How the “shrink’s bible” can make you sick

In essence, Dr. Allen Frances is the guy who wrote the book on mental illness. As editor of the 4th edition of the psychiatric reference book called the Diagnostic and Statistical Manual of Mental Disorders (universally known as the DSM-IV), he now makes this grim admission about what’s been called the “bible” of the psychiatric profession:   “We made mistakes that had terrible consequences.”     

Here’s a chilling example, according to Dr. Frances in an interview with Wired magazine, that links the American Psychiatric Association’s DSM’s role with the epidemic of bipolar diagnoses in children over the past decade.

“Shortly after the book came out, doctors began to declare children bipolar even if they had never had a manic episode and were too young to have shown the pattern of mood change associated with the disease. Within a dozen years, bipolar diagnoses among children had increased 40-fold.

“Many of these kids were put on antipsychotic drugs, whose effects on the developing brain are poorly understood but which are known to cause obesity and diabetes.”

In 2007, a series of investigative reports revealed that an influential advocate for diagnosing bipolar disorder in kids, the Harvard psychiatrist Joseph Biederman, failed to disclose $1.6 million in payments he’d received from Johnson & Johnson, makers of the bipolar drug Risperdal, or risperidone. (The New York Times reported that Biederman had told the company his proposed trial of Risperdal in young children will support the safety and effectiveness of risperidone in this age group.”).

Biederman (considered by many to be the poster boy for marketing-based medicine) has been under investigation* for the past two years by Harvard Medical School, in “what must be the longest investigation in that school’s history”, according to investigative journalist Alison Bass.

Dr. Frances now claims that this bipolar fad would not have occurred had his DSM-IV committee not rejected a move to limit the bipolar diagnosis to adults only.

This isn’t the first time that defining mental illness has led to rancor within the profession. It happened back in 1973, when a reluctant American Psychiatric Association was forced to acknowledge that homosexuality is not and never had been an illness.

Until then, however, the DSM had included homosexuality as a mental disorder.

That was before the APA decided (what were they thinking?) to hold their 1970 convention in San Francisco, where the gay liberation movement was at its peak after the Stonewall Riots. Gay liberationists stormed the convention and shouted down speakers in order to make their voices heard. Next thing you know, homosexuality was quietly removed as a form of mental illness from the next edition of the DSM as if it had never been there in the first place.

Another issue, says Dr. Frances, is the DSM’s evolution of what is called descriptive psychiatry: a checklist approach in which illnesses are defined by the symptoms patients present.

For example, if during a two-week period, you have five of the nine symptoms of depression listed in the DSM, then you are deemed to have “major depression” – no matter your circumstances or your own perception of your troubles.

Some have called this book “the bird watcher’s guide to psychiatry.”

“Doctors observe what the symptoms are, and then look them up in the DSM to identify the disorder, more for billing purposes than anything else.”

Dr. Frances says he now thinks his DSM-IV manual inadvertently facilitated over-diagnoses of autism, attention-deficit hyperactivity disorder, and bipolar disorder and, in the bargain, fostered an increasing tendency to chalk up life’s difficulties to mental illness – and then treat them with psychiatric drugs.

He adds that he had already regretted having remained silent when, in the 1980s, he watched the pharmaceutical industry insinuate itself into the American Psychiatric Association’s training programs. Multi-million dollar drug company contributions to those programs continued annually until 2008, when the APA finally decided to phase out industry-supported education.

But the more that doctors reading the DSM-IV concluded that their patients were mentally ill and in need of psychiatric drugs, the happier drug companies were.

In fact, Dr. David Healy, writing in the independent journal Public Library of Science Medicine, explained that after the DSM-IV expanded the definition of bipolar disorder, brand new medical journals were launched (like Bipolar Disorders and The Journal of Bipolar Disorders) along with a slew of bipolar societies and annual conferences, many heavily funded by pharmaceutical companies.”

And a 2006 University of Massachusetts and Tufts University study found that over half of 170 psychiatric “experts” who helped work on the latest edition of the DSM had financial links to drugmakers from 1989 to 1994, when the most recent edition of the DSM was released.

Those “financial links” included ownership of drug company stock, travel expenses, research funding, consulting fees and cash payment as gifts.

Even more alarming, all of the “experts” who developed parts of the DSM that define schizophrenia, mood disorders and psychotic disorders had these financial links. The study authors concluded:

“The connections are especially strong in those diagnostic areas where drugs are the first line of treatment for mental disorders.”

According to Wired, the fact that diseases can be invented (or, as with homosexuality, uninvented) and their criteria tweaked in response to social conditions is exactly what worries critics like Dr. Frances about some of the disorders proposed for the upcoming newest edition, the DSM-5, such as attenuated psychotic symptoms syndrome, binge eating disorder, temper dysregulation disorder and other “sub-threshold” diagnoses.

And Dr. Frances also warns that the new DSM-5, with its emphasis on early intervention, may cause a “wholesale imperial medicalization of normality” and a bonanza for the pharmaceutical industry” for which patients would pay the “high price of adverse effects, dollars, and stigma.”

He told Wired:

“This gives drugmakers a new target for their hard sell and doctors, most of whom see it as part of their job to write prescriptions, more reason to medicate.”

Read the rest of Dr. Gary Greenberg‘s Wired article, Inside the Battle to Define Mental Illness. Or read Dr. David Healy’s article in the journal, Public Library of Science Medicine, called The Latest Mania: Selling Bipolar Disorder.


* NEWS UPDATE:  Massachusetts General Hospital Discloses Sanctions against Three Psychiatrists for Violating Ethics Guidelines, July 1, 2011:   The Boston Business Journal said today that three psychiatrists have been sanctioned for failing to adequately report seven-figure payments they received from drug companies.

Drs. Joseph Biederman, Thomas Spencer and Timothy Wilens disclosed the disciplinary actions against them in a note to colleagues. According to a copy of the note made public upon request by the hospital, the three doctors:

• must refrain from “all industry-sponsored outside activities” for one year

• for two years after the ban ends, must obtain permission from Mass. General and Harvard Medical School before engaging in any industry-sponsored, paid outside activities and then must report back afterward

• must undergo certain training

• face delays before being considered for “promotion or advancement.”

The three doctors have been under the political microscope since June 2008 when Senator Charles Grassley, R-Iowa, began investigating conflicts of interest involving clinicians. Biederman and Wilens have since admitted to accepting $1.6 million from drug companies whose drugs they were promoting; Spencer took $1 million.

Senator Grassley said, according to an online version of the Congressional record:

“These three Harvard doctors are some of the top psychiatrists in the country, and their research is some of the most important in the field. They have also taken millions of dollars from the drug companies.”

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12 thoughts on “How the “shrink’s bible” can make you sick

  1. There is a real problem with the medicalization of life and presenting normal human emotion as a “sign” of an illness.

    It is easy to do and profitable. The influence of big pharma and their “thought leaders” is a major issue that we need to address.

    Thanks for highlighting this issue.

    • Hi Dr. Joe – When a credible source like Dr. Frances reveals his own concerns like this, it unfortunately casts doubt on the entire profession, even upon those who work hard in the mental health field to help those who genuinely need help. But the pervasive financial influence of drug companies on even clinical practice guidelines is frightening. Thanks so much for your comments.

  2. Two marketing exercises in “bundling” disorders which have had serious negative consequences have been AD/HD and anxiety/depression.

    The bundling of two previously unrelated disorders, one common (hyperactivity) and one uncommon (attention deficit) to spread the drug market share (Ritalin – a dopamine agonist for attention deficit) of the uncommon disorder to the much larger market, hyperactivity.

    On reading the diagnostic criteria for ADHD in DSM IV, I cannot find a single “sign” which does not describe the normal behaviour of children. To prescribe stimulants for children with “hyperactivity” (the new word for behaving like a child), even if the diagnosis were correct, is appalling!

    Anxiety/depression? Anxiolytics (drugs which “dissolve anxiety” – an interesting metaphor) are only taken when needed but anti-depressants are for the rest of your life “regardless of how good you feel because that just means the drugs are working well”.

    To move occasional customers over to permanent daily consumers is no doubt good for pharamaceutical market share, but what does it do for the patients? Anxious people can now worry about the depression they did not previously know they had, and depressed people can also become more depressed about their newly discovered anxiety disorder.

    • Interesting points, John. Anti-depressants are not, however, usually prescribed ‘for life’. The U.K.’s Royal College of Psychiatrists, for example, reports that “without any treatment, most depressions will get better after about 8 months. Current recommendation is that it is best to take antidepressants for at least six months after patients start to feel better, except for those with two or more attacks of depression, in which case treatment is continued for at least two years.” Regardless of the duration, however, it does seem that “bundling” two diagnoses for the price of one certainly expands market share for Big Pharma.
      Thanks for your comments.

  3. Carolyn —

    I have to use the DSM-IV on a daily basis; one can’t bill insurance without it….

    Part of the problem is the whole “medical model”, which assumes the metaphor of physical illness when dealing with matters of the mind and soul…. (Jung talks about the problem of our times being “Modern Man in Search of a Soul” — I don’t think you can bill insurance for this deep cultural and personal problem… better just to see it as “anxiety” or “depression” )

    And I think over-diagnosing kids as bipolar was a travesty….

    On a positive note, I would suggest that the inclusion and recognition of Post-Traumatic Stress Disorder in the DSM-IV (a story in itself) has been a very important shift in cultural consciousness about how trauma can affect people….

    Like everything else, the DSM-IV is political… the decisions are made by committees of people with vested interests and opinions, reflective of the culture biases…

    Thanks for bringing this to people’s attention….


    • I appreciate these excellent points, Steve. Isn’t it interesting that until you can “bill” for something, it doesn’t actually exist? As a heart attack survivor like you, I’m very interested in the subject of PTSD following heart attack. As the Canadian Medical Association Journal has reported: “…a heart attack can leave people as psychologically traumatized as victims of violence…”

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