Is the normal person an endangered species?
Psychiatrist Allen Frances, MD, posed that question in a recent essay published in Psychiatric Times, discussing what appears to be an epidemic of mental illness in our country. Here’s a startling example:The National Institute of Mental Health estimates that 20% to 25% of the US adult population — that makes about 45 million of us — has a diagnosable mental disorder. Is this possible? Or might the real problem be that doctors are overdiagnosing people who are simply experiencing expectable ups and downs of life or who just have personality quirks.
Dr. Frances believes that it is the latter. I found his essay so intriguing that I called him to chat about some of these provocative ideas. He told me that these past few decades have brought us one psychiatric fad after another, with the rapidly escalating diagnoses of autism, attention-deficit/hyperactivity disorder (ADHD) and even bipolar disorder among our children and, in adults, the increasing numbers of people being labeled as having such conditions as anxiety disorder, post-traumatic stress disorder, ADD/ADHD, depression and more.
Is Everyone Sick?
Dr. Frances is a professor emeritus at Duke University School of Medicine and was the chair of the DSM IV Task Force, the committee that worked from 1987 to 1994 to update the Diagnostic and Statistical Manual of Mental Disorders, the book that provides criteria for mental disorder diagnoses that is the bible of the mental health community (and which provides the basis for insurance coverage for treatment for mental illness). First published by the American Psychiatric Association in 1952, this essential tome gets updated every 15 to 20 years to ensure that it reflects the current state of knowledge of psychiatry, psychology and medicine as it pertains to mental disorders. But, Dr. Francis told me, the very process of regularly revising this manual may have contributed to the problem. Here are some highlights from our conversation…
Daily Health News: How does it happen that a mental disorder becomes what you call a “psychiatric fad”?
Dr. Frances: When the DSM is updated, we want to be sure that the criteria don’t miss anyone who suffers from a disorder, but our good intentions have unintended consequences — overdiagnosis is now causing far too many people to get caught in the psychiatric net. Unfortunately, there is no good way to determine the exact correct threshold of symptoms that turns a person who is more or less normal into one who has a psychiatric problem, but any time you see a significant and sudden jump in diagnoses of a particular disorder, there is reason to worry.
DHN: What is an example of a current psychiatric disorder fad?
Dr. Frances: Major depression is an important example of diagnostic inflation — 10% of the population now qualifies and is taking antidepressant medication. The criteria that psychiatrists use for major depressive disorder include feeling sad and tired and with reduced pleasure, appetite and sleep, for as little as two weeks, even if the mild symptoms are the result of painful life events. At least half the time, those symptoms will resolve on their own, usually within a few weeks — all too frequently these essentially normal people who are undergoing stress get labeled as having major depression and are put on medication to treat it. When they feel better, they may assume incorrectly that the medicine did the trick, not just time and their own resilience.
Drug Companies Are Part of the Problem
DHN: Can you talk about the role the pharmaceutical industry has played in creating these psychiatric fads?
Dr. Frances: Drug companies have one salesperson for every seven physicians, and they target primary care doctors, who do most of the prescribing of psychiatric drugs. The drug companies also aggressively market psychiatric diagnoses and drugs directly to patients on television, in print media and on the Internet. So patients come in primed to think that they might have a psychiatric disorder — they’re even told to “ask your doctor” about a drug to treat it. For example, a growing fad now is the issue of low libido in women resulting from efforts by the pharmaceutical industry to get women to think they have an inadequate sex life and so should pop a pill. At the same time, there is no pushback to advertising right now, no campaign to support normality. There’s also no widespread education the about placebo effect and the risk/benefit ratio of drugs. The issue of unnecessary medication being prescribed and drug side effects is by far the biggest danger of fads.
DHN: Can you explain what being given an erroneous diagnosis means to people?
Dr. Frances: Let’s take autism as an example. In the DSM IV, we included a broader definition of a condition called Asperger’s syndrome (the mildest form of autism, characterized by problems with social skills, communication and coordination… eccentric or repetitive behavior… rituals or unusual preoccupations… exceptional talent or skill in a single area… and a limited range of interests) because we wanted to be sure that these patients would have access to treatment, such as special education and behavior modification therapy. We were surprised by an enormous twenty-foldincrease in diagnoses! This is almost certainly due to a change in diagnostic habits, as we have no credible evidence that anything in the environment is causing such an increase. Rather, it is the labels that change and how they are used in practice. The diagnosis of autism is now being loosely used to explain all sorts of milder eccentricities and social difficulties.
Another troubling example is the vast overdiagnosis of bipolar disorder in children, which has seen an even greater (forty-fold) increase in the past 20 years. This means that kids who may be nothing more than irritable and difficult to manage end up taking unnecessary antipsychotic drugs over long periods of time. The serious side effects of these drugs can include obesity, diabetes, heart disease and perhaps shorter life spans.
DHN: What other risks to patients are associated with psychiatric fads?
Dr. Frances: Many people absolutely need the drugs that they are taking, but many others with mild and transient symptoms are taking potentially harmful medications that they do not need. Medicalizing “normalcy” means that we are spending huge health and educational resources on people who don’t need treatment or services — and for whom it might even be dangerous, as in the case of medication. This distracts attention and diverts funds from others who do need such help. Another problem is that there is a stigma involved in being diagnosed with a psychiatric condition, especially in childhood, when the diagnosis implies a lifelong one. Such a label lowers expectations for behavior and accomplishments and, later on, having the diagnosis can threaten an individual’s chances of getting a desirable job and health insurance.
Do You Really Need That Pill?
DHN: What advice do you have for people who are concerned that they or their children might be suffering from a mental disorder?
Dr. Frances: Never go off a drug without medical supervision, but do think carefully about your diagnosis and whether you really know that you need that pill you are being given. Make a careful evaluation of the problem. Psychiatric symptoms that are mild, relatively recent and/or a response to stress often get better on their own or with counseling and don’t require medication. When people start to feel better, they think it is the drug that is helping even though the placebo effect accounts for up to 50% of positive responses to medication. People may cling to an unnecessary drug and stay on it way too long. Be well-informed and periodically reevaluate your diagnosis and treatment.