Allen Frances, MD
Allen Frances, MD, former chair of the Task Force for DSM IV, professor emeritus, Duke University School of Medicine, Durham, North Carolina.
As a former practicing psychiatrist, Allen Frances, MD, is very concerned about how millions of people who are facing the unavoidable problems of everyday life and really are just the “worried well” are being overdiagnosed with psychiatric disorders and receiving unnecessary pharmaceutical treatment. Since the early 1980s, the number of Americans who meet the criteria for a mental disorder and who are being prescribed psychiatric drugs for depression, anxiety, sleep disorders and attention-deficit hyperactivity disorder (ADHD), among other conditions, has increased dramatically. So, too, are the diagnoses of autism and bipolar disorder in children. Some of these cases represent previously missed instances of mental illness, but more accurate diagnosis can’t explain why so many people, especially children, suddenly seem to be mentally ill.
Overtesting, overdiagnosing and overtreating are the hallmarks of our current health-care system, thanks to external forces that have put profit and expediency over appropriate care when it comes to mental and emotional issues.
One of the biggest drivers of this phenomenon is the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association. The current edition, updated in 2013, of the “psychiatric bible” converted millions of people into mental patients by arbitrarily broadening the definitions of existing disorders and adding new psychiatric illnesses. Examples: Everyday overeating has become “binge-eating disorder.” Normal concerns about physical symptoms now are considered to be “somatic symptom disorder.” Normal grief now is easily mislabeled as “major depressive disorder.”
Example: Sarah’s 33-year-old son committed suicide, and she was inconsolable. She couldn’t sleep or eat, cried all the time and was unable to focus or work. After two weeks, a friend suggested that she go to her primary care doctor, who diagnosed her as clinically depressed and put her on an antidepressant. Sarah took the medication for two weeks, but her symptoms grew so bad that she considered killing herself so she could join her son. Her doctor told her, incorrectly, that suicidal thoughts couldn’t be a side effect of the drug. She decided to stop taking it and began attending counseling and grief group meetings and gradually improved. Two years later, she says she can experience joy and laughter again though she continues to live with her grief.
Another driver is the pharmaceutical industry, which earns billions of dollars by selling psychiatric drugs. Psychotropic drugs are among the top sellers for many drug companies. Pharmaceutical companies also are major supporters of continuing medical education today, which is more focused on prescription pads than unprescribing and psychotherapy.
A third reason is the fact that there are no laboratory tests that can definitively say a person has a psychiatric illness. A diagnosis is made based on what a psychiatrist can glean from spending time with the patient during office visits and hearing about his/her symptoms, stressors, past history, family history and supports. The diagnosis is subjective and sometimes differs widely from one psychiatrist to another.
Severe, classic mental disorders such as schizophrenia and major depression are unmistakable and can be reliably diagnosed. But mild cases are on a continuum with the normal ups and downs, stresses, disappointments, sorrows and setbacks of living a typical life.
Examples: Temper tantrums can suggest bipolar disorder or, more simply, difficulty managing anger. Irritable, distancing behavior from veterans returning from tours of duty can indicate post-traumatic stress disorder or just a normal period of adjustment back to civilian life. Your grandson’s precocious, obsessive interest in video games and science fiction can suggest autism or just the interests of a normal young man in today’s world.
Unfortunately, most psychiatric diagnoses and treatments now are handled by rushed primary care doctors, often after 10-minute visits with patients they don’t know very well. General practitioners prescribe 90% of benzodiazepines (calming agents such as Valium, Xanax and Ativan)…80% of antidepressants…65% of ADHD drugs…and 50% of antipsychotics—even though primary care doctors have little training in psychiatry or the medications they are prescribing. Writing a prescription is the fastest way to get the patient out of the office. On the flip side, patients have an inbred belief in the wisdom of doctors and have been trained through the last 50 years that taking a pill fixes things. End result: The patient obediently follows the doctor’s advice, and both the doctor and the patient feel satisfied that something has been done—whether or not the problem is accurately diagnosed and properly treated.
To protect yourself from being diagnosed with a psychiatric disorder when you don’t have one…
Observe your symptoms for a few weeks. Watchful waiting and several visits with your primary care doctor are the best first step for many people with mild issues. Symptoms often go away on their own with the passage of a few weeks, and what’s often needed most is reassurance from a doctor that these feelings are normal—plus advice on how to cope and reduce stress without medication. Often, new symptoms result from increased life stress that is likely to be transient and better managed by problem-solving than pills. Psychotherapy also is often helpful. Be sure to rule out the possibility that symptoms may be due to a medication side effect or withdrawal…drug or alcohol use…or a medical illness.
Important: If your symptoms are severe, chronic or worsening or if you fear that you might hurt yourself or others, seek immediate psychiatric assistance.
Serious challenges in our medical system: Insurance companies often refuse to pay for a mental health visit unless a DSM-5 diagnosis is made, forcing doctors to prematurely identify the so-called illness and treat it with medication. Another challenge is that many mental health clinicians do not accept insurance and patients must pay out-of-pocket. Fortunately, a number of lower-cost services now are available via teletherapy. Your primary care doctor also may be a good resource for a referral to a therapist. Often a brief series of therapy sessions with the right person will have a significant impact on your symptoms and your life.
Be skeptical and well-informed. Don’t passively accept a psychiatric diagnosis and drug treatment—especially from your primary care doctor—without doing some research on websites from reputable institutions such as a medical school like Harvard, Mayo Clinic and others, and the government website Medline. Check whether your symptoms match the description of the disorder…have lasted long enough to meet the criteria…are causing you considerable distress…and/or are impairing your ability to work, take care of yourself and connect with others. Keep a diary of your symptoms to chart progress and share with your doctor.
Get more than one professional opinion, and include your family in decision-making. People usually come to their doctors’ offices on one of the worst days of their lives with transient problems that often will improve on their own or with reduced stress and increased support.
If you’re on a psychiatric drug currently: You may not need to take the medication for life, but don’t stop taking it abruptly or on your own. Many meds cause withdrawal syndromes that can be disruptive and even dangerous. Going off psychiatric medications always should be done gradually over weeks or months and only under medical supervision.
