By Rob Kall
Rob: "Radio ID" My
guest tonight is Allen Frances, M.D. He was the
chair of the DSM 4 Task Force and the chair of the
department of psychiatry at Duke University School of
Medicine, Durham, North Carolina. He's currently
Professor Emeritus at Duke. Welcome to the Show!
Allen: It's good to be
here.
Rob: Now, the reason I
contacted you is you wrote an article titled "DSM 5 Field
Trials Discredit the American Psychiatric Association."
Why don't you start off by explaining what DSM 4 and DSM 5
are and what they mean and why they are important?
Allen: This is the
diagnostic manual in psychiatry. Until 1980, no one much
cared about it, but DSM 3, published in 1980, became a
huge best seller. There are hundreds of thousands of
copies sold every year, and the reason it is so important
is because lots of decisions depend on it-- who gets
treated and who doesn't, who pays for the treatment, who
gets disability, who gets to pilot a plane, who gets to
adopt a kid, workman's compensation. All sorts of things
are triggered -- and school services in particular -- on
having a psychiatric diagnosis. It essentially sets the
boundary between who's normal and who's not. So this has
become an enormously important document. The last version
of it, which I was sort of the head person on, was
published in 1994, and there is a revision that is about
to appear next year; it's called DSM 5, and that revision
has been very controversial- I guess for reasons that we
will discuss. But the changes made there could determine
how tens of millions of people regard themselves: whether
they have a mental disorder or not, and it could determine
who gets medication and lots of people in our society are
getting medication they probably don't need; so the stakes
are pretty high.
Rob: As the Director
of Development of DSM 4- I may not have that title exactly
right; correct me if need be- you had to be pretty high in
terms of being a trusted member of this psychiatric
hierarchy. How did that happen? How did you get that
position?
Allen: I worked on DSM
3, and I was part of the group that prepared DSM 3R- that
was a revision in 1987- and so I had some experience in
the kinds of questions involved. It's a pretty tedious
job; I'm not sure that many people in the world would have
wanted to do it. So, yes, I was involved very much in how
psychiatric diagnosis would evolve, and I guess what has
happened in the last three years is I have become a critic
of that process. So, I went from being the director of a
program that was involved in preparing DSM 4 to being a
very sort-of staunch critic of how DSM 5 is being
prepared. I don't think that the process has been careful
enough or open enough to produce a document that will be
trustworthy.
Rob: You describe how
it affects people's lives, but it also affects business
too- the pharmaceutical business. How many billions of
dollars will be relying on DSM 5?
Allen: It's really
weird- the degree to which Americans are taking
psychotropic medications. In any given year, 20 % of
Americans will take a drug that is a psychiatric drug.
About 11 % of the population is on anti-depressants, and
20 % of women are on anti-depressants, 4% of kids are on a
stimulant, 4% of teenagers are on an anti-depressant.
Perhaps most remarkably, anti-psychotic drugs are amongst
the best selling drugs in America: 18 billion dollars a
year in anti-psychotic drugs, anti-depressants about 12
billion dollars a year, stimulant drugs about 7 billion
dollars a year. So we've really become a pill popping
culture and the drug companies have a huge stake in this.
We are the only country in the world now that allows drug
companies to advertise directly to consumers. So, you are
constantly seeing ads on TV, trying to disease-monger;
trying to suggest that you have one or another psychiatric
disorder, that this is a chemical imbalance in your brain,
that if you take a pill that will be the solution to all
of life's ills. And the drug companies have essentially
gone into the business of selling psychiatric diagnosis as
a way of selling pills. If they can convince enough
people that they are sick, then if people ask their doctor
for a pill, they are very likely to get it. If you ask
your doctor for a psychotropic medication, you're 17 times
more likely to walk out of the office with a pill. The
real problem here is that most of these pills are not
being prescribed with psychiatrists and aren't being done
after careful diagnostic interviews with someone who knows
something about psychiatric diagnosis. About 80 % of
psychotropic drugs in America are prescribed by primary
care doctors who have -- in most instances- very little
time- the average visit is about 7 minutes- in many
instances little or no training in psychiatry, some
instances no interest in psychiatry. And primary care
doctors tend to be inordinately influenced by drug sales
people. They get their education in psychiatry from
people who are selling drugs who have the story line that
psychiatric diagnosis is often missed, is very easy to
make, and that there is a simple pill that will solve all
the problems. So the current situation is weird; we have
90% of anti-anxiety drugs like Xanex being prescribed by
primary care doctors, and 80% of anti-depressants are
prescribed by primary care doctors. 60% of stimulants and
half of the anti-psychotics are being prescribed by
primary care doctors, very often after these brief seven
minute interviews, very often because the doctor has
samples that he has been given by the drug salesman that
he gives out. This is a convenient way to get the patient
out of the office quickly. And, the result is a
tremendous overdose, I think -- societal overdose- of
medication. 7% of the population is addicted to a
prescription drug- 7%.
Rob: How many?
Allen: 7% of the
population
Rob: 7%
Allen: 7, yes. And it
turns out that there are now more visits to the emergency
room for overdoses with prescription drugs than visits
with street drugs. In some ways, we have turned a very
bad corner where the drugs you get from the doctor can
cause you more harm than the drugs you would get from a
street corner pusher. So, I think that there has been a
kind of overdose of diagnosis and overdose of medication.
And part of my reaction to DSM 5 is that it will make this
worse by introducing new diagnoses that will have many
millions of people qualifying for a mental disorder who
--the night before it is published- would not have been
considered to have a psychiatric illness. And it's
reducing some of the thresholds for existing disorders,
which again will increase diagnostic inflation and make it
more likely that people will get psychotropic medication
that they don't really need plus the stigma of having a
diagnosis that you don't really have.
Rob: This is huge
for big Pharma, right?
Allen: Oh yeah. And
let me be clear; big Pharma has absolutely no influence on
what's happening. So the people preparing DSM 5 are not
doing this with the intention of helping the
pharmaceutical industry. They are not doing this because
of financial conflict of interest. They are doing this- I
think they are making a lot of very bad decisions, but the
decisions are being made for the purest of motives.
However, Pharma will be on the sidelines licking their
chops and figuring out how to exploit it.
Rob: Why do you think
this is happening then, because obviously you believe that
this is a terrible error or not maybe error because it is
intentional? They are making judgment calls that are
really bad you are pretty much saying.
Allen: Yeah, I think
that they are making very bad decisions for the purest of
reasons. The conflict of interest is not financial; it's
more intellectual, and there are two parts to it. One is,
if you are an expert working in a field, you tend to
develop a huge attachment to your field. You always worry
about the fact that you may miss a patient that has a
diagnosis in the area of interest that you have. So you
worry very much about expanding the domain of your area of
research and clinical interest. Experts never think about
the impact of people who are mislabeled; they always worry
about the people who are missed. And, they tend to
overvalue their own research and their own area of
interest. I think that is a big part of it.
Rob: You've written
about your concerns about the research and then the
quality standards. This is not about concerns is it? Is
that the same issue?
Allen: I think that very
often the experts are suggesting diagnoses that are based
on their own research or research of colleagues that is
very far inadequate of proving that the suggestion is safe
and scientifically sound. Normally, there will be a study
that shows there are some people who have a problem that
can't be diagnosed using the current system, and this will
be argued in support of evidence for adding a new
diagnosis or reducing the threshold of the existing one.
But the thing that is always missing in these calculations
is a thorough risk benefit analysis: thinking through all
the things that can go wrong for the people who are
mislabeled. Every time you make it easier to get a
diagnosis, you will pick up people who previously were
missed, but you will also pick up a bunch of people who
don't really need the label. And experts have a vested
interest in worrying about the missed patients; they have
much less concern about the mislabeled patient. The other
thing here is really interesting, and it goes to a much
larger question in American medicine, not just psychiatry:
there has been- in the past thirty years- a tendency to
think that we can do a kind of preventive medicine with
very early screening tests for a number of diseases. And
if we could get there early enough, if we could make the
diagnosis early enough and begin the treatment before the
disease could develop and do its worst harm- that this
would be in the long run what benefits the patient.
What's happening now, just in the last couple of years, is
the realization that we are doing way too much screening
in medicine and way to much preventative medicine. Very
often, you will see that the effect of early diagnosis is
to provide treatment and to do tests that are more
dangerous than the disease itself would have been. So
this is really a kind of sudden shift away from the notion
that we can screen for every illness and get there early
to a realization that this early screening may not have
improved outcomes and may have caused harm because the
treatments and the tests can be so harmful. So, recently,
there is an initiative called Choosing Wisely, developed
by eight of the different medical specialties saying, if
effect, let's pull back. Prostate screening was all the
rage; now the recommendation is don't screen for prostate-
that by and large it doesn't save lives and it causes a
tremendous amount of damage and unnecessary surgery- that
the prostate cancers that were picked up very often
wouldn't kill the person, but the treatments can be very
harmful to them. Breast cancer screening has turned out
to be way overdone, and it is important to begin targeting
it to particular age groups and to do it less frequently.
And, actually, they have identified about 46 different
areas in medicine where there has been too much testing
and treatment. Well, psychiatry is getting into this act
late in the day at just the wrong time and with the best
of intentions but probably the worst of unintended
consequences. The idea in DSM 5 was, if the rest of
medicine is screening early; why shouldn't we? And so a
number of the different suggestions are for disorders that
are much milder than the traditional psychiatric
disorders-intending to pick up earlier in the course the
sorts of problems that might develop into schizophrenia or
dementia, and hoping that you could intervene early before
the disease has fully announced itself and caused its
damage. But, in order to have a screening test-or a
screening diagnosis that is useful- you have to prove
three things. One, that it is going to be accurate- if
you are going to introduce a new diagnosis, you want it to
be accurate. The second is intervention that will be
really effective for it. It doesn't make sense to be
identifying something if you can't do something about it.
And, the third is intervention will be healthful and not
harmful- that it won't cause more side effects and more
complications than whatever benefit it will provide. It
turns out, for all of the suggestions being made in DSM 5,
there is no way of making the diagnosis accurately for
just the people who need it-that there will be what we
call a huge false positive rate- that in order to pick out
the person who might go on to have the problem, you'll
often be picking up maybe eight or nine people who
wouldn't. And, the intervention for them and the stigma
for them is unwarranted. There is really no excuse for
mislabeling someone and possibly giving him a treatment
that is going to be harmful, or to a label itself that may
be stigmatizing. The second issue is that for none of the
things being suggested in DSM 5 is there a proven
effective intervention. And, the third thing is-as we
were discussing before- very often the reflex, especially
in the United States, when there is a diagnosis of a
mental disorder, is to go right ahead and provide a
medication- particularly since so much of the diagnosis
and treatment is being done by primary care doctors in the
seven minute appointments influenced so much as they are
by the drug company sales people. So, for the new
diagnoses being suggested in DSM 5, very often there is a
risk --a high risk- that it is inappropriate. There is no
proof at all that the diagnosis will be helpful, because
none of the diagnoses have an intervention that has been
proven affective. And, in many instances, a person may
get medication that will be harmful as well as a harmful
stigma. So, my contention is that we shouldn't be
venturing into the area of preventive psychiatry just at a
time when preventive medicine is coming under such
criticism and scrutiny because it is premature. In
psychiatry, we certainly don't have the tools for an
accurate diagnosis before the illness has declared
itself. We don't have interventions that have been proven
to be helpful. And, the interventions that are likely to
occur might actually be quite harmful.
Rob: "Station ID" My
guest tonight is Dr. Allen Francis. He was the
chair of the DSM 4 task force and the department of
psychiatry at Duke University, and he has become a very
strong critic DSM 5, which is soon to be released upon the
public. Just to sum up a bit: you said that the new DSM
5, which is the official diagnostic standard for all kinds
of psychiatric problems, is going to create problems,
because there are going to be a lot of people who are
false positives- Many, many times more who are false
positives than are really diagnosable. And, then you said
that there is a medication response- specifically in the
United States- where the tendency is if somebody meets the
criteria that somebody reads in this, they are going to be
put on psychiatric medications. So, a couple of
questions: What is the percentage of people who are
currently diagnosed and medicated with psychiatric
medications in the United States? How does that compare
with other countries? How do you think that will change
with DSM 5? There you go- that is a couple for starters.
Allen: Good summary and
good questions. Currently, 20% of the population in any
given year will have a psychiatric diagnosis-20%. Of that
20%, only a quarter- so 5% of the whole population- have a
severe psychiatric disorder. 15% would have a mild to
moderate one. Lifetime- the rate would be 50%. And, the
scary thing is that these may actually be underestimates,
that if you carefully do prospective interviewing, it
turns out that by age 32, half the population would
qualify for an anxiety disorder, 40% for a mood disorder,
30% for a substance disorder. So, we have a situation in
which a very large proportion of the population would
qualify for a psychiatric disorder. Europe is catching
up; there is a lifetime rate of about 43%. And, a really
scary study recently showed that if you evaluate kids
carefully, by age twenty one 83% of kids would qualify for
a mental disorder.
Rob: 83% of kids would
qualify for medication?
Allen: No, for a mental
disorder.
Rob: Oh, for a mental
disorder.
Allen: And, so in other
words, if you do careful follow-ups -- you start taking a
population of kids, a general population of kids and you
follow them- randomly selected- for eight years- age 12
until 21- and you do careful interviews, you get a
tremendously high rate of disorder. Now, I think these
are exaggerated numbers. I think that the way that the
disorders are defined are too loose and the way the
studies are done tends to have a biased toward reporting
high numbers. But, I think that the problem- by the way,
Rob?
Rob: Yes?
Allen: I think the
battery in my phone might go out. If it does, I'll recall
on another phone.
Rob: I'll hang in
there and you call right back to the same number.
Allen: Yes, that would
be good. I think that the issue here that we have a
diagnostic system that encourages very high rates of
diagnosis. And, we have a capitalist system of medical
care that encourages drug companies to take full advantage
of these high rates of diagnosis: to encourage very loose
and inappropriate diagnosis and the resulting excessive
treatment with potentially very harmful medications.
Rob: Now, from what
you've described at the beginning of the interview, where
most of the psychiatric medications are prescribed by
general practitioners and not psychiatrists, this can't be
very good for the field of psychiatry in terms of their
making a living and the job being done properly. What do
you have to say about that?
Allen: I don't think
the living issue is really pertinent, because
psychiatrists are busy enough. I think that it's not like
they need more business. I think it is a terrible problem
in terms of shoddy diagnostic and loose prescription
habits reigning so supreme over good diagnostic practice.
It takes a long time really knowing someone to make an
accurate psychiatric diagnosis. It requires someone who
has substantial training; especially when the diagnosis is
of a mild condition that is on the fuzzy boundary with
normality. If someone has a clear cut psychiatric
problem, almost anyone can make the diagnosis, but the
people being diagnosed in primary care often present at
the boundary with normality. Here diagnosis is extremely
difficult. It often requires great expertise on the part
of the person doing it and often takes lots of time- both
in the individual interview and following people over
time- not jumping to a diagnosis. We have another problem
in America that [?unclear 21:26] you don't necessarily
have to have a diagnosis to get treatment. But, our
insurance systems were such that unless you get diagnosed
early, the doctor won't be paid for the treatment. There
is tremendous pressure, therefore, for people to be fit
into categories well before anyone can be sure that they
really need the diagnosis. Most of life's problems are
not mental disorders and we have tremendous resilience as
human beings. Most people with a psychiatric symptom
don't have a psychiatric disorder: it is not severe
enough, it is not prolonged enough. But very often, there
is a quick jump to making a diagnosis before one is
needed. And watchful waiting, for most people with mild
problems, watchful waiting is certainly the best first
step, because about half of them will get better just on
their own spontaneously within a few weeks. In our
system, once a person gets to the doctor's office, there
is a quick trigger response to make the diagnosis and put
them on medication that will [?unclear 22:26] it. And
then when the person gets better, we have what we call
placebo response, and about half the people with mild
problems have a placebo response. They don't know what
caused them to get better, so they'll often misattribute
the gains to the medication taken not realizing the fact
that they would have gotten better on their own. So, I
think, as a country, we would be a lot better off trusting
to natural resiliency- not jumping to the diagnosis when
the problem is mild. And there is another flip side to
this that is particularly tragic; while we are
over-diagnosing and over-treating people with mild
problems that probably very often don't need it we're
ignoring people who have severe problems. Only 1/3 of
people with severe depression see a mental health
clinician. The budgets for treating severe psychiatric
disorders have been slashed drastically in the last few
years because of the economic difficulties in the states.
So, we're terrifically undertreating people that have
clear-cut severe psychiatric disorders who could benefit
for sure from our efforts. And, as a country, we are
over-treating people who are probably- in many instances-
might be much better off without psychiatric diagnosis and
without psychiatric treatment.
Rob: So, what
strikes me about what you just told me is this requirement
for a diagnosis-for treatment. That means that psychiatry
is being driven by insurance company policies.
Allen: And even worse,
primary care, because at least when the psychiatrist has
made the diagnosis, he's probably spent some time with the
patient and he has some expertise in making the
diagnosis. The primary care doctor is basing the toughest
diagnostic quandaries-because the people they see are on
the boundary between normality and psychiatric disorder-
and they are jumping to a diagnosis in a few minutes
without the benefit of the time required, the watchful
waiting period that is often useful, and the training.
So, many people get labeled with a diagnosis they don't
need, and some of the diagnoses stick on you in a haunting
kind of way. It's a lot easier to make a diagnosis than
to get rid of one if it's wrong. So, sometimes once it
gets on the record, it takes on a life of its own; and,
I've talked to any number of people who have been
stigmatized terribly by getting a diagnosis-usually
bipolar disorder- that didn't apply to them, was made
casually. The doctor would say something like, "You have
a little bipolar disorder." But, once it gets in the
record, it lives on, and you may have trouble adopting a
child, you may have trouble getting life insurance,
because the diagnosis will haunt you even if it is
incorrect.
Rob: So, the worst
diagnoses in terms of stigmatizing people are bipolar
disorders? Any other ones?
Allen: Well, I think
Schizophrenia would carry the stigma, but it's not
mislabeled nearly as often as bipolar disorder. It has
been a kind of fad in diagnosing adults-actually kids-
incorrectly with bipolar disorder during these last 15 or
so years. It is part of the success of anti-psychotics
that they have gotten an indication for bipolar, and the
advertising was able to convince many patients and also
many doctors that bipolar disorder was being terribly
underdiagnosed and that lots of people had it. And so,
there is a tendency to take the slightest degree of mood
liability and misdiagnose it as bipolar disorder. And
lots of people have the diagnosis of bipolar disorder that
probably have been mislabeled. Let me make a point here
though, that I don't want people to listen to this and
just stop their medication. The two bad things that can
happen when you have a psychiatric disorder-one is being
mislabeled and getting medication you don't need, but
equally bad would be assuming you have been mislabeled
when you really need the medicine-when the diagnosis is
accurate- and stopping it on your own. And the worst
result of this phone call would be someone who really
needs the medicine with a diagnosis that really does make
sense stopping the medicine thinking that I am being so
critical of psychiatry and psychiatric medicine that their
best bet would be to stop it. For people who need
psychiatric medicine, for people who have a true
psychiatric diagnosis, the medicine is enormously
helpful. So, there are some anti-psychiatry folks who try
to criticize the field at large --they're dead wrong.
Psychiatry does a tremendous amount of good, and these
medicines are sometimes essential- indeed lifesaving- for
people. So, no one should say it is a trivial decision to
go off medication, because if you need it, you really do
need it. On the other hand, it is not a trivial decision
to go on medication. If you don't need it, it's not
necessary to take it; it may be bad for you. So, the
trick is figuring out which category you are in, to sort
of take a hard look at your symptoms, to discuss them in
detail with your family and with physicians, to become a
very informed and smart consumer, so that you are not
going to fall into either trap of over diagnosis and over
medication or under diagnosis and under medication. Our
country has both of these problems. You have way too many
people getting medicines they don't need, and way too many
people not getting medicines they desperately need. And
so I think the only way to try to work in this labyrinth
if you are a consumer is to get lots of knowledge
yourself, to share with your family so you get a second
opinion from them, to ask questions of the doctor and get
reasonable answers- if their answers don't seem
reasonable, to get second and sometimes even third
opinions. I think that the decision to be on or not be on
a psychiatric medication is a major one in a person's
life. It requires all the thought that you would put into
a decision on who you are going to marry, what car you are
going to buy, what house you are going to buy. It should
be done very carefully; it shouldn't be done casually in a
primary care doctor's office after seven minutes. And, it
shouldn't be done casually by the person themselves
listening to this phone call deciding that they are going
to go off their medicine. It is a very serious decision
one way or the other.
Rob: Wow! So, that's
pretty intense advice- going on a psychiatric medication
should be considered as seriously as you consider the
person you are going to marry. So, what you've basically
said here is there are a lot of people who are
inappropriately prescribed medications, but there are a
lot of people who need the medications and it will help
them and maybe change their lives and maybe even save
their lives. And, I've seen that. I totally agree with
you. How do people decide? I mean, here you've got
somebody obviously going through something in their life
that is bringing them to their GP, and the GP says, "Well,
it looks to me like you're bipolar. I've got some samples
from the pharmaceutical company. Why don't you try these
and see how you do; and then, here is a prescription that
you can get filled." Now your response is that people
need to be good consumers. They are under all kinds of
stress or something is going on in their lives that
brought them to the doctor. They are feeling really like
they want help. It's not an easy time to just very calmly
say, "Ok. Let me be a good consumer." What would you
suggest that they do when they are encountering this
situation? It sounds like the one where they are at the
greatest risk for being inappropriately put on medication.
Allen: You're
right on the
money, and I think that bad decisions are made in
situations where people are under stress and feel need for
urgent relief. And, those bad decisions sometimes hurt
for a lifetime, because many times people will stay on
medication for years, and maybe for life, that they
wouldn't have needed in the first place if they had just
waited a couple of weeks and they would have gotten better
on their own. I really can't emphasize enough that it is
not a trivial decision; it has been made a trivial
decision with the sort of propaganda that psychiatric
disorder is everywhere and that the medications are the
only way to correct chemical imbalance- that's kind of a
myth, because all problems in life are a chemical
imbalance- and that the medicines are completely innocuous
and you just pop a pill and you'll feel better. I think
that's dead wrong. I think that this is a very, very
serious decision that often has consequences that will go
on for years, and that unless- I think if you have a
clear-cut psychiatric disorder and it pops off the page
that you are a classic case, and if it is urgent, then by
all means treatment should be started right away:
diagnosis should be made, effectively, quickly,
immediately, and everything should be done to solve the
problem as soon as it's been clearly identified. But for
those mild problems that are in between normal and mental
disorder- and this is the majority of people who are
taking medicine who would be in that category; there are
only 5% of the population who has a severe mental
disorder. Three times as many people are being diagnosed
with mild problems. For those problems, people should be
aware of the fact that they often go away on their own,
that in studies, 50% of people in that category will have
a placebo response. It gets better without the active
medication. And that unless there is something urgent,
unless the problem is really clear cut, the best bet is
watchful waiting at the beginning to see how time and
natural healing affect things. The second intervention
after watchful waiting should be counseling and education,
not pills. And, I would say that for this group, pills
should be a third that is reserved when time and
counseling haven't worked. Counseling works as well as
pills for mild to moderate problems in psychiatry. So, I
think that the tendency because there is a huge drug
industry and the drug industry in total spends something
like 30 billion dollars a year on advertising- and just in
the anti-psychotic drugs alone they are spending I think
something like three billion dollars a year on
advertising- there is no constituency, there is no
propaganda campaign for watchful waiting. There is no
advertising for psychotherapy. And, so this is an
imbalance in the way consumers have come to understand
psychiatric problems with a very strong commercial
interest trumpeting the benefits of medication even in
certain situations where it doesn't make sense. And that
has led to the imbalance. I think that if you are a
consumer, you shouldn't trust the commercials. I mean,
one thing for sure- don't ask your doctor after seeing a
commercial, because once you ask your doctor it is likely
to trigger the reaction. You have the diagnosis, you get
the pill. I would always be doing research first on my
own. I understand that people with psychiatric problems
are under stress. I understand that many of them may not
have great insight as part of the problem or part of the
stress. But, what I am trying to emphasize is the
importance of individuals and of families taking part in
the decision making. You can only do this if you learn as
much as possible. And, you have to be cautious of what
you learn, because lots of the stuff on the internet
itself has been influenced by drug companies, so that
there is no one safe place to go where you'll be
absolutely sure that the information you get is
reasonable. But, I would always trust sights that are
non-profit more than I would trust sights that have
anything to do with profit. If you are seeing
advertisements on the side of the page, it is likely that
the content may have been influenced by the companies
involved.
Rob: >From what I
understand, the treatment of these acute problems, bipolar
disorder and schizophrenia, can be very different in other
countries so that drug intervention as the primary
treatment is not always the case. Often it is creating a
therapeutic milieu or community and that, from what I
understand, in those situations the recovery rate is much,
much higher.
Allen: Well, I would
put it a different way. If someone has clear-cut bipolar
disorder, if someone has severe depression, if someone has
schizophrenia, severe OCD, very severe panic disorder- in
these situations medication is almost always necessary
along with psychotherapy, along with social retraining and
other skill training. I think that the more severe the
problem and the more clear-cut the problem, the more
medication will be part of the treatment plan. The
problem we have here is pills being used for problems that
are very mild that would get better.
Rob: I think I lost
him. Yes, we've lost him. So, he'll be back in a minute
with a different phone. What I got that information from
is, I guess, two years ago, I attended a conference for
psychologists for social responsibility, and there was a
panel reporting that in countries where there is a better
social safety net- now I'm not talking about Medicare or
Social Security or anything like that; I'm talking about
families and communities that are there to help people who
are having problems- in that kind of milieu, from what I
understand, people get better at a much higher rate:
double the rate. And, actually, the numbers for people
who are only put on medication are not nearly as good.
So, that's one piece of it. Another piece is- and I'm
going to be asking Dr. Frances about this- is this idea of
people prescribing medications for bipolar disorder to
children, and prescribing ---- oh, you're back!
Allen: I'm back.
Rob: Alright, so what
I was saying while you were gone is that one of the
problems that I understand exists, in terms of this
over-diagnosing and over-prescribing, is with the kids
with bipolar disorder. Is there even a diagnosis for
childhood bipolar disorder in DSM 4?
Allen: No. The criteria
in DSM 4 is the same for adults. It is that the kids
would have to have cyclical episodes of clear-cut mania
and depression. The suggestion was made for DSM 4, going
back twenty years, that there be a separate criteria for
kids that would recognize that they are developmentally
different and that children are in different cycles and
that instead there are children who are irritable, who
have temper tantrums, who are conduct problems, and that
these may be precursors to bipolar disorder. We shot down
this idea, because we didn't think that there was enough
evidence for it and we realized that it might lead to wild
over-diagnosis. This didn't discourage the drug
companies, and in collaboration with a few thought leaders
in the field of child psychology who promoted this idea
very strongly, they were able to convince the field. They
were able to convince not just child psychiatrists, but
pediatricians and family care doctors. The rates of
childhood bipolar disorder have jumped forty times in the
last fifteen years, and the direct consumer advertising
was a wonderful way of promoting this, because you could
get the parents on board, teachers on board, with the idea
that any kid who had a conduct problem was really bipolar,
and that giving medication for that problem would be
helpful. The result has been an enormous overuse of drugs
in kids, and the drugs are particularly harmful in kids,
because they cause tremendous weight gain. The average
11-12 year old who weighs 110 pounds will gain 12 pounds
in 12 weeks on an anti-psychotic drug. They'll jump up
from 110 pounds to 122 pounds in just three months. We
already have an epidemic of childhood obesity. Obesity is
a risk factor for diabetes and cardiovascular disease and
for shortened life expectancy. And so, does it make sense
for us to be using what is essentially a fake diagnosis,
because childhood bipolar disorder has not been something
that is well studied or concerned- to give kids medication
that may cause them so much lifetime harm? It just
doesn't, in my view, it is one of the worst fads- I think
that there are a number of different fads in psychiatric
diagnosis- this is, I think, probably the least justified
and the most dangerous of the current fads in psychiatric
diagnosis.
Rob: Fads in
psychiatric diagnosis; ok, I want to cover that, but first
I want to pick up on one thing you said. Being put on a
psychiatric medication, like what would be used for
bipolar disorder, reduces your life expectancy doesn't
it?
Allen: Ok, I don't
want you to exaggerate this too much. I think that if you
need the medicine, the medical risks of obesity, diabetes
and cardiovascular disease are definitely worth it,
because the risks of not being treated are greater. These
medicines are enormously useful, essential, for people who
need them, and someone taking an anti-psychotic for a good
reason should certainly stay on them. But, taking these
medicines casually, because there were samples on the
shelf of your primary care doctor and he said after seven
minutes you might benefit from them; I think that is what
I am trying to fight against. I'm almost as worried about
the people who- I'm in some ways equally worried- about
the people who aren't getting medication they need as I am
about the ones who are getting too much medicine. So, we
have a misallocation where lots of people absolutely
definitely have a diagnosis or require medication that are
not getting it, because we have insufficient funding,
because sometimes they are hard to get into treatment, and
at the same time people who don't need it are being given
it casually and taking on the risks without there being
much benefit.
Rob: Ok, so there
were two pieces: one, I know that if you need the
medication and you go off it, it may not work if you go
back on it. Isn't that true?
Allen: Everyone is different; there is a variable, but
it certainly is not a good idea if you've had a good
response to medicine to go off it without great care and
thought about the risks and benefits.
Rob: If it is provisioned by a psychiatrist.
Allen: I would say yeah, definitely. I should state
that the longer a persons' brain has a psychiatric
symptom, the more embedded it tends to be, so that if a
person has mania and has lots of manic episodes, it may
make it more likely to have manic episodes in the future
and it may make it, as you suggest, more likely that they
will have difficulty being treated for the next manic
episode. So it is a very good idea to get there early and
to treat thoroughly real psychiatric symptoms. But on the
other hand, it is equally important that we not get there
so early that we are treating fake psychiatric symptoms
and giving medication that is not indicated. And, what
we've done is provide way too little money in treating the
serious and obvious psychiatric symptoms and way too much
money being wasted on treating situations that would do
better on their own.
Rob: So, again it goes back to what you said- going
on psychiatric medications like you would, selecting the
person you are going to marry-take it very seriously,
don't just jump on it. And so, I have a question. What
percentage of people who are put on these anti-psychotic
medications don't really need them? Is there any research
on that?
Allen: It is hard to say. I think we know a little
bit more about depression. 11% of the population is
taking an anti-depressant. In the surveys, only 3% of the
11%- a little less than one fourth- have actual depression
symptoms at the moment they are taking the medication.
So, 3% have depression symptoms, 8% don't but they are
still taking the medications. Now, some of those 8%
should be on medicine, because it serves a preventive
purpose. If someone has had loss or depression symptoms
in the past and they responded to medication, you don't
want to stop the medication. If someone has chronic
depression and they respond to medication, even though
they don't have symptoms at that moment, the medication is
serving a useful purpose. But, lots of people go on the
medication during a time when they were going to get
better anyway, that have a 50% placebo response rate.
And, of the 8%, no one knows for sure, but it is a safe
bet that at least half would be people who don't really
need to be on the medication. So, my guess is- and it is
a very rough guess, there is no right answer to this- if
we have 11% of the population taking anti-depressants,
maybe two thirds of those people really need them and
maybe one third don't. I think that with anti-psychotics,
the ratio is probably even worse, because they have been
so heavily publicized for off-label use. Twenty percent
of people with anxiety disorders now are getting an
anti-psychotic on top. They are being given out like
sugar water, and they are really not sugar water. So,
again, if someone has a clear-cut bipolar disorder or
schizophrenia, they should stay on their medicine. I
don't want anyone to be discouraged from hearing this. On
the other hand, if you are getting an anti-psychotic for
another indication, maybe you need it, but I would do a
lot of research on it and I would discuss it with a
doctor; and it has to be a good reason. If a doctor can't
explain something in ways you understand, it is a good
time to get a second opinion.
Rob: If somebody is put on a medication and they
don't really need it; what are the adverse side-effects,
the iatrogenic effects of it?
Allen: It varies medication by mediation, it varies by
dose, it varies with time, and some of these are just
unknown. We don't know what the effect would be of
putting people at the age of six on medication; what
affect that will have fifty or sixty years later, because
there just hasn't been time to study it. So I think it's
very specific to the individual medicine. Amongst the
drugs available on the market now, by far the most
problematic are the long term effects of anti-psychotics.
This weight gain issue is enormous even though the
medicines themselves are initially well tolerated in the
short run. For people who gain weight on them, that is a
huge issue that has to factored in. I think that there is
way too much anti-anxiety medicine being spread out.
Xanax is a very popular drug in primary care for anxiety.
The dose that is effective is very close to an addictive
dose, so that once on a heavy dose of Xanax it is very
hard to get off of it. The withdrawal symptoms mimic
anxiety or are worse than the anxiety you had when you
started, so that if you try to stop the pill you think you
are having a relapse and you have to stay on it. So there
are real addictive problems with the anti-anxiety agents,
particularly Xanax, and they are way over-used in primary
care. And then there is the real elephant in the room,
and those are narcotic prescription medications that have
taken off and in many instances are replacing street
narcotics. They are often responsible- in conjunction
with many anti-anxiety elements or alcohol- with drug
overdoses and with prescription addiction. It is a huge
problem in the military: 110,000 of our soldiers are on
psychotropic drugs, 110,000- I think about 8% of the
active duty. And many of them are receiving more than one
drug. There are instances where soldiers actually die
because of the prescription medicines that they have
received; they have overdoses of prescription medication,
and they are often also used in suicide attempts. So, I
think that if I had to pick the most dangerous drugs that
are being prescribed, I'd probably put the narcotic pain
medicines up there first, the anti-anxiety agents for
their addiction problems, and the anti-psychotic
medications because of the weight gain.
Rob: And what about these kids being put on stimulant
medications: Adderall and Ritalin and what have you under
the diagnosis of Attention Deficit Hyperactivity Disorder?
Allen: Thank you; I think that there are some kids for
whom these medicines are absolutely helpful and even
essential in their getting a decent education and being
able to function in school and with family. The problem
is that the rates of ADHD have tripled and the rates of
medication use have sky-rocketed, so that they are
currently being used for kids who are probably essentially
showing individual difference or developmental lags but
don't really have a mental disorder. A really chilling
study comes from Canada: they found- this is a large
sample, about ten thousand kids- that one of the best
predictors of getting a diagnosis of ADHD and getting
medication was when you were born. If you were born in
December, you had a tremendously lower rate- about 70% in
boys- of ADHD than if you were born in January. And, the
reasons are simple; that that was the cut-off for school.
The youngest kid in school is most likely to be
developmentally immature and most likely to get the
diagnosis of ADHD, most likely to be put on medication.
We have this strange, weird situation where we are
medicalizing immaturity; we're medicalizing the youngest
kid in the class. Each of the diagnoses and each of the
treatments make a lot of sense if it is done appropriately
where the symptoms are severe and enduring. The trouble
is, when you have fads, and it's like any kind of fashion-
there is a huge overshoot. And so kids that don't really
need the diagnosis, who would be better left alone or
better monitoring, or watchful waiting, or parent
training, or maybe school systems could pay more attention
to individual kids; a lot of this- of what gets diagnosed
as ADHD- may have to do with a school system that is under
trained and the easiest way of dealing with it is to
medicate each kid.
Rob: Now, when you medicate a kid with ADHD that
has its own risks as well. What are the risks when you
put a child on stimulant medication? Isn't it true that
sometimes that can actually precipitate other more severe
problems as well?
Allen: Well, as far as a tendency toward bipolar
disorder, there is a risk that it is going to stimulate
that. There is sleeplessness, there is lack of/difficult
with appetite, not gaining weight, not growing as you
might expect, there are very rare instances where you get
behavioral problems exacerbated, but they are real, and
very, very occasional cardiovascular problems. And also,
there is a huge secondary market; 30% of college kids and
10% of high school kids will have used someone else's
stimulant medication. There is a secondary market with
kids either selling or giving away their medicines to
their friends, and the medicine is being used more and
more for performance enhancement or recreation by people
who have either faked a diagnosis or have gotten the
diagnosis too casually and are in some instances handing
it around to the market or to their buddies. I think that
if someone has a substance abuse risk, one of the great
ways of getting supplies is to go to your doctor and say
that you have these symptoms. They are very easy to
describe, and if your doctor is a very loose
prescriber-and they are- there is a very quick
prescription of a stimulant medication that may actually
be addicting for that person or exacerbate psychiatric
problems. I don't think we should have the assumption
that every person who has distractibility or hyperactivity
needs medication. And one of the problems in DSM 5 is
that it will make it much easier for adults to get a
diagnosis of ADHD and adult distractibility can be caused
by any number of psychiatric problems as well as just a
part of life. If we make it easy for adults to get ADHD,
I think that will be the next fad. The next diagnosis
d'jour would be that lots of people are going to think
they have ADD and they'll be getting medication they don't
need often for recreational purposes or for performance
enhancement. I don't think that we should be handling
medical diagnosis this way; I think it should be carefully
done and the medication step should be equally
thoughtful. There should be a clear reason every time
someone takes a medication.
Rob: "Station ID" I'm speaking with Dr. Allen
Frances.
Allen: I think I'm going to have to go soon.
Rob: Ok. Just wrapping it up; Dr. Frances was the
chair of DSM 4 task force and the department of psychiatry
at Duke University. I wanted to take a kind of bigger
picture look at this. With DSM 5, it is going to change
America; it is going to change the percentage of people
who are diagnosed, the percentage of children who are
diagnosed and labeled. It is going to change the numbers
by the millions of people who are put on psychiatric
medications. Isn't that so?
Allen: Well, it's hard to know what the impact will
be. Not everyone who will qualify for a diagnosis will
get one, so that these [? 53: 42] studies, which show that
tens of millions of people might be diagnosed who would
have been diagnosed before if they went to the doctor and
asked for the diagnosis- but not all of them will do
that. I think it could have a substantial negative
effect, and that's why I'm so concerned about it.
Rob: What I'm concerned about is this is no small
change. Because of how influential the DSM has become, it
could change our American culture, and I'm curious if you
have had any thoughts on that really big picture? DSM 4
really took off, and DSM 5 is going to drastically expand
the percentage of people who are diagnosed or medicated.
How do you see that changing the American culture as
compared to other places where they don't do it this way?
Allen: I think that a lot of the damage has already
been done. I think we have a situation where we are using
way too many medications for way too many fake diagnoses.
I think that DSM 5 will make that worse; DSM 5 will turn
the temper tantrums of children into something called a
Disruptive Mood Disregulation Disorder. It'll turn the
normal forgetting of old age into something called Minor
Neurocognitive Disorder. It'll turn gluttony into Binge
Eating Disorder. It'll make grief into major depression.
So these are some serious problems, but I wouldn't
underestimate the problems we already have before DSM 5.
It may help to turn what is already a severe diagnostic
inflation into something of a diagnostic hyper-inflation,
but we already have the problem. It's not just DSM 5's
fault; it's something that we are living with now, and I
think the major hope that this can be reversed is the
tobacco industry. Thirty years ago the tobacco industry
was all-powerful, and who would have thought that at this
point smoking would have been reduced from 60% to 20% or
less in the population. It went from a sexy habit to a
dirty secret in the lives of the people who continue doing
it. The odds were against this ever happening because of
the huge financial power of the tobacco industry, but it
did happen. And, I think the pharmaceutical industry has
tremendously overstepped, and that even though it has
enormous resources and tremendous political pull, that
people may come to their senses and realize that we have
to pull back and try to use the medications more
thoughtfully where they belong. The companies are
constantly being fined. There have been- over the last
ten years- more than a dozen very large fines: the biggest
is three billion dollars, another 1.5 billion dollars for
off-label illegal marketing, in some cases criminally
illegal, of their products- anti-psychotics and
anti-depressants particularly. So, there has been a
government push-back against illegal drug company
practice, but the fines- even the three billion dollar
fine- is just the cost of doing business when the profits
are so large. I think that if some of the company
directors wound up being hit more with personal fines or
going to jail, if patents were shortened or illuminated
for drugs where there had been illegal marketing, if the
penalties were greater I think the companies would be
under better control. I think the idea that companies are
allowed to market to consumers is outrageous, not done
anywhere else in the world; that should be stopped. It's
better now than it was years ago, so there have been
efforts to monitor the pharmaceutical industry, and think
that they are successful to some degree but a lot more
needs to be done. I have to go.
Rob: Ok. Thank you so much! You have been a great
interview, and keep up writing about this. We need people
warning us what is going on here.
Allen: Thank you; and you ask good questions. You're a
smart guy. Thanks very much. Labels: allen francis, american psychiatric association, antidepressants, antipsychotic, anxiety, apa, apa. antidepressant, chemical imbalance, dsm, DSM5, pharmaceutical, psychiatrists
