Allen Frances interview (recorded Nov 10 2012):
by YouTube
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
Rob: 7%
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.
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