Review: Saving Normal by Allen Frances
I recently heard the wonderful Ginger Campbell interview Allen Frances on the Brain Science podcast. Almost before my headphones were off I had run out to buy Frances' book "Saving Normal, an insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life." Frances clearly and humanely outlines his case that "The cruelest paradox of psychiatric treatment is that those who need it often don't get it, while those who do get it often don't need it."
I had some concern, even after the very thoughtful interview on BSP, that this would be a soft-headed screed against psychiatry. I know a lot of people who have benefited from mental health treatment including psychiatric medication, and I think it is very wrong to frighten people away from psychiatry who really can use it. I needn't have worried. Frances is a psychiatrist with a great love for the profession and confidence in the good it can do. He is absolutely committed to the idea that psychiatry can be beneficial to seriously mentally ill people and at pains to illustrate that.
But he is also clear-sighted about the failings of psychiatry and medicine generally (he is very much talking about the US situation. I will reflect a little on the Quebec context below). The big failing Frances takes on is 'diagnostic inflation.' He means the tendency to expand the criteria that are used to diagnose mental illness, either by loosening criteria for exiting illnesses or by 'discovering' new illnesses. What prompted this call was the American Psychiatric Association's process to issue a fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM. Frances thinks the authors are too quick to expand definitions which will inevitably lead drug companies to step in and push for meds for people who could do without them. Frances is in a good position to comment because he was in charge of the DSM-4. He is very up front about his own failings in having lead that installment and apologizes for his mistakes. It is extraordinarily refreshing to hear someone with such a level of authority offer a public apology.
One of the diagnostic overreaches that he addresses is 'psychosis risk syndrome'. We are close to being able to identify people who are at high risk of developing psychotic disorders like schizophrenia. We know many of the risk factors including certain genetic markers, we think that delaying onset of schizophrenia means being less sick and we know that being very sick with schizophrenia is very hard. Why not target teens who are at elevated risk and are exhibiting "prodrome" symptoms; self-isolation, quirky or aggressive behaviour in the hopes of forestalling or even preventing the onset? Frances gives a very good answer to that. First of all, target them with what? The answer will probably be anti-psychotic medication. We have no indication that taking anti-psychotics before developing psychosis will help stave off or mitigate the effects of schizophrenia and the side effects can be very serious, including obesity and diabetes and everything that comes with that. And, he points out, we can identify teens who are at risk, but that would probably involve identifying a lot of kids who will never develop the disease and potentially subjecting them to this very serious intervention. It begins to look a lot like the aggressive screening and treatment of prostate cancer, too many people, too invasive for limited benefit. Frances doesn't mention the possibility that teens who are identified might benefit from interventions that have less potential downside like counseling about delaying use of street drugs including marijuana and psycho-education about reality testing. Given the way Quebec is headed, it seems unlikely that we will see a targeted public health campaign that relies on disease prevention using labour-intensive methods like psychoeducation.
Frances also alludes to something I have mentioned elsewhere in this blog; namely that not all conditions of the human soul are diseases in any recognizable sense and yet increasingly the DSM includes them. The idea that mild to moderate depression, or attention deficit disorder, or anxiety is a neurochemical imbalance fits very nicely with a drug company's bottom line. The emphasis of the last twenty years on neuroscience has tilted us towards a chemical fix for ailments of the mind. Yet not one significant advance in diagnosis or treatment of mental illness has come out of all the important research on neuroscience so far. Diagnosis remains entirely symptom-based. The mechanisms for the function of treatments is poorly understood, if at all.
“All of this may seem very much like “inside baseball” for people who don’t spend their days thinking about mental health but Frances makes a persuasive case that a lot of people are already getting a lot of powerful psychiatric medication that they don’t need...”
All of this may seem very much like "inside baseball" for people who don't spend their days thinking about mental health but Frances makes a persuasive case that a lot of people are already getting a lot of powerful psychiatric medication that they don't need, medicines with serious side-effects that may not have been adequately tested on the populations for whom they are being prescribed. He reports that the sale of anti-psychotic drugs at $18 billion (US) now delivers more cash to the pharmaceutical industry than anti-depressants. Anyone who has any experience with them knows anti-psychotics are powerful medications with very serious potential side-effects. They are helpful to people with psychosis. But now they are being marketed for use with children and the elderly. 20% of people treated by primary care physicians for anxiety now receive an anti-psychotic as well, according to Frances. The trend towards GPs prescribing psycho-active medication is troubling for Frances as well. That GPs give out anti-depressants and anti-anxiety medications routinely should surprise no one, but I was amazed to learn that 50% of anti-psychotics are prescribed by GPs. (I am not sure if that accounts for GPs taking over the prescription of anti-psychotics after an initial prescription by a psychiatrist.) Frances goes through the familiar litany of the dangers and over-promises regarding SSRIs for treating the 'worried-well' market. These are problems we see here in Quebec, though certainly not to the degree they are experienced in the US.
Whose fault is all of this? For Frances the answer is pretty clear. Big Pharma and the big money it is willing to throw around to advertise direct to consumers (only in the US and -- apparently -- New Zealand as well), to co-opt the better judgement of doctors and researchers as well as to fight legal battles and pay fines when they get caught behaving badly (as with the off-label marketing of anti-psychotics for kids). He gives policy recommendations for taming the excesses of big pharma. Naturally, dear to my heart are all the plugs that he makes for psychotherapy as an alternative or adjunct to pharmacology.
“There is no organized psychotherapy industry to mount a concerted competitive push-back against the excessive use of drugs.”
Here in Quebec, we are retrenching from any kind of public outpatient psychotherapy, at great cost to our well-being, I believe. It is nearly impossible in Montreal to get psychotherapy at a CLSC (public health and social service clinic). This despite the fact that we know that psychotherapy can sometimes head off episodes of serious mental illness later for certain people and keep them from needing much more expensive hospital care. Follow-up care after a psychiatric hospitalization is spotty and seems unlikely to get better with more cuts coming.
“The lack of a credible alternative is part of what is fueling the appetite for drugs. If we want to see the biomedical model of mental illness restored to a more modest role and with it the role of psychotropic medication, we need to take seriously the challenge of collectively creating a psychotherapy that is credible to the people it can help. ”
While I am a believer in psychotherapy, if I have a quibble with Frances, it is over this. My experience is that many psychiatrists and other psychotherapists have been and continue to be high-handed, overly jargonistic, faddish, opaque and sometimes deeply anti-scientific. Frances himself mentions the terribly misguided satanic ritual abuse accusations of the 1990s and the role played by therapists who "developed and instant expertise on day care sex." Many people mistrust us because they view psychotherapy as elitist mumbo-jumbo that changes tack every ten years. All those primary care doctors who are prescribing medications rather than sending their patients to therapists don't trust talk therapy. Why should patients? Hell, I have met quite a few psychiatrists who don't have faith in psychotherapy. The lack of a credible alternative is part of what is fueling the appetite for drugs. If we want to see the biomedical model of mental illness restored to a more modest role and with it the role of psychotropic medication, we need to take seriously the challenge of collectively creating a psychotherapy that is credible to the people it can help.