Monday, 10 October 2016

Are we all mentally ill? About Allen Frances

Allen Frances, psychiatrist professor emeritus at Duke University (USA) led the working group that developed the DSM-4 (Diagnostic and Statistical Manual of Mental Disorders). I follow the author’s activity, always critical and always documented, on twitter (@AllenFrancesMD) and, unaware of the framework of psychiatry, a question started spinning in my head. How could it be that someone who had led the fourth edition of the DSM was now the most lucid voice against the excesses of modern psychiatry? If I wanted to know the answer, I had no choice, but to read his latest book: "Saving Normal: An Insider's Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life".

Psychiatrization of normal

The author explains that 35 years ago, when categories and thresholds pf DSM diagnoses were first created, the sensitivity of the classification was the main objective. There were few psychiatrists and too many people in need of diagnosis were left outside the health system, but now with the DSM-4, and especially with the DSM-5, the pendulum has swung to the other extreme and has caused an alarming lack of specificity, which means that too many normal people exit the consultation room with a diagnosis (with code) and treatment, probably both unnecessary.

In the book, Allen Frances assumes his own responsibility in the mess of psychiatry today. He admits that the methodological rigor imposed in preparing the DSM-4, was not enough to stem the tide of over diagnosis induced by the classification itself and believes that the instrument should have been more active, especially to avoid false epidemics of autism, attention deficit disorder and bipolar disorder.  In DSM-5, now without the leadership of Allen Frances, instead of correcting the outbreak of diagnostic excesses, has only added fuel to the fire, and now the inflationary agents, the pharmaceutical industry's first, now has a code for every little extravagance of each person.

The author’s and the book’s objective

"My goal is - Frances says - to help save the normal people but also psychiatry. Psychiatry is a noble and indispensable profession, basically healthy and extremely effective when practiced well. Our results are equal or exceed those obtained for most other medical specialties. Taking care of the mental health of people is a special privilege. We get to know our patients closely; we comfort them and find ways so that they can help themselves. We can cure many; we help most and provide comfort and counsel to all. But psychiatry should be confined to its area of competence and essentially normal people should never become patients, while others who really are sick are being ignored."

"It should not be forgotten, he adds, that psychiatry is especially vulnerable to the manipulation of the lines separating normal from illness because it lacks biological tests and relies on subjective judgments."

How to contain diagnostic inflation?

Despite the author’s pessimism in reducing the epidemic of over diagnosis (there is too much money at stake), he prepares a package of proposals with the expectation that, sometimes or rarely David beats Goliath. Of all of these (some are logically related to more transparency and more control), I want to highlight five that I have found to be particularly timely:

a) The public authorities should be more belligerent and suppress drugs that are available on the market that are causing more harm than good.

b) A new classification of mental disorders should be developed, this time opening the door for the points of view of all health and social professionals involved, and not just psychiatrists.

c) Each modification of the diagnostic system, given the high risk of over diagnosis, should be subject to as rigorous research as new drugs.

d) The diagnostic process should be staggered. A diagnosis should be issued on the initial visit only when the case is very clear (the proposal of scale, certainly very elaborate, can be found in Chapter 7).

e) Family doctors may be part of the diagnosis-prescribing process in psychiatric disorders, with the only requirement being that they have sufficient training and dedication. 

Making it right

"The key ingredients to do it right are no mystery to anyone: a clinician with appropriate training, experience and empathy; patients who meticulously and honestly presents their problems, a positive therapeutic relationship and close monitoring of the progress. If the situation is not clear, definitive diagnosis should be delayed, uncertainty is far better than false certainty. One of the good indicators in measuring the success of any treatment, is the quality of the relationship between doctor and patient whilst a rightly made diagnosis is one of the best ways to build a strong therapeutic relationship."

In the epilogue of the book, the author says: "Those who oppose the diagnostic inflation are too few, weak, underfunded and disorganized and we face extraordinarily challenging obstacles, but we have a great advantage, our cause is right and that gives us strength."

I’d like to inform Frances Allen that he counts with the support of the group of collaborators and followers of this blog to generate professional and social debate for the defence of honest clinical practice. As he says, we are few and disorganized but we are convinced that clinical practice is a value that must be nourished by people and scientific evidence and not by widespread consumerism.

Jordi Varela

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