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.
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