Dr. Frances: I am a psychiatrist. I was chair of the DSM-IV task force. I have been quite critical of DSM-5 and concerned about the fact that too many people in the United States are already getting diagnoses and medicine they don’t need. I am worried that DSM-5 will make that worse.
CCPR: What makes you think that DSM-5 will make that worse?
Dr. Frances: There are a number of new diagnoses that will capture millions of people, and existing diagnoses like ADHD have been watered down, so it will be a lot easier for people to get the diagnosis. Twenty-five percent of the American public currently would quality for a mental disorder diagnosis (Reeves WC et al, Morbidity and Mortality Weekly Report 2011:60(03) ;1—32) and 20 percent are taking psychotropic medications (Medco Health Solutions, America’s State of Mind Report 2011: http://bit.ly/17VyHqK). An amazing Canadian study of a million kids showed that the best predictor of ADHD was whether a child was born in December or January, especially for boys. There is almost twice the rate of ADHD in the youngest kid in the class as opposed to the oldest kid in the class (Morrow RL et al, CMAJ 2012;184(7):755-762). Immature kids are being diagnosed with ADHD and often treated with medication. Twenty percent of high school boys in America get the diagnosis of ADHD and 10 percent of high school boys are on medication (Centers for Disease Control and Prevention, 2011-2012 National Survey on Children’s’ Health; http://1.usa.gov/Mb5D9L). This is ridiculous.
CCPR: One of your criticisms of DSM-5 is that the diagnoses don’t necessarily predict a clear prognosis or treatment approach.
Dr. Frances: My point regarding DSM-5 is that you don’t suddenly say that 10 million people have a mental disorder unless you know a lot more, unless you have evidence that that diagnosis is going to be useful. In DSM-5, diagnoses have been accepted on descriptive grounds. But this is not enough. We shouldn’t be adding diagnoses unless we know what the consequences are. The experience of the past is that every time we add a diagnosis it tends to be misused. And in this instance, the most likely misuse will be that people will begin treating it; the drug industry will be involved, and way before we know whether a medication is helpful, people are on medication. In 35 years of working with experts on diagnosis, I have never met one who said, “My area needs to be reduced.” Every expert wants to increase the purview; they always worry about missed patients; and they overvalue the research in their area, and their own research, so the system gets burdened with new diagnoses that are largely untested, just at the very beginning of understanding of whether they are useful or not, and then the unintended consequences come in.
CCPR: For example?
Dr. Frances: We have had a tripling in the last 20 years in ADHD (CDC op. cit) and a 40 times increase in autism since DSM-IV (CDC autism data, http://1.usa.gov/Gi1Nx). We have had a 40 times increase in childhood bipolar disorder (Moreno C et al, Arch Gen Psychiatry 2007;64(9):1032-1039)—even though we rejected the concept of childhood bipolar disorder in DSM-IV—because drug companies and thought leaders trumpet it and convince people that this is a phenomenon. A 40 times increase and a tremendous increase in the use of inappropriate antipsychotics in children. So the diagnostic system has to be protected. We shouldn’t be adding or changing diagnoses unless we know the consequences, and the one thing we have learned from past experience is that a likely consequence of any change is a lot of misdiagnosis and a lot of excessive treatment.
CCPR: You say in your book, Saving Normal, “Child psychiatrists often dare to go where no one has gone before and children wind up paying the price. They keep inventing new ways to wildly overdiagnose psychiatric illness in kids.”
Dr. Frances: Because insurance requires a diagnosis on the first visit, kids get a label that may last for life, and may be irrelevant to their long-term needs. But the labels don’t go away; they cause stigma and they haunt children and they lead to unnecessary treatment. We need to be careful. Diagnosis is a really serious thing and medication is a serious decision that needs to be made much more carefully with much more time and much more expertise. The thing we have to be aware of is that 80% of medications are given out in primary care.
CCPR: If your criticism is really about primary care doctors, why say that child psychiatrists wildly overdiagnose?
Dr. Frances: There are lots of things that are overdiagnosed in our field, but the three things that have come in the last 20 years—ADHD, autism, and bipolar disorder—have all been in child psychiatry and the primary specialties that deal with children. Children are the most vulnerable, there is the least research on how diagnosis and treatment affects them, and we shouldn’t be bathing them in so many drugs without much greater evidence than we have that they will be helpful.