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Diagnostic and Statistical Manual of Mental Disorders

How Australia adopted America’s bible of psychiatry

(Guest Editor – Jill Margo from AFR)

It’s time for a robust review into how America’s mental illness diagnostic manual, which has been fully adopted here, is affecting Australians. Critics of the American ‘Diagnostic and Statistical Manual of Mental Disorders’ say it promotes a “hyper-medicalised model” that reduces the complexity of human behaviour to a tick-box list, devoid of empathy. 

While Australians may decry the effects of Hollywood, Coca-Cola and McDonald’s on our culture, most are completely ignorant of the dominant role American psychiatry plays in contemporary Australia, says mental health researcher Dr Martin Whitely.

“It affects millions of individuals and their families,” says Whitely, a research fellow in Public Policy at Curtin University in WA. “The central document used in Australia to define who is sane and who is mentally ill – the Diagnostic and Statistical Manual of Mental Disorders (DSM) – has been drawn up entirely by committees in the US.

“The DSM is one of the most powerful cultural documents in our country. We have blindly followed America’s lead and a robust review of its impact on Australians is long overdue.”

He says this document is updated and expanded by committees of the American Psychiatric Association, to which Australia doesn’t belong and so has no say.

Dr Martin Whitely says it is time to but at least take steps towards breaking the American stranglehold on Australian mental health practice. 

“Yet we’ve adopted it as if it were the psychiatric bible full of indisputable truths. And it’s from a country that spends the most per capita on mental health interventions in the world, uses the most psychotropic drugs, has the highest rates of diagnosed psychiatric disorders and suffers seriously from capture by Big Pharma.”

The DSM promotes a “hyper-medicalised model” which, he says, reduces the complexity of human behaviour to a tick-box list, devoid of empathy for individual differences in disposition and circumstance.

“Anything that causes sadness, stress, anxiety or even boredom is regarded as a threat to mental health and a potential source of mental illness.

“But if you lose your job, are grieving a death or a relationship breakdown, or are experiencing any of life’s inevitable vicissitudes, it is very human to be deeply unhappy or anxious and some may even fleetingly consider ending it all.

“By following America, we have come to regard these normal, although troubling, human reactions as compelling evidence of mental illness.”


While critical of the easy acceptance of the DSM, Whitely says there needs to be a greater appreciation for how difficult psychiatry is.

“It is an ambiguous, demanding profession. Good psychiatrists understand their limitations and their obligation to first do no harm.

“Un-empathetic, overconfident psychiatrists are a problem, but time-pressured GPs and paediatricians with the DSM in one hand and a prescription pad in the other are an even bigger danger.

“Irrespective of their speciality, any doctor incapable of helping patients to withdraw from a mental health drug should not be allowed to prescribe one.”

However, he acknowledges that patients can be a big part of the problem by pressuring doctors for a quick fix. “People need to stop expecting a pill can resolve their own or their child’s problems and remember that if something sounds too good to be true … ”

A former member of the West Australian Parliament, Whitely has just published his second book, Overprescribing Madness: What’s Driving Australia’s Mental Illness Epidemic?. It investigates why one in six Australians take a mental health drug and suggests a series of reforms.

Millions of previously ‘healthy’ people have gone to bed well and woken with a diagnosable mental illness.

— Dr Martin Whitely, Curtin University

He wrote it during the pandemic, while watching prominent Australian psychiatrists make dire predictions about a spike in suicides that would overshadow deaths caused by COVID-19.

“Their call for extra resources for programs they lead would be entirely logical if the care they offer helped people distressed by unemployment, financial hardship and loneliness. However, evidence is mounting that far too often both the alternatives they promote and standard treatments make a bad situation worse.

“Most Australians seeking mental health help visit a GP, get a drug prescription – usually an antidepressant – and a bit of a chat about possible side effects, if they are lucky.


“There is a role for drugs, but we are increasingly too reliant on a quick diagnosis backed up by indiscriminate prescribing of pills that interfere with a patient’s biochemistry without addressing their underlying problems.”

While keen to acknowledge that the majority of Australian doctors prescribe responsibly, he says the “soft touch culture” of the medical profession and regulators means rogue prescribers are not accountable.

The first DSM, published in 1952, had 106 psychiatric disorders. The latest edition, DSM-5, has 312 disorders with broader diagnostic criteria, or diagnostic creep.

Whitely says this expands the net, so that with each new edition “millions of previously ‘healthy’ people have gone to bed well and woken with a diagnosable mental illness”.


Talking with the voices in your head

Australia never formally adopted the DSM; it became the orthodoxy by default. While most people assume it develops through scientific advancement, Whitely says it has always been driven by money, politics and culture, as illustrated by the removal of homosexuality as a psychiatric disorder in the 1970s.

“That hard-fought victory over medicalised bigotry resulted from changing social norms, co-ordinated protest and lobbying. That is politics, not science.”

When DSM-5 was published in 2013, a backlash was unleashed by the leader of the previous edition, Professor Allen Frances, who regretted that his 1994 edition had helped to trigger “false epidemics” for autism and ADHD. He warned of the dangers of diagnostic creep and over-treatment.

In Australia, we have a large workforce, with many people trained elsewhere, who bring their own experiences and expertise to the process.

— Associate Professor Vinay Lakra

Whitely says Australia has an alternative to the DSM in the manual developed by WHO, called the International Classification of Diseases (ICD), which is used largely in hospitals for codification and funding. Although far from perfect, he describes it as less extreme.


“Adopting the ICD would be a baby step, but at least a step towards breaking the American stranglehold on Australian mental health practice,” he says.

As psychiatry is constantly evolving, the incoming leader of the Royal Australian and New Zealand College of Psychiatrists, welcomes constructive criticism.

Its president-elect, Associate Professor Vinay Lakra, says this critique is not about psychiatrists but about the framework they use to diagnose and help people.

“Sometimes people do not neatly fit into the diagnostic categories, which is a fair criticism of our diagnostic system,” says Associate Professor Vinay Lakra. 

While the DSM is widely used for classification and very important for diagnosis, it’s not an article of faith, like a bible. He says the ICD is very similar in approach to the DSM, with minor variations. That a new version of the ICD is due soon illustrates how the two systems complement each other in the evolution of the diagnosis of psychiatric disorders.

“I think it’s probably not completely right to say the DSM is a cultural American document because it takes research from elsewhere, particularly the English-speaking world, into account. People on its committees have connections with researchers and clinicians across the world and there’s input from that process too.”

The DSM-5 actually talks of “cultural formulation”. It says that in its development process, the work groups made a concerted effort to modify culturally determined criteria so they would be more equivalent across different cultures.

“In Australia, we have a large workforce, with many people trained elsewhere, who bring their own experiences and expertise to the process.”

Lakra says the DSM is not used alone. While it has a central role, Australian psychiatrists also have home-grown clinical guidelines and Mental Health Acts in each state that provide safeguards.

Psychiatry places great importance on patient-centred care and engaging patients in their own care, and he says its important to note that psychotherapy is becoming more accessible.


The science behind the voices in your head

“Sometimes people do not neatly fit into the diagnostic categories, which is a fair criticism of our diagnostic system, and is the reason why training is so important and why we have other tools,” says Lakra.

So, given that the DSM is a crucial tool with limitations, should its impact on Australians be reviewed?

“That’s a fair question and I’ll have to reflect on it,” says Lakra.

Dash Editor

Self-confessed confused news junkie, with lifelong additions to coffee, great conversations, perfection in all its forms, cold wine, hot music and puppy dogs.

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