PCBH Corner #49: ‘Saving Normal,’ w/ Allen Frances, MD — Transcript

Dr. Allen Frances discusses overdiagnosis in psychiatry, the impact of DSM changes, and challenges in primary care psychiatric treatment.

Key Takeaways

Overdiagnosis in psychiatry can cause more harm than good, especially when done hastily in primary care.
DSM revisions have unintentionally contributed to diagnostic inflation and increased medication use.
Primary care providers need more training, time, and behavioral health support to improve psychiatric diagnosis.
Psychotherapy and normalization should be prioritized over immediate pharmacological treatment.
Careful evaluation over multiple visits is essential to avoid premature and incorrect psychiatric diagnoses.

Summary

Dr. Allen Frances reflects on his skepticism about overdiagnosis in psychiatry since his residency in the late 1960s.
He authored a 1982 paper titled 'No Treatment as the Treatment of Choice,' emphasizing cautious diagnosis.
Frances was involved in the development of DSM-III and DSM-IV and hoped for conservative diagnostic criteria.
He critiques DSM-5 for worsening overdiagnosis and its ripple effects, especially in primary care.
Primary care prescribes 80% of psychiatric medications, making it the main arena for psychiatric care.
Overdiagnosis leads to unnecessary medication, lifelong labeling, and potential harm to patients.
Primary care faces challenges like limited time, lack of behavioral health integration, and insufficient training.
Frances advises careful, conservative diagnosis and ruling out medical causes before psychiatric labeling.
He highlights the importance of psychotherapy and normalization over quick medication prescriptions.
Special attention is needed for vulnerable populations like children and the elderly to avoid misdiagnosis.

Full Transcript — Download SRT & Markdown

Speaker A

All right, welcome back to another PCBH Corner. I'm so excited to be joined by Alan Francis, who probably many know, who has done a lot of different writings. I got to know him by his book Saving Normal, which I'm hoping to talk a little bit about.

Speaker A

talk a little bit about um and I know we're kind of on a time we want to make the most use of this so Dr Francis I wanted to jump in um and my first question is probably a

Speaker A

And I know we're kind of on a time limit. We want to make the most use of this. So, Dr. Francis, I wanted to jump in, and my first question is probably a big question that I'm excited to see where your mind goes.

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might be heading as a field of Psychiatry or psychology and particularly with diagnosing uh then we might be heading to a place that is getting to be unworkable that we might be going down a path that we don't

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You know, after reading that book Saving Normal, throughout this I kept asking, like, when was the moment that you realized we might be getting this wrong? Or we might be heading, as a field of psychiatry or psychology, and particularly with diagnosing, that we might be heading to a place that is getting to be unworkable? That we might be going down a path that we don't necessarily want to be going down? When was that moment that you realized that?

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period of time warehousing them and um in 1982 I wrote a paper called um no treatment as the treatment of choice so that even though I was part of dsm3 I was always sort of the skeptic on uh the

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Well, I was a resident in the late '60s, and we were way overdiagnosing schizophrenia and giving people enormous doses of antipsychotics, keeping them in the hospital for a really long period of time, warehousing them.

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don't need so I've been a kind of cautious I I have great respect for diagnosis and I've spent a lot of my life working on it it's done well done accurately it it's life enhancing it's not as life-saving but overdone and done

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And in 1982, I wrote a paper called "No Treatment as the Treatment of Choice." So, even though I was part of DSM-III, I was always sort of the skeptic on the overuse of psychiatric diagnosis. I always felt we should underdiagnose rather than overdiagnose.

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development of the dsm-4 about what your Hope was for the DSM for and then the Rippling out effect that just was unintended and then obviously the DSM five unfortunately maybe having that even worsen for people working in primary care which as we said is the

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It's always easy to increase the severity of a diagnosis. Once a person gets a label, it haunts them for life. That overdiagnosis leads to tons of medication that people don't need.

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um to not continue to maybe uh have this tendency of over diagnosing I think Primary Care is really the main arena for psychiatric care so 80 of psychiatric medications are given in primary care only 20 percent of psychiatric medications are given by

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So, I've been kind of cautious. I have great respect for diagnosis, and I've spent a lot of my life working on it. It's done well, done accurately, it's life-enhancing. It's not life-saving, but overdone and done carelessly, a diagnosis can lead to as much tragedy as the underlying disorder.

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specialty Psychiatry so I I couldn't emphasize enough how important is the work of the people that you're you're helping to uh to educate um I think that Primary Care is also the hardest Place diagnosis it's the hardest Place partly

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And so, my emphasis is on cautious, careful, conservative diagnosis.

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patient and they have to get the patient out happy and the easiest way to get the patient out happy is to write a script the hardest because most primary care practices don't have Behavioral Health components your people are doing a very

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So, let me ask you this, because you talk about this in the book when you oversaw the development of the DSM-IV about what your hope was for the DSM-IV, and then the rippling out effect that just was unintended, and then obviously the DSM-5, unfortunately, maybe having that even worsen.

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patients who've gotten a psychiatric diagnosis who didn't need one many of those patients got that psychiatric diagnosis in Primary Care the quick and careless default psychiatric diagnoses when there's medical uncertainty is is a global problem in our system that if the

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For people working in primary care, which, as we said, is the audience that largely works in it, primary care, as you know, is fast-paced. It is where the majority of people that are receiving psychotropics get prescribed. A lot of diagnoses are rendered very quickly.

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my first thought with anyone who has a fresh psychiatric symptom who's on medication particularly in the elderly is it's a medication side effects much more likely for an elderly person to have an onset a late onset of medication-induced psychiatric symptoms

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What advice would you give people that are working in primary care to not continue to maybe have this tendency of overdiagnosing?

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because so many people are taking medic drugs from medical problems that that cause psychiatric symptoms and because medical problems become more and more common as people age Dr Francis I love you saying because this is something we talk about with both our psychology

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I think primary care is really the main arena for psychiatric care. So, 80% of psychiatric medications are given in primary care. Only 20% of psychiatric medications are given by psychiatrists.

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almost the algorithm that I'm going through to make sure I'm ruling out what is the more likely thing rather than a psychiatric diagnosis of what's going on I love that you said that that's great so for you it seems like the suggestions

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And particularly benzodiazepines, 90% of benzodiazepines are given in primary care. 80% of antidepressants, 60% of antipsychotics, and 50% of stimulants are given in primary care.

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and the elderly so in kids there's a huge tendency to weigh over diagnose so many of the problems in in kids are due to acute stressors environmental um difficulties family difficulties school bullying all sorts of problems that kids

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So, really, primary care is a much more important arena for psychiatry than specialty psychiatry. So, I couldn't emphasize enough how important the work of the people that you're helping to educate is.

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because they get medication they don't need and they get the label for often for life that will do much more harm than good and similarly with the elderly the the idea that most problems in the elderly are caused by Nuance that

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I think that primary care is also the hardest place for diagnosis. It's the hardest place partly because there's the least time. It's the hardest place because the primary care docs themselves usually have not had much training.

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diagnosing taking time you can't do an evaluation in 15 minutes or 45 minutes you can't do an evaluation one visit that very often you have to take the time of seeing someone over a number of visits before you can make the diagnosis

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It's the hardest place because they only have 15 minutes or less, and they have to fill out records for each patient, and they have to get the patient out happy.

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make Maybe we take years of medication and visits it's expensive to over diagnose and forcing diagnoses early forces over diagnosis and over treatment it would be much smarter if they paid more for valuation visits so you wouldn't have to have a diagnosis we're

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And the easiest way to get the patient out happy is to write a script. The hardest because most primary care practices don't have behavioral health components.

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psychiatric problems the use of advice normalization Psychotherapy is much cheaper in the long run than starting a pill it's very cheap and easy to store the pill in a first visit but then the person may be taking that for years or decades getting

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Your people are doing a very important service. In many practices, that service is just completely unavailable.

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the the research that's coming out a lot from Europe um that thankfully is starting to infiltrate some of our poignant Care Resources like up to date about watchful waiting right which really is almost kind of like active waiting as you said

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It's the hardest because there's no harder place to make a diagnosis than in primary care. I've seen hundreds and hundreds of patients, maybe thousands of patients, who've gotten a psychiatric diagnosis who didn't need one.

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um drug response rate may be 40 to 50 percent so you're getting like a four to one advantage to active medication with real psychiatric problems for mild psychiatric problems Placebo response rates over 50 percent the active drug response rate may be 70 so you're

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Many of those patients got that psychiatric diagnosis in primary care. The quick and careless default psychiatric diagnoses when there's medical uncertainty is a global problem in our system.

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office with the medication the odds are at least half they're going to get better in two weeks without the medication but once they take the pill they will miss attribute the benefit to the pill rather than the passage of time

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That if the doc can't explain it on medical grounds, the assumption is always, "Well, you must have, it must be in your head. It must be a psychiatric problem."

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that it was a relapse of the original problem not the withdrawal effect of the medication so it confirms the idea that the pill is crucial to their existence so you get many people come to the office with a problem that would get

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On the other side, very many problems that look psychiatric are really medication or medically induced.

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years later when they try to stop the pill it may have withdrawal effects and when they they feel symptoms again they'll say aha I'm sick the pill made me well I have to stay on the pill so many people stay on pills for years or

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My first thought with anyone who has a fresh psychiatric symptom who's on medication, particularly in the elderly, is it's a medication side effect.

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for the placebo effect to kick in because all this attention will help people get better on their own time will help them get better on their own and then you're not forcing them into years and years of treatment

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Much more likely for an elderly person to have an onset, a late onset of medication-induced psychiatric symptoms than for it to be a primary psychiatric disorder.

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wrote a blog post about this particularly with the guidelines that came out about potentially screening uh children for anxiety about what the ripple effect of that's going to be what do you make of a lot of these guidelines

Speaker A

And my second thought is going to be medical problems. I will be thinking of a primary psychiatric disorder as only a third possibility in anyone, you know, past youth.

Speaker A

is recommended uh these are the guidelines that are coming out but make sure that we don't use it in a way that continues to go down this road that we know isn't workable I think a lot of the

Speaker A

Because so many people are taking medic drugs from medical problems that cause psychiatric symptoms, and because medical problems become more and more common as people age.

Speaker A

doing and expanding their diagnosis they'll never understand the risks and unintended consequences they never work in Primary Care no expert in Psychiatry has spent a lot of time very few have spent a lot of time in primary care they decide Things based on

Speaker A

Dr. Francis, I love you saying that because this is something we talk about with both our psychology trainees and our family medicine residents: the importance of understanding base rates about what most likely is producing something or being seen.

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disorder in a expert Clinic is going to be very high the true base rate of a disorder in people presenting in Primary Care is going to be much lower you make many more errors false positive diagnoses and Primary Care with the same

Speaker A

And I love how you've been saying that, like when I start to see symptoms at a certain age, this is almost the algorithm that I'm going through to make sure I'm ruling out what is the more likely thing rather than a psychiatric diagnosis of what's going on.

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thing because it leads to labeling the kid stigmatizing the kids and worst of all often giving a medication so I I'm very much I'm very much for screening in high-risk populations gotcha gotcha pregnant women women who've just delivered kids with a high

Speaker A

I love that you said that. That's great. So, for you, it seems like the suggestion for people working in primary care is maybe slow down a little bit, don't give this diagnosis automatically a lot.

Speaker A

to make sure that she's not going to get a a depression or a psychosis that may be very harmful to her very harmful to the child and to their relationship high-risk population High base rate of problems terrible consequences all make

Speaker A

I mean, I think that in the two age groups in terms of base group rates where diagnoses are most often wrong are kids and the elderly.

Speaker A

of kids who are going to be mislabeled as having mental health disorders and the benefits to the small number who may be identified properly do not outweigh the tremendous risk to the large number are going to be misidentified that the

Speaker A

So, in kids, there's a huge tendency to overdiagnose. So many of the problems in kids are due to acute stressors, environmental difficulties, family difficulties, school bullying, all sorts of problems that kids have get translated into, "Oh, they have a severe psychiatric problem," where very often they'll be outgrowing it either because they've outgrown the situation or because life experience has made them less shy or less impulsive.

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psychiatric problems so we had 600 000 people in jail or living on the streets because we don't provide them with psychiatric care we're not taking care of they're not enough child clinicians in America to take care of the existing

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And that overdiagnosing in kids is particularly bad because they get medication they don't need, and they get the label often for life that will do much more harm than good.

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illnesses who desperately need help and we can't help them but if we add more kids they'll they'll become even more lost than the noise you know it was something that I love that you wrote about in the book and you wrote written

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And similarly, with the elderly, the idea that most problems in the elderly are caused by a nuanced psychiatric disorder is just wrong.

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people don't like this term but this worried well kind of aspect and we're providing care to people that it's like there's a lot of people out there that do have these very impactful impairing uh concerns and pathologies and the care

Speaker A

Most psychiatric problems, they always are caused by medication or medical side effect of the illness.

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might need it uh in my benefits that's a very clear so in the U.S first of all any any study that discusses the rate of psychiatric disorder in the general population misstates the actual rate the studies are all done by telephone by non

Speaker A

And so, being aware of the fact that not everything that looks like a primary psychiatric problem is a primary psychiatric problem, underdiagnosing, taking time—you can't do an evaluation in 15 minutes or 45 minutes. You can't do an evaluation in one visit.

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care doc or if I'm a psychiatric psychologist working in a primary care saying aha half the population has a disorder that makes me think a high base rate I should have a high index of Suspicion in actual fact most those

Speaker A

Very often, you have to take the time of seeing someone over a number of visits before you can make the diagnosis.

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an upper limit not as an actual rate but most people miss that step the percentage of people in the U.S who are taking a psychotropic medication is 20 one out of every five that's a ridiculously high number amen absolutely

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And the trouble with the insurance system is it tends to force the diagnosis well before a person could reasonably, carefully make one.

Speaker A

15 studies in 10 different countries with maybe tens of millions of kids and the most consistent finding in all Psychiatry is that the um birth date of a child is the best predictor of whether they get an ADHD diagnosis that the

Speaker A

This is crazy for the insurance companies because what happens is that people jump to diagnoses and to treatments that will make... Maybe we take years of medication and visits. It's expensive to overdiagnose.

Speaker A

way you can understand this is that we're taking immaturity the kid being the youngest kid in the class and giving it a mental disorder label and saying they have ADHD and how do we interpret why this happens well if you have big

Speaker A

And forcing diagnoses early forces overdiagnosis and overtreatment. It would be much smarter if they paid more for evaluation visits so you wouldn't have to have a diagnosis.

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least mature especially boys who mature later and so those parents oh my kid has ADHD no the kid really is just the youngest kid in the class but we're taking an educational problem that if you have kids who are a year different

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We're evaluating an individual very often over three or four visits, evaluation visits, and you realize that the psychiatric problem either doesn't exist at all or is transient and that you won't need medication.

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mental patient and then often enough giving him Ritalin as a solution and and you think about the Rippling out effect of that as you said like how that individual then starts to see themselves within their context and then you know

Speaker A

you add this is the thing that uh you know my mind has found so fascinating over the past three years with covid that has come on it's like you know if you wanted a recipe for depression and ADHD symptoms it's covid right I mean

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about you know the scare and the the explosion of diagnoses that are that are going on now it's like we really probably should just pause for over a couple years to make sure we know what we're dealing with even from covet and

Speaker A

those contextual variables that are going on I I I think it's no brainer that covet itself can cause psychiatric symptoms I think it's a no-brainer that being isolated at home and often in very difficult conditions the stress of that

Speaker A

can cause um psychiatric symptoms so it's no surprise that psychiatric symptoms have increased and that some of those symptoms represent real mental disorder but we should also realize that not every human distress is a mental disorder if we have through Evolution

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certain emotional reactions of anxiety and depression that come as a realistic response to external stressors and that labeling everyone who felt anxious or sad or socially isolated during covert as mentally ill misses the fact that this is a social problem it's not a mental

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sort of problem individual and Psychiatry is not the cure for every problem every emotional understand not there's not a pill for every problem that Humanity faces and by medicalizing all emotional distress we often miss the social context the the if

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we wanted to improve the mental health of America most in the shortest period of time it wouldn't be doubling and trembling the number of mental health workers it would be providing a fairer system economically the biggest causes of

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mental illness the external stresses are the most disabling for people or or socioeconomic the U.S spends something like two to three times as much on medical care as the rest of the world the rest of the developed world and we have lousy

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results they're overall in medicine a lot of this has to do with the waste and the corruption in the medical system but it also has to do with the fact we get lousy outcomes why we over invest and invest poorly in

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medical care we under invest in Social programs a social safety net and countries in Europe spend as much total as we do on medical care and social safety programs combined but their ratio is different they have less expenditure

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and Medical Care More on social safety net programs and they get much better outcomes on medical disorders forget Psychiatry on medical disorders maybe 80 percent of outcome in medical and psychiatric problems is due to the social context in which the the problem

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occurs it's caused sometimes and the way it's handled so we we have a great under investment in the U.S in taking care of people into improving their lives a great under investment in Psychological Services in the U.S most parts of the U.S you can't

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find the psychologist you can't get a psychiatrist no availability everyone's taken we don't provide caring services and we over medicalize problems and give way too much in terms of medical treatment medical testing and medical treatment Dr Francis again I I could talk to Dave

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for days with you about this topic and the one last question I wanted to ask before we wrap up because I I found a blog post and I loved how you talked about this and I wanted to see if you

Speaker A

could just expand on this briefly about what you meant about the bug that you wrote about patient-centered versus lab-centered personalized medicine and about how this this this uh uh saying about personalized medicine also kind of goes along with what we're talking about

Speaker A

of kind of over diagnosing and what that is looking at can you talk briefly about the differences between those two and what you would hope the healthcare field would be moving towards one of the unfortunate things about American medicine is that it's a

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for-profit system where uh labels are thrown out less because they have clinical meaning and more because they have marketing appeal so personalized medicine has become the label the last 15 years and the idea is that we're going to really understand the genetics

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of each person in such a way that we'll have a personalized treatment plan that will not be what everyone else is getting but just for you and will be triply expensive and that we do is more personalized than what the next guy does

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so come to us don't go to him uh makes this not just um cynical in terms of money grabbing rather than really caring for people but but also um ironic is that there's no medicine in the world that's less personalized than

Speaker A

ours yeah there's a great cartoon with a doctor uh facing his computer and the patient looking at his back of his head and saying this is American personalized medicine the doctors no longer have time to talk to patients the rush it's

Speaker A

factory labor the doctor's given you know 12 to 15 minutes to complete the visit maybe also write the record if they don't do it during the session they have to do it at night they don't get to know their patients they have huge

Speaker A

panels the doctors are switched they'll never revisit getting to a doctor is the most impersonal thing in the world the call centers that lead to an appointment that are often you know wait on hold for 30 minutes before you get your

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appointment everything about the system in American medicine is impersonal and I think if we had a true personalized medicine it would be that the visits would be longer if we could do one thing that would make Primary Care better it

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would be longer Primary Care visits smaller panels with people who knows get to know their patients we'd have many fewer Specialists and many more primary care doctors the Specialists have controlled medicine in America from the very beginning and so they decide which

Speaker A

um for Specialties get the most money which Specialties get the most emphasis in medical school we have a terrific disproportion of medical students going into specialty training because those are the most powerful departments in any medical school and because the

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reimbursements because they all usually help to control who gets what are very disproportionate with with people who do Specialty Services gain way more than they should be getting procedures and people who do Primary Care getting way too little to spend time with patients

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if we were to do real personalized medicine it won't be some fancy genetic study that results in a hundred thousand dollar a year treatment for a few people that may improve their care real personalized medicine would be spreading

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out to everyone where there's much more time with a primary care doctor and with the people that you're particularly helping to educate the people who work with primary care doctors behavioral health workers that try to bring some personalized medicine into practices

Speaker A

that often lack it otherwise and I loved even in your blog post about how how we introduce ourselves to someone in a waiting room how we you know if we're running late how we acknowledge that and we apologize that becomes this uh

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continuous relationship and really can be healing and is that personalized business I loved uh the last thing I'm going to say is that I've treated people I've always worked in emergency rooms I've treated people for 15 years and had

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no impact on their lives I've seen thousands of patients who are 15 minutes in an emergency room that's something that I don't remember had them come up to me years later and say you know doc you said something you

Speaker A

probably don't remember you said something that changed my life that's an important lesson the lesson in that is that you can never take as routine any meeting with any patient your 15th patient of the day you're tired you want

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to go home it's just oh just on the patient from the patient's point of view meeting you might be the moment that changes their life and you should always be working with every patient with a thought I what can I say now that will

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make a difference you know don't just think about the forms you have to fill out is there something about this person's life and where they're situated what the stresses are if I give them this particular insight about it this

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cognitive reframing this piece of advice will that help change them and I think it doesn't always work or maybe it doesn't even often work but we should always have that excitement with each visit that I can do something that will

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make a difference you know you made my day because I got a full day of clinic right now after this I'm going to be asking myself that every single time I go to see a patient how can I make a

Speaker A

difference in this individual's life so thank you for that Dr Francis I'm gonna put in the uh description of this the link to your book saving normal so people can check that out and do but Dr Francis my grad attitude again for the

Speaker A

work that you've done given us time today cannot express my gratitude enough my gratitude to you and to the people who you're working with because they really are the heart of what's important in Psychiatry these days I appreciate

Speaker A

that I appreciate well thank you again I hope people enjoy this as always please uh you know share this video widely put comments questions where hopefully can get some responses to it but I hope everybody enjoyed this pcph corner and

Speaker A

tune in until next time bye-bye see ya

Topics:Allen FrancesSaving NormalpsychiatryoverdiagnosisDSM-IIIDSM-IVDSM-5primary care psychiatrypsychotropic medicationsmental health diagnosis

Frequently Asked Questions

What is Dr. Allen Frances' main concern about psychiatric diagnosis?

Dr. Frances is concerned about the overdiagnosis of psychiatric disorders, which can lead to unnecessary medication and lifelong labeling that may harm patients.

How does primary care impact psychiatric medication prescribing?

Primary care providers prescribe about 80% of psychiatric medications, often under time constraints and with limited behavioral health support, which can contribute to overdiagnosis and overtreatment.

What advice does Dr. Frances give to primary care providers regarding psychiatric diagnosis?

He advises cautious, conservative diagnosis, ruling out medical causes first, and emphasizes the importance of psychotherapy and normalization over quick medication prescriptions.

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