TCPR: Dr. Frances, you have criticized both the process and the product of DSM-5. First, please tell us where you think they went wrong in the process.
Dr. Frances: In terms of the process, DSM-5 was far too ambitious in wanting to promote a paradigm shift for the field. And, in establishing unrealizable ambitions, it incorporated suggestions that I think will do more harm than good for patients. In addition, the DSM methods were disorganized, deadlines were consistently missed, and there was no clear central direction about the level of evidence necessary before changes could be included.
TCPR: And what about the finished product?
Dr. Frances: As the result of the problems with the process, we have a product that makes worse some of the troubling trends in psychiatry that were already evident in the DSM-IV era. Even before DSM-5, psychiatry had a severe problem with diagnostic inflation, and extensive diagnosis and treatment of people who would probably do better without it. DSM-5 is likely to make the diagnostic inflation worse.
TCPR: Can you tell us some of the particular cases of diagnostic inflation you worry about in DSM-5?
Dr. Frances: For starters, the most controversial suggestion was the one that allows major depressive disorder to be diagnosed after just two weeks of sadness, loss of interest, loss of appetite, trouble sleeping, and reduced energy in someone suffering from bereavement. Grief is a completely normal aspect of human being/mammalian functioning. It would be abnormal if people didn’t have those five symptoms after two weeks of losing the love of their life. Bereavement, as defined in DSM-IV, did not need fixing. In DSM-IV, major depression could be diagnosed if someone had symptoms of suicidal ideation, psychosis, severe agitation, severe retardation, or inability to function. Real depressions were not going to be missed, even when they occurred during bereavement. The changes in DSM-5 perpetuate a longstanding problem: too often, what we call “major depressive disorder” is not major; it is not depressive; and it is not really a disorder.
TCPR: What else do you see as problem diagnoses?
Dr. Frances: Another controversial suggestion was to include somatic symptom disorder, which requires the patient to have only one somatic symptom that the doctor thinks is more distressing than it should be. This is a remarkably loose definition. In the one field study trial, one-fourth of chronic pain patients, one-fifth of cancer patients, and six percent of the general population would be diagnosed with somatic symptom disorder (Freedman R et al, Am J Psychiatry 2013;170:1–5; Regier DA et al, Am J Psychiatry 2013;170:59–70). Many people with unexplained physical problems are absolutely ballistic about this, and I think they are right. Their fear—and their experience—is that doctors face uncertainty when diagnosing their problems, and say that it is all in their heads. This may result in inadequate medical evaluation.
TCPR: And what else?
Dr. Frances: I am concerned about the inclusion of mild neurocognitive disorder, which is impossible to distinguish from the normal forgetting of aging given current tools. It will be some years before we will have a biological test or cure for Alzheimer’s. Because of DSM-5, a large number of diagnoses of mild neurocognitive disorder will encourage people to do all sorts of testing that lacks sensitivity and specificity.
TCPR: One your strongest criticisms regards the overdiagnosis of ADHD. Please tell us about how DSM-5 contributes to this.
Dr. Frances: DSM-5 makes it easier than ever to diagnose ADHD. It is particularly easier for adults to be diagnosed, and in adults it is virtually impossible to distinguish a desire for greater concentration and cognitive performance from ADHD. Every psychiatric condition under the sun causes attention problems, so making it easier to jump to ADHD means that other diagnoses may be missed. We also have a huge secondary market in the use of stimulants. Thirty percent of college students and 10 percent of high school students take drugs that have been diverted from people who have legal prescriptions. We don’t need an adult population that is bathed in stimulants for fake ADHD.
TCPR: And you say that with these increased diagnoses, drug companies see greater potential for marketing medications, leading patients to request these drugs, further feeding the overdiagnosis.
Dr. Frances: Yes, take binge eating disorder for example. It’s possible that 10 to 20 million patients may be labeled with a mental disorder because they binge eat one time a week for a few months. Drug companies are already jumping on this. One company’s stock prices went up dramatically because it reported a positive result using stimulants for binge eating.
TCPR: Where else do you think this tendency to overdiagnose comes from? When did we start to narrow what is considered “normal” so dramatically?
Dr. Frances: Many of our experts have an intellectual conflict of interest. I have never met an expert who ever said, “Let’s narrow my diagnosis.” They are always worried about missed patients and under-recognized conditions. They are interested in more research dollars for their area to legitimize what is within the DSM. My sad feeling is that if anything can be misused in diagnosis, if there is a loophole, the world will drive a truck through it. Drug companies have the freedom to advertise directly to consumers in this country—which they have nowhere else in the developed world, except New Zealand. Finally, insurance carriers require a diagnosis before paying bills. It would be better, as it is in many countries, if you didn’t have to make a diagnosis on your first visit. You could provide an extensive evaluation period of five or six visits, during which time many patient’s problems would resolve without a diagnosis, without the stigma, and in many cases without long-term treatment with unnecessary medication.
TCPR: Your newest book is called Saving Normal. What exactly is “normal” and why is it so hard to define?
Dr. Frances: Unfortunately, there is no definition of normal that works very well. It is necessarily going to be at least a somewhat arbitrary and subjective construct. One of the problems is epidemiology. Epidemiological studies all exaggerate the rate of mental disorders. Most have the systematic bias of lay interviewers who don’t ask about—and can’t judge—clinical significance. As a result, rates given in epidemiological studies are at the upper screening limits. The National Institute of Mental Health (NIMH) now reports that 25 percent of the population has had a mental disorder in the past year, and 50 percent have at any point during the lifespan (Reeves WC et al, Morbidity and Mortality Weekly Report 2011:60(03);1–32). So psychiatry has steadily expanded its boundaries from the six disorders in the first DSM, all of which resulted in long-term asylum care, to the now couple of hundred
disorders, many of which are indistinguishable from normal life and human distress. This results in often harmful and unnecessary treatments for people, and also has led us become a pill-popping society.
TCPR: As a psychiatrist, surely you agree that accurate psychiatric diagnosis can help a large number of people.
Dr. Frances: Yes. While we are overdiagnosing and overtreating people who may not need it, we are neglecting psychiatric patients with severe mental illness. In the past 50 years we have closed a million psychiatric beds in the US as part of deinstitutionalization. The assumption was that much of the money saved would follow patients to the community, to provide treatment and decent housing. Instead, mental health budgets have always been austere, and in recent years have been the victim of severe cuts. We now have a million psychiatric patients in prison or jail, usually for nuisance crimes that could have been avoidable had there been adequate community care and decent housing. Police are now the first responders to psychiatric troubles, and they have learned that taking someone to the ER is usually futile because there will be no bed or crisis outpatient appointment available. Unfortunately, psychiatric patients are the most likely to do poorly when incarcerated.
TCPR: How do you suggest that psychiatrists might deal with this?
Dr. Frances: I think clinicians should make sure before giving a diagnosis that the patient has undergone a very thorough medical and psychiatric evaluation and that the symptoms are severe and persistent enough to cause clinically significant distress or impairment. Even though those are subjective terms, they provide a rough and ready guideline that would keep us from diagnosing mental disorder in people we have seen for only a few minutes with mild problems that often take care of themselves.
TCPR: Don’t we as psychiatrists already have roles as gatekeepers in preventing overdiagnosis?
Dr. Frances: Well, first off, 80 percent of psychiatry is not done by psychiatrists. The drug companies know that there are 10 times more primary care doctors than psychiatrists and direct their marketing to them. Primary care doctors prescribe 80 percent of all medications: 90 percent of anti-anxiety agents, 80 percent of antidepressants, 60 percent of stimulants, and even 50 percent of antipsychotics. Often the prescription or the free sample is offered after a seven-minute evaluation on a first visit without sufficient time or sufficient longitudinal follow-up. Primary care doctors have been marketed to aggressively with the messages that mental disorders are easy to diagnose, due to a chemical imbalance, and treatable by a pill. This leads to sloppy, fast, careless diagnosis and treatment.
TCPR: What else can be done?
Dr. Frances: One recent endeavor is the Choosing Wisely initiative, established by the professional medical organizations in the United States, including the APA. Each organization is trying to identify which tests are unnecessary, which treatments are being overdone, and which diagnoses are not being handled well. So even though we, as individuals, may not have control over diagnostic inflation and drug companies, I think all of medicine is beginning to realize that loosening thresholds for diagnoses, and the widespread use of screening tests, does not improve outcome, might actually harm patients, and increases healthcare costs for individuals and for society. Even with this initiative, a separate problem lies with the NIMH, which funds most psychiatric research in this country. There has been a reduction in the mission and research protocol with the NIMH away from encouraging clinical research, social systems research, and health services research. Instead, the NIMH has become a mere brain institute, and this neuroscience focus becomes more intense with each passing year. As a result, the last 30 years of research has been so remarkably productive in teaching us how the brain works, but so remarkably unproductive in helping our patients.
TCPR: In closing, what should we as psychiatrists keep in mind when approaching patients?
Dr. Frances: It’s important to remember that receiving a diagnosis is a remarkably important moment in a person’s life, and an accurate diagnosis can bring enormous benefits and reduce the lifetime burden of illness. I don’t think there is enough emphasis on how much time and effort it takes to give a diagnosis and how sacred a moment it is to the patient. I do not like to make a diagnosis on the first visit unless the presentation is crystal clear and classic. Hippocrates said it is more important to know the patient who has the disease, rather than the disease the patient has. So, I think the training in psychiatry, to me at least, has to go back to a richly humane biopsychosocial model that understands people, not just disorders, and tries to find the very best treatment without being restricted to just prescribing a pill.
TCPR: Thank you, Dr Frances.
Dr. Frances is the author of Essentials of Psychiatric Diagnosis (The Guilford Press 2013) and Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life (HarperCollins Publishers 2013).