Allen Frances, psychiatrist professor emeritus of Duke University (USA) led the working group that developed the DSM-4 (Diagnostic and Statistical Manual of Mental Disorders). I follow the activity of the author, always critical and always documented on Twitter (@AllenFrancesMD) and, unfamiliar with the framework of psychiatry, a question began to run through my mind. 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"
Psychiatry taking over normality
The author explains that 35 years ago when the categories and diagnostic thresholds of the first DSM were created, the sensitivity of the classification was the main objective. There were few psychiatrists and too many people in need of diagnosis who were outside the health system but now, with the DSM-4, and especially with the DSM-5, the pendulum has swung the other way and has caused an alarming lack of specificity, which means that too many normal people leave the office with a diagnosis (with a code) and a treatment, probably both of which are unnecessary.
In the book, Allen Frances explains his position in relation to his responsibility in the mess of today's psychiatry. He admits that the methodological rigor that he imposed in the elaboration of the DSM-4 was not enough to contain the avalanche of overdiagnosis induced by the classification itself and considers that the instrument should have been more active, especially to avoid the false epidemics of autism, deficit of attention and bipolar disorder. The DSM-5, already without the leadership of Allen Frances, instead of correcting the outbreak of diagnostic excesses, has done nothing but add fuel to the fire, and now the inflationary agents, the pharmaceutical industry, already have a code for each little extravagance of each person.
The objective of the author and the book
"My goal -Frances writes- is not only to help “save normal,” but also to help save psychiatry. Psychiatry is a noble and essential profession, sound at its core, and extremely effective when done well. Our outcomes match or exceed what is achieved by most other medical specialties.12 And being a mental health caregiver is a special privilege—we get to know our patients intimately, console their sorrows, and find ways to help them help themselves. We can cure many, help most, and provide compassion and advice for all. But psychiatry must stay within its proper competence and stick to what it does best—helping people who really need and can most benefit from our efforts. We should not be making patients of people who are basically normal and ignoring those who are really sick."
Frances says that it should be remembered that "Psychiatry is especially vulnerable to manipulation of the normal/disease boundary because it lacks biological tests and relies heavily on subjective judgments that can be easily influenced by clever marketing."
How to contain diagnostic inflation?
Despite the pessimism of the author in reducing the epidemic of overdiagnosis (there is too much money at stake), he elaborates a package of proposals with the expectation that, on very few occasions David beats Goliath. Of all of them (some logically are related to more transparency and more control), I want to highlight five, which I have found especially appropriate:
- Public decision makers should be more confrontational and suppress drugs available on the market that are causing more harm than good.
- A new classification of mental disorders should be developed, one that opens the doors to the point of view of all the health and social professionals involved, not only of psychiatrists.
- Every modification of the diagnostic system, given the high risk of overdiagnosis, should be subjected to a rigorous investigation as that received by new drugs.
- The diagnostic process should be staggered. A diagnosis should be made at the first visit only when the case is very evident (the staging proposal, by the way very elaborate, will be found in chapter 7).
- Family doctors can be part of the diagnostic-prescribing process in psychiatric pathologies, with the only requirement being that they have sufficient training and dedication.
Getting it right
"The key ingredients to getting it right are not mysterious: a clinician with appropriate training, experience, and people skills; a patient who presents an honest and thorough description of problems; the development of a positive therapeutic relationship between them; and sufficient time to explore the past and see how things are developing in the present. If the situation is unclear, definitive diagnosis should be postponed—uncertainty is far better than false certainty. One of the best predictors predictors of the success of any treatment is the quality of the relationship that forms between clinician and patient. A great relationship certainly doesn’t guarantee a quick cure and a lousy one doesn’t foreclose it, but on average the better the relationship, the better the result. And a well-done diagnosis is one of the best ways of cementing a solid therapeutic relationship."
The author writes in the epilogue of the book: "We opponents to inflation are too few, weak, unfunded, disorganized, and face odds that are impossibly imposing, but we have a big advantage on our side—our cause is right, and right sometimes does make might."
I would like to inform Allen Frances that he can rely on 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 fuelled by people and scientific evidence and not by widespread consumerism.