October 15, 2012 | 8
The psychiatrist is Allen Frances. The journalists are 48 enthusiastic and committed participants at the National Institute of Health’s 2012 Medicine in the Media course (#NIHMiM12). It’s an evidence boot camp that started on Sunday night (October 14), with 12-hour-days ahead – and many of those hours will be spent learning about statistics. But the audience’s eagerness for this immersion experience was not the reason for the question about their sanity.
Frances is a retired psychiatrist and you might know of him from his blogging or frequent media interviews. He chaired the committee that developed the DSM-4: the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders. And he’s a key leader in the charge of dismay about the next edition, DSM-5, that’s due to appear later this year. It will likely vastly expand the many ways you can get a mental illness label. You can read more about that at Scientific American and an important article on conflicts of interest in PLoS Medicine.
The intriguing question about our sanity wasn’t directed particularly at the journalists, scientists and doctors in the crowd. It was a dig at what Frances called “diagnostic inflation” in psychiatry. Even with DSM-4, this problem was already starting to gallop away from us, as more and more of the “symptoms of daily life” were re-cast as mental disorders – with drugs carrying common adverse effects and a high price tag as the prescription.
How big is the problem? Using DSM-4 criteria for mental disorders, almost half the people in the US are getting a diagnosis of a mental disorder in their lifetime – and other countries aren’t far behind. Frances fears that “the pool of normal is becoming a small puddle.”
Unless there are more changes, in the world of DSM-5, if a person can get out of childhood and adolescence without a mental illness label, it could be something of an achievement. People aren’t changing, Allen said, but the new labels and widening of scope of existing labels set the scene for “epidemics” of illness.
The symptoms of everyday life are being misinterpreted as – treatable – mental disorders, even when diagnosis is fuzzy at best and the benefits of treatment don’t outweigh the harms. It’s a problem that is not restricted to psychiatry, as an article and conference announcement about over-diagnosis in the BMJ this year pointed out.
Frances called for “Saving Normal” (the title of his forthcoming book). Some of his prescriptions are radical. For example, not just fines for drug companies that misbehave, but reduction of patents. And an “FDA” to determine diagnoses rather than allowing specialist groups who are over-invested in their “pet” diagnoses to hold such sway: “If you’re an expert you love your diagnosis – it becomes your pet. It’s human nature.”
Allen pointed to the change in power of the tobacco industry as a reason for hope that the tide could be turned on this issue. He called on the media to pay more attention to the fines being levied against companies who breach marketing rules, and less to the “breathless claims” of press releases promoting diseases and treatments.
Frances Allen got the 2012 Medicine in the Media course started with a storm of intellect and passion – and tweets; lots of tweets (hashtag NIHMiM12). As you’d expect from a meeting of 48 committed journalists with a shared beat, this is an articulate, well-informed and feisty crowd. One of the first questions to Frances referred to his call for skepticism about the claims of passionate experts hyping a pet issue. He was asked, as a passionate expert himself: “Why should we believe you?” The spirited dialogue on Frances’ statements about benzodiazepines that followed was a demonstration of the value and importance of good journalism.
Around 250 journalists applied for the course. The successful participants come from a range of major broadcast networks, one cable network (CNN), daily newspapers, science and women’s magazines, radio and more. More blogging from the course to come. But for this first night, the last words have to be on the consequences of over-medicalization in health care more generally, where the well are over-treated and the needy are far too often under-treated.
Frances had the death of a dear friend this weekend at the top of his mind. His friend was, against his hopes for a hospice ending, pulled into the vortex of hospital death. On this over-medicalization of dying: “It’s an insult to the dignity of death. It’s an insult to the dignity of love.”
Interests: I am presenting at the NIH Medicine in the Media course and while I work at the NIH’s National Center for Biotechnology Information, I am not part of the organization of this event. The views expressed here are my own. Medicine in the Media is an annual event organized by the NIH’s Office of Disease Prevention.
Image: By the author at Statistically Funny