Allen Frances interview (recorded Nov 10 2012):
Allen J. Frances on the overdiagnosis of mental illness Psychiatrist and author, Allen J. Frances, believes that mental illnesses are being over-diagnosed. by YouTube
Rob: "Radio ID" My guest tonight is Allen Frances, M.D. He was the chair of the DSM 4 Task Force and the chair of the department of psychiatry at Duke University School of Medicine, Durham, North Carolina. He's currently Professor Emeritus at Duke. Welcome to the Show!
Allen: It's good to be here.
Rob: Now, the reason I contacted you is you wrote an article titled "DSM 5 Field Trials Discredit the American Psychiatric Association." Why don't you start off by explaining what DSM 4 and DSM 5 are and what they mean and why they are important?
Allen: This is the diagnostic manual in psychiatry. Until 1980, no one much cared about it, but DSM 3, published in 1980, became a huge best seller. There are hundreds of thousands of copies sold every year, and the reason it is so important is because lots of decisions depend on it-- who gets treated and who doesn't, who pays for the treatment, who gets disability, who gets to pilot a plane, who gets to adopt a kid, workman's compensation. All sorts of things are triggered -- and school services in particular -- on having a psychiatric diagnosis. It essentially sets the boundary between who's normal and who's not. So this has become an enormously important document. The last version of it, which I was sort of the head person on, was published in 1994, and there is a revision that is about to appear next year; it's called DSM 5, and that revision has been very controversial- I guess for reasons that we will discuss. But the changes made there could determine how tens of millions of people regard themselves: whether they have a mental disorder or not, and it could determine who gets medication and lots of people in our society are getting medication they probably don't need; so the stakes are pretty high.
Rob: As the Director of Development of DSM 4- I may not have that title exactly right; correct me if need be- you had to be pretty high in terms of being a trusted member of this psychiatric hierarchy. How did that happen? How did you get that position?
Allen: I worked on DSM 3, and I was part of the group that prepared DSM 3R- that was a revision in 1987- and so I had some experience in the kinds of questions involved. It's a pretty tedious job; I'm not sure that many people in the world would have wanted to do it. So, yes, I was involved very much in how psychiatric diagnosis would evolve, and I guess what has happened in the last three years is I have become a critic of that process. So, I went from being the director of a program that was involved in preparing DSM 4 to being a very sort-of staunch critic of how DSM 5 is being prepared. I don't think that the process has been careful enough or open enough to produce a document that will be trustworthy.
Rob: You describe how it affects people's lives, but it also affects business too- the pharmaceutical business. How many billions of dollars will be relying on DSM 5?
Allen: It's really weird- the degree to which Americans are taking psychotropic medications. In any given year, 20 % of Americans will take a drug that is a psychiatric drug. About 11 % of the population is on anti-depressants, and 20 % of women are on anti-depressants, 4% of kids are on a stimulant, 4% of teenagers are on an anti-depressant. Perhaps most remarkably, anti-psychotic drugs are amongst the best selling drugs in America: 18 billion dollars a year in anti-psychotic drugs, anti-depressants about 12 billion dollars a year, stimulant drugs about 7 billion dollars a year. So we've really become a pill popping culture and the drug companies have a huge stake in this. We are the only country in the world now that allows drug companies to advertise directly to consumers. So, you are constantly seeing ads on TV, trying to disease-monger; trying to suggest that you have one or another psychiatric disorder, that this is a chemical imbalance in your brain, that if you take a pill that will be the solution to all of life's ills. And the drug companies have essentially gone into the business of selling psychiatric diagnosis as a way of selling pills. If they can convince enough people that they are sick, then if people ask their doctor for a pill, they are very likely to get it. If you ask your doctor for a psychotropic medication, you're 17 times more likely to walk out of the office with a pill. The real problem here is that most of these pills are not being prescribed with psychiatrists and aren't being done after careful diagnostic interviews with someone who knows something about psychiatric diagnosis. About 80 % of psychotropic drugs in America are prescribed by primary care doctors who have -- in most instances- very little time- the average visit is about 7 minutes- in many instances little or no training in psychiatry, some instances no interest in psychiatry. And primary care doctors tend to be inordinately influenced by drug sales people. They get their education in psychiatry from people who are selling drugs who have the story line that psychiatric diagnosis is often missed, is very easy to make, and that there is a simple pill that will solve all the problems. So the current situation is weird; we have 90% of anti-anxiety drugs like Xanex being prescribed by primary care doctors, and 80% of anti-depressants are prescribed by primary care doctors. 60% of stimulants and half of the anti-psychotics are being prescribed by primary care doctors, very often after these brief seven minute interviews, very often because the doctor has samples that he has been given by the drug salesman that he gives out. This is a convenient way to get the patient out of the office quickly. And, the result is a tremendous overdose, I think -- societal overdose- of medication. 7% of the population is addicted to a prescription drug- 7%.
Rob: How many?
Allen: 7% of the population
Allen: 7, yes. And it turns out that there are now more visits to the emergency room for overdoses with prescription drugs than visits with street drugs. In some ways, we have turned a very bad corner where the drugs you get from the doctor can cause you more harm than the drugs you would get from a street corner pusher. So, I think that there has been a kind of overdose of diagnosis and overdose of medication. And part of my reaction to DSM 5 is that it will make this worse by introducing new diagnoses that will have many millions of people qualifying for a mental disorder who --the night before it is published- would not have been considered to have a psychiatric illness. And it's reducing some of the thresholds for existing disorders, which again will increase diagnostic inflation and make it more likely that people will get psychotropic medication that they don't really need plus the stigma of having a diagnosis that you don't really have.