Rob: Ok, so there were two pieces: one, I know that if you need the medication and you go off it, it may not work if you go back on it. Isn't that true?
Allen: Everyone is different; there is a variable, but it certainly is not a good idea if you've had a good response to medicine to go off it without great care and thought about the risks and benefits.
Rob: If it is provisioned by a psychiatrist.
Allen: I would say yeah, definitely. I should state that the longer a persons' brain has a psychiatric symptom, the more embedded it tends to be, so that if a person has mania and has lots of manic episodes, it may make it more likely to have manic episodes in the future and it may make it, as you suggest, more likely that they will have difficulty being treated for the next manic episode. So it is a very good idea to get there early and to treat thoroughly real psychiatric symptoms. But on the other hand, it is equally important that we not get there so early that we are treating fake psychiatric symptoms and giving medication that is not indicated. And, what we've done is provide way too little money in treating the serious and obvious psychiatric symptoms and way too much money being wasted on treating situations that would do better on their own.
Rob: So, again it goes back to what you said- going on psychiatric medications like you would, selecting the person you are going to marry-take it very seriously, don't just jump on it. And so, I have a question. What percentage of people who are put on these anti-psychotic medications don't really need them? Is there any research on that?
Allen: It is hard to say. I think we know a little bit more about depression. 11% of the population is taking an anti-depressant. In the surveys, only 3% of the 11%- a little less than one fourth- have actual depression symptoms at the moment they are taking the medication. So, 3% have depression symptoms, 8% don't but they are still taking the medications. Now, some of those 8% should be on medicine, because it serves a preventive purpose. If someone has had loss or depression symptoms in the past and they responded to medication, you don't want to stop the medication. If someone has chronic depression and they respond to medication, even though they don't have symptoms at that moment, the medication is serving a useful purpose. But, lots of people go on the medication during a time when they were going to get better anyway, that have a 50% placebo response rate. And, of the 8%, no one knows for sure, but it is a safe bet that at least half would be people who don't really need to be on the medication. So, my guess is- and it is a very rough guess, there is no right answer to this- if we have 11% of the population taking anti-depressants, maybe two thirds of those people really need them and maybe one third don't. I think that with anti-psychotics, the ratio is probably even worse, because they have been so heavily publicized for off-label use. Twenty percent of people with anxiety disorders now are getting an anti-psychotic on top. They are being given out like sugar water, and they are really not sugar water. So, again, if someone has a clear-cut bipolar disorder or schizophrenia, they should stay on their medicine. I don't want anyone to be discouraged from hearing this. On the other hand, if you are getting an anti-psychotic for another indication, maybe you need it, but I would do a lot of research on it and I would discuss it with a doctor; and it has to be a good reason. If a doctor can't explain something in ways you understand, it is a good time to get a second opinion.
Rob: If somebody is put on a medication and they don't really need it; what are the adverse side-effects, the iatrogenic effects of it?
Allen: It varies medication by mediation, it varies by dose, it varies with time, and some of these are just unknown. We don't know what the effect would be of putting people at the age of six on medication; what affect that will have fifty or sixty years later, because there just hasn't been time to study it. So I think it's very specific to the individual medicine. Amongst the drugs available on the market now, by far the most problematic are the long term effects of anti-psychotics. This weight gain issue is enormous even though the medicines themselves are initially well tolerated in the short run. For people who gain weight on them, that is a huge issue that has to factored in. I think that there is way too much anti-anxiety medicine being spread out. Xanax is a very popular drug in primary care for anxiety. The dose that is effective is very close to an addictive dose, so that once on a heavy dose of Xanax it is very hard to get off of it. The withdrawal symptoms mimic anxiety or are worse than the anxiety you had when you started, so that if you try to stop the pill you think you are having a relapse and you have to stay on it. So there are real addictive problems with the anti-anxiety agents, particularly Xanax, and they are way over-used in primary care. And then there is the real elephant in the room, and those are narcotic prescription medications that have taken off and in many instances are replacing street narcotics. They are often responsible- in conjunction with many anti-anxiety elements or alcohol- with drug overdoses and with prescription addiction. It is a huge problem in the military: 110,000 of our soldiers are on psychotropic drugs, 110,000- I think about 8% of the active duty. And many of them are receiving more than one drug. There are instances where soldiers actually die because of the prescription medicines that they have received; they have overdoses of prescription medication, and they are often also used in suicide attempts. So, I think that if I had to pick the most dangerous drugs that are being prescribed, I'd probably put the narcotic pain medicines up there first, the anti-anxiety agents for their addiction problems, and the anti-psychotic medications because of the weight gain.
Rob: And what about these kids being put on stimulant medications: Adderall and Ritalin and what have you under the diagnosis of Attention Deficit Hyperactivity Disorder?
Allen: Thank you; I think that there are some kids for whom these medicines are absolutely helpful and even essential in their getting a decent education and being able to function in school and with family. The problem is that the rates of ADHD have tripled and the rates of medication use have sky-rocketed, so that they are currently being used for kids who are probably essentially showing individual difference or developmental lags but don't really have a mental disorder. A really chilling study comes from Canada: they found- this is a large sample, about ten thousand kids- that one of the best predictors of getting a diagnosis of ADHD and getting medication was when you were born. If you were born in December, you had a tremendously lower rate- about 70% in boys- of ADHD than if you were born in January. And, the reasons are simple; that that was the cut-off for school. The youngest kid in school is most likely to be developmentally immature and most likely to get the diagnosis of ADHD, most likely to be put on medication. We have this strange, weird situation where we are medicalizing immaturity; we're medicalizing the youngest kid in the class. Each of the diagnoses and each of the treatments make a lot of sense if it is done appropriately where the symptoms are severe and enduring. The trouble is, when you have fads, and it's like any kind of fashion- there is a huge overshoot. And so kids that don't really need the diagnosis, who would be better left alone or better monitoring, or watchful waiting, or parent training, or maybe school systems could pay more attention to individual kids; a lot of this- of what gets diagnosed as ADHD- may have to do with a school system that is under trained and the easiest way of dealing with it is to medicate each kid.
Rob: Now, when you medicate a kid with ADHD that has its own risks as well. What are the risks when you put a child on stimulant medication? Isn't it true that sometimes that can actually precipitate other more severe problems as well?
Allen: Well, as far as a tendency toward bipolar disorder, there is a risk that it is going to stimulate that. There is sleeplessness, there is lack of/difficult with appetite, not gaining weight, not growing as you might expect, there are very rare instances where you get behavioral problems exacerbated, but they are real, and very, very occasional cardiovascular problems. And also, there is a huge secondary market; 30% of college kids and 10% of high school kids will have used someone else's stimulant medication. There is a secondary market with kids either selling or giving away their medicines to their friends, and the medicine is being used more and more for performance enhancement or recreation by people who have either faked a diagnosis or have gotten the diagnosis too casually and are in some instances handing it around to the market or to their buddies. I think that if someone has a substance abuse risk, one of the great ways of getting supplies is to go to your doctor and say that you have these symptoms. They are very easy to describe, and if your doctor is a very loose prescriber-and they are- there is a very quick prescription of a stimulant medication that may actually be addicting for that person or exacerbate psychiatric problems. I don't think we should have the assumption that every person who has distractibility or hyperactivity needs medication. And one of the problems in DSM 5 is that it will make it much easier for adults to get a diagnosis of ADHD and adult distractibility can be caused by any number of psychiatric problems as well as just a part of life. If we make it easy for adults to get ADHD, I think that will be the next fad. The next diagnosis d'jour would be that lots of people are going to think they have ADD and they'll be getting medication they don't need often for recreational purposes or for performance enhancement. I don't think that we should be handling medical diagnosis this way; I think it should be carefully done and the medication step should be equally thoughtful. There should be a clear reason every time someone takes a medication.
Rob: "Station ID" I'm speaking with Dr. Allen Frances.
Allen: I think I'm going to have to go soon.
Rob: Ok. Just wrapping it up; Dr. Frances was the chair of DSM 4 task force and the department of psychiatry at Duke University. I wanted to take a kind of bigger picture look at this. With DSM 5, it is going to change America; it is going to change the percentage of people who are diagnosed, the percentage of children who are diagnosed and labeled. It is going to change the numbers by the millions of people who are put on psychiatric medications. Isn't that so?
Allen: Well, it's hard to know what the impact will be. Not everyone who will qualify for a diagnosis will get one, so that these [? 53: 42] studies, which show that tens of millions of people might be diagnosed who would have been diagnosed before if they went to the doctor and asked for the diagnosis- but not all of them will do that. I think it could have a substantial negative effect, and that's why I'm so concerned about it.