Invest in ME Conference 12: First Class in Every Way
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Is Mentally Ill the New " Normal "? from Allen Frances, MD, former chair of Task DSM

Discussion in 'Other Health News and Research' started by *GG*, Mar 1, 2011.

  1. *GG*

    *GG* Senior Member

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    Is the normal person an endangered species?

    Psychiatrist Allen Frances, MD, posed that question in a recent essay published in Psychiatric Times, discussing what appears to be an epidemic of mental illness in our country. Heres a startling example: The National Institute of Mental Health estimates that 20% to 25% of the US adult population -- that makes about 45 million of us -- has a diagnosable mental disorder. Is this possible? Or might the real problem be that doctors are overdiagnosing people who are simply experiencing expectable ups and downs of life or who just have personality quirks.

    Dr. Frances believes that it is the latter. I found his essay so intriguing that I called him to chat about some of these provocative ideas. He told me that these past few decades have brought us one psychiatric fad after another, with the rapidly escalating diagnoses of autism, attention-deficit/hyperactivity disorder (ADHD) and even bipolar disorder among our children and, in adults, the increasing numbers of people being labeled as having such conditions as anxiety disorder, post-traumatic stress disorder, ADD/ADHD, depression and more.

    Is Everyone Sick?

    Dr. Frances is a professor emeritus at Duke University School of Medicine and was the chair of the DSM IV Task Force, the committee that worked from 1987 to 1994 to update the Diagnostic and Statistical Manual of Mental Disorders, the book that provides criteria for mental disorder diagnoses that is the bible of the mental health community (and which provides the basis for insurance coverage for treatment for mental illness). First published by the American Psychiatric Association in 1952, this essential tome gets updated every 15 to 20 years to ensure that it reflects the current state of knowledge of psychiatry, psychology and medicine as it pertains to mental disorders. But, Dr. Francis told me, the very process of regularly revising this manual may have contributed to the problem. Here are some highlights from our conversation...

    Daily Health News: How does it happen that a mental disorder becomes what you call a "psychiatric fad"?

    Dr. Frances : When the DSM is updated, we want to be sure that the criteria dont miss anyone who suffers from a disorder, but our good intentions have unintended consequences -- overdiagnosis is now causing far too many people to get caught in the psychiatric net. Unfortunately, there is no good way to determine the exact correct threshold of symptoms that turns a person who is more or less normal into one who has a psychiatric problem, but any time you see a significant and sudden jump in diagnoses of a particular disorder, there is reason to worry.

    DHN: What is an example of a current psychiatric disorder fad?

    Dr. Frances : Major depression is an important example of diagnostic inflation -- 10% of the population now qualifies and is taking antidepressant medication. The criteria that psychiatrists use for major depressive disorder include feeling sad and tired and with reduced pleasure, appetite and sleep, for as little as two weeks, even if the mild symptoms are the result of painful life events. At least half the time, those symptoms will resolve on their own, usually within a few weeks -- all too frequently these essentially normal people who are undergoing stress get labeled as having major depression and are put on medication to treat it. When they feel better, they may assume incorrectly that the medicine did the trick, not just time and their own resilience.

    Drug Companies Are Part of the Problem

    DHN: Can you talk about the role the pharmaceutical industry has played in creating these psychiatric fads?

    Dr. Frances : Drug companies have one salesperson for every seven physicians, and they target primary care doctors, who do most of the prescribing of psychiatric drugs. The drug companies also aggressively market psychiatric diagnoses and drugs directly to patients on television, in print media and on the Internet. So patients come in primed to think that they might have a psychiatric disorder -- theyre even told to "ask your doctor" about a drug to treat it. For example, a growing fad now is the issue of low libido in women resulting from efforts by the pharmaceutical industry to get women to think they have an inadequate sex life and so should pop a pill. At the same time, there is no pushback to advertising right now, no campaign to support normality. Theres also no widespread education the about placebo effect and the risk/benefit ratio of drugs. The issue of unnecessary medication being prescribed and drug side effects is by far the biggest danger of fads.

    DHN: Can you explain what being given an erroneous diagnosis means to people?

    Dr. Frances : Lets take autism as an example. In the DSM IV, we included a broader definition of a condition called Aspergers syndrome (the mildest form of autism, characterized by problems with social skills, communication and coordination... eccentric or repetitive behavior... rituals or unusual preoccupations... exceptional talent or skill in a single area... and a limited range of interests) because we wanted to be sure that these patients would have access to treatment, such as special education and behavior modification therapy. We were surprised by an enormous twenty-fold increase in diagnoses! This is almost certainly due to a change in diagnostic habits, as we have no credible evidence that anything in the environment is causing such an increase. Rather, it is the labels that change and how they are used in practice. The diagnosis of autism is now being loosely used to explain all sorts of milder eccentricities and social difficulties.

    Another troubling example is the vast overdiagnosis of bipolar disorder in children, which has seen an even greater (forty-fold) increase in the past 20 years. This means that kids who may be nothing more than irritable and difficult to manage end up taking unnecessary antipsychotic drugs over long periods of time. The serious side effects of these drugs can include obesity, diabetes, heart disease and perhaps shorter life spans.

    DHN: What other risks to patients are associated with psychiatric fads?

    Dr. Frances : Many people absolutely need the drugs that they are taking, but many others with mild and transient symptoms are taking potentially harmful medications that they do not need. Medicalizing "normalcy" means that we are spending huge health and educational resources on people who dont need treatment or services -- and for whom it might even be dangerous, as in the case of medication. This distracts attention and diverts funds from others who do need such help. Another problem is that there is a stigma involved in being diagnosed with a psychiatric condition, especially in childhood, when the diagnosis implies a lifelong one. Such a label lowers expectations for behavior and accomplishments and, later on, having the diagnosis can threaten an individuals chances of getting a desirable job and health insurance.

    Do You Really Need That Pill?

    DHN: What advice do you have for people who are concerned that they or their children might be suffering from a mental disorder?

    Dr. Frances : Never go off a drug without medical supervision, but do think carefully about your diagnosis and whether you really know that you need that pill you are being given. Make a careful evaluation of the problem. Psychiatric symptoms that are mild, relatively recent and/or a response to stress often get better on their own or with counseling and dont require medication. When people start to feel better, they think it is the drug that is helping even though the placebo effect accounts for up to 50% of positive responses to medication. People may cling to an unnecessary drug and stay on it way too long. Be well-informed and periodically reevaluate your diagnosis and treatment.

    Source(s):

    Allen Frances, MD, former chair of the Task Force for DSM IV, professor emeritus, Duke University School of Medicine, Durham , North Carolina .
     
  2. *GG*

    *GG* Senior Member

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    I know there has been some talk on this subject, glad to see that ME/CFS is not the only group to have to deal with this!

    GG
     
  3. *GG*

    *GG* Senior Member

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    Are Endoscopies More Dangerous Than We Knew? by Daniel A. Leffler, MD BIDMC Boston

    If you have the misfortune to develop mysterious pain in your lower esophagus or stomach, your doctor might order an endoscopy to take a closer look. Depending on the severity of your symptoms, thats probably a good idea -- but before you go for the test, I want to alert you to new information about some problems with this very common procedure. Its not that its horribly dangerous, but rather because it appears that few doctors are taking the time to really educate their patients on what to expect after the endoscopy is done.

    Endoscopy... and Then What?

    An endoscopy, used by gastroenterologists to get to the root of digestive problems or pin down the cause of pain in the gastrointestinal tract, involves inserting a flexible tube with a tiny light and camera through the throat and down to the esophagus and upper stomach. The widely dreaded colonoscopy that is used to screen for colon cancer is another example of an endoscopic procedure, though obviously coming from the other end. No one considers these procedures fun... but most patients go home afterward and put it behind them (as expected) without much thought. However, a new study shows that two to three times as many endoscopy and colonoscopy patients as was previously thought end up in emergency rooms in the day or so after the procedure.

    I spoke with Daniel A. Leffler, MD, gastroenterologist and study author, who said that it is important to realize that some discomfort is actually normal and expectable after an endoscopic procedure -- these are invasive procedures, after all. Typical aftereffects include bloating, nausea, sore throat -- virtually all of which will clear up within a day or two and are no cause for alarm, Dr. Leffler said. Whats most important, he said, is that doctors should tell patients about the difference between discomfort that they may experience that isnt worrisome and those more urgent symptoms, including bleeding and fever, that require immediate medical attention.

    The new research from Harvards Beth Israel Deaconess Medical Center examined electronic records tracking the reasons why patients visited several different hospital emergency rooms. This data can be more easily analyzed than paper records, so it brought to light the higher number of people experiencing post-endoscopic procedure problems. All in all, compared with the 0.05% complication rate that was previously considered the norm, the study revealed that 1.07% of patients whod had upper endoscopies and just under 1% of colonoscopy patients landed in the emergency room. The most common complaints were abdominal pain (47%), GI tract bleeding (12%) and chest pain (11%).

    What to Expect

    If your doctor advises you to have an endoscopic procedure, Dr. Leffler says to ask about your doctors overall safety history, including rates of serious complications (such as perforation of the colon). While this information may have been difficult to come by in the not-so-distant past, doctors are under more pressure today to track such data and make it available to patients, Dr. Leffler said. "A group that does not collect safety data or whose results are worse than average would be concerning," he added, noting also that "the more patients who request this sort of data, the more easily available it will become."

    Source(s):

    Daniel A. Leffler, MD, director of clinical research, department of gastroenterology, Beth Israel Deaconess Medical Center , Boston .
     

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