Allen Frances Seeks the “Middle Way”

On January 15, 2016, Allen Frances, MD, Professor Emeritus at Duke University, published an article on the Huffington Post.  The piece is titled:  Psychiatric Medicines Are Not All Good or All Bad.

The article denounces both the “medication fanatics” who prescribe psychiatric drugs when they are not needed, and the “die-hard anti-medication crusaders who try to persuade everyone, including those who really need meds, that they are globally unhelpful and globally harmful.”

Dr. Frances advocates a middle ground in which people who need psychiatric drugs get them, and people who don’t, don’t.  On the face of it, this would seem a fairly non-contentious matter, but Dr. Frances’s path to this conclusion is fraught with problems which in my view warrant discussion.

Mental Illness or Transient Emotional Distress

Here are some quotes from the article, interspersed with my comments.

“To take or not to take psychiatric medicine? That is the question.

Far too many people answer yes and take meds they don’t really need for problems that would get better just with the passage of time and/or brief counseling.

More than 20 percent of Americans are on at least one psychotropic drug (sometimes several), too often not for real mental disorders, but for transient emotional distress or for the demoralization that comes from difficult life circumstances.”

In the third paragraph above, Dr. Frances is drawing a sharp line between “real mental disorders” on the one hand, and “transient emotional distress or…the demoralization that comes from difficult life circumstances” on the other.

Here again, apart from the implication that “mental disorders” have some ontological reality, this distinction has a ring of reasonableness, but in fact, within the parameters of psychiatry’s own classification system (the DSM), there is no reliable way to draw this distinction.

To illustrate this, let’s consider “major depressive disorder,” one of psychiatry’s so-called illnesses.  Presumably, Dr. Frances would consider this a “real mental disorder.”

Here are the DSM-5 diagnostic criteria for major depressive disorder:

“A.  Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly attributable to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.  (Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with out a specific plan, or a suicide attempt or a specific plan for committing suicide.

B.  The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C.  The episode is not attributable to the physiological effects of a substance or to another medical condition.

Note:  Criteria A-C represent a major depressive episode.

Note:  Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered.  This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.

D.  The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

E.  There has never been a manic episode or a hypomanic episode.

Note:  This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.” (p 160-161)

So let’s go through the nine “symptoms” and see how we might manage to distinguish those that are indicative of “real mental disorders” from those that should more properly be considered “transient emotional distress or…the demoralization that comes from difficult life circumstances.”  And to concretize our deliberations, let’s invent a “patient”:  a 65-year-old women (I’ll call her Alice), whose husband of 45 years has, out of the blue, informed her that he is leaving her for his 35-year-old secretary who is pregnant with his child, and who really understands him.  And let’s say that Alice is feeling pretty down – in fact, she’s devastated.

“Symptom” # 1.  Alice meets the requirements of symptom # 1.  She has been feeling sad, empty, and hopeless since her husband’s revelation three weeks earlier, and she is frequently tearful.

But what’s particularly noteworthy here is that there is no way to inject into one’s considerations of “symptom” # 1 any information about Alice’s husband’s infidelity or his decision to abandon her.  This was Robert Spitzer’s “great contribution” to psychiatry:  focusing on problems of thinking, feeling, and behaving regardless of the sources of these problems.  It was this honing in on the phenomena presented  that was supposed to lift psychiatry out of the stone-age of psychosocial speculation, and place it on a truly objective and scientific basis.  And this preoccupation with the phenomena, and the utter disregard for the obvious underlying causes, was slavishly echoed in DSM-IV and DSM-5.

It is obvious that Alice is depressed and demoralized because of the “difficult life circumstances” in which she finds herself. But it is equally obvious that she meets the criteria for “symptom” # 1.

In addition, the minimum duration of two weeks makes a mockery of Dr. Frances’s notion of distinguishing real “mental disorders” from “transient emotional distress.”  In the APA’s “diagnostic” system, depression lasting more than two weeks passes the duration test for major depressive disorder.  This, incidentally, is the same duration requirement specified in DSM-III and in Dr. Frances’s own DSM-IV.

 “Symptom” # 2.  Here again, without a doubt, Alice meets the requirements. She’s an old-fashioned lady, and her husband and family had been the center of her world.  Not surprisingly, she’s not getting a lot of joy out of life, she doesn’t feel inclined to go out socializing, or engaging in other activities.

If anyone were to ask her why she’s feeling down, she would, if she felt like confiding in the questioner, explain what had transpired three weeks earlier, and by any ordinary standards, this explanation would be accepted as the true proximate cause of her distress, inactivity, and lethargy. But in the world of psychiatry, none of this matters.  As with “symptom” # 1, there is no way to inject into “symptom” # 2 any consideration of “difficult life circumstances.”

Alice has been markedly despondent and noticeably lethargic and anhedonic for three weeks, so at this point she’s batting two out of two. And remember, she only needs five positive symptoms to have the “illness major depressive disorder.”  So let’s forge on.

“Symptom” # 3.  Significant weight loss or weight gain or decrease or increase in appetite.

Note the proliferation of “ors” – a standard feature of psychiatric “diagnoses.”  So we have four ways in which Alice can “score” on “symptom” #3:  gaining weight (5% per month); losing weight (5% per month); reduced appetite; or increased appetite. And we need only one of these to confirm this “symptom.”

Alice’s husband, let’s call him George, left her three weeks ago. At that point, her weight had been, say 125 pounds.  Since then, she hasn’t been eating too well.  She can’t be bothered to cook very much, and she has lost 5 pounds.  Five pounds over three weeks is the equivalent of about 6 ½ pounds a month, slightly more than a 5% loss in weight.

Bingo!  Alice scores positive on “symptom” # 3.  And readers, please note.  The decrease in appetite doesn’t have to be every day.  The wording in DSM-5 (and incidentally in DSM-IV) is nearly every day.  What does “nearly” mean?  Five days a week?  Four days a week?

And remember, we can’t dismiss Alice’s symptoms as “transient” because they’ve been present for more than two weeks!

“Symptom” # 4.  Insomnia or hypersomnia nearly every day.

One thing that psychiatrists do well is weave their net tight, and in this respect, “symptom” # 4 is a doozy.  Here’s the DSM-5 text on this “symptom” (p 163):

“Sleep disturbance may take the form of either difficulty sleeping or sleeping excessively (Criterion A4).  When insomnia is present, it typically takes the form of middle insomnia (i.e.,  waking up during the night and then having difficulty returning to sleep) or terminal insomnia (i.e., waking too early and being unable to return to sleep).  Initial insomnia (i.e., difficulty falling asleep) may also occur.  Individuals who present with over-sleeping (hypersomnia) may experience prolonged sleep episodes at night or increased daytime sleep.”

So, and readers please be warned, this is very abstruse, insomnia can occur at the beginning of the night, or the middle of the night, or towards the end of the night, and hypersomnia can occur during the night or during the day.  So that pretty much covers it.

As mentioned earlier, Alice has been married to George for 45 years.  In all of that time, apart from three obstetrical confinements, she has never slept alone.  The marital bed, which for more than two-thirds of her life had been a place of comfort, solace, safety, and joy, is now a barren and desolate cave, redolent with the aura of betrayal, abandonment, and loss.  She hears house noises that she never before noticed, and the sides of the bed feel cold and foreboding.  So she tosses back and forth, and watches the hours pass on the digital clock.

And then, every few days, utterly spent from the lack of sleep, she crashes on the couch and sleeps for twenty-four hours straight through.

So she has insomnia or hypersomnia nearly every day.

Four out of four.  One more “symptom” and she “has” major depressive disorder.

And with regards to Dr. Frances’s call to distinguish between “real mental disorders” and “transient emotional distress or for the demoralization that comes from difficult life circumstances,” note that as with the earlier “symptoms,” there is no way to register such distinctions.  There is no way within the DSM criteria to acknowledge that Alice’s insomnia or hypersomnia – or any of the other so-called symptoms – are nothing more or less than the result of a truly devastating life event.

Rather than belabor the matter unnecessarily with regards to “symptoms” 5-9, perhaps it is sufficient to note that all of the points made above concerning “symptoms” 1-4 apply also to the latter group.  Alice’s movements are slowed, her energy level is low, she wonders if George’s betrayal was somehow her fault, she is experiencing difficulty making decisions, and she has fleeting thoughts that life isn’t worth living.

So, by the APA’s own standards, Alice has major depressive disorder.  But she also has what Dr. Frances calls “the demoralization that comes from difficult life circumstances.”  And to clarify the invalidity of Dr. Frances’s distinction, it should be noted that the APA specifically asserts that the latter does not and should not constitute an exclusion factor if the criteria for the former are met.  The passage in question is the second “note” between criterions C and D:

“Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) ;may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A. which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered.  This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.”

So, what’s being said here, if we apply it to Alice, is that even if her despondency, lethargy, insomnia, etc., are “understandable” and “appropriate” given her circumstances, the assignment of a “diagnosis” of major depressive disorder should still be “carefully considered.”  But the only way to carefully consider a diagnosis of major depressive disorder is by comparing the individual’s presentation with the nine so-called symptoms.  And there is nothing in any of the nine items that takes cognizance of the reasons a person might be depressed or anxious or inattentive or whatever.  Indeed, this institutionalized indifference to underlying causes and precipitating factors is one of the primary criticisms directed against psychiatry, and to which psychiatry has, in turn, been utterly deaf.

So, to put it briefly, Dr. Frances’s exhortation to distinguish between “real mental disorders” and “the demoralization that comes from difficult life circumstances” is meaningless.  Dr. Frances was a key player in the creation and promotion of a facile checklist system of “diagnosis,” that systematically excluded any consideration of the real psychosocial causes of the problems involved.  Now, as the inevitable and eminently foreseeable consequences of this travesty are being exposed in clear relief, Dr. Frances seeks to reintroduce a consideration of these causes, but without repudiating the spurious medicalizing pigeonholes, and without acknowledging his own role in their creation and promotion.

. . . . . 

Here’s another quote from Dr. Frances’s paper:

“Meds that are very helpful for clear-cut psychiatric disorders usually do more harm than good when used for the everyday difficulties that life throws at us.”

Here again, we see the implied assertion that it is possible to distinguish between “clear-cut psychiatric disorders” and the “difficulties that life throws at us.”  In reality, every “symptom” listed in the APA’s catalog of labels can be readily conceptualized, understood, and addressed as a response to difficulties, or sub-optimal situations, in which people find themselves.  The notion that an individual who scores five out of nine, or three out of six, or four out of ten, on one or other of the APA’s facile check lists, has an illness, is an entirely arbitrary assertion.  Psychiatry has never proven this assertion with regards to any of its so-called diagnoses.  They simply state it to be so.  The fiction embedded in the DSM and in psychiatric practice world-wide is that every conceivable human problem of thinking, feeling, and/or behaving that crosses arbitrary and intrinsically vague criteria of severity, frequency, and duration is an illness, which warrants psychiatric “treatment.”  This “treatment” almost invariably consists of drugs, or high-voltage electric shocks to the brain.

. . . . .

“When prescribed loosely, meds provide little benefit, risk harmful side effects, distract attention from solving the real life problems, and reduce people’s trust in their own resilience and the help they can receive from family and other social supports.”

This is a particularly interesting sentence, in that, with one small amendment, it expresses almost the entire anti-psychiatry position:

Psychiatry as it is practiced in most parts of the world today provides little benefit, risks harmful side effects, distracts attention from solving the real life problems, and reduces people’s trust in their own resilience and the help they can receive from family and other social supports.

. . . . . 

The Undertreated “Mentally Ill” Individuals 

“But there is another side of the equation. Far too many people who need drugs don’t take them — either because treatment is unavailable or because they don’t realize or accept the fact that they need it.”

This has been a common theme within pharma-psychiatry for the past five years or so:  the untold millions of mentally ill people languishing despondently without appropriate treatment.

Dr. Frances provides no reference to support this claim, but that’s not too serious a deficiency, in that pharma-psychiatry has in recent years produced several demographic studies showing that the number of people who “have” a particular “mental illness” routinely exceeds the number of people who are receiving “treatment” for this particular “illness.”

But how do we know that the individuals concerned have the “illness”?  There is only one possible answer to this question:  because they meet the DSM criteria for that particular “diagnosis.”

So Dr. Frances is apparently willing to rely implicitly on the validity and reliability of the DSM criteria when bemoaning the plight of the languishing untreated millions, but seeks to establish transience and life circumstances exclusions from the same criteria when striving to exculpate psychiatry from the charge of wholesale drug pushing.

Or to put the matter more simply:  how does Dr. Frances know that the languishing millions have real “mental illnesses”?  Perhaps their distress is simply a reflection of “the demoralization that comes from difficult life circumstances,” and they would “get better just with the passage of time and/or brief counseling.”

The fact is that psychiatry’s agenda is – and for at least the past fifty years has been – to widen its diagnostic net, and to get as many people into “treatment” as possible. To this end, psychiatry has fabricated an invalid, hopelessly vague “diagnostic” system into which almost any person experiencing even the slightest distress or problem from whatever cause can be readily shoe-horned.  This is not an accident.  It is clearly evident in virtually every facet of psychiatry, including its present push for early intervention for depression, social awkwardness, unusual thinking patterns, inattentiveness, etc… And in this regard, it is noteworthy that Dr. Frances’s own DSM-IV was a major development in these endeavors.  For Dr. Frances to seek to distance himself now from the rampant drug-pushing that characterizes his chosen profession is disingenuous at the least.

. . . . .

“So we are trapped in the cruel, dumb, and sometimes tragic paradox that the wrong people often take meds, while the right ones don’t.

This terrible situation has many causes that have been discussed already in previous blogs. Our focus here will be on what has been a futile and harmful struggle between two different “one glove fits all” mentalities.

On one side are medication fanatics — some of whom are psychiatrists but also many primary doctors who prescribe 80% of psych meds.

On the opposing side are die-hard anti-medication crusaders who try to persuade everyone, including those who really need meds, that they are globally unhelpful and globally harmful.”

So, Dr. Frances tells us that we are “trapped” in the situation of over-drugging some people, while under-drugging others.  This “tragic paradox” has many causes, but the cause on which Dr. Frances is focusing here is the futile and harmful struggle between the “medication fanatics” (most of whom, incidentally, are GP’s!) and the “die-hard anti-medication crusaders who try to persuade everyone, including those who really need meds, that they are globally unhelpful and globally harmful.”

Well this is all quite a leap, but let’s see if we can disentangle any coherent threads.

Dr. Frances asserts that “we” are trapped in this tragic paradox.  By “we,” he perhaps means psychiatry, or maybe all humanity.  It’s not clear.  But let’s initially assume that he means psychiatry, at which point it becomes obvious that the statement is false.  Psychiatry is not in any sense trapped in any of this.  Rather, organized psychiatry is exulting in the success of its burgeoning influence, and has employed tawdry PR practices to push the expansionist balloon to ever increasing limits.  Renée Binder, MD, is the President of the APA.  In her list of top ten accomplishments by the APA in 2015, she cites the development of early intervention programs with schools, judges, employers, and “faith-based leaders.”  She also cites “Increasing access to care for our patients through tele psychiatry.”

But if by “trapped” Dr. Frances is referring to those millions who were lured into psychiatry’s web of drug dependence by the “incurable disease” hoax, and who now find themselves unable to quit, then of course Dr. Frances is correct.  These individuals are indeed trapped.  Or if Dr. Frances is referring to those even more misfortunate people who are incarcerated without trial in psychiatry’s so-called hospitals, and forcibly drugged and shocked, then again, Dr. Frances is correct:  these people are indeed trapped.

The proximate cause of the rampant drugging has been psychiatry’s expansionist agenda; and the mechanisms that facilitated this expansion were the unabashed invention of new “illnesses,” the inherent vagueness of the “diagnostic” criteria, and the deliberate exclusion of any consideration of psychosocial causative factors.

And with regards to the “die-hard anti-medication crusaders who try to persuade everyone, including those who really need meds, that they are globally unhelpful and globally harmful,” I can only say that I haven’t encountered many such individuals within the anti-psychiatry community.  In fact, the general stance that I have perceived within this community towards people who choose to take psychiatric drugs is one of concern, coupled with respect for the right of each individual to make his or her own decisions on these matters.  There is wide condemnation, however, within this community of psychiatry’s almost universal practice of inducing people to take drugs under the pretense that they are suffering from incurable illnesses, for which they need the drugs to maintain “remission.”  Within the anti-psychiatry movement, this practice is rightly considered a hoax and a travesty of medical practice.

. . . . . 

At this point in his article, Dr. Frances inserts what I assume is a copy of a letter that he had received from Virgil Stucker, MBA, in which Virgil calls for a ” middle ground between opposing wholesale beliefs that psychiatric medicine is all good or all bad.”

Dr. Frances echoes this theme, and then:

“I used to be more enthusiastic about the possibility of psychosocial treatment replacing meds, or markedly reducing the doses need, even in the most severely ill. In the mid 1980’s, I helped plan and conduct a large study that compared three medication strategies in the continuation phase of treatment for people who had recovered from a psychotic episode: 1) usual dose; 2) one fifth dose, and; 3) placebo. All groups also received intense family support in the community. Some people did fine with less or no meds. But the catastrophes remain unforgettable.”

Here again, Dr. Frances provides no references.  He has been a prolific writer over the years, and it is entirely possible that he has in the past advocated replacing psychiatric drugs with psychosocial interventions, but I’ve never come across this theme in his writings.  If he would care to provide references, I’d be happy to take a look.

Similarly with regards to the study that he helped plan and conduct in the mid-80’s.  I searched the PubMed list of his publications from 1980 to 1990, but could find nothing that seemed to match the description Dr. Frances provides here.  Again, I’d be happy to take a look at the study if Dr. Frances will provide the reference.

It’s difficult to offer any comment on Dr. Frances’s reminiscence that “the catastrophes remain unforgettable.”  We’ve all seen catastrophes in this business.  Most of the ones I’ve seen have been the direct result of the toxicity and disempowerment that are an integral part of psychiatry’s “treatments.”

But subjective assessments, as Dr. Frances should know, are notoriously unreliable.  Which is why, in complex matters in which we have a personal stake, it is better to rely on science.  Robert Whitaker, of MIA, wrote a response to Dr. Frances’s paper on January 27, and on the subject of science vs. subjective impressions, he wrote:

“In his Huffington Post blog, Allen Frances argues for prescribing practices that he describes as a middle way. Prescribe them to the right patients, because for these patients the drugs can be life-saving, but curb the overuse and polypharmacy that can prove harmful to so many, particularly for those who have ordinary problems, as opposed to real psychiatric disorders. As you can see in his blog, he also sees this middle way as informed by his own clinical experience.

But, here’s the rub: the ‘middle way’ he describes is not an evidence-based practice. It is not a practice that is informed by science that tells of drugs that induce a dopamine supersensitivity, which may increase the biological vulnerability to psychosis; or of science that tells of drugs that shrink the brain, with this shrinkage associated with worse negative symptoms and functional impairment; or of animal research that tells of why antipsychotics fail over time; or of science that tells of much higher recovery rates over the long term for unmedicated patients. Those are drug effects that are not immediately visible to the clinician, but rather are made known through the illuminating powers of science, and they pertain to those with ‘clear cut psychiatric disorders’ too.”

. . . . .

Back to Dr. Frances’s paper, in which he concludes:

“There will never be one right decision on psychiatric medicine that applies to everyone. In the US, there has been far too much acrimony and far too little cooperation among providers, families, and disaffected users — as if there were one right answer. This results in bad treatment and ineffective advocacy for the mentally ill. Mental health care in Europe is in much better shape because no such opposition hinders cooperative efforts in clinical decision making or political advocacy.”

The meaning here isn’t entirely clear.  Dr. Frances seems to be saying that acrimony and lack of cooperation between psychiatrists and non-compliant clients results in “bad treatment” and “ineffective advocacy.”  Earlier in his paper, he stressed that there were two sides to the coin:  the “medication fanatics” and the “die-hard anti-medication crusaders.”  But now the onus seems to be sliding towards the “disaffected users.”  And this is confirmed in the next sentence:

“Mental health care in Europe is in much better shape because no such opposition hinders cooperative efforts in clinical decision making or political advocacy.” [Emphasis added]

Note the word opposition; not disagreement; not conflicting views; not differences of opinion; but opposition.

And what kind of opposition?  Opposition that “hinders cooperative efforts in clinical decision making or political advocacy.”

Now, as I’ve said before, Dr. Frances’s writing isn’t always entirely clear, but I can’t find any interpretation of this last sentence other than:  things are much better in Europe because they don’t have an anti-psychiatry movement which challenges psychiatrists’ clinical decision making, and which undermines psychiatry’s efforts to lobby politicians on matters pertaining to psychiatry’s agenda.

So, while Dr. Frances began by decrying two villains:  the “medication fanatics” and the “die-hard anti-medication crusaders,” in the final analysis, he seems to have settled on just one:  the antipsychiatry movement whose members have the audacity to challenge psychiatrists’ clinical decision making, and pharma-funded political lobbying.

So much for his pursuit of a middle ground!

. . . . . 

Incidentally, on a factual note, I don’t think the situation in Europe is any more or less favorable to psychiatric hegemony than is the case here in the US.  I believe that in all parts of the world, the psychiatric hoax is widely accepted, and psychiatric “treatments” are widely practiced.  But everywhere there is “a stirring in the hills.”  A stirring whose growing energy will one day sweep psychiatry and all its fraudulent works and pomps into the great maw of historical obscurity.  And people will ask:  How could something so fundamentally flawed and rotten have been accepted and promoted by civilized people for so long?  And people will dig up the writings of psychiatrists like Dr. Frances, and they will shake their heads in wonder and horror that apparently educated people could lend their support to such a destructive and far-reaching hoax.