Saving Normal : An Insider's Revolt Against Out-of-control Psychiatric Diagnosis, Dsm-5, Big Pharma, and the Medicalization of Ordinary Life (9780062229274)

by Frances, Allen

  Some doctors seem to use the same combination of medications on every patient, regardless of symptom presentation. The prescribed doses are sometimes high enough to cause serious problems on their own and are especially dangerous if the patient pushes the envelope by drinking alcohol, using drugs, or even taking a few extra pills. The wildest prescribers tend to accumulate deaths over the years, usually without inviting much-needed discipline or increased supervision.

  All this said, polypharmacy is sometimes rational and even necessary. The combination of antipsychotic and antidepressant works much better than either alone in treating bipolar disorder or psychotic depression. When a patient has had a definite but partial response to one drug, another may be needed to get a full response. And rarely does adding a pill for sleep make sense. But most polypharmacy is unnecessary, unsupported by research, unmonitored, harmful, and even dangerous.

  Too Little Psychotherapy

  There is no organized psychotherapy industry to mount a concerted competitive push-back against the excessive use of drugs. Psychotherapy is a retail, individualized, preindustrial craft that doesn’t lend itself to the wholesale industrial standardization of product and people that has been so lucrative for Pharma. The different psychotherapies and their practitioners are extremely fragmented and lack the financial resources needed to break the drug company monopoly of the airwaves. Talk doesn’t pay—psychiatrists who provide psychotherapy along with medication during a forty-five-minute outpatient visit earn 41 percent less than do psychiatrists who provide three fifteen-minute medication management sessions.61 The percentage of visits to psychiatrists that included psychotherapy dropped from 44 percent in 1996 to 1997, to 29 percent in 2004 to 2005.62,63

  Psychotherapy also lacks a unified, catchy message to counter the seductively misleading drug company promo “it is all chemical imbalance.” But psychotherapy does have a much more important and truthful story to tell—that it performs as well as drugs when compared head-to-head in people with mild to moderately severe problems.64, 65, 66 Though psychotherapy takes a bit longer to work and costs more upfront, it has more enduring beneficial effects, and that may make it cheaper and better in the long run than long-term medication. Taking a pill is passive. In contrast, psychotherapy puts the patient in charge by instilling new coping skills and attitudes toward life. Japan has caught on to this advantage. Until recently, all of its psychiatric treatment was medication based, but now the government is making a concerted national effort to break the drug monopoly by promoting cognitive therapy as an alternative—because it works well and is cost-effective.

  The Power to Label Is the Power to Destroy

  Merriam-Webster defines the word stigma as an identifying mark, a specific diagnostic sign of disease, or a scar or spot on a plant or animal. Some dictionaries even use “the stigma of mental illness” as the best specific example of the disadvantages suffered by those who are marked. Being “normal” and fitting in with the pack are a key to survival. Evolution has wired into human nature an uncharitable wariness and lack of compassion for those who are different and don’t satisfy tribal standards.

  Having a mental disorder label “marks” someone in ways that can cause much secondary harm.67 Stigma takes many forms, comes from all directions, is sometimes blatantly overt, but can also be remarkably subtle. It is the cruel comment, the unkind smirk, the extrusion from the group, the lost job opportunity, the rejected marriage proposal, the ineligibility for life insurance, the inability to adopt a child or pilot a plane. But it is also the reduced expectation, the helping hand when none is needed or wanted, the solicitous sympathy that one cannot really be expected to measure up. And the secondary psychological and practical harms of having a mental disorder come only partly from how others see you. A great deal of the trouble comes from a change in how you see yourself—the sense of being damaged goods, feeling not normal or worthy, not a full-fledged member of the group.

  It is bad enough that stigma is so often associated with having a mental disorder. But the stigma that comes from being mislabeled with a fake diagnosis is a dead loss with absolutely no redeeming features. Labels can also create self-fulfilling prophecies. If you are told you are sick, you feel and act sick, and others treat you as if you are sick. The sick role can be enormously useful when someone truly is sick and needs respite and care. But the sick role can be extremely destructive when it reduces expectations, truncates ambitions, and results in a loss of personal responsibility.68

  And when a society allows the overdiagnosis of a significant proportion of its individuals as “sick,” it becomes an artificially “sick” society rather than a resolutely resilient one. Our ancestors lived through wars and privations unimaginable to us—without resorting to an overdose of labels and an overuse of pills.

  Turning Bad into Mad

  Diagnostic inflation is an ever-present danger at the boundary between psychiatry and the law. “I would rather be hung as a man than acquitted as a fool.” So screamed Charles Guiteau to the jury during his trial for the assassin of President James Garfield in 1881.69 He was renouncing the insanity defense offered by his lawyers—preferring instead to be seen as a messenger of God sent to save the United States from an evil administration. Better to be convicted as a criminal than absolved as a mental patient because this would reduce the credibility of his claims. Setting a precedent that continues to this day, many doctors testified on both sides of this landmark case—some seeing Guiteau as crazed, others as a sane, if misguided, criminal.

  This debate rages on with no solution. Are political terrorists like the Unabomber or the Norwegian mass murderer Anders Breivik best considered political criminals or mental patients? When assassins strike public figures or innocent bystanders, the media always questions whether they are crazy, never wonders how much they were egged on by venomous political discourse or how they so easily got that semiautomatic. Many (perhaps most) political assassins and mass murderers are on the fuzzy boundary between the merely strange and the legally insane. Depending on your perspective, they can plausibly be seen as either violent political or religious extremists or as delusional psychotics. The adversarial testimony of expert psychiatric witnesses on both sides of this divide invariably cancels out. Ultimately it is a societal, not a medical, choice, whether to consider such individuals mad or bad. Most defendants would, like Guiteau, much prefer to be punished than treated—lest their message be muffled. I would agree with them. Except in the clearest cases to the contrary, diagnostic inflation should be tamed in the courts. Bad should usually trump mad.

  Paying the Bill for Diagnostic Inflation

  No one has calculated the total direct and indirect monetary costs of diagnostic inflation, but it must add up to a vast fortune of wasted resources. First, there is the cost of all the unnecessary and overpriced drugs and the doctors’ visits needed to prescribe them. Add to this the downstream costs that arise from the many and expensive complications that arise from excessive drug use. In the short term, this includes the costly emergency room visits and hospitalizations for overdoses. Then there are the long-run massive but hidden costs of treating the medical and psychiatric complications caused by medication use—most especially the secondary obesity, diabetes, and heart disease. And how do we cost the lost years of life for those who die early because of the harmful short-term or long-term impact of unnecessary drugs?

  Next we have to add the cost of lost work productivity. Linking psychiatric diagnosis to disability artificially inflates both—those who are mislabeled are more likely to become absentees or to stop working altogether. Holland and Denmark discovered that national sick days and disability skyrocketed when a psychiatric diagnosis or work stress was a readily accepted reason for not working. The disability decision is often an irrevocable moment in a person’s life: gaining disability is a wonderful short-term respite from terribly worrying financial pressures, but it may lead to chronic vocational invalidism.

  Then there are the costs of o
ther services provided to people mislabeled as mentally ill—the mental health and medical visits, the added school services, training programs, and so on. It seems harsh to begrudge these to anyone, and in the individual case a caring clinician will be tempted to up-diagnose to help his own patient get the benefit. But budgets are usually a zero-sum game—helping this person who has only a marginal need will mean depriving someone else who has a crying-out-loud need.

  Finally, we come to the forensic and correctional costs of diagnostic inflation. A single death penalty sentencing hearing can cost $5 million for endless and futile debates on the presence or absence of a highly dubious mental disorder. A year in a psychiatric hospital for someone inappropriately committed under an SVP statute costs more than a year at Harvard. Civil lawsuits based on creative claims of psychiatric damage drag on seemingly forever and eat up treasures in legal bills and fees for expert witnesses. Psychiatry and the law often don’t mix well—but they always cost a lot whenever they become entangled.

  The enormous waste caused by diagnostic inflation goes unchecked because there are no feedback controls to contain it and no economic incentives to promote careful diagnosis. Waste never enters into the considerations of those who develop the DSMs or those who apply it or to the drug companies who profit from it. Parents understandably want services for their child and consumer advocacy groups understandably want services for their constituents. It always appears that someone else is paying the bill and no one is minding the store to ensure rational and fair allocations. The net result is inevitable: unnecessary demand created by diagnostic inflation results in wasted expenditures, while those in desperate need remain badly underserved.70

  Diagnostic inflation is a public health and public policy dilemma that urgently needs solving. Costs will be further amplified by the extension of health insurance to some 34 million more Americans under the Affordable Care Act, especially given its requirement that insurance include comprehensive care for mental disorders. These are wonderful policy changes. A greater investment is certainly needed to shore up our badly shortchanged mental health system. But the additional expenditures are unpredictable, likely to be in the many billions each year, and because of diagnostic inflation, the money will be spent where it is likely to do least good.

  Curing diagnostic inflation will be an uphill struggle, with steps to be described later. But first we have to understand the large role diagnostic fads have played in the psychiatric past, the grave damage they are doing in the present, and the significant risk that new fads will create mayhem in the immediate future.

  PART II

  Psychiatric Fads Can Be Bad for Your Health

  CHAPTER 4

  Fads of the Past

  We don’t see things as they are. We see things as we are.

  TALMUD

  FADS IN PSYCHIATRIC diagnosis come and go. All of a sudden everyone seems to have the same problem. Quack theories explain the outbreak; quack treatments presume to provide cure. Then, equally suddenly, the epidemic runs its course and the once ubiquitous diagnosis disappears from circulation.1

  Fads depend on the combination of a plausible idea and our copycat, follow-the-leader herd instinct. Like stock market fluctuations, they are probably most common during times of instability, uncertainty, and change. The causes can be deep and general to the human condition or quite specific to a given historical development, the publication of a popular book or movie, or a new medical treatment. Some of the misleading ways of understanding psychiatric disorder have lasted for millennia, others only for decades. Demonic possession is so powerful and plausible an explanation for strange feelings, thoughts, and behaviors that it recurs at all times and in all places. Multiple personality disorder is a much less satisfying fad—it pops up only rarely and never lasts very long.

  People don’t really change much, but labels do. Humanity’s symptoms and behaviors may oscillate a bit but probably remain basically stable over time. In contrast, the way we characterize them can fluctuate as wildly as changing fashions in music or hemlines. The symptoms and suffering are real—but sometimes we get trapped by explanations and labels that are just plain wrong and far too convincing.

  Being aware of fads of the past will help us be skeptical about whatever has become a “diagnosis du jour” in the present. The best antidote to following foolish current or future fashion is appreciating how harmful previous fashions have been. History never precisely repeats itself because its complex interactions are pregnant with probabilistic permutations. But history does have to rhyme, because the underlying forces shaping it are fairly stable, even if outward appearances are in apparent flux. The more we know the rhymes of the past, the less likely we are to mindlessly repeat them in the future.

  Demonic Possession (Circa: Then, Now, and Always)

  Demonic possession is the oldest of fads and the newest; it is recorded in the earliest written documents and reported in today’s newspaper. Belief in devils may be the fruit of ignorance—but it is too appealing a model ever to disappear from human belief and provides stiff competition to the slender comforts of rational thought, mainstream religion, and psychiatry. It will always be with us in one form or another and every so often explodes into a fad, sometimes with devastating results.2

  The real beauty of demonic possession is that it not only describes the problems but also provides a compelling explanation of their cause and a ready suggestion for their cure. A demon has possessed the person, taking control of his thoughts, feelings, and behaviors and causing a whole grab bag of symptoms that could be divided into at least a dozen different DSM mental disorders. Today’s psychiatrist can describe schizophrenia, but can’t begin to explain it. The medicine man or priest is in a much more powerful position. He has sure knowledge of what is causing the symptoms and a specific treatment intended to separate the patient from the disease. Exorcising the demon can work well when the exorcist and the patient both believe it will.

  The belief in demonic control is universal across cultures and enduring through time because it makes so much sense to most people; it taps into something basic in human psychology and explains a large part of human experience in a simple and plausible way. The battle against demons appeals to the theological mind; cures most of the symptoms that ail us; ministers to the soul; and binds the tribe. Demons are a completely logical, if prescientific, way of understanding the changes caused by psychiatric and medical illness (and also by drugs, dreams, and trance states). It appears silly only to us children of the Enlightenment who believe in biological causes of strange behavior. But there is one unavoidable problem with this otherwise useful diagnostic category—it has provided a wonderful excuse for the persecution, torture, and murder of the mentally ill. The very most inhumane treatment could easily be justified on the spurious grounds that it was part of a holy fight against the devil.

  Modern psychiatric diagnosis and demonic possession could be seen as opposite ways of explaining the causality of troubled behavior—disease of the brain versus disease caused by spirits. Most people in the developed world are more comfortable with modern science. But not all. More than a third of Americans believe that demons and angels play an active role in their daily lives. And worried that victims of possession are being misdiagnosed by psychiatrists as schizophrenic, modern-day exorcists have posted detailed Internet diagnostic manuals teaching how to spot the devil in the disease. The Catholic Church is less radical in its belief in demons, recommending exorcism only when the symptoms are specific to sacrilege and after mental illness has been ruled out. Outbreaks of demonic possession occur all the time in war-torn Africa. The latest epidemic in the United States occurred twenty years ago as part of the hysteria around “satanic ritual abuse.”

  Dance Manias: Tarantism and Saint Vitus’s Dance (Circa: 1300 to 1700)

  Dance manias came in two quite similar forms: tarantism in southern Italy and Saint Vitus’s dance in northern Europe. The symptoms were some combination of melancholy, vision
s, headache, fainting, breathlessness, twitching, loss of appetite, soreness, swelling, and premonitions of imminent death. In the south these were attributed to the bite of the tarantula, endemic to the area. Onset was usually during the height of midsummer, and heat was presumed to enhance the toxic effects. Saint Vitus’s dance was a northern European variant with many of the same symptoms, cured in the same way, but with a more religious cast.

  Regardless of cause, the recommended treatment was a frenetically rapid, deliriously dizzying, whirling dance, to be continued to the point of physical exhaustion and mental rejuvenation. Dancing was presumed to remove the spiders’ poison (in the south) or the demon from the soul (in the north). Tens, or hundreds, or even thousands of people would participate jointly in a group epidemic and cure that would last continuously for hours, days, or even weeks. Alcohol was used in large quantities and sleep deprivation also played a role. As is also true today, it was often difficult to separate the side effects of the treatment from the symptoms of the illness. People would behave strangely, tear off clothing, scream, squeal, laugh or weep uncontrollably, be openly sexual, and make animal gestures. Unlike the treatments used in most fads (e.g., bleeding, purging, mercury poisoning), the dance frenzy may have had beneficial effects mediated by the vigorous physical exercise, catharsis, distraction, and group cohesion.