FULL TRANSCRIPT OF THE RECOMMENDED DOSE WITH RAY MOYNIHAN - Episode 2 Dr Allen Frances
25 October 2017
Ray Moynihan: Hello and welcome to the Recommended Dose - the podcast promoting a more questioning approach to healthcare. I'm Ray Moynihan. Today, a conversation with the plain-speaking Doctor Allen Frances, who's been described as one of the most prominent psychiatrists on the planet. At one time responsible for actually writing the psychiatrist manual of mental disorders, the DSM, in recent years, Allen Frances has become one of its loudest critics, concerned that expanding definitions of disease are turning more and more ordinary life into mental illness. And he argues that one of the best examples of an individual being medicalised unnecessarily is the President of the United States, Donald Trump, the subject of Allen Frances's latest book. Oh, and I should mention, this interview was done via Skype. [00:01:00] So, please forgive the little Skype sounds sprinkled through. Though, if you think of them as raindrops, they do sound kind of sweet.
Allen Frances: Most sensible people in the United States are terribly disturbed by Trump. He's attacking American democracy. Democracy's always fragile. He's attacking the health of the world because of his withdrawal from the climate talks. An absolute disaster. We've had ignorant presidents before, we've had narcissistic presidents before, we've had aggressive presidents before. We've never had one president nearly as dangerous to our country or our world as Donald Trump. People who have training in mental health want to do something. And if you have a hammer, you try to find a nail. And so, what they've done is suggest, and there's a petition that's been signed by more than 50,000 mental health professionals. They suggest that Donald Trump should be removed from office based on having a mental illness, and that [00:02:00] mental illness usually described as Narcissistic Personality Disorder.
It happens I wrote the criteria for this disorder almost 40 years ago, the ones that are still in use. And he doesn't really basically meet the criteria. He's the most narcissistic person maybe who ever lived. But, you have to have clinically significant distress or impairment, and Trump is the kind of person who feels too little distress and causes impairment in others, rather than experiencing it himself. He's President of the United States as a result of his outrageous behavior, not punished for it. And so, the theme of the book I've written is that Trump isn't crazy, we are. That as a society, we're ignoring the crucial existential threats of the future. We're not being good shepherds of our world. We're not facing properly the problems of global warming and overpopulation and migration and civil wars. And that our behaviour is going to leave [00:03:00] much less to our children than they deserve. We're making short-term decisions that are dangerous. So, we're the problem, not Trump, and the book tries to address ways of taming him, and of curing our own societal delusions.
Ray Moynihan: And that book is called, I think I'm right in saying, "Twilight of American Sanity?" Is that right? And it's sort of out now, I think.
Allen Frances: Well, it's "Twilight of American Sanity: A Psychiatrist Analyzes the Age of Trump." And it's orderable now, but it will be appearing officially on September 5th.
Ray Moynihan: It's very confident of you, an individual psychiatrist, to be essentially diagnosing an illness within society rather than diagnosing an illness within an individual. Where does that confidence come from in you?
Allen Frances: I think the things I say in the book are absolute common sense. And the fact that society is not facing overpopulation, is not facing global warming, is not facing resource [00:04:00] depletion, I think this is a societal delusion. Trump isn't delusional because he has lots of people agreeing with him. But, when a society ignores these threats, when it puts our children in danger, I think that anyone who can spot this, the psychiatrist is trained to spot delusions, has a citizen's responsibility to stand up and say, "We've got to look at ourselves, take a very deep look in the mirror, and start facing our future, otherwise we will destroy it."
Ray Moynihan: Do you feel like you're diagnosing a society rather than diagnosing an individual?
Allen Frances: Yeah. In other words, I think the premise of the book is that it's a waste of time, and kind of a waste of the integrity of our profession, to be throwing psychological names at Donald Trump. He's just the surface symptom. We have to look at the deeper societal sickness.
Ray Moynihan: Making these claims, being so publicly critical [00:05:00] of Donald Trump, and indeed, I think you've got lots of media attention in recent times, and no doubt you're gonna get a lot more, you must be, apart from confident, you must be very brave, Allen.
Allen Frances: What can I lose at this point? I'm almost 75 years old, and I've had a happy life. At this point, I think I have a responsibility to my kids, my grandkids, and to future generations to do what little I can. I'm not grandiose in the way Trump is about the impact of this book, but I think we all have a job to do at this point. I have never been politically active in my life. I've been missing in action through most of the political turmoils of my adult life. I think this is the first time I feel a sense where it's imperative for all of us ... all of us in the United States, at least, to take action to tame this very dangerous person. Abraham Lincoln said, "You can fool all the people some of the time. You can fool some of the people [00:06:00] all the time. But you can't fool all the people all the time." And I think our job now is to make sure that as few people as possible are fooled by Trump, and that we can tame him.
Ray Moynihan: You're listening to the Recommended Dose, today with Dr Allen Frances, an emeritus professor at Duke University in the United States, author of a new book called "The Twilight of American Sanity," and one of the fiercest critics of this process of medicalisation.
Allen Frances: We're turning the everyday distress of life ... The human condition is filled with anxiety, with sadness, with loss, with disappointment. The tendency over the course of the last 40 years, at least, has been to turn the stuff of life into mental disorder. The best customer for a drug is someone who's basically well. Because of the placebo [00:07:00] effect, people who are basically well will show the highest percentage of satisfaction with treatment. They would get better without treatment, they'd get better with pill placebo. But, if they're on medication they don't need, they will attribute the improvement in the way they feel to that medication.
And so, the combination of people wanting solutions to problems that sometimes don't lend themselves to pill solutions, greedy drug companies pushing sickness in the United States, pushing it on TV [00:07:30] and the internet with abandon, we get advertisements as frequently for drugs as we do for automobiles or beers. The insurance companies don't help because they require a diagnosis for payment early in the course of seeing a patient. When it comes to most psychiatric problems, they get better in a week, two weeks, three weeks on their own. But if someone's forced to give a diagnosis to a patient and to start medication early in the contact, that most doctors feel that pressure from the insurance [00:08:00] companies, then it's very possible the person will be put on the medicine that they don't need. And in the United States, and I believe also in Australia, about 80% of the psychiatric medicines given are given by primary care doctors, usually after about 10 minutes of appointment, without them having great specialized knowledge of psychiatry and psychiatric disorder, and how to diagnose it. And very often influenced by drug salesmen.
So, my concern is that we're way over-medicating [00:08:30] the problems of everyday life. And then, parallel to that, we're terrifically neglecting people who are really sick. If the resources are expended for people who are basically well, they're not available for people who are very sick, and I think that's true in Australia as well. My plea over these years has been, let's focus on the people who are really sick and who are not being treated well. Let's not mislabel as mentally ill people who would do better without that label, the stigma of that label, do better without the side effects of medication they basically [00:09:00] don't need.
Ray Moynihan: Can you give us a couple of examples of where you see ordinary life or ordinary behavior being transformed into mental illness or medical conditions?
Allen Frances: The one that's probably most common and has been for 30 years is mild forms of depression, that really aren't depression, being diagnosed as major depressive disorder. Which is really not major, not depressive, not disorder. That we should all expect [00:09:30] to have transient periods where life's not kind to us, where we've lost a job or lost a loved one. In which we have episodes of sadness that usually aren't severe and don't last very long. The drug companies have convinced the world that major depressive disorder is one entity, that it's always a chemical imbalance, and that it always requires a chemical solution in the form of a pill. 11% of the American population is taking an antidepressant. And amongst women over 40, it's one in [00:10:00] four. Just absolutely outrageous and ridiculous.
So, I would say that depression, in general, and grief in particular, is very often over-diagnosed and over-treated with medication. It's quite common for minor symptoms of anxiety that are perfectly expectable, built in by evolution to protect us from dangers, to be misinterpreted as mental disorder and treated with pills. Kids who have temper tantrums can now get a psychiatric diagnosis. [00:10:30] As I stop being able to remember things in the way I once could, I can be diagnosed with [inaudible 00:10:37] cognitive disorder, even though that diagnosis, at this point, provides really no value and would just give me a sense of anxiety about the future without anything to do about it, will likely be wrong much more often than it's right. So, in general, we've taken everyday experiences that are part of the human condition and we're over-diagnosing them as mental disorder [00:11:00] and way too often providing a pill when there's not really a pill solution for every problem in life.
Ray Moynihan: You mentioned kids. I think you've been particularly concerned about the way in which the behaviors of children have been over-medicalized. Can you talk about a couple of examples there?
Allen Frances: Well, the biggest disaster is attention deficit disorder. A good friend of mine, Keith Connors, just died. He died a few weeks ago. And we ... Keith, Barney, Carol and I wrote his obituary. [00:11:30] Keith helped write it before he died. We wanted to provide a last warning to parents and doctors to stop over-diagnosing attention deficit disorder. A voice from the grave. The proper rate of diagnosis for attention deficit disorder might be two or three percent. At this point in the United States, by the time a child is 18 years old, they have a 15% chance of getting the diagnosis, and seven or eight percent are on medication. This is absolutely ridiculous. [00:12:00] We're turning immaturity into a disease.
A study done by Martin Whitely recently in Perth confirmed what's been done in several other countries. The remarkable result being that the youngest kid in the class is twice as likely as the oldest kid to get a diagnosis of ADHD, to be treated with medication. We've turned immaturity into a disease. There's been a tremendous increase in the diagnosis of childhood bipolar disorder that's completely [00:12:30] unwarranted, has been driven very much by the drug companies and the thought leaders they've hired to promote it. And in the United States, there's a terrific overuse of antipsychotics in children with behavior problems where there's no indication for antipsychotics, off label usage.
So, I think we're doing a massive world-wide experiment on immature brains, bombarding them with very powerful chemicals with no knowledge whatever about what the long-term outcome will be, [00:13:00] and without informed consent. I think every kid who gets on a medication should have, before this is accepted, a written informed consent from the doctor to indicate what the possible risks are. I think, if that were part of the procedure instead of just a 10-minute evaluation and a quick prescription, many fewer kids would be getting medication that's unneeded and maybe much more harmful than helpful.
Ray Moynihan: In the 1990s, Allen Frances was head of the task force that put [00:13:30] together the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, the so-called psychiatrist bible of disorders commonly known as the DSM. The first edition in the 1950s was a slim, little-known American volume of just over 100 pages and included around 100 disorders. By the time Allen Frances oversaw the fourth edition of the DSM, it was close to 1,000 pages with hundreds of disorders. [00:14:00] And by then, the DSM was firmly part of the popular culture in many nations. The fifth edition, the DSM-5, was published in 2013, and continued that expansion of the psychiatric empire, despite the vigorous opposition from people like Allen Frances.
Allen Frances: It's a manual of mental disorders that establishes which psychiatric conditions should be included and considered psychiatric conditions. [00:14:30] And provides criteria for them, so that different evaluators, different physicians or other mental health workers, can agree when a given person merits a diagnosis. I got involved in criticizing DSM-5 because it was opening the floodgates even further. And I think that we all need to realize that the DSM system, at this point, will easily diagnose a number of people who would not benefit from medication. They may benefit from psychotherapy, [00:15:00] and many of them at the borders will do well just with time and the healing power that comes from family, from change life circumstances, and from normal resilience.
Ray Moynihan: I think I've read you talking about your role helping to run that fourth edition of the DSM, the manual of mental disorders. And is it right that you feel some responsibility for helping to create what I think you've called fake epidemics [00:15:30] of ADD, some autism disorders, and bipolar in kids? Is that the case?
Allen Frances: Well, I think that we added Asperger's to DSM-4. It didn't exist as a diagnosis before. We did it because child psychiatrists and other mental health professionals said that, for every kid who met the strict criteria for autism, there would be three or four kids who needed help but didn't fit the criteria. What we'd failed to anticipate [00:16:00] was the tremendous explosion that, once we added a much milder form of autism to the manual, there was no stopping how often it would be mislabeled in kids. So, we did a very careful field trial, and we found that it would increase the rate of autism by three times. In fact, the rate of autism has gone up by 40 times in most countries around the world. So, very mild forms of behavior that would have been considered eccentric now got the psychiatric diagnosis [00:16:30] for Asperger's, partly because that led to greatly increased school services.
We rejected childhood bipolar disorder as a special entity. But that took off because of the drug companies, despite our rejection. So, I think what we were naïve about was the fact that things in the manual, anything in the manual that can be possibly misused ... misused by the drug companies, misused by school services ... anything that can possibly be misused will be misused.
Ray Moynihan: We'll talk about the [00:17:00] drug companies in a minute, but does it feel to you like you've had some sort of major life change? Because, looking at your life, at your career, there you are, right inside the psychiatric establishment. You're at the top of it, in a way. You're a senior person in the medical establishment. And now, it seems to me that you've become one of the fiercest critics of that establishment. Was there some sort of change? Was it slow? Was it quick? How do you see it?
Allen Frances: I don't see myself changing. I see the world changing some. [00:17:30] I wrote a paper in 1982, "No Treatment as the Treatment of Choice." I was concerned even then, well before being involved with DSM-4, about the risks of over-diagnosis and over-treatment. I think that what changed was the tremendous power of the drug companies, starting in 1987 with Prozac, to market psychiatric disease as a way of selling pills. So that, for quite a bit of time while the drugs were on patent, the most profitable area for the drug companies was [00:18:00] psychiatric disorder. The drug companies are completely without scruple. They're very close to the drug cartels in their level of morality. And they push medication well beyond where medication is useful. And I think that was a learning experience for me, that the fears I had before were magnified that much more when the drug companies were able to become so powerful.
I think that DSM-5 set off in a very wrong direction. There was an attempt to [00:18:30] make a paradigm shift to be creative. And at this point, the most important thing we have to do is avoid over-diagnosis. The DSM-5 people were way too worried about under-diagnosis.
Ray Moynihan: So, let's talk about drug companies, because another of the ironies here, I think I'm right in saying, is that you yourself, when you were a high-flying psychiatrist, were actually very close to the drug companies. You, like many senior specialists, like many senior psychiatrists, were [00:19:00] receiving benefits, money, travel, consultancies, and so on. Can you talk about that, and how ironic it is that you've now become one of their critics?
Allen Frances: Oh sure. I think that the relationship with drug companies that I had then, [inaudible 00:19:19] I certainly would not do now. At the time, it seemed like it was a win-win. That the research that we were doing with drug companies and the department of psychiatry at Duke, that [00:19:30] the practice guidelines we developed, were actually gonna help people, not hurt them. I think that there was ... And I think most people in the field who've been involved in this over a period of time think that there's been a radical change, which started in the early '90s, in the attitudes of the drug companies. That, prior to this, before psychiatric drugs were a big money-maker, the tendency was to feel that the alliance between academia and industry was productive on both ends. I think the drug [00:20:00] companies really tasted the possibility for enormous profits beyond what anyone would have imagined before, the Prozac experience being the prototype for that, and it become remarkably ruthless. But, would I have done any of this 20 years ago knowing what I know now? Obviously not.
Ray Moynihan: So, are you saying to me that you regret that involvement, that financial engagement with the drug industry?
Allen Frances: Oh, sure.
Ray Moynihan: What would be your advice to young researchers, to young doctors starting out now, [00:20:30] who are still flooded by pharmaceutical company influence from virtually the minute they start medical school? Offers of dinners, travel, research funding. What would be your advice to those young doctors?
Allen Frances: Have absolutely no financial conflict of interest and be very wary of an emotional or intellectual conflict of interest. A lot of the mistakes made by DSM-5 were not related to the people being [00:21:00] controlled by drug company money. But, they were controlled by their own love for the disorders that they had been researching. So that, when we had to tame experts, it was because they had fallen in love with their pet diagnoses.
Ray Moynihan: It's important to stress at this point that, while Allen Frances is a critic, he's not in any way against medications or psychiatry.
Allen Frances: It's critical I am about the overuse of medication. I'm equally determined to defend the proper [00:21:30] use of medication. And for the severely mentally ill, very often medication is absolutely essential and life-saving. We have 350,000 people with severe mental illness in prison in the United States, an absolute disaster and a shame on our country. We have 250,000 homeless. And the reason for the criminalization of the mentally ill and their neglect to back alleys is a lack of funding for treatment and for housing. The anti-psychiatry movement [00:22:00] has focused on medication as the cause of the problem, and as psychiatry as the coercive problem. Whereas, I've been very active in defending appropriate treatment, defending the idea that, for some people, medication is enormously useful and worth the side effects.
Ray Moynihan: So, what you're saying is that, in some ways, while you're a critic of psychiatry, you're a critic of the drug industry, you're still fundamentally a strong believer in the importance of psychiatry and the importance of psychiatric diagnoses, [00:22:30] and indeed, in the importance of psychiatric medicines.
Allen Frances: Yeah. For the five percent of the population with severe illness, and probably five to 10 percent of the population at large, medication's often worth the risks. Given all the side effects, given all the complications, given the placebo effect, for that group of people, it's essential. And I feel like much more of the opposition I experience comes from people who want to wipe out all of medication and all of psychiatry. [00:23:00] I haven't experienced much opposition from the mental health professions.
Ray Moynihan: Well, you should say that a lot of your ideas on medicalization were encapsulated in your last book, Saving Normal, yeah?
Allen Frances: And that book, Saving Normal, was very influenced by your book, Selling Sickness.
Ray Moynihan: Well, thank you for saying it, but as we both know, this concern about over-medicalization has deep roots that go back decades if not centuries or millennia. Correct me [00:23:30] if I'm wrong, but really, what we're talking about is, first do no harm. One of those primary principles that underpin the entire history of modern medicine. That, in our attempt to help people, there's a risk we might do harm, and so, let's be conscious of that. Am I right in saying that that's the ultimate root?
Allen Frances: This is a brilliant point, Ray, that's been ignored. Hippocrates worked on the island of Kos, and nearby was the mainland of Konides. They were the two most prominent [00:24:00] medical schools in ancient Greece. Konides had a very active, aggressive treatment policy and very specific diagnoses. And Hippocrates saw the harm done. The patients who had been harmed by treatment. And that's where the idea of do no harm came from. Medicine has forgotten this. And not just psychiatry, and not even primarily psychiatry. I think the biggest problems of over-testing and over-treatment are in general medicine, and maybe even, especially in surgery. [00:24:30] So that the work in psychiatry is a very small facet of a much larger David and Goliath struggle to get to right care, to the appropriate level of testing and treatment. We've gone way overboard in the developed world in giving too much treatment to people who can afford it, and at the same time neglecting those who can.
Ray Moynihan: And in that David and Goliath battle that you portray, what's the role of good evidence? The sort of evidence that comes from systematic reviews, that comes from summaries [00:25:00] of evidence. What's the role of evidence do you see?
Allen Frances: Well, I know that there's a conflict of interest in that you guys are represented by Cochrane, but I'm a tremendous fan, not of all the Cochrane reports. I think some of the Cochrane reports are terribly biased. There are a few of them in psychiatry that make no sense. But, overall, evidence is the truth, despite Donald Trump, will set you free. And evidence is absolutely crucial in making medical decisions. You can't trust all of it, and it takes time to gather enough reliable evidence to be confident. [00:25:30] But without evidence, it's a crapshoot that we'll be governed by commercial, for-profit elements that so determine how people are treated.
I think that the biggest role for change will come from the evidence-based guidelines and from a press that's educated to advertise to the people reading the article not just the possible miracle medical benefit, which is always exaggerated, but also the possible realistic [00:26:00] risk of side effects. People are way too frightened of disease, way too little frightened of the treatments for disease.
Ray Moynihan: You're talking there about the need to change the way we report about medicine. And that's a message for journalists and media organizations, I guess, to make the reporting of medicine more realistic and based on good evidence. But what can people do? What can the people listening to this do in their own lives, [00:26:30] in their own decisions, those of their loved ones when they're interacting with the healthcare system? What can they do to help protect themselves against an unnecessary diagnosis or unnecessary treatment?
Allen Frances: And also to protect their children, which is even at this point, a bigger issue in regard to attention deficit disorder, the use of antipsychotics and unnecessary use of antidepressants. It's not just protect yourselves, but protect your kids. I think the most important thing is to be informed. [00:27:00] And the internet has a lot of nonsense, but it also has a lot of very good information. And everyone should ask questions. Better to write them down before you see the doctor. It's easy to forget what you want to say. You should always have at least three questions written down before you see the doctor. You should ask for explanations. If he's giving a diagnosis, why? On what basis? What criteria? How does the diagnosis fit you? If he's [00:27:30] giving a treatment, why this particular treatment, especially if it's medication? What are the alternatives? What are the options? And what would the doctor do himself for himself, or for a child, or for another family member?
Don't be shy, and don't rush into things. If people have severe classic presentations of disorder, they need immediate treatment. In fact, they're the ones most likely to be neglected. Only one third of people with severe depression get medical consultation. But, if you have a problem [00:28:00] that's more short-term, related to a stress in life, the result of a loss, I'd be very much inclined to give it time, watchful waiting, the resilience of everyday life, and psychotherapy. For most mild to moderate problems, psychotherapy is far better as a first choice than medication. So, I think the more informed people are of other alternatives, the less shy they are of asking doctors to justify their [00:28:30] thinking and to provide them with options. Not just one answer, one prescription. The more likely they will be to avoid treatment that's unnecessary.
Ray Moynihan: I think I'm right in saying that many people see great benefit in receiving a diagnosis, either for themselves, or for their children, or for their aging parent. That there's a strong motivation often to grab a diagnosis that will give reassurance, or will open up a pathway to treatment. And so, [00:29:00] what do you think is driving that?
Allen Frances: I think that, since the dawn of time, since the day of the shaman, people have tried to have explanations for why they're feeling badly and why they're behaving badly, or why their relatives are feeling badly or behaving badly. And there have been, over the course of time, hundreds of different solutions offered. Mostly with magical benefits, and often with very severe side effects. [00:29:30] I think that, in the modern world, so much information is available so easily and so easily misunderstood, especially since profit drives the way the information is provided, that people who feel pain want a solution to it. Emotional pain, or physical pain. But, the price they pay for a pill that's inappropriate is not worth it.
And people have to learn that an accurate diagnosis and a good medication treatment plan for a problem that requires it is a wondrous thing. [00:30:00] And I've seen hundreds, maybe over 1,000 patients, get tremendous benefits from an appropriate diagnosis which calms them down. When you learn what panic disorder's about, it changes your world. It explains what was previously unexplainable. It means you're not longer uniquely damned. People understand your problem. It's an empathic moment when you can convey an accurate diagnosis. But an inaccurate diagnosis carries tremendous stigma and risk of a dangerous treatment. And people have [00:30:30] to learn not to accept the first thought, but to really thoroughly make sure that a diagnosis fits them like a glove before accepting it, and that the medication's absolutely necessary before it's taken.
And I think the biggest problem on the doctor end is too little time. That the more time you have to get to know the patient, the more weeks and months you can spend before making a diagnosis, the less likely you'll be inaccurate in your diagnosis. It's the easiest thing in the world to give a diagnosis and [00:31:00] to write a pill prescription. It's the hardest thing in the world, often, to get rid of a diagnosis once it's been established, and de-prescribing medication requires much more skill than prescribing it. A wrong diagnosis made in 10 minutes can haunt for life. Very hard to eradicate. A medication given casually can do great harm, very little good, no indication. So, this is a serious moment in a person's [00:31:30] life. It's a serious as buying a house. And you wouldn't go and buy your house after a 10-minute evaluation. People should be as careful in accepting diagnosis or giving diagnoses, and as careful in considering medication as they would be for a major life decision.
Ray Moynihan: You've been listening to the Recommended Dose with me, Ray Moynihan, funded by Cochrane Australia with production by Shauna Hurley. And editing from Liam Blake and Yan Muths. If you like it, please recommend it and check out other episodes in the series.
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