The history of medicine has its glorious moments, but is also littered with false theories, blind allies, and harmful treatments. The emergence of invasive therapies in ancient Greece inspired Hippocrates to make 'First, Do No Harm' the foundational injunction of western medicine. Psychiatric medicines are quite effective when correctly prescribed for clearcut disorders. But Americans are taking too much medicine, often casually and unnecessarily prescribed by the wrong people for the wrong reasons, and causing lots of needless harm.
The really bad news is that the bulk of psychiatry is no longer done by psychiatrists. Psychiatric medicines are most often prescribed by primary care doctors who are always busy and usually under trained in psychiatry. And their diagnostic and treatment decisions are heavily influenced by drug company advertising aimed directly at patients combined with aggressive marketing campaigns aimed at doctors.
The result is massive overprescription of medicine for off label, untested, and inappropriate indications. Drug companies have more unregulated freedom in the U.S. than anywhere else in the world to push their product where it does not belong. Their success is measured in returns to shareholders, not benefits to patients.
It simply makes no sense that the antipsychotics are now the largest revenue producers among all classes of medicines -- bringing in $15 billion per year -- much of it coming from excessive use in vulnerable populations of children and the elderly. Antipsychotics often cause large weight gains increasing the risks of diabetes, heart disease, and shortened life expectancy. Almost equally concerning is that eleven percent of U.S. adults are taking an antidepressant medicine, making these the fourth most lucrative class for drug companies. Perversely, only a third of severely depressed people get the medicine they so desperately need, while many taking antidepressants do not need them at all and receive no more than placebo effect. And 4% of our kids are on stimulants for ADD, sometimes without a careful diagnostic workup and consideration of alternative approaches. A large secondary market has encouraged a third of college students to use stimulants for performance enhancement and/or recreation. We seem to be creating a brave new world in which everyone will take a psychiatric medicine, and some will take two or three or even more.
Psychiatric diagnosis and treatment is particularly subject to fads and undue drug company influence because judgments are still based on subjective data that cannot be confirmed or disproved by laboratory tests. The pride of psychiatry is the enormous neuroscience base accumulated in the past thirty years, but the brain is the most complicated organ in the known universe and reveals its many secrets only very slowly. We have learned a great deal about normal brain functioning -- but still know very little about what causes the mental disorders. This enormous leap from basic brain science to clinical psychiatry will take decades to bridge in very small steps. In the meantime, decisions about diagnosis and treatment are only as good as the people making them -- and too often they are made after brief and cursory evaluations that ignore best diagnostic and treatment practices.
I am a psychiatrist and was chair of the group that prepared DSM-IV -- the manual that currently guides psychiatric diagnosis. Sad to say, DSM-IV is often used carelessly or not at all (especially in primary care) -- resulting in a great deal of mislabeling and unnecessary treatment. The overdiagnosis of mental disorders has recently gotten out of hand with faddish false epidemics of childhood bipolar disorder (increased by forty fold), autism (increased by twenty fold), and attention deficit (doubled). One quarter of the general population would now qualify for a diagnosis in any given year, more than half lifetime.
The next edition of the diagnostic manual (DSM 5) is in preparation now and will become official in 2013. I'm terribly concerned that it will make our current worrying situation a great deal worse. Unless its ambitions are trimmed dramatically, DSM 5 will promote the misdiagnosis of tens of millions of people and an even greater misuse of potentially harmful medication. It proposes to introduce many new diagnoses and broaden the criteria for existing ones. Normal grief will be mislabeled major depression; everyday worries, stress, and sadness will become mixed anxiety/depression; one episode of binge eating a week will label you mentally ill; older people with expectable memory problems will be inaccurately warned that they are on the road to dementia; difficult to manage kids will be given unproven diagnoses that will lead to even more misuse of antipsychotic drugs, and there will be a further boost to the false epidemic of attention deficit disorder.
The people working on DSM 5 mean well, are not drug company shills, and genuinely believe their suggestions will help patients. The problem is that they are researchers who have worked in ivory tower settings with little experience in how the diagnostic manual is often misunderstood and misused in actual practice. A suggestion that might be fine in their own hands can cause disaster if misapplied by a less expert primary care doctor. As researchers they are much less worried than I am that their proposals are largely untested. They call them 'scientific hypotheses' that can always be tested and corrected after DSM 5 is published. This is dead wrong and dangerously reckless. DSM 5 will have a dramatic effect on peoples lives and everything in it must be certified safe and scientifically sound.
Final decisions on DSM 5 will be made soon. I will post a series of blogs highlighting its worst proposals and updating the efforts to shoot them down before they can become official. Public health will be adversely affected by DSM 5 -- the public should become informed and have its say before it is too late.
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.
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