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Disorders Without Borders? The Expanding Scope of

Psychiatric Practice

Nikolas Rose

Biosocieties / Volume 1 / Issue 04 / December 2006, pp 465 - 484

DOI: 10.1017/S1745855206004078, Published online: 05 December 2006

Link to this article: http://journals.cambridge.org/abstract_S1745855206004078

How to cite this article:

Nikolas Rose (2006). Disorders Without Borders? The Expanding Scope of Psychiatric Practice.
Biosocieties, 1, pp 465-484 doi:10.1017/S1745855206004078

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BioSocieties (2006), 1, 465–484 ª London School of Economics and Political Science
doi:10.1017/S1745855206004078

Disorders Without Borders? The

Expanding Scope of Psychiatric Practice
Nikolas Rose
Department of Sociology, London School of Economics and Political Science, Houghton Street,
London WC2A 2AE, UK
E-mail: n.rose@lse.ac.uk

Abstract
There has been much recent debate and controversy over the apparent expansion of the use of cer-
tain psychiatric classifications, and the treatment of those so diagnosed, in particular their treatment
with psychiatric drugs. Some have suggested that this arises from ‘disease mongering’ by a pharma-
ceutical industry keen to sell its products. Others have implied that psychiatrists are the key agents,
acting as ‘moral entrepreneurs’ claiming that society is ignoring an area of suffering that they are
best placed to understand and treat. Others have suggested that the expansion is part of a social
and cultural malaise, in which individuals increasingly define problems of living as disorders in
need of treatment. This article reviews the evidence of the expanding scope of psychiatric diagnosis,
focusing on depression, attention deficit hyperactivity disorder and personality disorder. It examines
a number of arguments that seek to account for this expansion and suggests that we need a more
complex approach to understand the growth of these diagnoses, not only addressing marketing
of drugs by pharmaceutical industry and the role of doctors, but also examining the pressures
and incentives that lead to the ascription of such diagnoses and their treatment with drugs.

Keywords diagnosis, epidemiology, medicalization, psychiatry, psychopharmaceuticals

Thank you for inviting me to present the 18th Aubrey Lewis Lecture—it is an honour to pay
respect to the lasting relevance of his work.1 It was at Sussex University in 1967, reading
Michel Foucault’s Madness and civilization (1967), that I first came across the name of
Aubrey Lewis. I like to think that I first read the piece that opens his 1967 collection The
state of psychiatry—a review of the French publication of Foucault’s Histoire de la folie à
l’âge classique.2 It ends thus:

Since the Age of Reason came to a close the face of psychiatry has changed: no one
could doubt that it has changed for the better. But how much of this change is the

Nikolas Rose is the Martin White Professor of Sociology at the London School of Economics and Political Science,
and Director of the BIOS Centre for the Study of Bioscience, Biomedicine, Biotechnology and Society. His most
recent book is The politics of life itself: Biomedicine, power, and subjectivity in the twenty-first century (Princeton
University Press, 2006).

1 This is a transcript of the 18th Aubrey Lewis Lecture, given at the Institute of Psychiatry, Kings College, Univer-
sity of London, on 2 February 2006. I would like to express my thanks to Dr George Szmukler, Dean of the Insti-
tute, for inviting me to give this lecture and his generous introduction, and Prof. Simon Wessely for stimulation,
sources and his kind words at the event.
2 Foucault’s original text is now translated as History of madness (2006).

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work of doctors and how much the product of the Zeitgeist, or rather of social and
technological movements working powerfully on the course of human affairs? . . .
[M. Foucault’s] brilliant book, erudite but overloaded with antithesis and abstruse
generalizations, is the most original contribution that has been made to the wretched
story of unreason in the Age of Reason. Carried to a later period, his studies might
illuminate problems that have contemporary urgency. (Lewis, 1967b: 8)

What would it mean to answer this challenge, to carry his studies to our own period and to
address issues that have contemporary urgency? And what, in our recent history, has
resulted from the work of doctors, and what from other social and technological move-
ments? To undertake this task, we would need to grasp the distinctions between the work
of psychiatry today and its role in the Age of Reason. Ours is, it is true, still an age of con-
finement, perhaps a new age of confinement, with the construction of a whole archipelago
of ‘secure’ institutions for those thought too risky to share our everyday world. This tells us
something about the limits of normality in our age of choice, consumption, autonomy, self-
advancement and personal responsibility—our Age of Freedom. But it is not this carceral
logic that I want to talk about tonight.
Histoire de la folie argued that psychiatry was born in the asylum. It was the asylum that
gathered together all those heterogeneous individuals that, for 150 years, psychiatry tried to
arrange in a single classificatory scheme. What else linked together the uncontrollably mis-
erable, the sexually promiscuous, the blasphemers, alcoholics and gamblers, the deluded and
the demented? What except the walls of the asylum? What except the fact that, in an age of
wage labour, urban existence, domesticated family life and the habits of civility, these were
individuals who could not meet the obligations of civilization?
The modern age of diagnostic classification began in the asylum. Up through the first
half of the twentieth century, those who would be the proper subjects for psychiatric atten-
tion were those who inhabited its enclosed spaces. But today, the diagnostic manuals are no
longer confined by the walls of the asylum. Their categories and dimensions seem to cap-
ture, not a small pathological minority but almost all of us. Psychiatric diagnostics includes
a multitude of conditions that are on the borders of normality—anxiety, panic, mild to
moderate depression, personality disorder and, of course, the disorders of childhood such
as attention deficit hyperactivity disorder (ADHD), conduct disorder and autism spectrum
disorder. Diagnosis leads to treatment, which usually entails the prescription of a psychiatric
drug. Such drugs are created and marketed by large pharmaceutical companies, required to
increase their market share and maximize shareholder value. And our public health bodies
argue that many of us who deserve such treatment do not get it, that this ‘burden of disease’
has a major impact on economy and society. Hence my title: ‘disorders without borders?’
Are doctors and psychiatrists too ready to diagnose disorder for variations in mood or
behaviour that would once have been considered part of the normal ups and downs of
life? Or is it the reverse—is there much undiagnosed and untreated psychiatric illness,
demanding greater disease awareness among professionals and public, more effective diag-
nosis, and the ready provision of appropriate psychiatric drugs? If so, has there always
been such a high prevalence, or does this arise from the particular pattern of stresses in
our ‘postmodern’ age? Or, perhaps, there is a third possibility—that we in the West have
become too ready to reach for medical fixes to the difficulties of our children, to our own
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unhappiness or to the troublesome behaviour of others, in pursuit of contentment or adjust-

ment? The question of the proper scope of psychiatry was one to which Aubrey Lewis
returned on many occasions.
I must immediately disappoint you—I do not have many answers to these questions! But
they do link to a related question. What kinds of beings have we human beings become?
And what does it cost us, individually and collectively, to have become such creatures?
Many thinkers in the early twentieth century answered in terms of a ‘civilizing process’ of
increasing constraints imposed on basic instincts by the organization of complex societies.
Some saw this as the basis for a critique of the constraints of civilization, the hope for an
escape into freedom. I take the opposite view—freedom as a form of life exacts its own
costs. Is the contemporary expanded role of psychiatry part of those costs of our own Age
of Freedom?

An expanding problem
Health, as Lewis reminded us in his 1953 lecture to the British Sociological Association is a
‘social concept’:

the doctor is not necessarily acting outside his proper scope if he attends to people
who are not ill. . .. Extension of the doctor’s province has gone very far in psy-
chiatry. . .. He is nowadays often, and quite properly, asked to investigate and treat
disturbances of behaviour in children which can hardly be included within any war-
ranted conception of illness. . .. He may likewise investigate or treat criminals, drug
addicts, prostitutes and sexual perverts. It may be that there is no form of social devia-
tion in an individual which psychiatrists will not claim to treat or prevent—the preten-
sions of some psychiatrists are extreme. That time has not come, fortunately. (in
Lewis, 1967b: 190)

He added that coda in 1953; but, 50 years on, has that time now come?

In 2001 the World Health Organization (WHO) published Mental health: New under-
standing, new hope, to draw attention to the public health issues raised by rates of mental
disorders across the world. It estimated that more than 25 per cent of people are affected
by mental disorders at some point in their lives. It claimed that depression affects over
340 million people worldwide. It predicted:

By the year 2020, if current trends for demographic and epidemiological transition
continue, the burden of depression will increase to 5.7% of the total burden of dis-
ease, becoming the second leading cause of DALYs [disability adjusted life years]
lost. Worldwide it will be second only to ischemic heart disease for DALYs lost for
both sexes. In the developed regions, depression will then be the highest ranking cause
of burden of disease. (WHO, 2001: 30)

Other reports paint a similar picture. In the US, in June 2005, Kessler and his colleagues,
on the basis of a household survey of over 9,000 people, using a diagnostic interview,
reported that, in any one year, 26.2 per cent of adult Americans reported having symptoms
that would qualify them for a DSM-IV diagnosis of mental disorder, with the anxiety
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Table 1. 12-month and lifetime prevalence of disorders in 9,282 respondents

Disorder 12-month prevalence (%) lifetime prevalence (%)

Anxiety disorders
Panic disorder 2.7 4.7
Agoraphobia without panic 0.8 1.4
Specific phobia 8.7 12.5
Social phobia 6.8 12.1
Generalized anxiety disorder 3.1 5.7
Post-traumatic stress disorder 3.5 6.8
Obsessive compulsive disorder 1.0 1.6
Separation anxiety disorder 0.9 5.2
Any anxiety disorder 18.1 28.8
Mood disorders
Major depressive disorder 6.7 16.6
Dysthymia 1.5 2.5
Bipolar I and II disorders 2.5 3.9
Any mood disorder 9.5 20.8
Impulse control disorders
Oppositional defiant disorder 1.0 8.5
Conduct disorder 1.0 9.5
Attention deficit/hyperactivity disorder 4.1 8.1
Intermittent explosive disorder 2.5 5.2
Any impulse control disorder 8.9 24.8
Substance disorders
Substance disorder (any) 3.8 14.6
Any disorder
Any 26.2 46.4
1 disorder 14.4
2 disorders 5.8 27.7
3 or more disorders 6.0 17.3

Source: Kessler (2005a, 2005b)

disorders leading at 18.1 per cent, followed by mood disorders, notably depression, at 9.5 per
cent and impulse control disorders at 8.9 per cent—a total of over 57 million Americans diag-
nosable with mental disorder in any one year (Kessler et al., 2005; see Table 1). And they
concluded that ‘About half of Americans will meet the criteria for a DSM-IV disorder some-
time in their life, with first onset usually in childhood or adolescence’ (Kessler et al., 2005a).
The belief that around half of the population will meet the criteria for a mental disorder
at some time in their life was originally proposed by Kessler and his colleagues a decade ago
(Blazer et al., 1994; Kessler et al., 1994; Wittchen et al., 1994). It is not a peculiarly Amer-
ican perception. In 2005, a Task Force of the European College of Neuropsychopharmacol-
ogy on ‘The Size and Burden of Mental Disorders in Europe’ reported the results of a series
of studies that aimed ‘to reach a consensus on what we know about the size, burden and
cost of ‘‘disorders of the brain’’ in each European country and—ultimately—in Europe as
a whole’ for a total of 20 mental and neurological disorders (Wittchen et al., 2005: 355).
The results were truly alarming (see Table 2).
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Table 2. Size and burden of mental disorders in Europe

Estimated number of subjects in the general EU population (age 18–65) affected by mental disorders with past
12 months

Diagnosis (DSM -IV) 12-month estimate (%) 12-month estimate (million)

Alcohol dependence 2.4 7.2
Illicit substance dependence 0.7 2.0
Psychotic disorders 1.2 3.7
Major depression 6.1 18.4
Bipolar disorder 0.8 2.4
Panic disorder 1.8 5.3
Agoraphobia 1.3 4.0
Social phobia 2.2 6.7
Generalized anxiety disorder (GAD) 2.0 5.9
Specific phobia 6.1 18.5
Obsessive-compulsive disorder (OCD) 0.9 2.7
Somatoform disorders 6.3 18.9
Eating disorders 0.4 1.2
Any mental disorder 27.4 82.7

Source: Wittchen and Jacobi (2005).

Some 27 per cent or 82.7 million of the adult European Union (EU) population (18–65
years of age):

. . . is or has been affected by at least one mental disorder in the past 12 months.
Taking into account the considerable degree of comorbidity (about one third had
more than one disorder), the most frequent disorders are anxiety disorders, depressive,
somatoform and substance dependency disorders. . .. Only 26% of cases had any con-
sultation with professional health care services, a finding suggesting a considerable
degree of unmet need. (Wittchen and Jacobi, 2005: 357)

And the editorial of this special issue summed up the situation thus:

Even though only a restricted range of all existing mental and neurological disorders
from the ICD 10 or the DSM-IV was considered, there is clear evidence that more
than one-third of the adult EU population is or has been affected by at least one dis-
order in the past year, or 50% of the EU population . . . if lifetime risk is considered. . ..
[M]ental disorders are associated with immense costs of over 290 billion Euros, the
majority of which were not healthcare costs. (Wittchen et al., 2005: 355–356)

The message is self-evident—we need more research, earlier diagnoses, better treatment,
and education and training of policy makers and the public about this public health pro-
blem. This report was one basis for the European Commission (EC) Green Paper, Improving
the mental health of the population: Towards a strategy on mental health for the European
Union, which estimated that ‘mental ill health costs the EU an estimated 3%–4% of GDP,
mainly through lost productivity’ (EC Health and Consumer Protection Directorate-
General, 2005: 4) and proposed a strategy to promote the mental health of all (2005: 8).
It would be difficult to disagree. But how has this perception arisen at the start of the
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Fig. 1. Antidepressant prescribing USA: 1990–2001 in standard dosage units

Source: IMS Health

twenty-first century? A perception of a Europe, indeed a world, so ravaged by mental ill

health that a diagnosable mental disorder afflicts every third person each year, of whom
probably two-thirds remain undiagnosed and untreated. Is it, perhaps, something to do
with those ‘risk factors’ identified by the WHO and repeated in that Green Paper—access
to drugs and alcohol; displacement; isolation and alienation; lack of education, transport,
housing; neighbourhood disorganization; peer rejection; poor social circumstances; poor
nutrition; poverty; racial injustice and discrimination; social disadvantage; urbanization;
violence and delinquency; war; work stress; unemployment (WHO, 2004b: 21). A doleful
and familiar list, it is true. But can these travails have really become more intense, in this,
the most wealthy and healthy of all parts of this planet in the most wealthy and healthy cen-
tury of human existence. If not that, then what? Has the population of Europe, indeed the
world, always been so beset by undiagnosed mental illness? Or, as I will suggest, do these
figures arise from something else? But first, some more data.
Consider, first, depression. I have already noted the WHO’s predictions about the rising
worldwide burden of depression. The US National Institute of Mental Health (NIMH) esti-
mates that in any given one-year period, 9.5 per cent of the population, or about 18.8 mil-
lion American adults, suffer from a depressive illness. But perhaps the most telling evidence
comes from other statistics: the use of medication for the treatment of depression. While
there is no direct correlation between prescribing data and prevalence, prescribing data
does index a certain kind of perception as to the existence and nature of a treatable malaise
(Rose, 2004).3 Over the decade from 1990 to 2000, the overall psychiatric drug market
increased by 126 per cent in Europe and a phenomenal 638 per cent in the United States,
where, by 2000, the value of sales of prescribed psychiatric drugs amounted to almost

3 The figures that follow, and those represented in Table 1, are from a specially commissioned study carried out by
IMS Health for ‘The Age of Serotonin’ research project at Goldsmiths College, University of London, funded by
the Wellcome Trust Programme in Biomedical Ethics. More detailed analysis is given in Rose (2004).
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$19 billion. The growth of actual doses of psychiatric medication prescribed from 1990 to
2000 is less marked—an increase of 26.9 per cent in Europe and 70.1 per cent in the United
States. In both the UK and the USA, the key growth area has been the antidepressants, with
prescriptions of these drugs increasing by around 200 per cent over the decade. In the USA,
the SSRI family of antidepressants shows a spectacular rise of over 1,300 per cent. But the
traditional antidepressants also rise, and by 2001 they still amounted to 48 per cent of the
total antidepressant market.
Let me turn to anxiety. In 1999, the NIMH estimated that 19 million Americans aged
18 to 54, or 9.5 per cent of the population, were thought to have anxiety disorders—
encompassing panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder,
phobias such as social phobia (5.3 million Americans), and generalized anxiety disorder
(some 4 million Americans). This is not just a matter of interest to the health professionals.
A recent ‘Stakeholder Insight’ report, for example, entitled Anxiety disorders—More than
just a comorbidity, is available online at the price of just £8,000. It notes that:

. . . anxiety disorders are considered the most prevalent of psychiatric disorders. How-
ever, poor diagnostic rates and treatment outcomes mean there is still consider scope
for manufacturers to move into the anxiety market. . .. Despite a fifth of the total
population across the seven major markets suffering from an anxiety disorder only
a quarter of these individuals are diagnosed and therefore treated. As a result, drug
manufacturers are failing to maximize revenues from the anxiety disorders market.
Investment in awareness campaigns is essential. (Datamonitor, 2004)
And we are given the following key reasons for reading the report:

Assess the size of the drug-treated population by gaining an understanding of the pre-
valence of anxiety with comorbid psychiatric disorders; Target physicians more effec-
tively, through an understanding of prescribing behavior; Identify commercial
opportunities by benchmarking current products and assessing unmet needs and
future market potential. (Datamonitor, 2004)

I want to turn to the disorders of children, but before I do so, let me say a few words
about personality disorder. Studies of non-patient populations since the 1980s, using
DSM criteria, have reported prevalence rates of personality disorder of between 9 and 13
per cent (Samuels et al., 2002). The 2001–02 National Epidemiologic Survey on Alcohol
and Related Conditions (NESARC), which administered a standardized diagnostic instru-
ment to 43,093 adults aged over 18 in the US, reported that almost 15 per cent of Ameri-
cans, or 30.8 million adults, met DSM-IV diagnostic criteria for at least one personality
disorder (Grant et al., 2004). The most common disorders were obsessive-compulsive per-
sonality disorder (16.4 million people), followed by paranoid personality disorder (9.2 mil-
lion) and antisocial personality disorder (7.6 million). Other personality disorders affecting
substantial numbers of Americans were schizoid (6.5 million), avoidant (4.9 million), his-
trionic (3.8 million) and dependent (1 million) (Bender, 2004). They excluded borderline,
schizotypal and narcissistic disorders, but NIMH estimates that ‘borderline personality dis-
order’ alone affects a further 5.5 million Americans (NIMH, 2001).
In DSM-IV, a personality disorder is defined as ‘‘an enduring pattern of inner experience
and behavior that deviates markedly from the expectations of the individual’s culture, is
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pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time,
and leads to distress or impairment’’ (DSM-IV: 629). Here we can glimpse some of the
dynamics behind these figures. DSM criteria require judgements of thought and behaviour
against expectations and ascribe deviations to individuals. Outside clinical settings, non-
therapeutic judgements by interviewers play a key role in transforming a set of interview
responses into a diagnosis. In this context, then, I cannot agree with the WHO that ‘Mental
and behavioural disorders are identified and diagnosed using clinical methods that are simi-
lar to those used for physical disorders. . .. Mental disorders can now be diagnosed as reli-
ably and accurately as most of the common physical disorders’ (WHO, 2001: 22). I will
return to this presently.
If adults, today, seem so afflicted by mental ill health, so too do children. Across
the twentieth century, we witnessed the discovery of all those minor mental troubles of chil-
dren, which became understood in terms of maladjustment or childhood neuroses, which, if
left untreated, might develop into frank mental illness—the field of child guidance clinics
and later of child psychiatry. But what of today? In December 2005, the American media
carried alarming figures from a report based on a survey of 70,000 people in the United
States using DSM criteria: apparently nearly 1 in 10 American teenagers, or 2.2 million,
experienced major depression in 2004 although less than half had talked to a medical pro-
fessional about this (Substance Abuse and Mental Health Services Administration
[SAMHSA], 2005). Again, this is not a uniquely American phenomenon. ‘Some two million
young people in the European Region of the World Health Organization (WHO) suffer
from mental disorders ranging from depression to schizophrenia’ opens the briefing paper
to the WHO Ministerial Conference on Mental Health held in Helsinki in January
2005—a paper that has, as its epigraph, a comment from the former WHO Director
for Child and Adolescent Health, Hans Troedsson: ‘it is a time bomb that is ticking’
(WHO, 2004a). These are not the mild neuroses of child guidance—bed wetting, night
terrors, separation anxiety, fear of the dark and the like. Amongst the most prevalent
disorders, according to this report, are depression, suffered by 4 per cent of 12- to
17-year-olds and 9 per cent of 18-year-olds; conduct disorder, apparently a condition that
has increased over five-fold in the past 70 years in Western countries; eating disorders;
post-traumatic stress disorder, diagnosed frequently in areas of Europe such as the Balkans;
and attention deficit hyperactivity disorder—the last being the only category which the
paper considers a ‘controversial diagnosis surrounded with concerns about context’
(WHO, 2004a: 2).
ADHD has indeed become the most ‘controversial’ disorder on the border. It is well
known that it is more frequently diagnosed and treated in the USA than elsewhere in the
world, leading to the suggestion that it is what the anthropologists would term a ‘culture-
bound syndrome’. The US still uses over 90 per cent of the world’s supply of methylpheni-
date and dexamphetamine, the two drugs commonly used for those so diagnosed. In the dec-
ade from 1990 to 2000, in the United States, prescribing rates for these psychostimulants
rose eight-fold (Rose, 2004). Olfson et al. report, on the basis of a nationally representative
survey of medical treatment in the US, that between 1987 and 1997:

the rate of outpatient treatment for ADHD increased from 0.9 per 100 children in
1987 to 3.4 per 100 children in 1997. This corresponds to an estimated increase
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from approximately 493,000 treated children in 1987 to 2,158,000 treated children in

1997. (Olfson et al., 2003: 1073)

This occurred despite a decrease in the proportion of children in the United States who
received non-hospital medical treatment: most of the children were treated with psychosti-
mulant medication. This trend has continued—in Virginia in 2003, 17 per cent of school
pupils were diagnosed with ADHD.
In Great Britain, the 2000 survey of the mental health of children and adolescents, reported
a much lower prevalence—only 1.4 per cent of children in England, Scotland and Wales could
be diagnosed with hyperactivity disorder, although 10.4 per cent apparently had some kind of
mental disorder, the most common being conduct disorder and emotional disorders at 4.3 per
cent (Meltzer et al., 2000). But a recent NHS audit of children’s health in Scotland reported
that, between 1996 and 2003, prescriptions of Ritalin for 6- to 14-year-olds went up nine-
fold, from 69.1 to 603.2 per 10,000 population: it estimated that about 5 per cent of Scottish
children ‘had ADHD’ (National Health Service Quality Improvement Scotland, 2004; for
data from elsewhere see Fogelman et al., 2003; Miller et al., 2001).
Now consider a 2005 report from Espicom Business Intelligence:

The value of the ADHD market was US$2.4 billion in 2004. . .. Global sales of ADHD
[sic] are forecast to reach US$3.3 billion by 2010. This will be due to greater penetra-
tion in the treatment of new patients particularly adult ADHD, improvements in
patient compliance . . . and the development of novel classes of drugs in late-stage
clinical trials. . .. Over 8 million adults in the US may exhibit the symptoms of
ADHD, while only an estimated 600,000 are being treated. . ..
The ADHD market is still in its infancy and is a classic example where a niche
market has been exploited by biotechnological companies and pharmaceutical
companies, having recognized its potential, are launching new agents to capitalize
on future growth. (Episcom Business Intelligence, 2005)

Other psychiatric medications are also being prescribed to children in increasing

quantities. Wong and Murray found that, between 2000 and 2002, there were rising
trends in prescribing antidepressants, stimulants, antipsychotics, benzodiazepines and
other anxiolytics in all seven countries they studied—the UK, France, Germany, Spain,
Argentina, Brazil and Mexico, as well as in the US and Canada, with the lowest percentage

Table 3. Psychotropic drug prescribing: prescription rates increases 2000–02 for under-18s.

Germany 13%
Canada 15%
France 30%
United States 30%
Spain 48%
Brazil 49%
Argentina 54%
Mexico 56%
United Kingdom 68%

(Source: Wong et al., 2004)

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increase in Germany, at 13 per cent, and the highest in the UK, at 68 per cent (Wong et al.,
2004).
In 2006, a study of trends in the prescription of psychotropic medications to adolescents
aged 14 to 18 years in office-based care in the United States from 1994 to 2001—based on
data from an official national survey—claimed that visits that resulted in a psychotropic pre-
scription increased from 3.4 per cent in 1994–5 to 8.3 per cent in 2000–01, with increases
especially evident after 1999. By 2001, one out of ten office visits to doctors by adolescent
males in the US resulted in a prescription for a psychotropic medication (Thomas et al.,
2006).
Enough of these figures. I think you get the picture!

Accounting for expansion

How should we make sense of such data? Can it really be that half of us, over our lifetimes,
will suffer from a mental disorder? Of course, we wouldn’t be surprised if half of us, in our
lifetimes, suffered from a physical disorder—indeed we would be surprised if this was not
so. And we would want to make health services available to all and be scandalized if only
a quarter of those conditions were treated. Yet we are troubled by such a perception of pre-
valence of mental disorders. Why? Is this a residue of an earlier age of stigma? A throwback
to an earlier age of anti-psychiatry? A suspicion of the very idea of a mental disorder? A
belief that this perception serves some interests but not others? A specific worry about
drug treatment? Or is it, perhaps, the sense that the very idea of normality or mental health
is at stake.
In what follows, I would like to explore five interlinked hypotheses that might account
for the perceptions of the rates of mental disorder that I have sketched.
* first, that, in reality, there is more mental disorder today than in previous times;
* second, that we are more aware of mental disorder and better at recognizing it;
* third, that this arises from what the sociologists term ‘moral entrepreneurship’ on the part
of psychiatrists as passionate advocates for a cause they believe in: a neglected source of
misery only they can identify and conquer;
* fourth, today’s favourite culprit, ‘Big Pharma’ —that it is the pharmaceutical companies,
in a cynical search for market share, profit and shareholder value, who, in a multitude of
ways, are distorting our perception and treatment of mental disorder;
* fifth, that this arises from a reshaping of our discontents in a psychiatric form—perhaps
even a psychiatrization of the human condition itself.

Hypothesis 1: There is just more of it about

The perception that mental disorder is on an alarming upward trend because of the condi-
tions of modern life has been a recurrent theme since at least the birth of psychiatry in the
nineteenth century. Aubrey Lewis himself points this out in his classic paper on Social Psy-
chiatry, which he delivered in 1957:

It has long been customary to assert that mental disorder is on the increase, because of
the more and more complex strains which society imposes on its members. A hundred
and thirty years ago the psychiatrist Esquirol read a paper in Paris on the
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question: ‘Are there more madmen today than there were forty years ago?’ There was
then widespread alarm at ‘the [f]rightful increase of insanity’, which people said
menaced France with calamity. In his admirable review Esquirol showed that the
alleged increase was spurious; more people had come into hospitals, but . . . the repu-
tation of the asylums had changed from that of cruel prisons to humanely conducted
hospitals. Many quiet patients who would not formerly have been sent to these insti-
tutions were now admitted and came willingly. Hence the apparent increase. (in
Lewis, 1967a: 263)

Most social scientists are similarly unconvinced that the rise in psychiatric diagnoses
reflects a ‘frightful increase’ in mental disorder. There is good evidence that poverty, poor
housing, stressful working experiences and the like are associated with increased rates of
psychiatric morbidity. But I don’t think we can extrapolate historical trends from this, or
agree that contemporary social conditions are more pathogenic than those of earlier times.
To be blunt, the question ‘Is there more mental disorder today than before?’ is impossible to
answer because our own notions of normality and mental disorder are inescapably histori-
cally and culturally specific.

Hypothesis 2: We are just better at recognizing it

Do mental disorders simply await their recognition by adequate diagnostic schemes? I don’t
think so. Our perception of ‘mental disorder’ today bears little relation to that in other times
and places. From the mid-nineteenth to the mid-twentieth century, the walls of the asylum
marked a distinction between two empires, that of madness and that of nervous disorders,
the property of different explanatory systems, different institutions, different cultural under-
standings, different authorities. This distinction weakened in the mid twentieth century,
with the unlocking of wards, day hospitals, out-patient provision and so forth. From the
1980s, community psychiatry multiplied the sites for the practice of psychiatry—in psychia-
tric wards in general hospitals, special hospitals, medium secure units, day hospitals, out-
patient clinics, child guidance clinics, prisons, children’s homes, sheltered housing, drop-in
centres, community mental health centres, domiciliary care by community psychiatric
nurses, schools and, of course, in the general practitioner’s surgery. This blurred the distinc-
tion between psychiatric professionals who treated the mentally ill and those who treated
what once were termed ‘neuroses’ —the complaints of those who were unable to function
according to the norms and expectations of the various departments of life. In short,
more and more people and problems were opened up to the diagnostic gaze and therapeutic
interventions of psychiatry (Rose, 1986).
This changing territory of psychiatry has been embodied in diagnostic manuals and clas-
sifications across the second half of the twentieth century. Many of a psychoanalytic persua-
sion in the US, and many social psychiatrists in the UK, argued that that there was no clear
distinction between normality and mental illness, that, as Karl Menninger put it, ‘most peo-
ple have some degree of mental illness at some time, and many of them have a degree of
mental illness most of the time’ (Menninger et al., 1965: 33). This expansion of the psychia-
tric gaze, embodied in the first and second Diagnostic and Statistical Manuals published
in 1952 and 1968, was one element in criticisms that psychiatry was simply medicalizing
difference and was an apparatus of social control. Some suggest that the publication
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of DSM-III in 1980 was a response to that criticism (Wilson, 1993). It stressed that that
diagnosis must be based on a pattern of symptoms that was not merely an expectable
response to an event, but a manifestation of a dysfunction in the person: ‘Neither deviant
behavior . . . nor conflicts that are primarily between the individual and society are mental
disorders unless . . . a symptom of a dysfunction in the person’ (American Psychiatric Asso-
ciation, 1980). In a moment I will question the success of that attempt to avoid psychiatriz-
ing problems of living. But DSM-III does not restrict the scope of mental disorder. Its claims
to provide neutral empirical descriptions of symptom patterns did quite the reverse. It
implied that psychiatrists could diagnose as mental disorders, things ranging from trouble-
some conduct in children to men’s problems in getting an erection. The diagnostic manuals
of our own age are analogous to those that arose from the nineteenth-century asylums—
they suggest some fundamental connections between all those under the gaze of the psychia-
trist in our own Age of Freedom.
These changes were accompanied by another—a contested and partial unification of
treatment in the form of psychiatric drugs. This is not the place to tell that history, or the
ways in which drugs became part of the treatment for almost all conditions within the
expanded psychiatric system. Nor is it the place to discuss the implications of the new brain
sciences and the suggestion that variations in the neurotransmitter system underpin not only
frank mental disorders but also variations in personality, as well as transient fluctuations in
mood or conduct. Here I want to note just one consequence. We now have a group of
loosely related drugs that claim to treat not just major psychotic breakdowns, but the minor
troubles that impair people’s capacity to think, feel or act in the ways in which they or
others would want them to. This makes it possible to believe that all these conditions
have a ‘family resemblance’ —that conditions from autistic disorder to zoophilia are
varieties of the same sort of thing.

Hypothesis 3: Psychiatrists as ‘moral entrepreneurs’

Undoubtedly proclamations by public health bodies about the personal and social harm
from untreated mental disorders stem from genuine concerns. Frank Ayd’s 1961 book
Recognizing the depressed patient has often been cited as contributing both to the increase
in diagnoses of depression and to its framing as a condition treatable with drugs. Ayd had
carried out the clinical trials for amitryptiline as an antidepressant for Merck who held
the patent, and Merck distributed his book widely. As Emily Martin (2005) has pointed
out, drawing on his interview with David Healy, Ayd was a passionate believer in the
need for psychiatric drugs to alleviate mental illness: in 1957, he ‘spoke of the emerging psy-
chopharmacology as a ‘‘blessing for mankind’’ ’ —and his wife sometimes compared him to
John the Baptist preaching the coming thing (Healy, 1996: 85). In those days, pharmaceu-
tical companies were viewed as ethical allies with public health professionals in the defeat
of disease: on the evidence of the recent success of new drugs for physical conditions,
their prospects to improve the human condition, in alliance with psychiatrists, seemed
enormous.
The sociologist Howard Becker coined a term for such campaigns—‘moral entrepreneur-
ship’ (Becker, 1963). This is not meant to disparage them, but merely to describe their evan-
gelical quality and the many characteristics shared by such campaigns for righting wrongs.
Today, after years in the doldrums, biological psychiatrists and psychopharmacologists are
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excited, perhaps with good reason, about their capacity to treat and perhaps even to cure.
This excitement goes hand in hand with endeavours to convince us of the seriousness of
the problem to which these treatments are a solution. But we need to interrogate this way
of formulating the problem and its solution.
I have suggested that these alarming figures arise, in part at least, from the methods of
inquiry themselves—epidemiological surveys using diagnostic interviews. WHO asserts
that psychiatric diagnoses, today, are not just reliable but also valid. The debate over diag-
nosis in psychiatry has run for centuries, and so have arguments over its desirability, relia-
bility and validity. Critics suggest that many diagnoses, especially those ‘on the borders’, are
judgements of social deviance or problems of living that have no place in psychiatry, or that
they misrecognize intelligible responses to social situations as symptoms of individual psy-
chopathology (Double, 2002; Wakefield, 1992). DSMs from the 1980s claimed to answer
this criticism. But their criteria for personality disorder and many other disorders explicitly
require an assessment of the conduct, mood or thoughts in question against a norm of social
functioning, or a norm of appropriate responses to a particular situation such as sexual
attraction or bereavement. These diagnostic manuals thus capture behaviour that, as Jerome
Wakefield puts it, ‘need not originate in dysfunctions’ and some that is ‘clearly the result of
conflict with others or with society’ (1997: 635).
DSM-IV stipulates that diagnoses should not be made where patterns of behaviour
are responses to external conditions, rather than reflecting a dysfunction within the
individual. Wakefield himself, in his research on conduct disorder, suggests that clinicians
can make that distinction. But he also points out that while DSM-IV says this, the items
in its diagnostic checklist, for conduct disorder and many other disorders, concern only
the behaviour of the individual (Wakefield et al., 2002). How, then, can those using such
checklists avoid ‘false positives’? DSM-IV tries to deal with this by adding a ‘clinical signif-
icance criterion’, of the form ‘The symptoms cause clinically significant distress or impair-
ment in social, occupational, or other important areas of functioning’ (Spitzer and
Wakefield, 1999: 1857). But the epidemiological surveys that generate such high prevalence
rates are not conducted by clinicians in clinical settings. Even in clinical settings, evidence
shows that initial medical diagnoses depend a great deal upon the background expectations
and beliefs of the doctor, and are shaped by such issues as the gender, age, race, social
background and demeanour of the patient. The same is true in psychiatry, where diagnoses
may also be shaped by prior information available to the diagnostician as to the background
of the proto-patient, their pathway to the clinic, their previous history and so forth.
Further, in sites outside the clinic there are often incentives to diagnose, rather than not
to diagnose.
Consider, for example, ADHD. The authors of the Olfson study, to which I referred
earlier, suggest that the overall observed increase might have arisen as a result of the recog-
nition by the US Department of Education, in 1991, that ADHD was a disability that con-
ferred eligibility for special education. This, combined with awareness campaigns and the
activities of ADHD advocacy groups, increased the willingness of school teachers and others
to identify the condition, the use of school-based clinics to diagnose it and the take-up of
assessment instruments to make the diagnosis (Olfson et al., 2003). Or consider the case
of ‘autism spectrum disorder’. Gurney and colleagues conducted an age-period-birth cohort
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analysis of special educational disability data in Minnesota from 1981 to 2002 school years.
They report:

Autism spectrum disorder prevalence among children aged 6 to 11 years increased

from 3 per 10,000 in 1991–1992 to 52 per 10,000 in 2001–2002. All other special
educational disability categories also increased during this period, except for mild
mental handicap, which decreased slightly from 24 per 10,000 to 23 per 10,000.
We found that federal and state administrative changes favoring identification and
reporting of autism spectrum disorders corresponded in time with the increasing rates
. . . (Gurney et al., 2003)

Psychiatric diagnoses today take place in a climate where ideas of risk, precaution, pre-
vention are in the ascendant. We know from other examples—for instance, screening pro-
grammes for breast cancer or prostate cancer—that the health consequences of screening
are ambiguous—widespread screening generates false positives, leading to many being
brought within the scope of treatment and started on the career of patient who would never,
in fact, suffer from or be troubled by that condition. Historians of medicine identify many
similar examples of ‘diagnostic creep’, often elicited by the technology itself—diagnostic
tools elicit signs that are taken as evidence of pathologies that would previously have
been invisible, and these ‘proto-diseases’ are themselves taken to require treatment
(Rosenberg, 2003). No wonder, then, that many are so concerned with the widespread
use of diagnostic tests that transform malaise into psychiatric classifications requiring
treatment. Such tests are now found in self-help form on internet websites, in checklist
form in schools and clinics, and in screening programmes such as those proposed by
George W. Bush’s New Freedom Commission on Mental Health. And such screening and
testing is often proposed or supported by pharmaceutical companies (Lenzer, 2004).

Hypothesis 4: Big Pharma

This leads me naturally to my fourth hypothesis—Big Pharma is to blame. The industry, it is
claimed, uses its wealth, its lobbyists, its tame psychiatrists, the cunning of the marketing
profession to influence governments, regulators, researchers, medical practitioners and
patients. Its aim is simply to increase markets, not merely by selling new cures for old dis-
eases, but constructing new diseases to fit the products that claim to treat them. There
has, of course, been much controversy over the safety and efficacy of the new generation
of psychopharmaceuticals. Critics also suggest that the pharmaceutical companies promote
the illusion that their different drugs are each targeted to a specific condition, a claim that
has more to do with marketing products to fit discrete DSM-IV diagnoses than any actual
evidence of such specificity. This is not the place to evaluate these arguments: I want to
make some different points.
Pharmaceutical companies certainly seek to increase the use of their products through
influencing the prescribing practices of doctors, though most doctors claim to resist this
influence. They also act directly on potential patients as consumers of their products. In
the United States, the use of ‘direct to consumer’ advertising for psychopharmaceuticals
has come under particular scrutiny—especially advertisements relating to mild to moderate
depression, anxiety disorders, conditions such as pre-menstrual dysphoric disorder and
even bipolar disorder. Such advertising seeks not just to market a drug, but to reshape the
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potential patient’s understanding and presentation of their condition to their doctor in the
form of a particular DSM disorder for which a specific drug has been licensed and mar-
keted. Disorder and remedy are mutually aligned. There is some evidence that that physi-
cians today feel under pressure from patients to prescribe particular drugs. Certainly, in
medicine as in consumption more generally, we are seeing a phenomenon that is driven,
in part at least, by the reshaping of demand.
Pharmaceutical companies seek to increase demand for their products in many ways.
They fund, and sometimes set up, campaigning groups for particular conditions. They sup-
port and sometimes initiate disease awareness campaigns for conditions where they have the
patent for the treatment. These campaigns point to the misery caused by the apparent symp-
toms of this undiagnosed or untreated condition, and interpret available data so as to max-
imize beliefs about prevalence, shaping malaise into a specific clinical form. Such campaigns
often involve the use of public relations firms to place stories in the media, providing
victims—sometimes celebrities—who will tell their stories and supplying experts who will
explain them in terms of the new disorder. For example Roche’s 1997 campaign for its
antidepressant Auroxix (moclobemide) for the treatment of social phobia in Australia
involved the use of the public relations company to place stories in the press, an alliance
with a patients group called the Obsessive Compulsive and Anxiety Disorders Federation
of Victoria, funding a large conference on social phobia and promoting maximal estimates
of prevalence (Moynihan, Heath et al., 2002). These are not covert tactics—as a quick
glance at the ‘Practical Guides’ published on the web by the magazine Pharmaceutical
Marketing will show.
There is, therefore, some evidence for Hypothesis 4—that Big Pharma is responsible. But
I think this is only part of the picture. This is not to say that there is not corrupt practice, to
condone the non-disclosure or manipulation of the results of clinical trials, or to deny that
some doctors, and some public health officials, and all pharmaceutical companies, have a
vested interest in promoting the beliefs in the widespread prevalence of disorders, the
damage wrought to individuals and society by their inadequate or partial treatment, and
their ready and effective treatability by drugs. But I think that we need, at the very least,
to situate it in a wider context.

Hypothesis 5: The psychiatric reshaping of discontents

The shaping of discontent today certainly has novel features, including the role of the phar-
maceutical industry and the massive capitalization of ill health. But at any time and place,
human discontents are inescapably shaped, moulded, given expression, judged and
responded to in terms of certain languages of description and explanation, articulated by
experts and authorities, leading to specific styles and forms of intervention. What, then, is
specific to today?
As Simon Wessely points out, experiencing symptoms is the rule, not the exception:

In one early survey 14% of a community sample reported having no symptoms at

all. . .. An American study of healthy university students taking no medication found
that no fewer than 81% had experienced at least one somatic symptom during the pre-
vious three days. . .. Over a six week period 43% of normal American women reported
at least one somatic symptom . . . whilst women in South London experienced
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symptoms on one day out of three, chiefly headache and fatigue. . .. A population
based survey of the Nordic countries will report that up to 75% of subjects experi-
enced at least one subjective health complaint in the last 30 days—with more than
50% experiencing tiredness, and 33% muscular pain. (1997)

He is reviewing evidence on somatic symptoms. But as he recognizes, experiencing a

symptom is not, as it were, a ‘raw feel’. And perhaps at least a part of the pool of malaise
available to be recoded as physical illness is also available to be recoded in psychiatric terms.
It might be recoded by those carrying out public heath surveys with a gaze attuned to the
symptomatic. It can be recoded by proto-patients themselves, once categories such as gener-
alized anxiety disorder or pre-menstrual dysphoric disorder become available to them. It can
be recoded by medical market research agencies seeking to chart and delineate potential
markets for their products. And it can be recoded by psychiatrists and general practitioners.
Such recoding depends on two things—a norm against which experience can be judged
as abnormal, and a set of beliefs and words to enable it to be understood and communi-
cated. These disorders on the borders, I suggest, are experienced and coded as such, by indi-
viduals and their doctors, in relation to a cultural norm of the active, responsible, choosing
self, realizing his or her potential in the world though shaping a lifestyle. And they are given
form by the availability of categories such as depression, panic, social anxiety disorder
and ADHD.
For our disorders on the borders, we can think of a term such as depression—which
exists in a zone of transaction between experts and lay people—as a ‘problem/solution com-
plex’: it simultaneously judges mood against certain desired standards, frames discontents in
a certain way, renders them as a problem in need of attention, establishes a classification
framework to name and delineate them, scripts a pattern of affects, cognitions, desires
and judgements, writes a narrative for its origins and destiny, attributes it meaning, identi-
fies some authorities who can speak and act wisely in relation to it and prescribes some
responses to it. These are powerful condensations, ways of making aspects of existence intel-
ligible and practicable.
It is too simple to see actual or potential patients as passive beings, acted upon by the
marketing devices of Big Pharma who invent medical conditions and manipulate individuals
into identifying with them. The process is more subtle. Companies explore and chart the
experienced discontents of individuals, link these with the promises held out by their drugs,
and incorporate those into narratives that give those drugs meaning and value. It is this
intertwining of products, expectations, ethics and forms of life, that I think is involved in
the development and spread of psychiatric drugs. In engaging with these images and narra-
tives, in the hopes, anxieties and discontents they shape and foster, individuals play their
own part in the medicalization of problems of living.
Today, health has become a central ethical principle, and it is not surprising that discon-
tents so often find their expression in medical or psychiatric terms. Over the first 60 years or
so of the twentieth century, human beings came to understand themselves as inhabited by
a deep interior psychological space, to evaluate themselves and to act upon themselves in
terms of this belief. But over the past half century, human beings have also come to see
themselves as ‘biological’ creatures—to understand ourselves, speak about ourselves and
act upon ourselves as the kinds of beings whose characteristics are shaped by our biology.
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This development—I call it somatic individuality—is reshaping the borders of normality and
pathology, of mental illness and mental health. We are coming to think of ourselves as indi-
viduals whose moods, desires, conduct and personalities are shaped, in part, by the particu-
lar configuration of our neurochemistry, and which can therefore be moderated or
modulated by acting upon that neurochemistry, acting upon our brains through drugs.
This new way of thinking has not effaced older religious or psychological styles of
thought about our discontents. Unlike in many other disorders, the claim that psychiatric
disorders have a biological basis is hotly contested. On the one hand, many individuals
refuse to think of their conditions in these terms. On the other hand, there is much evidence
to suggest that many still see mental disorders as different in kind from physical illness,
excluded and stigmatized. But nonetheless, I think these changes that I have tried to docu-
ment, shaped by many different factors, do indicate that we are witnessing a ‘psychiatriza-
tion’ of the human condition. In shaping our ethical regimes, our relations to ourselves, our
judgements of the kinds of persons we want to be, and the lives we want to lead, psychiatry,
like the rest of medicine is fully engaged in making us the kinds of people who we have
become.

Conclusion
The borderlines of illness have long been subject to debate: are headache, insomnia, back
pain and the like diseases, symptoms of diseases or inescapable conditions of life itself?
Who should decide—doctors, medical administrators, patients themselves? Where are the
boundaries between conditions for which an individual is to be accorded responsibility,
and those for which responsibility is to be located elsewhere—in the organs, in fate, in
heredity (Rosenberg, 2003)? And medicine has always practised beyond disease—in child-
birth, infertility, grief and much more. Why does the extension of medicine trouble us for
some problems and not others? Why is it preferable to place some aspects of life under
one description—as a problem of living for example—rather than another—as a condition
that can be alleviated by drugs?
I have taken my distance from some critics. But I do still think that, for these disorders
on the borders and their treatment with drugs, there are grounds for concern. They arise
from a particular way in which these different processes are interlinked in current
conditions—the extension of diagnostic categories, the perception of the public health pro-
blems generated by untreated mental disorder, the demands for disease recognition, moves
to screening, fears of risk and hopes for prevention by early intervention at a presympto-
matic level, and the widespread use of the simple prescription of pharmaceutical remedies.
All this, I think, serves to lower the threshold at which individuals are defined, and define
themselves, as suitable cases for treatment. It increases the numbers of those who enter
upon a ‘moral career’ as a person suffering from a treatable condition, and reduces the
age at which many enter upon this career. These are powerful mechanisms for recruiting
individuals, turning them from non-patients to proto-patients, to actual patients. They are
powerful mechanisms for retaining individuals within this domain. No walls are now
needed to sustain a lifetime career under the psychiatrist. Whether or not the drugs
cause more damage than they cure, whether or not this generates careers for psychiatric
researchers, demands for psychiatric professionals, satisfaction for public health
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professionals or profits for pharmaceutical companies, we have yet to count the costs of this
way of organizing and responding to discontents in our own Age of Freedom.
To conclude, let me return to Aubrey Lewis and his view of the proper sphere of the
psychiatrist in his 1963 lecture ‘Medicine and the Affections of the Mind’:

We can . . . agree that the practice of psychiatry should be limited to illness and its
prevention, and that illness occurs broadly where there is disabling of distressing inter-
ference with normal function But in the last thirty years the impatience and perhaps
the credulity of public opinion has pressed upon the psychiatrist requests that he treat
people who are not ill and advise on problems that are not medical. It needs no
logician to detect the fallacy in the syllogism which runs: psychiatrists are experts in
mental disorder; mental disorder is a form of abnormal behaviour; therefore psychia-
trists are experts in abnormal behaviour of every sort. Yet in matters touching upon
misbehaviour in children, vocational selection, troubles in marriage, crime, and
many other tribulations, the psychiatrist has sometimes assumed responsibility, or
had responsibility thrust upon him, beyond the range of his medical functions. . ..
There is no other branch of medicine which finds it so difficult to say ‘no’; and is so
often blamed when it says ‘yes’. (in Lewis, 1967b: 277–278)

Perhaps, these thoughts from 40 years ago may cause some psychiatrists to pause, to
wonder whether, in the cases of the disorders on the borders at least, they are saying yes
too often, and ought to practise saying no.
Thank you for your attention.

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