CanJPsychiatry 2013;58(10):566–569
In Debate
Should Psychiatry Be Expanding Its Boundaries? Robert Michels, MD1; Allen Frances, MD2 1
Walsh McDermott University Professor of Medicine and Psychiatry, Cornell University, New York, New York. Correspondence: 418 East 71 Street, Suite 41, New York, NY 10021; [email protected].
2
Professor Emeritus and former Chair, Department of Psychiatry, Duke University, Durham, North Carolina; Chair, DSM-IV Task Force. Correspondence: 1820 Avenida Del Mundo, Coronado, CA 92118; [email protected].
Progress Is Preferable to Stagnation
P
sychiatry is the branch of medicine that deals with people who are vulnerable to or troubled by mental, emotional, or psychological pain, distress, or disability, and for whom the profession may provide prevention, relief, support, care, treatment, cure, or rehabilitation. That is a broad definition; it could encompass most of the universe. However, at any given time, the scope of psychiatry, including the range of people who should be considered potential patients, is limited by the limits of psychiatric knowledge and capacity—for whom will psychiatric intervention make a difference? As that knowledge and capacity expand, so will the boundaries of psychiatry. Note that these boundaries are not limited by decisions of the profession, by its desire for influence or power, or by the deliberations of a committee writing a diagnostic manual. If the latter does its job well, it does not decide what the boundaries should become, it describes the boundaries that exist at that time. It also recognizes that they will change over time as new knowledge leads to the development of new interventions that make a difference where previously there were none—for example, dietary interventions that prevent the development of mental disability in infants vulnerable to phenylketonuria, psychosocial interventions that diminish the risk of posttraumatic stress disorder in trauma victims, or psychopharmacologic interventions for patients with mild chronic mood disorders. In each of these situations, people who were not previously viewed as psychiatric patients achieved that status because the psychiatric profession developed the ability to help them. Psychiatry is a relatively young profession, perhaps 250 years old. Over those years, psychiatry has grown immensely in its knowledge and its capacity to help people, and, as a result, its boundaries have expanded. It began with the care of patients with serious disability and psychosis, but new knowledge and new treatments have expanded its domain to encompass patients with less disability who could live in the community but not thrive, patients with mood or anxiety disorders who were not psychotic and did not require institutionalization, people with serious personality disorders, people with addictions, and others. None of these expansions resulted from a decision about 566 W La Revue canadienne de psychiatrie, vol 58, no 10, octobre 2013
diagnostic nosology or nomenclature. Each resulted from the recognition of a social need, dissatisfaction with the profession’s capacity to respond, the search for new knowledge, the trial of new interventions, and the profession’s and the public’s recognition of the social value of defining new populations as psychiatric patients. It would be tragic if this process were to come to a halt—our capacity is too limited and people who need more than we can now offer are too numerous. We look forward to finer distinctions among people who suffer and greater precision in our capacity for differential therapeutics, a concept that I believe Dr Frances and his colleagues developed.1 Interventions that operate at the genetic or epigenetic level, developmental interventions that are targeted at patterns of mental functioning, and strategies for counselling parents raising vulnerable children, all have promise. Certainly we do not want a committee that sits around and, without reference to what is happening in the outside world, decides whom should be included in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The only thing that might be even worse would be to freeze the accepted domain of psychiatry to the boundaries it happens to have in 2013, rejecting future advances and the benefits that they will offer because we do not want to medicalize normal life. Normal life once included tuberculosis and scurvy; now it does not. It once included many who suffered from panic disorder and bipolar disorder; now there are fewer. It still includes many with addictions and personality disorders; in the future, some of these whom we now cannot help will have richer, more gratifying lives. They and their loved ones will embrace the gains provided by the continued medicalization of a painful normality for which advances in psychiatric knowledge will lead to new possibilities. While this continues, a series of professional committees will describe and codify it in futures DSMs. And, we hope, a series of knowledgeable, loyal, and brilliant critics like Dr Frances will monitor the situation and remind us of the danger that professional hubris may lead to building a hoped for, but not yet achieved progress into, nosology that reflects fantasies about the future rather than realities of the present, with the socially undesirable consequences of premature medicalization. www.LaRCP.ca
Should Psychiatry Be Expanding Its Boundaries?
Acknowledgements
Dr Michels has no funding or conflicts of interest to declare.
Reference
1. Frances AF, Clarkin J, Perry S. Differential therapeutics in psychiatry. New York (NY): Brunner/Mazel; 1984.
Robert Michels
Diagnostic Inflation Can Be Bad for Our Patients’ Heath
T
he fall of empires is often caused by foolishly ambitious boundary expansions that dilute resources needed to protect the central homeland. Psychiatry is already in a state of dangerous diagnostic inflation—its elastic boundaries perilously stretched by the aggressive drug company marketing of psychiatric ills. By mislabelling the worried well as mentally disordered, DSM-5 will turn this current inflation into future hyperinflation. Precious resources are wasted at the boundaries of psychiatry, while our core patients receive shamefully inadequate care. Shrinking state budgets shortchange the people who are clearly ill and who most need and can benefit from our help, while millions of newly minted nonpatients receive care they do not need and that may do more harm than good. We are becoming an artificially sick society that paradoxically ignores the people who are really sick.
How Bad Is Current Diagnostic Inflation?
The numbers are astounding. Twenty per cent of our population regularly takes a psychotropic pill, and, among that 20%, 6% are addicted.1 And many people take more than one type of drug as casual polypharmacy has gotten increasingly out of hand. Eighty per cent of the prescriptions are written by primary care doctors2 who have only 7 minutes to spend with each patient and get most of their education in psychiatry from drug salesman. You know we are in trouble when prescribed drugs cause more overdoses, emergency department visits, and deaths than street drugs.3 The drug companies are doing well—having become the third most profitable industry after oil and banking. Antipsychotics are among the very best-selling drugs in the United States at $18 billion/year; antidepressants at $12 billion, and attention-deficit disorder (ADD) drugs at $7 billion are close behind. Xanax is one of the most prescribed drugs in primary care medicine—despite being highly addictive and having little real indication.4–6 Twenty-five per cent of the population meets criteria for a diagnosis of mental disorder in any year; 50% in a lifetime.7 And these numbers double when people are studied prospectively.8 A recent study reported that more than 80% of kids have a mental disorder before they are 21.9 www.TheCJP.ca
It is not that we are getting sicker. People change slowly, if at all. It is just that the labels are applied so loosely as to sometimes be meaningless.
Ten Easy Steps Toward Understanding Diagnostic Inflation
01. There is no operational definition of normality. Normal– abnormal are locked in a tautological embrace that resists all the untangling solutions drawn from linguistics, philosophy, statistics, psychological testing, sociology, or psychoanalysis. 02. There is no general definition of mental disorder that provides any guidance in deciding which specific mental disorders should be included in DSM or which specific person should be diagnosed with a mental disorder. 03. Our current array of accepted mental disorders are temporary constructs based on historical accretion, not clearly delineated diseases. 04. Any line currently drawn to separate normal from mental disorder will necessarily be fuzzy, arbitrary, and elastic. 05. Seemingly small changes in defining and assessing what are the recognized mental disorders can cause huge swings in rates of mental disorder and who is considered normal and who is not. 06. Given the lack of an operational gold standard, utilitarian considerations should govern how we define what percentage of the population are considered normal, and what percentage abnormal. Granted, risks and benefits are subject to different interpretations and are often difficult to quantify, their assessment is the best criterion in determining whether we want to cast a wide net in defining mental disorder or to be cautiously restrictive. 07. The DSM is meant to set the boundary between normal and abnormal, but the words, as written, are easily misused and stretched whenever there is an external reward attached to rendering a diagnosis. 08. The real world provides many financial incentives to loose diagnostic practice. These incentives include drug company profits and the determination of whether someone is eligible for treatment reimbursement, disability payments, and school and other services. 09. Through its overwhelming advertising to so-called patients and marketing to doctors, Big Pharma has become the most powerful influence determining who is considered sick and who is normal. Drug companies pursue profits from expanding markets—they are not dedicated to good patient care. Enormous fines for illegal marketing have failed to prevent their relentless efforts to convince us we are all sick. 10. There are grave risks to diagnostic inflation—dangerous drug side effects; misallocation of resources; stigma and reduction of expectations and personal responsibility; and the development of a pill-popping, sick rather than resilient society. The Canadian Journal of Psychiatry, Vol 58, No 10, October 2013 W 567
In Debate
How Much Worse With DSM-5?
I will collect a bunch of new diagnoses now that DSM-5 has been published. My forgetting in old age is now minor neurcognitive disorder. My heroic pig-outs are binge eating disorder. My distractibility is adult ADD. When I grieved the death of my wife, I had major depressive disorder. My wife was worried about her cancer, so she had somatic symptom disorder. And I have unspecified behavioural addictions to the beach and to my Blackberry. And let us not forget that my twin grandsons’ temper tantrums will become disruptive mood dysregulation disorder. In the post–DSM-5 world, most people will have trouble getting through life without at least one mental disorder label—and many will collect a whole bunch. DSM-5 got off to a bad start and was never able to establish a sure footing. Its leaders initially articulated an unrealizable goal—to produce a paradigm shift in psychiatry. When its first effort—a more biological diagnostic system—was revealed as ridiculously premature, DSM-5 established preventive psychiatry as its next innovation. Mild disorders would be introduced and thresholds of existing disorders lowered so that psychiatric illness could be diagnosed early and then treated before causing serious damage. Great idea. Terrible result. Preventive psychiatry is an idea decades before its time. Effective prevention requires tools for accurate diagnosis and effective treatments that are also safe. None of these 3 conditions is currently met. All of the DSM-5 changes will result in high false-positive rates; none has an effective treatment; and all risk overtreatment with harmful drugs. Psychiatry is also following a bad model in opening its diagnostic doors wide open. Preventive testing and treatment—a golden boy in medicine during the past 30 years—has recently been revealed as usually more dangerous than helpful. The history of psychiatry is already littered with fad diagnoses that, in retrospect, did far more harm than good. DSM-5 will start a half-dozen or more new fads, which will be detrimental to the misdiagnosed people and costly to our society. The motives of the people who worked on DSM-5 have often been questioned. They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM-5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine. However, I know the people who worked on DSM-5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies. Theirs is an intellectual, not a financial, conflict of interest that results from the natural tendency of highly specialized experts to overvalue their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM-5 to real-life clinical practice (particularly in primary care where 80% 568 W La Revue canadienne de psychiatrie, vol 58, no 10, octobre 2013
of psychiatric drugs are prescribed). If we leave it up to the experts and the drug companies, soon everyone will be sick and on pills. New diagnoses in psychiatry are more dangerous than new drugs because they influence whether millions of people are placed on drugs they do not need. Before their introduction, new diagnoses deserve the same level of attention to safety that we devote to new drugs. Instead, DSM-5 is recklessly growing our diagnostic system and drug companies will be busy selling it.
Summary
Dr Michels and I are not having an academic debate on the epistemology of normality. And I am not just joking about the reckless overinclusiveness of DSM-5. Where we draw the line between normal and abnormal has enormous reallife consequences—whether people die young because of obesity, diabetes, and heart disease secondary to an unnecessary antipsychotic prescription; whether we waste our resources on the worried well who often do better without them, while allowing the people who are severely impaired to languish unattended; and whether our society should succumb to Pharma’s seduction and enter a Huxleian brave new world of better living through chemistry. Medicalizing normally is dangerous for the people who are mislabelled and destructive to a vibrant and resilient society. Diagnostic inflation is bad enough when driven by wellmeaning, if misguided, doctors and researchers—but it is terrifying when driven by a greedy and often unscrupulous pharmaceutical industry. I do not think that there is any way that even a man of Dr Michels’ extraordinary debating gifts can possibly turn his sow’s ear into a silk purse.
Acknowledgements
Dr Frances has written 2 books that are critical of DSM-5, Saving Normal and Essentials of Psychiatric Diagnosis. He has no other funding or conflicts of interest to declare.
References
1. Medco Health Solutions, Inc (Medco). America’s state of mind. Franklin Lakes (NJ): Medco; 2011. 2. Mark TL, Levit KR, Buck JA. Datapoints: psychotropic drug prescriptions by medical specialty. Psychiatr Serv. 2009;60(9):1167. 3. Centers for Disease Control and Prevention (CDC). Prescription painkiller overdoses at epidemic levels [Internet]. Atlanta (GA): CDC; 2011 [date cited unknown]. Available from: http://www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html. 4. IMS Institute for Health Informatics. The use of medicines in the United States: review of 2011. Parsippany (NJ): IMS Institute for Health Informatics; 2012. 5. Stagnitti MN. Trends in the use and expenditures for the therapeutic class prescribed psychotherapeutic agents and all subclasses, 1997 and 2004. Rockville (MD): Agency for Healthcare Research and Quality; 2007 Feb. Statistical brief #163. 6. Pratt LA, Brody DJ, Gu Q. Antidepressant use in persons aged 12 and over: United States, 2005–2008. NCHS Data Brief. 2011;(76):1–8. 7. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602. www.LaRCP.ca
Should Psychiatry Be Expanding Its Boundaries? 8. Moffitt TE, Caspi A, Taylor A, et al. How common are common mental disorders? Evidence that lifetime prevalence rates are doubled by prospective versus retrospective ascertainment. Psychol Med. 2010;40(6):899–909. 9. Copeland W, Shanahan L, Costello EJ, et al. Cumulative prevalence of psychiatric disorders by young adulthood: a prospective cohort analysis from the Great Smoky Mountains Study. J Am Acad Child Adolesc Psychiatry. 2011;50(3):252–261.
Allen Frances Rebuttals .
Neither Too Fast nor Too Slow
D
r Frances is essentially correct! He argues against “foolishly ambitious boundary expansions,” “mislabelling,” “care . . . that may do more harm than good,” against “labels . . . applied so loosely as to sometimes be meaningless,” “fad diagnoses that . . . [do] more harm than good,” and “recklessly growing our diagnostic system.” I agree. So does everyone else. Of course, the solution is thoughtful, prudent, cautious, appropriate expansion of psychiatry’s boundaries, not rigid refusal to consider change. As he points out, our current boundaries are “temporary constructs,” and at any time in history they should be determined by “utilitarian considerations” based on the assessment of risks and benefits. They have steadily expanded since the beginning of psychiatry, because of the steady growth of knowledge, the steady increase in the benefit–risk ratio of intervention. We certainly hope that this continues. He is concerned that 20% of the population meets the current criteria for mental disorder. So am I, but he is concerned that it is too high and I am concerned that it is too low. Consider all of those aging people who used to be suffering from normal senility, a hopeless condition, but now have Alzheimer disease, a pathologic entity for which some treatments exist now and more will be available within a few years. Further, prevention seems highly plausible. I would rather be a patient with Alzheimer disease than a so-called normal person with senility. Alzheimer patients and their families are fortunate that no one of Dr Frances’ brilliance persuaded the field not to medicalize normal senility. I would hope that over the years we will develop interventions that will help far more than 20% of the population, alleviating their psychological pain and disability. The history of psychiatry, like the history of civilization, is of steady expansion of our knowledge and our ability to improve people’s lives because of that knowledge. Dr Frances is certainly correct: our fantasies can extend beyond our current capacity, and we must guard against the damage that may result. We can also err in the other direction, restricting our efforts to only the people most seriously impaired, and defining all others as variants of normal, not appropriate for further research or the development
www.TheCJP.ca
of new treatments, and able to fend for themselves. It is a Goldilocks problem; the boundaries may be either too big or too small. We should avoid both, and get them just right. Certainly our history and our human values argue that just right will not be static, but steadily expanding. Robert Michels
Normal Is Worth Saving
D
r Michels makes my point better than I can myself when he warns of
the danger that professional hubris may lead to building a hoped for, but not yet achieved progress into, nosology that reflects fantasies about the future rather than realities of the present, with the socially undesirable consequences of premature medicalization. p 565
However, he leaves out the other external pressures that drive diagnostic inflation and deplete the resources that are desperately needed to treat people who are truly ill. It is not just professional hubris that leads to overpromising and overdiagnosing. The drug companies drain crucial billions of dollars a year by convincing people who are not sick and who do not need medicine that they are and they do. The autism epidemic did not occur because of new scientific findings, but because the diagnosis is a ticket to desirable school services. The ADD fad is due to drug marketing, school chaos, and diversion for recreation and performance enhancement—not because more kids really have ADD. And it goes on and on. This is not an ideal or idealistic world in which the growth of psychiatric diagnosis provides an unaltered good for its recipients and reflects the result of dispassionate scientific progress. The recklessly expansive decisions made in DSM-5 reflected the intellectual conflict of interest of naive experts who overestimated benefits and minimized risks. They will be exploited by cynical drug companies making unrealizable claims. Most of the inappropriate medication will be prescribed by harried primary physicians who do not know any better. Patients will suffer. I feel a special responsibility for saving normal because I was so involved in the DSM-III, DSM-III-R, and DSM-IV processes that truncated it. But I do not think it is my fight alone. Psychiatry is the only profession with the knowledge and prestige to trigger a return to sane diagnostic and prescription habits. We must spread the word that accurate psychiatric diagnosis cannot be done in 7 minutes by a primary care doctor; that proper medication treatment precludes the premature use of pills for expectable life problems; and that normal is worth saving. Allen Frances The Canadian Journal of Psychiatry, Vol 58, No 10, October 2013 W 569
In Debate
Should Psychiatry Be Expanding Its Boundaries? Robert Michels, MD1; Allen Frances, MD2 1
Walsh McDermott University Professor of Medicine and Psychiatry, Cornell University, New York, New York. Correspondence: 418 East 71 Street, Suite 41, New York, NY 10021; [email protected].
2
Professor Emeritus and former Chair, Department of Psychiatry, Duke University, Durham, North Carolina; Chair, DSM-IV Task Force. Correspondence: 1820 Avenida Del Mundo, Coronado, CA 92118; [email protected].
Progress Is Preferable to Stagnation
P
sychiatry is the branch of medicine that deals with people who are vulnerable to or troubled by mental, emotional, or psychological pain, distress, or disability, and for whom the profession may provide prevention, relief, support, care, treatment, cure, or rehabilitation. That is a broad definition; it could encompass most of the universe. However, at any given time, the scope of psychiatry, including the range of people who should be considered potential patients, is limited by the limits of psychiatric knowledge and capacity—for whom will psychiatric intervention make a difference? As that knowledge and capacity expand, so will the boundaries of psychiatry. Note that these boundaries are not limited by decisions of the profession, by its desire for influence or power, or by the deliberations of a committee writing a diagnostic manual. If the latter does its job well, it does not decide what the boundaries should become, it describes the boundaries that exist at that time. It also recognizes that they will change over time as new knowledge leads to the development of new interventions that make a difference where previously there were none—for example, dietary interventions that prevent the development of mental disability in infants vulnerable to phenylketonuria, psychosocial interventions that diminish the risk of posttraumatic stress disorder in trauma victims, or psychopharmacologic interventions for patients with mild chronic mood disorders. In each of these situations, people who were not previously viewed as psychiatric patients achieved that status because the psychiatric profession developed the ability to help them. Psychiatry is a relatively young profession, perhaps 250 years old. Over those years, psychiatry has grown immensely in its knowledge and its capacity to help people, and, as a result, its boundaries have expanded. It began with the care of patients with serious disability and psychosis, but new knowledge and new treatments have expanded its domain to encompass patients with less disability who could live in the community but not thrive, patients with mood or anxiety disorders who were not psychotic and did not require institutionalization, people with serious personality disorders, people with addictions, and others. None of these expansions resulted from a decision about 566 W La Revue canadienne de psychiatrie, vol 58, no 10, octobre 2013
diagnostic nosology or nomenclature. Each resulted from the recognition of a social need, dissatisfaction with the profession’s capacity to respond, the search for new knowledge, the trial of new interventions, and the profession’s and the public’s recognition of the social value of defining new populations as psychiatric patients. It would be tragic if this process were to come to a halt—our capacity is too limited and people who need more than we can now offer are too numerous. We look forward to finer distinctions among people who suffer and greater precision in our capacity for differential therapeutics, a concept that I believe Dr Frances and his colleagues developed.1 Interventions that operate at the genetic or epigenetic level, developmental interventions that are targeted at patterns of mental functioning, and strategies for counselling parents raising vulnerable children, all have promise. Certainly we do not want a committee that sits around and, without reference to what is happening in the outside world, decides whom should be included in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The only thing that might be even worse would be to freeze the accepted domain of psychiatry to the boundaries it happens to have in 2013, rejecting future advances and the benefits that they will offer because we do not want to medicalize normal life. Normal life once included tuberculosis and scurvy; now it does not. It once included many who suffered from panic disorder and bipolar disorder; now there are fewer. It still includes many with addictions and personality disorders; in the future, some of these whom we now cannot help will have richer, more gratifying lives. They and their loved ones will embrace the gains provided by the continued medicalization of a painful normality for which advances in psychiatric knowledge will lead to new possibilities. While this continues, a series of professional committees will describe and codify it in futures DSMs. And, we hope, a series of knowledgeable, loyal, and brilliant critics like Dr Frances will monitor the situation and remind us of the danger that professional hubris may lead to building a hoped for, but not yet achieved progress into, nosology that reflects fantasies about the future rather than realities of the present, with the socially undesirable consequences of premature medicalization. www.LaRCP.ca
Should Psychiatry Be Expanding Its Boundaries?
Acknowledgements
Dr Michels has no funding or conflicts of interest to declare.
Reference
1. Frances AF, Clarkin J, Perry S. Differential therapeutics in psychiatry. New York (NY): Brunner/Mazel; 1984.
Robert Michels
Diagnostic Inflation Can Be Bad for Our Patients’ Heath
T
he fall of empires is often caused by foolishly ambitious boundary expansions that dilute resources needed to protect the central homeland. Psychiatry is already in a state of dangerous diagnostic inflation—its elastic boundaries perilously stretched by the aggressive drug company marketing of psychiatric ills. By mislabelling the worried well as mentally disordered, DSM-5 will turn this current inflation into future hyperinflation. Precious resources are wasted at the boundaries of psychiatry, while our core patients receive shamefully inadequate care. Shrinking state budgets shortchange the people who are clearly ill and who most need and can benefit from our help, while millions of newly minted nonpatients receive care they do not need and that may do more harm than good. We are becoming an artificially sick society that paradoxically ignores the people who are really sick.
How Bad Is Current Diagnostic Inflation?
The numbers are astounding. Twenty per cent of our population regularly takes a psychotropic pill, and, among that 20%, 6% are addicted.1 And many people take more than one type of drug as casual polypharmacy has gotten increasingly out of hand. Eighty per cent of the prescriptions are written by primary care doctors2 who have only 7 minutes to spend with each patient and get most of their education in psychiatry from drug salesman. You know we are in trouble when prescribed drugs cause more overdoses, emergency department visits, and deaths than street drugs.3 The drug companies are doing well—having become the third most profitable industry after oil and banking. Antipsychotics are among the very best-selling drugs in the United States at $18 billion/year; antidepressants at $12 billion, and attention-deficit disorder (ADD) drugs at $7 billion are close behind. Xanax is one of the most prescribed drugs in primary care medicine—despite being highly addictive and having little real indication.4–6 Twenty-five per cent of the population meets criteria for a diagnosis of mental disorder in any year; 50% in a lifetime.7 And these numbers double when people are studied prospectively.8 A recent study reported that more than 80% of kids have a mental disorder before they are 21.9 www.TheCJP.ca
It is not that we are getting sicker. People change slowly, if at all. It is just that the labels are applied so loosely as to sometimes be meaningless.
Ten Easy Steps Toward Understanding Diagnostic Inflation
01. There is no operational definition of normality. Normal– abnormal are locked in a tautological embrace that resists all the untangling solutions drawn from linguistics, philosophy, statistics, psychological testing, sociology, or psychoanalysis. 02. There is no general definition of mental disorder that provides any guidance in deciding which specific mental disorders should be included in DSM or which specific person should be diagnosed with a mental disorder. 03. Our current array of accepted mental disorders are temporary constructs based on historical accretion, not clearly delineated diseases. 04. Any line currently drawn to separate normal from mental disorder will necessarily be fuzzy, arbitrary, and elastic. 05. Seemingly small changes in defining and assessing what are the recognized mental disorders can cause huge swings in rates of mental disorder and who is considered normal and who is not. 06. Given the lack of an operational gold standard, utilitarian considerations should govern how we define what percentage of the population are considered normal, and what percentage abnormal. Granted, risks and benefits are subject to different interpretations and are often difficult to quantify, their assessment is the best criterion in determining whether we want to cast a wide net in defining mental disorder or to be cautiously restrictive. 07. The DSM is meant to set the boundary between normal and abnormal, but the words, as written, are easily misused and stretched whenever there is an external reward attached to rendering a diagnosis. 08. The real world provides many financial incentives to loose diagnostic practice. These incentives include drug company profits and the determination of whether someone is eligible for treatment reimbursement, disability payments, and school and other services. 09. Through its overwhelming advertising to so-called patients and marketing to doctors, Big Pharma has become the most powerful influence determining who is considered sick and who is normal. Drug companies pursue profits from expanding markets—they are not dedicated to good patient care. Enormous fines for illegal marketing have failed to prevent their relentless efforts to convince us we are all sick. 10. There are grave risks to diagnostic inflation—dangerous drug side effects; misallocation of resources; stigma and reduction of expectations and personal responsibility; and the development of a pill-popping, sick rather than resilient society. The Canadian Journal of Psychiatry, Vol 58, No 10, October 2013 W 567
In Debate
How Much Worse With DSM-5?
I will collect a bunch of new diagnoses now that DSM-5 has been published. My forgetting in old age is now minor neurcognitive disorder. My heroic pig-outs are binge eating disorder. My distractibility is adult ADD. When I grieved the death of my wife, I had major depressive disorder. My wife was worried about her cancer, so she had somatic symptom disorder. And I have unspecified behavioural addictions to the beach and to my Blackberry. And let us not forget that my twin grandsons’ temper tantrums will become disruptive mood dysregulation disorder. In the post–DSM-5 world, most people will have trouble getting through life without at least one mental disorder label—and many will collect a whole bunch. DSM-5 got off to a bad start and was never able to establish a sure footing. Its leaders initially articulated an unrealizable goal—to produce a paradigm shift in psychiatry. When its first effort—a more biological diagnostic system—was revealed as ridiculously premature, DSM-5 established preventive psychiatry as its next innovation. Mild disorders would be introduced and thresholds of existing disorders lowered so that psychiatric illness could be diagnosed early and then treated before causing serious damage. Great idea. Terrible result. Preventive psychiatry is an idea decades before its time. Effective prevention requires tools for accurate diagnosis and effective treatments that are also safe. None of these 3 conditions is currently met. All of the DSM-5 changes will result in high false-positive rates; none has an effective treatment; and all risk overtreatment with harmful drugs. Psychiatry is also following a bad model in opening its diagnostic doors wide open. Preventive testing and treatment—a golden boy in medicine during the past 30 years—has recently been revealed as usually more dangerous than helpful. The history of psychiatry is already littered with fad diagnoses that, in retrospect, did far more harm than good. DSM-5 will start a half-dozen or more new fads, which will be detrimental to the misdiagnosed people and costly to our society. The motives of the people who worked on DSM-5 have often been questioned. They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM-5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine. However, I know the people who worked on DSM-5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies. Theirs is an intellectual, not a financial, conflict of interest that results from the natural tendency of highly specialized experts to overvalue their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM-5 to real-life clinical practice (particularly in primary care where 80% 568 W La Revue canadienne de psychiatrie, vol 58, no 10, octobre 2013
of psychiatric drugs are prescribed). If we leave it up to the experts and the drug companies, soon everyone will be sick and on pills. New diagnoses in psychiatry are more dangerous than new drugs because they influence whether millions of people are placed on drugs they do not need. Before their introduction, new diagnoses deserve the same level of attention to safety that we devote to new drugs. Instead, DSM-5 is recklessly growing our diagnostic system and drug companies will be busy selling it.
Summary
Dr Michels and I are not having an academic debate on the epistemology of normality. And I am not just joking about the reckless overinclusiveness of DSM-5. Where we draw the line between normal and abnormal has enormous reallife consequences—whether people die young because of obesity, diabetes, and heart disease secondary to an unnecessary antipsychotic prescription; whether we waste our resources on the worried well who often do better without them, while allowing the people who are severely impaired to languish unattended; and whether our society should succumb to Pharma’s seduction and enter a Huxleian brave new world of better living through chemistry. Medicalizing normally is dangerous for the people who are mislabelled and destructive to a vibrant and resilient society. Diagnostic inflation is bad enough when driven by wellmeaning, if misguided, doctors and researchers—but it is terrifying when driven by a greedy and often unscrupulous pharmaceutical industry. I do not think that there is any way that even a man of Dr Michels’ extraordinary debating gifts can possibly turn his sow’s ear into a silk purse.
Acknowledgements
Dr Frances has written 2 books that are critical of DSM-5, Saving Normal and Essentials of Psychiatric Diagnosis. He has no other funding or conflicts of interest to declare.
References
1. Medco Health Solutions, Inc (Medco). America’s state of mind. Franklin Lakes (NJ): Medco; 2011. 2. Mark TL, Levit KR, Buck JA. Datapoints: psychotropic drug prescriptions by medical specialty. Psychiatr Serv. 2009;60(9):1167. 3. Centers for Disease Control and Prevention (CDC). Prescription painkiller overdoses at epidemic levels [Internet]. Atlanta (GA): CDC; 2011 [date cited unknown]. Available from: http://www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html. 4. IMS Institute for Health Informatics. The use of medicines in the United States: review of 2011. Parsippany (NJ): IMS Institute for Health Informatics; 2012. 5. Stagnitti MN. Trends in the use and expenditures for the therapeutic class prescribed psychotherapeutic agents and all subclasses, 1997 and 2004. Rockville (MD): Agency for Healthcare Research and Quality; 2007 Feb. Statistical brief #163. 6. Pratt LA, Brody DJ, Gu Q. Antidepressant use in persons aged 12 and over: United States, 2005–2008. NCHS Data Brief. 2011;(76):1–8. 7. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602. www.LaRCP.ca
Should Psychiatry Be Expanding Its Boundaries? 8. Moffitt TE, Caspi A, Taylor A, et al. How common are common mental disorders? Evidence that lifetime prevalence rates are doubled by prospective versus retrospective ascertainment. Psychol Med. 2010;40(6):899–909. 9. Copeland W, Shanahan L, Costello EJ, et al. Cumulative prevalence of psychiatric disorders by young adulthood: a prospective cohort analysis from the Great Smoky Mountains Study. J Am Acad Child Adolesc Psychiatry. 2011;50(3):252–261.
Allen Frances Rebuttals .
Neither Too Fast nor Too Slow
D
r Frances is essentially correct! He argues against “foolishly ambitious boundary expansions,” “mislabelling,” “care . . . that may do more harm than good,” against “labels . . . applied so loosely as to sometimes be meaningless,” “fad diagnoses that . . . [do] more harm than good,” and “recklessly growing our diagnostic system.” I agree. So does everyone else. Of course, the solution is thoughtful, prudent, cautious, appropriate expansion of psychiatry’s boundaries, not rigid refusal to consider change. As he points out, our current boundaries are “temporary constructs,” and at any time in history they should be determined by “utilitarian considerations” based on the assessment of risks and benefits. They have steadily expanded since the beginning of psychiatry, because of the steady growth of knowledge, the steady increase in the benefit–risk ratio of intervention. We certainly hope that this continues. He is concerned that 20% of the population meets the current criteria for mental disorder. So am I, but he is concerned that it is too high and I am concerned that it is too low. Consider all of those aging people who used to be suffering from normal senility, a hopeless condition, but now have Alzheimer disease, a pathologic entity for which some treatments exist now and more will be available within a few years. Further, prevention seems highly plausible. I would rather be a patient with Alzheimer disease than a so-called normal person with senility. Alzheimer patients and their families are fortunate that no one of Dr Frances’ brilliance persuaded the field not to medicalize normal senility. I would hope that over the years we will develop interventions that will help far more than 20% of the population, alleviating their psychological pain and disability. The history of psychiatry, like the history of civilization, is of steady expansion of our knowledge and our ability to improve people’s lives because of that knowledge. Dr Frances is certainly correct: our fantasies can extend beyond our current capacity, and we must guard against the damage that may result. We can also err in the other direction, restricting our efforts to only the people most seriously impaired, and defining all others as variants of normal, not appropriate for further research or the development
www.TheCJP.ca
of new treatments, and able to fend for themselves. It is a Goldilocks problem; the boundaries may be either too big or too small. We should avoid both, and get them just right. Certainly our history and our human values argue that just right will not be static, but steadily expanding. Robert Michels
Normal Is Worth Saving
D
r Michels makes my point better than I can myself when he warns of
the danger that professional hubris may lead to building a hoped for, but not yet achieved progress into, nosology that reflects fantasies about the future rather than realities of the present, with the socially undesirable consequences of premature medicalization. p 565
However, he leaves out the other external pressures that drive diagnostic inflation and deplete the resources that are desperately needed to treat people who are truly ill. It is not just professional hubris that leads to overpromising and overdiagnosing. The drug companies drain crucial billions of dollars a year by convincing people who are not sick and who do not need medicine that they are and they do. The autism epidemic did not occur because of new scientific findings, but because the diagnosis is a ticket to desirable school services. The ADD fad is due to drug marketing, school chaos, and diversion for recreation and performance enhancement—not because more kids really have ADD. And it goes on and on. This is not an ideal or idealistic world in which the growth of psychiatric diagnosis provides an unaltered good for its recipients and reflects the result of dispassionate scientific progress. The recklessly expansive decisions made in DSM-5 reflected the intellectual conflict of interest of naive experts who overestimated benefits and minimized risks. They will be exploited by cynical drug companies making unrealizable claims. Most of the inappropriate medication will be prescribed by harried primary physicians who do not know any better. Patients will suffer. I feel a special responsibility for saving normal because I was so involved in the DSM-III, DSM-III-R, and DSM-IV processes that truncated it. But I do not think it is my fight alone. Psychiatry is the only profession with the knowledge and prestige to trigger a return to sane diagnostic and prescription habits. We must spread the word that accurate psychiatric diagnosis cannot be done in 7 minutes by a primary care doctor; that proper medication treatment precludes the premature use of pills for expectable life problems; and that normal is worth saving. Allen Frances The Canadian Journal of Psychiatry, Vol 58, No 10, October 2013 W 569
