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Saturday, 6 July 2013




The Diagnostic and Statistical Manual, the DSM, was first launched in 1952 with 106 conditions identified. Over the past 60 years the number of mental illnesses for which there is now a diagnosis has more than tripled.

Dr Allen Frances led the team who rewrote the guidelines for diagnosis in 1994 with DSM IV, but in recent times, he's done an about-face, condemning his own work, labelling some of the writing in that DSM IV as a mistake. But what troubles him more is that the latest diagnostic regime, DSM V, goes further down the road of labelling a range of what he calls unfortunate human behaviours as mental illnesses.

In his new book, called Saving Normal, Dr Frances argues that there is now an increasing tendency to chalk up life's difficulties to mental illness. Dr Frances joined us a short time ago from San Diego.

Dr Frances, welcome to Lateline.

ALLEN FRANCES, AMERICAN PSYCHIATRIST: Thank you very much for inviting me.

EMMA ALBERICI: Tell us, what were the mistakes that you say you made in hindsight in leading this team that developed the DSM IV?

ALLEN FRANCES: We were very worried about diagnostic inflation in psychiatry and excessive treatment. So we were quite conservative in our efforts and accepted only two of 94 changes. But our conservatism was absolutely overwhelmed by drug company marketing. And despite our best intentions, there have been three epidemics: attention deficit disorder, autism and bipolar disorder. If I had it to do over again, we would have been even more conservative, more restrictive and we would've put lots of warnings in most of the diagnoses that were being overdone. That might not have worked, but we should've tried harder.

EMMA ALBERICI: So how much influence do you say big pharmaceutical companies exercise in the drafting of these DSM - what is now DSM V?

ALLEN FRANCES: They've absolutely no influence at all in the drafting, but they wait on the sidelines, eagerly awaiting the new manual because it will allow them marketing opportunities that will result in billions of dollars of extra revenue.

EMMA ALBERICI: You say no influence at all in the drafting and yet it was revealed that one influential advocate for diagnosing bipolar disorder in children failed to disclose money he received from the makers of the bipolar drug Risperdal. Did you see much evidence of this kind of conflict of interest during your time on the DSM taskforce?

ALLEN FRANCES: Well he's actually had no influence on the DSM - neither DSM IV or DSM V. His suggestions were rejected both times. But it shows the power of the drug industry that one very influential and well-financed thought leader can convince the field of paediatricians and child psychiatrists to give kids medicine that they certainly don't need that will make them fat and increase the risk of diabetes and heart disease and maybe even a shortened life span. The drug companies are enormously powerful and it's my belief that they should not be allowed to market at all. We stopped big tobacco's influence by preventing its advertising. I think we should be doing the same thing with the pharmaceutical industry.

EMMA ALBERICI: So what is your concern about the DSM V in particular and in isolation?

ALLEN FRANCES: I'm afraid that it will turn what we consider everyday normal problems of life, expectable parts of the human condition, into mental disorder and that this will often result in excessive use of medications that can be quite harmful and are very costly. The worst suggestions in DSM V will turn normal grief into major depressive disorder, will turn the forgetting of old age into mild neurocognitive disorder, will turn worrying about your cancer into somatic symptom disorder, will turn temper tantrums in kids into disruptive mood disregulation disorder, will have attention deficit disorder be virtually ubiquitous and an easy means of getting stimulant drugs for performance enhancement and for recreation.

EMMA ALBERICI: But presumably these were the best and brightest minds in the field of psychiatry who were putting together these guidelines on diagnosis.

ALLEN FRANCES: I've been herding experts in psychiatry for 35 years. I've never met an expert who ever said, "Let's narrow my area." Experts have an intellectual conflict of interest. They love their pet area of research. They're enormously naive about the risks that suggestions that might work well for them will be horribly disruptive, especially in primary care practice. 80 per cent of psychiatric drugs are prescribed by primary care doctors, usually after a seven-minute visit, often with little experience in the field and very much influenced by drug salesmen. Suggestions that they're dreamed up by experts that may possibly work for them in their own research clinics can be absolutely disastrous under these very different conditions of average everyday practice.

EMMA ALBERICI: Part of your regret over the DSM IV was the classification, as you mentioned, of bipolar disorder. How did you manage to get that wrong?

ALLEN FRANCES: Well we didn't get it wrong. What we did was add something called bipolar II. It made a lot of sense, there was a lot of scientific support for it. It was meant to protect patients with unipolar depression from actually becoming bipolar because of the medication, the anti-depressant medication they received. But what happened three years after the publication of DSM IV was that the drug companies came out with new products, very expensive, on-patent products which gave them both the motive and the means for a remarkably heavy advertising campaign. And at the very same time in the United States they got the unprecedented right to advertise directly to consumers as well as marketing heavily to doctors.

Bipolar II, as conceived by us, was a very reasonable suggestion. But the way you write the manual isn't necessarily the way the manual will be used. And the drug companies were able to convince patients and doctors that typical problems were really elevated mood. And this resulted in enormous overuse of anti-psychotic drugs when they weren't really needed.

EMMA ALBERICI: Now you're clearly troubled by the rising levels of diagnosis of mental illness in children. Are children more mentally disturbed than they once were, or is something else at play beyond the influence of the drug companies?

ALLEN FRANCES: The history of psychiatry is the history of fad diagnoses. Fashion plays a large part. And fashion is now being very much influenced especially by the drug companies. Children are particularly difficult to diagnose. They have a short track record. Developmental factors can be very much at play. A kid may look disturbed this week and very much better two weeks later. So I think that we should be especially cautious in diagnosing children and instead there's been a loosening of diagnosis and with it the excessive use of medication for children who very much will likely do better without it. I believe in stepped diagnosis, caution, first do no harm, watchful waiting. Diagnosis when it's absolutely necessary should certainly be made and treatment begun promptly. But if the picture is unclear, as so often it is with children, parents would be advised to be very cautious, to get second opinions and to see how things work out over time.

EMMA ALBERICI: So you're not discounting the diagnosis of attention deficit disorder or attention deficit hyperactivity disorder?

ALLEN FRANCES: All of the diagnoses in the manual are valuable when they're used cautiously, but can be dangerous if they're used carelessly. Very often now diagnoses are made after very brief contacts with patients. Attention deficit disorder in its classic and severe form definitely needs to be treated promptly. But the tripling of the rates of attention deficit disorder mean that many kids who don't need the diagnosis are being treated. There's an incredible study from Canada. The very best predictor of attention deficit disorder was whether you were born in January or December. What this means is that the youngest kids in the class are almost twice as likely to get a diagnosis of attention deficit disorders as the oldest kids in the class. We're turning being young into a mental disorder and that makes no sense at all. We should be spending less money on drugs for ADD, more money for smaller class sizes and more physical education so that kids can blow off steam and be less active in the classroom.

EMMA ALBERICI: Now one of the other issues you've had with the DSM V is the inclusion of preventative psychiatry. Tell us what your concern is specifically there.

ALLEN FRANCES: It's a wonderful idea to try to prevent disease before it manifests itself fully. But what we've learned from the last 35 years of preventive medicine and surgery is that very often the intervention is worse than the disease. And the medical specialties in America are joining with the British Medical Journal in a campaign to reduce the excessive use of screening tests because they often are more harmful than helpful. Psychiatry does not at this point have the capacity to identify people accurately who will be at risk for later psychiatric disorder. We don't have interventions that are proving themselves effective in preventing later mental disorder and many of the interventions are themselves quite dangerous, especially medication. So it's a great mistake to move forward with preventive psychiatry before it's been tested by research. Australia's embarked on a tremendous experiment, nationwide experiment in this area that's really a public health flyer, the consequences of which are impossible to predict and I think are very much unsupported by the existing literature.

EMMA ALBERICI: In the DSM IV - you did allude to this earlier with the issue around bereavement - and in the DSM IV a person could not be diagnosed with a depressive episode within two months of the death of a loved one. That exclusion has now been lifted. Are you comfortable with that given the advice has changed from my reading four times since 1952?

ALLEN FRANCES: Well actually, let me correct you a bit on this. In DSM IV if a person has severe depression after losing someone they've loved, if they're suicidal or delusional, if they can't function, if they're very agitated, if they have a history of major depressive disorder, the diagnosis can certainly be made as soon as it needs to be made. But DSM IV said if someone's experiencing mild symptoms that are completely the equivalent of typical grieving, there's no sense at all in making a diagnosis of major depressive disorder. In DSM V, if you feel sad, if you lose interest, appetite, trouble sleeping, less energy for just two weeks after losing the love of your life, that can be diagnosed as major depressive disorder and drug salesmen can try to convince doctors that medication is indicated. This is substituting a superficial medical ritual for the deep and important human cultural rituals around death that have been built up over hundreds of thousands of years. It's normal to grieve. We shouldn't be calling this mental disorder. We shouldn't be treating it with medication, unless it's severe.

EMMA ALBERICI: I wanted to talk about post-traumatic stress disorder. The DSM V has added symptoms to make it easier to diagnose. Given the numbers of soldiers returning from Iraq and Afghanistan, is that a development you welcome?

ALLEN FRANCES: I think the problem here is that post-traumatic symptoms are a normal human response to the horrors that many of our soldiers are subjected to. But calling it mental disorder and requiring it for benefits often makes the problem worse, stigmatises the individual, stigmatises the whole group of returning soldiers because the rates are reported as being so high. I think it would be much better if we provided more benefits for all the troops coming home, regardless of whether they have this diagnosis or not. I think that requiring a diagnosis of post-traumatic stress disorder to get veterans' benefits increases the rates artificially and makes the transition to civilian life that much harder. So I would treat post-traumatic symptoms as a problem of war. I would not necessarily see it as a mental disorder, and if we took better care of our troops coming home, the rates would go way down.

EMMA ALBERICI: Do you worry that sounding the alarm as you have will undermine the authority of all doctors in the mental health field? I mean, their reputations after all rest on their ability to put a name to a patient's suffering.

ALLEN FRANCES: No, I very much support the diagnostic system and I'm a great believer in psychiatry. I've seen tens of thousands of patients who've benefited from psychiatric treatment. I'm worried about it extending itself too thin beyond its area of competence. Careful diagnosis and careful treatment saves lives and dramatically improves them. What I'm worried about is excessive diagnosis and excessive treatment for the worried well. The worst thing that could come from this is if people lose faith in psychiatry, stop their medicine, get sick and maybe even kill themselves. So people should not lose faith in psychiatry. It's a lot better than DSM V.

EMMA ALBERICI: Let me use the title of your book; how do you "save normal"?

ALLEN FRANCES: I think it's very important to save normal and very important to save psychiatry. We need to tighten the diagnostic system. We need to control big pharma. We need to change insurance policies that encourage doctors to diagnose early in order to be reimbursed for the visit. Watchful waiting for mild problems often is the very best policy. We need to use psychotherapy more for mild conditions and medication less. I think that psychiatric diagnosis has become too important to be left in the hands of one small and biased professional association. And we need a new mechanism for vetting psychiatric diagnoses that's just as careful as the mechanism we use for vetting new drugs. At this point, psychiatric diagnoses can be much more dangerous than new drugs. New drugs usually have the same old side effects; psychiatric diagnosis can include millions of people who previously were not subjected to medication they didn't need.

EMMA ALBERICI: Dr Frances, thank you so much for taking the time to speak to us tonight.

ALLEN FRANCES: It's my pleasure and I hope it was helpful.

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