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.