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.
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