effects. If you need it and don’t use it, you likely will suffer.
Here comes the blasphemy
There is a grey area when it comes to psychiatric illness. Not all psychiatric symptoms represent a mental illness. People can go to their primary care doctor and receive medical care for general diagnoses for dry skin, headache, or fatigue. People also should also be able to get treatment for general mental health concerns, such as anger, aggression, or self-injurious behavior without being labeled with a psychiatric illness. People should be able to seek and receive help for symptoms of mental illness that do not necessarily meet criteria for mental illness. I believe people should be able to see their doctor or counselor for emotional and/or behavioral problems, and, as appropriate, have their listed diagnoses be the symptoms that brought them to their doctor.
It seems logical, right? We should be able to go to a doctor or counselor for anger and just leave it at that, so why can’t we do that in America? Money. Medical/psychiatric care does not occur in the US unless someone – usually your health insurance – pays for it. To get effective treatment for a mental health symptom in the US, you need to get labeled with a disorder. Don’t get me wrong – mental illness exists, but people should be able to reach out and get help before a condition worsens to the point of mental illness.
Think about it. There is no middle ground or grey area for diagnosis or help. You are either normal or darn crazy. This aspect of mental health stigma may prevent many who need psychiatric care from seeking it. People are worried about labels. As a specific example, many gun owners are worried about being labeled with a psychiatric disorder if it may one day restrict their right to gun ownership. If there are gun owners out there who would feel comfortable seeking help for “anger” but not “Intermittent Explosive Disorder,” wouldn’t you want them to seek help? There are hundreds of other specific examples of why someone would want to avoid receiving a major psychiatric diagnosis. What our society needs is for people to seek treatment prior to their problems becoming severe.
The extremes between psychiatric diagnosis and the rest of medicine
The 10th revision of the International Classification of Diseases, or ICD-10 for short, is what insurance companies use to pay for health care, and allows a person to seek and receive help for almost any non-psychiatric medical condition, such as being assaulted by a box turtle (W59.22XA: Contact with turtles, struck by turtle, initial encounter). Whereas if a child bites another child at daycare, what are the diagnosis and code? Clearly biting others is not normal, often leads to the biter getting kicked out of daycare, and scares the victim and his or her parents. If ICD-10 had kept pace with mental health as it has with box turtle assaults, a physician would be able to diagnose and code something like, “Little dude bites other little dudes when provoked, initial encounter (W.6.66).” Instead, our diagnostic options include Intermittent Explosive Disorder or the broadly inclusive diagnosis of “Unspecified Disruptive, Impulse-Control, and Conduct Disorder.” It would be more accurate and less stigmatizing to be able to give specific diagnoses for specific behaviors, emotions or thoughts, as appropriate. There are just over 300 mental health codes in ICD-10 out of 68,000 total codes. Not all significant emotional, thought and behavioral problems can be boiled down to about 300 diagnoses (400 diagnoses if you include the “bonus” codes called the Z-codes).
It is a popular misconception that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is responsible for psychiatric diagnoses in American medicine. This is not true. DSM-I to today’s DSM-5 all have been based on ICD. If you don’t believe me, just read the first 10 pages of DSM-5. The National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS) are federal agencies which adapt and approve ICD for use in the U.S. ICD is owned and produced by the World Health Organization (WHO), which has done some tremendous and amazing things in promoting health and reducing disease burden across the world, but I think they have it wrong (or had it wrong) when it comes to mental health.
True story
In 2014, I was thinking about this idea of trying to promote changes within ICD-10 and the World Health Organization. I actually wrote a letter to the WHO pointing out the stigma and barriers to health that mental health diagnoses create in our society. I reached out to them with this idea that people should be able to receive care for any concern related to mental health, whether it be anger, jealousy or excessive spending. I went through various websites and reached out to experts in Geneva Switzerland and the response I got was… radio silence. My conclusion in 2014: whether or not you can reach out to a US therapist or doctor in a confidential manner about a mental health or behavioral concern is determined by people who make decisions in Europe.
One of the biggest events in psychiatry just flew under the radar…
Something amazing happened since my grandiose failed attempt in 2014 to change ICD-10. There was no fanfare. No one tweeted about it from Washington DC. I just found out about it when fact-checking this article. On October 1, 2018, the United States government approved the use of some new ICD-10 diagnosis codes for mental health concerns that are not recognized as illnesses by the field of psychiatry. There was no big announcement by the American Medical Association (AMA) or the American Psychiatric Association (APA). There was just some really smart person at the federal level who turned on the codes to benefit all Americans. In the US, you can now receive treatment for the following concerns [cue drumroll…]:
Nervousness (R45.0)
Restlessness and agitation (R45.1)
Unhappiness (R45.2)
Demoralization and apathy (R45.3)
Anger and irritability (R45.4)
Hostility (R45.5)
Violent behavior (R45.6)
State of emotional shock and stress, unspecified (R45.7)
Other symptoms and signs involving emotional state (R45.8)
Intentional self-harm by unspecified sharp object, initial encounter (X78.9XXA)
Pinch me. Am I dreaming?
The first edition of DSM (based on ICD-6) was published in 1952. At the time of this article that I am writing today, 68 years have passed. We now have broken through the stigma of mental health diagnoses. In America, you now can receive mental health treatment for a concern/symptom rather than a psychiatric diagnostic label. Wow!
What you can do
If this is important to you, one of the first things you can do is educate your primary care physician (PCP) about the ICD-10 changes that have taken place and inform him or her that you want treatment for your primary concern, not for a stigmatizing label. You can educate your local doctors and psychiatrists about this change in American medical coding and diagnoses because they likely have not heard anything about this issue from the AMA or APA.
Imagine getting quality mental health treatment (medication and/or psychotherapy) for a diagnosis that is no more specific or stigmatizing than “nervousness”, “unhappiness” or “irritability.” Picture yourself reaching out for help and feeling unafraid to do so because you will not be labeled, shunned or have your civil rights curtailed for doing so.
What needs to be done
We still need mental health parity in the US. There are loopholes for avoiding our mental health parity laws. There is likely another fight to take on which is getting access to mental health services for the above non-stigmatizing diagnostic codes. Others have argued that insurance companies are balancing their books and making their profits by denying payment for psychiatric services. Do not be surprised if your insurance company will not reimburse medical treatment (medications and psychotherapy) for the newly approved treatment codes above. We still need to fight for mental health treatment to be covered by insurance companies at the same level as the rest of medicine.
If you have concerns about loopholes that have been created to allow companies and organizations to ignore/bypass federal mental health parity laws (such as “self-funded” ERISA health insurance plans), please read my article “The Strengthening Behavioral Health Parity Act (SBHPA): An Enormous Step Forward in Mental Health Parity.”
For further reading, check out:
My article “Does a Psychiatric Diagnosis Even Matter?”
My article “Finding a Good Psychiatrist”
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) by the APA (See Len’s Book Review)
