Allen Frances Takes on the Over-Prescription of Antidepressants

The prominent psychiatrist explores why antidepressants remain highly overprescribed and offers solutions to the problem.

Ayurdhi Dhar, PhD
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Eminent psychiatrist Allen Frances recently wrote an article exploring the reasons for the over-prescription of antidepressants.

Writing in the HealthWatch Newsletter, Frances explains that industry corruption is no longer the only factor behind the skyrocketing use of antidepressants, given that many of the drugs are now off-patent and therefore less profitable for pharmaceutical companies. Other reasons must be identified if public health advocates are to reduce the harm caused by inappropriate prescriptions.

Doctor Handing Pills Through Laptop.

Despite the growing popularity and usage of antidepressants, research has raised serious doubts concerning their efficacy for depression. Industry corruption has been one of the main reasons behind their continued popularity. Ghostwriting, misleading conclusions, PR campaigns, etc., have all been used to push antidepressants into the market despite concerns about the efficacy and safety of long-term use.

Other studies have raised concerns over the withdrawal and side effects caused by antidepressants. The acknowledgment of withdrawal effects has been seen as a victory for service users who, despite years of being told that withdrawal is mild and short, insisted on having their voices heard. All of this has led to an increasing focus on helping patients safely withdraw from these drugs, with experts suggesting months of slow discontinuation.

Frances writes this new article at a time when the discussion about the efficacy and safety of antidepressants has received mainstream attention, at least in countries like the UK. Once the chair of the DSM IV task force, Frances has become a fierce critic of overdiagnosis and overprescribing in psychiatry. He has written numerous books and articles criticizing lowered diagnostic thresholds and the unscrupulous inclusion of certain diagnostic categories in the DSM-V.

Frances writes that despite these drugs being off-patent, their use has grown exponentially in the US and the UK. At the same time, there is little evidence suggesting that psychiatric disorders have increased to warrant such an increase in prescription. He gives several reasons for this increase.

First, he notes that most of the prescribers are general practitioners who do not know their patients very well and often see them only on a day when the patient is in the midst of deep suffering. Given the lack of history with the patient, they may feel pressure to prescribe antidepressants to address the immediate symptoms.

Frances writes that half the patients who begin to take the drugs stay on them for at least two years, and many will stay on them for decades. For people with mild or moderate symptoms, this is “the worst practice” as most of these symptoms would likely have dissipated over time, with help in stress reduction or when the stressor went away.

He notes that there are two primary reasons people stay on antidepressants for years. The first is the effect of misattribution. People who start feeling better after taking the antidepressants might assume that it is due to the drugs that they are feeling better. In most cases, those with mild symptoms would have just started feeling better over time or as the stressful event resolved itself. Thus, once they believe that these pills work, it is difficult for them to stop.

The second important reason for the continued use is withdrawal symptoms. Frances notes that patients can experience debilitating withdrawal symptoms when they stop their antidepressants. He writes:

“Withdrawal can be very unpleasant and scary, causing lethargy, sadness, anxiety, irritability, trouble concentrating, sleep problems, nightmares, ’flu symptoms, nausea, dizziness, and strange sensations.”

Given that there is insufficient information regarding the severity of antidepressant withdrawal in the medical community and among the lay public, withdrawal is often confused with relapse resulting in a vicious cycle of long-term prescribing.

He further problematizes their increasing use in children and adolescents despite evidence that they might be linked to higher rates of suicide. Frances maintains that antidepressants are beneficial for severe depression, where placebo and psychotherapy might fail. According to Frances, if we can correctly ensure that only those with severe symptoms receive antidepressants and others are treated with time or therapy, we would be on the correct path.

Frances writes that the placebo response is powerful for people with milder and moderate symptoms. In other words, these people benefit from just thinking that they are on antidepressants but that severe depression might require actual antidepressant usage.

As a solution to this growing problem of over-prescription, he suggests having general physicians take time to know and understand their patients and ensure that milder symptoms are treated with watchful waiting, stress reduction techniques, and advice. Moderate depression should first be treated with psychotherapy instead of medication.

But diagnosing depression can also be tricky. As Frances has previously noted, diagnostic inflation and lowered thresholds have made more and more people fit into psychiatric categories. The use of self-report inventories, which are commonplace among general practitioners, contributes heavily to overdiagnosis, leading to overmedication. The use of screening instruments should be restricted for groups at high risk, such as people with a history of suicidal behavior.

Frances ends his article by noting that while training general practitioners and having them take time to get to know their patients is costly and time-intensive, in the long run, it protects patients from the harms of unnecessary medication. Lastly, for those who can overcome their depression through other means, it also provides a sense of strength and resilience.

 

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Frances, A. J. (2021 April 22). Why are antidepressants so overprescribed? And what to do about it? NewsWatch, 115, 4-5 (Link)

16 COMMENTS

  1. “Frances maintains that antidepressants are beneficial for severe depression, where placebo and psychotherapy might fail. According to Frances, if we can correctly ensure that only those with severe symptoms receive antidepressants and others are treated with time or therapy, we would be on the correct path.”

    Somehow, I hope Dr Frances is reading this. There are a couple of things left out of his critique that I want to address. The first of these is, I feel, the strongest current influence, especially with May being Mental Health Awareness Month, and that is the dominant cultural dialogue surrounding concepts of “mental illness”. This dialogue frames “mental illness” as a medical construct with “treatments” available to alleviate it. Indeed, advocacy programs are measured in part on how well they increase “help seeking” behaviors. This perpetuates a narrative that those who choose not to seek professional “help” or medical “treatment” for their mental distress don’t know what’s best for them, increase the burden on their support network, or are even potentially dangerous. (Although, slightly kinder framing such as “emotionally unstable” might be used, it has the same effect.) So we have a cultural narrative that highly stigmatizes those who refuse “treatment”.

    We also have a supply and demand problem. There aren’t enough “treatment” providers to go around when a full third of the population is IN treatment of some sort with a fifth of us currently taking psychotropic drugs, and the cultural narrative suggesting that many more SHOULD BE in “treatment” of some variety. This sets up a scenario where people with less means believe that legitimate medical care is being unfairly withheld from them, and serves to increase their despair on a number of fronts. This withholding of what is viewed as medical care becomes yet another way they experience being oppressed by those who might have the power to mandate such “care” be equally accessed. This is a false scarcity being introduced – the economics of care, so to speak.

    Third, Psychiatry itself has an attribution and replication problem. These are expressed in the low interrator reliability as well as the lack of homogeneity between people inside diagnostic groupings. One person’s “severe depression” is evidence of infection. Another person’s “severe depression” is due to past and current traumas. Yet a third group has a cancer or underlying auto inflammatory illness. The fourth group has severe nutrient deficiencies. The fifth group is grieving longer and/or more deeply than the culture believes is “healthy”. The sixth subset of “severely depressed” people are extremely poor and stressed just trying to survive neoliberal economic reality. Antidepressants not only do not solve any of the underlying issues, they may very well be throwing a bomb into the mix when that person either becomes hypo/manic OR fails to respond, creating further “what’s WRONG with me/you” dialogue, both internal and external. Then arrives the pharmaceutical cocktail – assuming they weren’t started on a cocktail from the first visit – or recently, the promotion again of a range of psychosurgical options. The surgeon is ALWAYS waiting to fix what drugs don’t.

    And here we see why his alternatives to antidepressants – time and therapy – may also be wholly inadequate to address a person’s deep suffering.

    “The use of screening instruments should be restricted for groups at high risk, such as people with a history of suicidal behavior.”

    Of course, those of us with a history of suicidal behavior eventually learn not to disclose such thoughts. Many of us learn the value of stoicism, because suffering in silence can be safer than suffering in the presence of a “treatment” provider or a well meaning friend or relative who will push us into “treatment” or then blame us for our suffering if we don’t accept what passes for “treatment”.

    What Dr Frances has yet to fully grasp is that the entire barrel is rotten. It is not general practitioners alone driving the high rate of psychotropic prescribing. It is the cultural narrative that Frances himself helped frame during his reign at the top of his profession. That narrative reinforces that there is nothing wrong with the system. The problem isn’t schools, or an unjust economy, or systemic oppression, or disconnection from our families and communities. The problem lies within us. And that narrative is reinforced among the helping professions, not just doctors. We have a cabal of professional responders from police to psychotherapists to social workers to teachers all reinforcing the “take your meds as prescribed” line. We have direct to consumer ads urging us to ask our doctors if a certain drug is right for us. We have advocacy groups and celebrities and scriptwriters promoting the “mental illness” and “seek treatment” narratives. We have social media campaigns raising “awareness”. But there is still very little room for those with lived experience to push back against these dominant narratives when so many are under the belief that we are not “compliant”, potentially dangerous, unaware of the severity of our suffering, need coercion or force “for our own good”, etc.

    What I’m waiting for, without holding my breath, is an actual mea culpa for the culture he helped to shape. I’m waiting for an admission, not that the pills are overprescribed, but that he misled, regardless of intent, the entire western world to believe that mental suffering is an illness to be cured with psychoactive drugs. And I’m waiting for an acknowledgement that “symptom” reduction may not be the best approach at all. I’m waiting to hear the possibility that feelings have a purpose, that we weren’t created nor are we evolved to have feelings for no good reason. I want to hear him say that he knows our feelings are essential guides to navigating our lives. I want to hear him say he’s sorry for leading much of the world to believe otherwise. I want this to be more than an academic exercise for him and for him to feel the damage and grief he and his profession have caused. Only then will anything Dr Frances has to say have any meaning whatsoever.

    • Kindredspirit, this is the best comment I have ever read about Allen Frances. Powerful and spot on. To Frances, psychiatry is fundamentally sound, real mental illness exists, and psychiatric drugs are useful and life-saving. They key, to him, is for psychiatry to be done “correctly,” to diagnose accurately, and to medicate properly when indicated. His apparent problem is that it is done “incorrectly” too often, leading to “misdiagnosis/overdiagnosis” and improper “treatment.”

      He is clearly incapable of acknowledging that the entire enterprise is not only broken but fundamentally rotten. He has too much skin in the game. He is one of the more high-profile examples of a KOL-level psychiatrist who waits until retirement to publicly admit that the profession has “problems” without having the courage to admit what we know they know but won’t say.

      • Thank you. I appreciate this comment. I think the thing that truly makes me despair is that even when there is a physical illness within the patient, accessing accurate diagnosis and adequate treatment can present it’s own nightmare, furthering the despair and hopelessness that lead patients to psychiatric responses from medical providers. It has become very difficult to navigate the medical system without receiving or at least being offered a psychiatric drug or diagnosis. As Rosalee has detailed regularly, her cancer treatments came with anxiety diagnosis and drugs. Pills are easier to provide than care, and this is fundamentally what’s wrong with medicine as a whole. Psychiatry is just the glaring example of general medicine’s failure to provide care and healing.

        Thank you for pointing out the major pitfall of opinion or thought leaders as well. This is something that I don’t think has been talked about much recently but I think is behind a lot of the proliferation of conspiracy theory in our culture generally. It seems that a lot of us have a sense that things aren’t really as they seem, whether it’s from news or government, that we’ve been taught from an early age to rely on expertise and downplay our own senses, accumulated knowledge and wisdom. But what it is leading to, as people begin to wake up to all of the ways we are misled or otherwise “managed” is chaos and conflict. When we stop believing we can trust the people in charge, whether it is politicians, or newscasters, or doctors, it leaves us in a state of having to figure everything out on our own. Some are more academically-minded than others and have an easier time doing this, but many (even smart people) end up falling prey to charismatic individuals on all ends of the political spectrum. Humans will go to great lengths to avoid the cognitive dissonance induced by uncertainty. I believe that a lot of the current cultural conflict is directly attributable to the unethical practices of opinion generators like Allen Frances and many others who have participated in ghostwriting or giving speeches at major conferences in exchange for renumeration or public status. That many of them wait until retirement, if ever, to issue any sort of mea culpa is pretty damning. The big question then becomes what do we do to repair the damage that these people leave behind. QAnon and the like (on both sides) are clearly filling a big void in very uncertain times. And homeopathy, which is surging, is not the answer to bad medicine, either. This is, I suppose, the issue I’d really like Frances and his ilk to attempt to repair. But as you say, his position is that things are fundamentally ok, we just need to address “mis/over”diagnosis. The captain of this ship is attempting to pretend it isn’t sinking when we can plainly see the water rising around us.

  2. Please let us not blame general practioners for “overprescriptions. Let’s blame psychiatry who is the sole entity that sits in a board room and comes up with more and more disorders, and who tells people that feeling distress, EVEN to the point of disruption of their lives has to be drugged.

    Psychiatry has always advertised that Something, Anything, needs to be dealt with on that person, on that faulty brain.

    That whole idea, EVEN IF there were or are “faulty” brains, simply has the certainty of it all going wrong, for millions of people.

    The whole path psychiatry is on has gone all wrong because it always was. It’s a hard pill to swallow, and then where do they start?

    But having millions of people who want and need help is no excuse to keep harming them further.
    Medicine should divorce itself from harming people, not that psychiatry is medicine.

    In the VERY LEAST, psychiatrists should not be allowed near kids.

  3. Allen just can’t get himself to say it.
    He can talk about how efficacy has been shown not to exist, yet in the same breath he uses the word “overprescribing”.
    There should be no prescribing of drugs that harm.

    People will have bad lives. These AD’s are poisons. The people who think they help have natural ups and downs, when on or off. and when they stop the AD, they mistake the scrambled brain as their usual distress.

    Some realize 20 years later that it was a hoax.

    And it’s the most horrible world that does this to kids.

  4. Were Allen Frances to take on the prescribing of so called anti-depressants, benzos, and neuroleptics we might be getting somewhere. As is, he’s just another drug pushing doctor complaining about all those other doctors with his little under the counter drawer full of pills to pitch. Over prescribing in general is any prescribing. Of course, we could work on getting the percentage of people on this pill or that down to a more reasonable percentage. Allen Frances is, like, we should get people to stop prescribing this so much, except to people who really need it, and ditto this and this and this. I would argue that much of this need is imaginary and manufactured.

    • Well Allen was upset enough to stomp out of the boardroom, but he cannot get himself to become an activist against the crimes psychiatry commits. The guy is ancient, won’t be around forever, yet refuses to help kids. Perhaps he has a bit of a conscience that is trying to absolve itself, by a little of this and that, but he remains weak.
      He loses nothing by standing up, absolutely nothing, so perhaps he is just stupid.

  5. I’ve read Dr. Francis’s latest missive. Once again he blames those nasty general practitioners. without ever adducing a shred of evidence that they are doing any more harm than their colleagues who are board-certified in psychiatry, and whose entire income stream depends on diagnosing and drugging as many people as possible.

    Some more gems from his article:

    “Between one-third and one-half of patients taking antidepressants long-term have no evidence-based reason to be on them.”

    But since there is no credible evidence that antidepressants produce any long-term benefits, plus lots of evidence of harm, in what sense is there any “evidence-based reason” for anybody to be on them?

    “Withdrawal can be very unpleasant and scary…”

    Why not come out and say “life-destroying?”

    “…for some withdrawal can last 6 months.”

    Why not mention that for some, it can last years?

    “Some highly publicized reviews of the depression literature have concluded that antidepressants are no more effective than placebo. I would argue that this is an artefact caused by the fact that so many of the subjects included in these studies had only milder symptoms that are very placebo responsive. Severe depressions do not respond to placebo…”

    Actually, Dr. Kirsch demolished this argument years ago in his 2008 meta-analysis in PLoS Medicine. All but one of the trials in his analysis had been conducted on patients whose baseline scores qualified them as “very severely depressed,” and exclusion of this one trial did not substantially change the results. Only the most severely depressed patients – those with HAM-D scores in excess of 28 on intake – experienced an improvement that exceeded the NICE threshold for clinical significance – and interestingly, in this group of patients, the increased difference between placebo and drug scores was due to a lowering of the placebo effect, not an increase in the drug effect.

    Nothing new here. The same tired old tropes Dr. Francis has been peddling for years now.

    • Well it is psychiatry that tells GP’s to prescribe drugs. It is psychiatry that tells them to be on the lookout for victims.

      Hence then, psychiatry and real medicine which used to be real medicine and science, have become cozy bedded and wedded.
      Everyone and their dog can now be psychiatrized.

      Since pets are now analized and drugged by their vets, I bet Allen would blame either the vet or the dog.

      Not as if psychiatry accepts doggy clients with those bitey issues, or “separation anxiety”.

  6. I can’t understand why an article about Allan Frances – the man who was instrumental in the gross enlargement of psychiatric diagnoses as the chief editor of DSM IV and as someone largely responsible through a lucrative kickback from Janssen Pharmaceuticals for promoting the wide-spread prescription of Risperidal off label for a multitude of ‘conditions’ to young adults suffering from anxiety and elderly people in care homes – is being published on this forum. He now wants to re-frame his legacy by becoming a reformer of the mass prescribing of psychotropic medication he largely put in motion which has ruined millions of lives. I don’t understand why he is being allowed to do so. If ever there was a case for ‘cancel culture’ it’s this man. There is a recent video of him up on Youtube giving a lecture on the widening of psychiatric diagnosis – one of his opening remarks was ‘Psychiatry is a noble profession’. He obviously likes to think of himself that way – by allowing him a forum you are allowing him to burnish his image.

  7. THIS guy…

    He was directly responsible for me losing 15 years of my life to a false diagnosis of bipolar 1 in 2004, becoming bankrupt & homeless, with quantifiable, documented iatrogenic damages…body & soul…that included 19 seizures POST a guided psychotropic drug withdrawal (for 2+ years). I achieved rare vacation of the ‘LIFELONG, chronic, acute’ mental illness label he had crafted so effectively vis a vis his leadership of DSM-IV. Oh, & the nerve damages in both eyes from Rispedal finally left me 3 years after dosing.

    I contacted him thru social media as my MIA 2-part essay “Full Moral Status…” was published, alerting him to his ‘profound effect’ he had on my life.

    He perceived that carefully worded sentence as a compliment (!)…responding with a ‘you’re welcome’ and pledging to read it.

    Any reader who is uncertain of France’s participation-trophy contributions to the welfare of mankind should read another more credible & distinguished MIA contributor’s essay, the scathing takedown of Allen by Paula Caplan, PhD entitled “Diagnosisgate: Conflict of Interest at the Top of Psychiatry”.

    Nailed it …and then some.

    And Allen (I know you are reading these comments)…I’ll never forgive you.

    “Saving Normal” didn’t ‘save’ you & your forever stained legacy….it just expanded (once again) your bank account…you know…the usual result of your involvement in the psychiatric industry.

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