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?
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.