Allen Frances, "godfather" of DSM-4, on problems with DSM-5 and current mental health care

[HereSince1628]

Last edited Sun Mar 17, 2013, 11:06 AM - Edit history (1)

Dr. Frances chaired the committee that supervised the production of the DSM-IV, this is a transcript of an interview with him conducted by Rob Kall, some time in 2012, the transcript was published at OpEdNews. 3/15/2013.

http://www.opednews.com/articles/1/Transcript-Problems-With-by-Rob-Kall-130315-772.html

In the 5 page transcript he self-identifies as a staunch critic of the soon to be released DSM-5, but, imo, his strongest criticisms in this interview are on how mental health-care, particularly treatment involving medication, is practiced in the US.

No summary of transcript of a half-hour conversation is going to be adequate to capture everything, but his main concerns with the DSM-5 seem to be, that the DSM expands/loosens definitions of illness this extends the pathological range of symptoms into what has previously been considered subclinical and not needing treatment.

Rather than considering some sort of conspiracy by authors of the DSM-5 & pill-pushers, Frances predicts these bad outcomes from the DSM-5 as a consequence of the way mental health-care is currently conducted in the US.

While driven by a desire by the psychiatric industry to catch mental illness early and possibly prevent the damage these illnesses do to the lives of the persons they afflict, he is concerned about a movement toward over-diagnosis and over-medication, particularly of children.

He sees a troubling interaction between pharmaceutical companies and primary care. According to Frances most of the prescriptions written for psychiatric medication occur outside of psychiatry. Primary care physicians (PCPs), mostly without the expertise Frances thinks is necessary are doing most of the prescribing. These PCPs are under pressure to move patients quickly through the exam room, and satisfy their patients' expectations with too-quick diagnoses and prescriptions of psychiatric medications. Frances feels the loosening of diagnosis criteria will result in overdiagnosis, overmedication, and undo harm from medications and social stigma applied to those diagnosed as mentally ill.

[Tobin S.]

1. I sort of agree about primary care physicians

While I think it should be within their power to prescribe psychiatric meds, I think people who are taking psychiatric meds should be in the care of a psychiatrist. I can think of cases where a primary care physician might need to write a prescription for such meds, but he or she shouldn't be the main physician responsible for the care of a psychiatric patient.

[HereSince1628]

2. A couple of thoughts...

Co-payments are higher for specialists, so patients might go to pcp's to save money

The insurers plan for mental health care may not offer much coverage, so patients may be reluctant to use them on symptoms which might turn out to be nothing.

That's a consequence of capital-centric system for health care funding.

In the interview Allen Frances suggests patients seek help from pcp's when symptoms aren't profoundly disruptive. They would probably get to a mental health clinic if their symptoms were profoundly disruptive but when symptoms are not profound patients end up reporting less obvious symptoms. Allen suggests getting such subtle presentation right is some of the most difficult diagnostic work done in psychiatry...pcp's are at a real disadvantage.