On May 16, 2018, the prestigious and venerable psychiatrist Allen Frances, MD, gave an interview to Christiane Amanpour on CNN. You can see the video here. It’s titled How Antidepressant Withdrawal “Can Trap People”.
Here’s how the interview opened:
CA: “So you know, I just wanted to start by saying that who knew that antidepressants were addictive. It’s not what you associate with things like antidepressants. You think of pain-killers, obviously, and drugs and alcohol, and cigarettes.”
AF: “Well they’re not really addictive in the sense that benzodiazepines are addictive, or cocaine or alcohol. They don’t cause the same degree of functional impairment when you’re taking them, but they definitely do have a withdrawal syndrome, and that withdrawal syndrome traps people. It’s so easy to start an antidepressant and sometimes so very difficult to stop it.”
One could quibble with the phrase “not really addictive”, but Dr. Frances does acknowledge that antidepressants “have a withdrawal syndrome” which “traps people”, which is pretty much what the word addictive means.
In addition, DSM-IV (1994), drafted under Dr. Frances’s chairmanship, was clear and specific concerning the addictive properties of antidepressants. The section on Substance-Related Disorders contains the following:
“Many prescribed and over-the-counter medications can also cause Substance-Related Disorders. Symptoms are often related to the dosage of the medication and usually disappear when the dosage is lowered or the medication is stopped. However, there may sometimes be an idiosyncratic reaction to a single dose. Medications that may cause Substance-Related Disorders include, but are not limited to, anesthetics and analgesics, anticholinergic agents, anticonvulsants, antihistamines, antihypertensive and cardiovascular medications, antimicrobial medications, antiparkinsonian medications, chemotherapeutic agents, corticosteroids, gastrointestinal medications, muscle relaxants, nonsteroidal anti-inflammatory medications, other over-the-counter medications, anti-depressant medications, and disulfiram.” (p 175) [Emphasis added]
This recognition is repeated almost verbatim in DSM-IV’s Text Revision (2000) on page 191.
However, if we fast-forward to DSM-5 (2013), we find no mention of antidepressants in the section Substance-Related and Addictive Disorders. All that remains is an entry called Antidepressant Discontinuation Syndrome, relegated to the chapter Medication-Induced Movement Disorders and Other Adverse Effects of Medication. The point of which was, I suggest, to undo the “damage” that DSM-IV had done to psychiatry’s mainstay drug class, by removing the reference to antidepressants from the substance use/dependence chapter. Additionally, note the use of the word “discontinuation” rather than the more usual “withdrawal”, which has connotations of dependence and addiction.
So essentially, Dr. Frances and his DSM-IV colleagues opened the door to the notion that antidepressants could be addictive. For psychiatry this posed the threat of a recurrence of the benzodiazepine reversal of the 80’s, and had to be quashed.
The Antidepressant Discontinuation Syndrome entry in DSM-5 contains this very telling quote:
“Symptoms appear to abate over time with very gradual dosage reductions. After an episode, some individuals may prefer to resume medication indefinitely if tolerated.” (p 713)
which sounds very like a sanitized description of addiction.
Also of note in DSM-5, there is this pure gem of psychiatric arrogance and deception:
“Symptoms of tolerance and withdrawal occurring during appropriate medical treatment with prescribed medications (e.g., opioid analgesics, sedatives, stimulants) are specifically not counted when diagnosing a substance use disorder. The appearance of normal expected pharmacological tolerance and withdrawal during the course of medical treatment has been known to lead to an erroneous diagnosis of ‘addiction’ even when these were the only symptoms present. Individuals whose only symptoms are those that occur as a result of medical treatment (i.e., tolerance and withdrawal as part of medical care when the medications are taken as prescribed) should not receive a diagnosis solely on the basis of these symptoms. However, prescription medications can be used inappropriately, and a substance use disorder can be correctly diagnosed when there are other symptoms of compulsive drug-seeking behavior.” (p 484)
In other words, if the customer takes the pills exactly as prescribed, including, presumably, any prescriber-approved increases, he or she cannot become addicted, and “diagnostic” assessments that suggest otherwise are “erroneous”, even in cases where tolerance and withdrawal are clearly evident. The only way that prescription medications can cause addiction is through inappropriate use and “compulsive drug-seeking behavior” on the part of the client.
In DSM-IV (1994) and DSM-IV-TR (2000), there was specific acceptance that use of antidepressants can cause substance use problems, and there is no reference to inappropriate use. In DSM-5 (2013), all reference to antidepressants has been removed from the Substance Use chapter, and the general point is made that people can’t become addicted to “…prescribed medications (e.g., opioid analgesics, sedatives, stimulants)…” and, presumably, antidepressants, as long as they take them as prescribed. In typical shoulder-sloping fashion, the APA has absolved itself of any responsibility for iatrogenic antidepressant and opioid addiction, and has laid the blame squarely on the “compulsive drug-seeking behavior” of the clients. How convenient, particularly in the context of the present opioid and antidepressant addiction epidemics and the “apparently unmotivated” suicides and murders.
But Dr. Frances offers no criticism of psychiatry for this deceptiveness, nor even for reversing the candid admissions that he himself drafted into DSM-IV and DSM-IV-TR.
. . . . . . . . . . . . . . . .
Here are some more quotes from the CNN interview, interspersed with my comments:
CA: “And how do you find that out? I mean how much science is there on the difficulties, and how do people know when they’ve been on it too long, or it seems such a fluid area of medication and prescription.”
AF: “Well, it’s a deeply held secret. There’s almost no research on the withdrawal syndrome. There’s absolutely no interest on the part of the pharmaceutical companies in advertising the fact that getting on an antidepressant may trap you for years and maybe for life. So they’ve discouraged research, they don’t report adverse findings. The pharmaceutical industry is only marginally less ruthless than the drug cartels, and it’s not in their interest to advertise this, so there’s been very very little research, and we really don’t know how the long-term use of these medications may affect the brain. We’re doing a kind of public health experiment on hundreds of millions of people around the world without really understanding the long-term effects.”
Note the sentence: “There’s almost no research on the withdrawal syndrome.” The first antidepressants were developed in the 1950’s and were on the market by 1960, fifty-eight years ago. At the present time, untold millions of antidepressant prescriptions are being written world-wide each year.
Yet here’s Dr. Frances telling us that there’s “almost no research on the withdrawal syndrome”. And is he telling us this as an indictment of psychiatry? Is he acknowledging that routinely prescribing and promoting brain-impairing pills on which there is virtually no withdrawal research is a disgrace to the profession of psychiatry? No. Again, in the same shoulder-sloping fashion, he’s blaming pharma! Pharma have “no interest” in the addictive potential of these products. Pharma have “discouraged” research. Pharma doesn’t report adverse findings. Pharma are almost as ruthless as the drug cartels.
So, what we’ve got here is a self-styled medical profession that has been prescribing and actively promoting a class of drugs for almost 60 years, with little or no information concerning their withdrawal characteristics. And Dr. Frances blames pharma for this state of affairs! Why couldn’t organized psychiatry (e.g. the APA and Britain’s Royal College of Psychiatrists) have pursued such research? Why couldn’t the psychiatry departments of various colleges have pursued such research, either singly or collaboratively? And how could psychiatry be so venal and corrupt as to promote and prescribe these drugs without even this basic level of knowledge concerning their addictive potential?
And note the phrase: “…we really don’t know how the long-term use of these drugs may affect the brain.” After 60 years and countless millions of prescriptions, psychiatry doesn’t know how the long-term use of these drugs may affect the brain!
And from there to the truly macabre:
“We’re doing a kind of public health experiment on hundreds of millions of people around the world without really understanding the long-term effects.”
And although Dr. Frances doesn’t acknowledge this, the “we” of this quotation can only be psychiatry. Psychiatry, if we accept Dr. Frances’s statement, is surreptitiously experimenting on hundreds of millions of people worldwide, without even a semblance of informed consent.
But, in fact, it’s even worse than that, because they’re not really doing an experiment. In a genuine experiment, negative results are published. But psychiatry is just dishing out the pills, trotting out the “safe-and-effective” pablum, and suppressing negative information.
On August 22, 2013, Connecticut Assistant Attorney General, Patrick B. Kwanashie, stated publicly that the “medications” that Adam Lanza was taking when he murdered 26 people in New Haven, Connecticut on December 14, 2012 would not be made public, lest such publication might encourage other people to “stop taking their medications”. He made his statement in response to AbleChild’s request for Adam Lanza’s medical records. And although Mr. Kwanashie didn’t divulge the information, it is clear from what he did say that Adam Lanza was indeed taking psychiatric “medications”.
If Allen Frances is genuinely interested in these matters, shouldn’t he have protested this cover-up? Shouldn’t the APA, who tell us that they have their “patients” best interests at heart, have been screaming their objections to the very heavens? Shouldn’t they have initiated lawsuits to have the information divulged? Shouldn’t they have used every ounce of clout at their disposal to have this issue opened to public scrutiny?
Meanwhile, the shootings and suicides continue.
In 2016, the late Senator John McCain and Congressman David Jolly introduced twin bills in their respective chambers mandating post-mortem drug screening, including screening for psychiatric drugs, in the cases of all military veterans who had taken their own lives. The bills died from lack of support. Why did the APA not support this proposal? Shouldn’t psychiatry want the link between antidepressants and suicide publicized? Did Dr. Frances himself support the bills?
. . . . . . . . . . . . . . . .
CA: “New figures from the New York Times show that fifteen and a half million Americans have been taking antidepressants for at least five years, and that rate is almost double since 2010 and more than triple since 2000. How easy is it to actually get the prescription in the first place?”
AF: “There’s nothing easier in the world than starting an antidepressant. Primary care doctors are given far too little time with their patients, and the only way they can get a patient out of the office satisfied after a seven-minute visit is to write a prescription. 80% of the antidepressants are prescribed by primary care doctors, usually after seven minutes, under heavy pressure from both the patient and from the drug company to prescribe the medication. On the other hand, stopping the medicine can take years. It requires for some people a very, very slow taper, and without that they’ll have symptoms of return of anxiety, of depression, flu-like physical symptoms, and often they will misattribute these return of symptoms to thinking that they’re getting depressed again, when in fact it’s just the result of withdrawal side effects.”
Well there’s not much ambiguity there: the GPs are to blame. But not entirely – they are given “far too little time” and they are under “heavy pressure” from the drug companies (mean ol’ pharma again) and from “the patient”.
This, of course, is the same drum that Dr. Frances has been beating for the past decade or so: psychiatrists are the good guys; and all the woes associated with the use of psychiatric drugs are to be laid at the feet of pharma, the over-prescribing GP’s, and the drug-seeking “patients”.
But, as always, Dr. Frances chooses to ignore the most salient point: that if psychiatry had not invented the spurious illnesses, not a single one of those prescriptions could ever have been written. If psychiatry had not self-servingly concocted and promoted the great lie that every significant problem of thinking, feeling, and behaving constitutes a drug-correctable aberration of brain chemistry – “an illness, just like diabetes” – then none of the problems that Dr. Frances laments could have occurred.
In addition, Dr. Frances’s efforts to slough responsibility for the present state of affairs onto the GP’s is particularly untenable. GP’s, the world over, take their leads from the specialists. The vast majority of ear, nose, and throat problems, for instance, are treated by GP’s, not ENT doctors. But the GP’s make use of diagnostic procedures and treatments that have been developed, formalized, and packaged by the specialists for use in general practice. Ordinarily, only the unusual, difficult, or intractable cases are referred to the experts. New discoveries or improved procedures developed by the specialists are passed along to the GP’s for general use through peer-reviewed journals, continuing education, and other means.
But – and this is the critical point – if it were discovered that the GP’s were making serious, systematic, diagnostic or treatment errors on a large scale, immediate corrective measures would be undertaken by the specialists, using every available means of dissemination. Is Dr. Frances seriously trying to persuade us that GP’s are systematically ignoring psychiatry’s criteria and wantonly mis-prescribing pills, and all that the poor psychiatrists can do is watch helplessly from the sidelines and wring their hands in pious but hopeless frustration? Where are the press releases from the APA denouncing the malpractice? Where is the exchange of correspondence between the APA and the American Academy of Family Physicians? Where are the complaints from the APA to the various medical licensing boards? Where are the warnings to the public?
Psychiatry has labored diligently for decades to promote the spurious notion that depression which exceeds certain arbitrary, vague, and unvalidatable thresholds of severity, duration, and impact constitutes a brain illness. And the fact is that, with the help of pharma dollars, they have been phenomenally successful in selling this destructive and disempowering hoax.
Psychiatry has knowingly and deliberately created a system and an ethos in which virtually anybody who is experiencing the ordinary slings and arrows of misfortune can be diagnosed with a “brain disease” and prescribed drugs and/or electric shocks. Every move that psychiatry has made in the past fifty years has been calculated to further this end. Against this background, Dr. Frances’s persistent efforts to shift the blame for this state of affairs to GP’s, pharma, insurance companies, and even to the clients themselves, is a distortion of the historical record.
In addition to all of this, Dr. Frances is choosing to ignore the well-established fact that the prescribing practices of psychiatrists are just as hurried and perfunctory as those of the GP’s.
Here are some illustrative quotes going back to 2009.
“There can be little doubt in our current era that the brief ‘med check’ is becoming standard practice in psychiatry.” (p 1)
Glen Gabbard, MD, Psychiatrist, Psychiatric Times, September 3, 2009
“Even psychiatrists who deplore 15-minute med checks recognize that they have become standard care in psychiatry.” (p 40)
Douglas Mossman, MD, Psychiatrist, Current Psychiatry, June 2010
“I think many of my colleagues have practices with four, five, six hundred patients. And people are surprised when they hear those numbers, but when you’re seeing patients for 15 or 20 minutes every month, every two months, sometimes every six months, or once a year, quite frankly, you can imagine how you could have that many patients.” (p 5)
Daniel Carlat, MD, Psychiatrist, NPR July 13 2010
“Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, [Donald Levin, MD, Doylestown, Pennsylvania] first established a private practice in 1972, when talk therapy was in its heyday.
Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart.” (p 2)
Gardiner Harris, Journalist, New York Times, March 5, 2011
“In the past few decades, the focus has shifted more toward the brain and away from the mind. And changes in reimbursement systems today have rewarded hurriedly written prescriptions and encouraged psychotherapy to be provided by nonpsychiatrist therapists.” (p 4)
Jeffrey Lieberman, MD, Chair, Dept of Psychiatry, Columbia University, Psychiatric News, August 27 2013
Note the condoning phrase: “… changes in reimbursement systems today have rewarded hurriedly written prescriptions…”. Psychiatrists, poor little lambs that they are, just couldn’t resist these rewards.
“In the old days, people made fun of those rigid 50 minute appointments psychiatrists had with patients that focused mainly on psychotherapy. In today’s world, however, an appointment that long for all but new patients has become a dinosaur of the past at many clinics. In its place is now the infamous 15-minute ‘med check’ which focuses on symptoms, medications, and side effects.” (p 1)
David Rettew, MD, Psychiatrist, University of Vermont, Psychology Today, November 10, 2015
“Today, many outpatient psychiatric care providers are employed to provide ‘medication management’ in brief 15- to 20-minute visits. In qualitative interviews, patients and psychiatric care providers alike expressed that psychiatric care has been narrowed to the act of prescribing medications.” (P 1-2)
William Torrey, MD, (Professor of Psychiatry, Dartmouth School of Medicine) et al, Psychiatry Online, March 1 2017
“The 15-minute medication management visit has become one of the standards of psychiatric practice.” (p 1)
Mark Moran, Senior Reporter at Psychiatric News, Psychiatric News, May 30 2017
“‘It’s like going through a McDonald’s drive-thru. You drive through the window, they give you your prescriptions, and you’re on your way.’
When interviewed, a psychiatric outpatient used these words to describe what it is like to receive care in a 15- to 20-minute ‘med check’ visit—a form of psychiatric service delivery that is now found across the country.” (p 1)
William Torrey, MD, (Professor of Psychiatry, Dartmouth School of Medicine) et al, Psychiatry Online, June 15 2017
The reasons that psychiatry has almost entirely abandoned talk therapy in favor of hurried med-checks and prescriptions are: firstly, it enables them to make a great deal more money; secondly, it entails less stress and effort; thirdly, it helps psychiatrists feel like they are “real doctors” – confirming “diagnoses”, adjusting doses, checking for adverse effects, etc; and fourthly, the med-check approach is entirely consistent with the bio-bio-bio, chemical imbalance approach that has been avidly promoted by psychiatry since the drugs came on the market. Here’s another quote from the very eminent and scholarly Dr. Lieberman. The quote is from the same paper cited above:
“In the revisions that will follow DSM-5, which was released in May, we anticipate that psychiatric diagnoses will move beyond descriptive phenomenologic criteria to measures of pathophysiology and etiology and that they will involve laboratory tests to identify lesions and disturbances in specific anatomic structures, neural circuits, or chemical systems, as well as susceptibility genes—the kinds of tests that routinely inform the diagnosis of infection, cardiovascular disease, cancer, and most neurological disorders. The research that occasions these developments may not just enhance our ability to make diagnoses, but may fundamentally redefine the nosology of mental disorders.” (p 3)
Well, we’re 5½ years post-DSM-5, and as yet none of Dr. Lieberman’s bio-centric predictions have come through. Nevertheless, the spurious chemical imbalance theory remains the primary driving force behind the rushed assessments and the hurriedly-written prescriptions. After all, if “major depressive disorder” can be “diagnosed” by confirming five hits on the facile checklist, and if responsiveness to “treatment” and potential adverse effects can be assessed with a few more brusque questions, then why waste time asking customers irrelevant questions about their personal lives, their relationships, their fears, their loneliness, their empty nests, their sense of purposelessness? Fill out the forms, write the prescriptions, and next please! Kerchung.
. . . . . . . . . . . . . . . .
CA: “Well in fact there is one woman who is one of the people you focused on in your book, and it’s Sarah, and just to remind again that 80% of antidepressants you say are prescribed loosely by GPs after an interview that usually lasts less than about ten minutes. So this Sarah says that she was misdiagnosed as being a depressive when she was just really very sad and grief-stricken about the suicide of her son, and she told you, quote: ‘The doctor was clinical, brushing aside my fears and my loss. I needed someone who would understand and share the pain that I was going through, not put a cold, medical label on it.’ How much of that kind of situation and diagnosis did you see as you were doing your book?”
AF: “Well I think she’s a particularly poignant, heart-breaking case, because her son had actually himself been mistreated, over-prescribed medication. It caused side effects, and he actually killed himself with the medication he was prescribed. She’s feeling grief, and after a few minutes, a doctor over-prescribes medication for her. This is a very common story. I think people have to become educated for themselves, their family members, and particularly their children, not to accept a quick diagnosis of depression, not to accept the pill. The diagnosis of depression should take not just one session, but normally weeks, and sometimes even months. Most people come to a doctor on the worst day of their life. If nothing is done except watchful waiting, support, advice, most of those people get better in the short run. What’s happening now is they get a very quick prescription of a pill, and then there may not be an end point, because stopping the pill will be so difficult, and the person will assume that the pill is keeping them well.”
In this context, it’s worth mentioning the bereavement exclusion, which in DSM-III effectively barred the “diagnosis of major depression” in cases of bereavement, except in cases of “prolonged duration”, which was generally accepted as two years. Dr. Frances’s DSM-IV reduced the waiting period to two months, and DSM-5 eliminated the bereavement exclusion altogether.
It also needs to be asked: where did the woman – Sarah – get the idea that a physician would understand and share her pain of bereavement? In the old days, which I – and I’m sure Dr. Frances – well remember, people didn’t consult physicians for sadness or bereavement. They discussed these matters with family, friends, relatives, neighbors, colleagues, clergy, etc., and they found in these discussions resonance, comfort, support, encouragement, and hope. Today, many people consult physicians because they have been sold the falsehood that depression is an illness, a neurochemical imbalance, that can only be ameliorated by psychiatric drugs. And psychiatrists have been the primary promoters and, incidentally, beneficiaries of this falsehood.
. . . . . . . . . . . . . . . .
CA: “Well, let’s play a little bit of devil’s advocate, because you make a bit of a distinction between situational grief and feeling really low, and then proper depression. I mean, there are, there is some benefit, isn’t there, to be treated, potentially with medication, even for a situational amount of feeling low. Is there, or not? Can one sort of micro-target like that?”
AF: “Well, let’s be very clear. There’s a cruel paradox that we’re over-treating the worried well and we’re terribly neglecting the really ill, and the medications are absolutely essential for people with severe depression. There’s no one size fits all. It’s not that medicines are good or bad. Medicines that are very effective for the few become harmful only when they’re misused with the many. I think in terms of situational depressions, short-term reactions to job loss, divorce, financial troubles, it’s always better to watchfully wait, and psychotherapy is by far the preferable first line treatment instead of medication.”
Apart from the unsubstantiated assertion that “medications are absolutely essential for people with severe depression”, Dr. Frances’s response has a superficial ring of plausibility and correctness. But, like everything else, in psychiatry the logic is problematic. Let’s take a look.
The implication in Dr. Frances’s response is that within the psychiatric framework, it is possible to distinguish between people “with severe depression” who are “really ill”, and people who have “situational depression”, and who are, presumably, not really ill (“the worried well”).
But in fact, one of the primary agendas of every DSM since DSM-III has been cause-neutrality. This principle was initiated in DSM-II (1968) and – except for the bereavement exclusion – was largely integrated into psychiatric “diagnosis” in DSM-III (1980). According to this principle, if you’ve got the “symptoms” – regardless of their proximate cause – you’ve got the disease. So, with regards to depression, if a person meets five or more of the nine items on the facile and unvalidatable checklist, he or she has depression – the illness. Whether the depression is a short-term reaction to a job loss, divorce, financial trouble, exploitation, persistent abuse, poverty, being in prison, or anything else, is entirely irrelevant. This, of course, is nonsense, but it has been a central pillar of psychiatry since DSM-III (1980). And it has been a central pillar of psychiatry because it is good for business. If people are despondent, they can be enrolled as paying clients. They can’t be allowed to slip the net just because there’s a perfectly good reason for their sadness!
So when Dr. Frances draws a distinction between situational depression and severe depression, he is not reflecting psychiatry’s formal position, and he is certainly not reflecting current psychiatric practice.
Psychiatry’s movement to cause-neutrality was deliberate, relentless, and selective. Selective, in the sense that it was the psychosocio-economic-cultural causes that were eliminated from consideration, while the putative biological causes were promoted with all the energy and resources that psychiatry could muster, including pharma-developed CE credits – not only for psychiatrists – but for virtually every profession that had any interaction with psychiatry’s targeted population. The push towards so-called cause-neutrality was firmly established in DSM-III (1980), was developed and reinforced in DSM-III-R (1987) and DSM-IV (1994), and was completed in DSM-5 (2013).
At present, the only residue of “situational depression” in the DSM is adjustment disorder with depressed mood. This “diagnosis” has an interesting history.
In DSM-I (1952), it was called “adult situational reaction” and was described as follows:
“This diagnosis is to be used when the clinical picture is primarily one of superficial maladjustment to a difficult situation or to newly experienced environmental factors, with no evidence of any serious underlying personality defects or chronic patterns. It may be manifested by anxiety, alcoholism, asthenia, poor efficiency, low morale, unconventional behavior, etc. If untreated or not relieved such reactions may, in some instances, progress into typical psychoneurotic reactions or personality disorders.” (p 41)
The term “low morale” suggests mild depression, while the phrase “with no evidence of any serious underlying personality defects or chronic patterns” suggests an absence of “mental disorders”. The preamble to this section of the manual is also interesting:
“This general classification should be restricted to reactions which are more or less transient in character and which appear to be an acute symptom response to a situation without apparent underlying personality disturbance. The symptoms are the immediate means used by the individual in his struggle to adjust to an overwhelming situation.” (p 40)
In DSM-II (1968), the name of the “diagnosis” was altered to adjustment reaction of adult life. No definition was provided, but a number of examples were described, including:
“Resentment with depressive tone associated with an unwanted pregnancy and manifested by hostile complaints and suicidal gestures.” (p 49)
This “diagnosis” occurs in the section headed “Transient Situational Disturbances” which are described as follows:
“This major category is reserved for more or less transient disorders of any severity (including those of psychotic proportions) that occur in individuals without any apparent underlying mental disorders and that represent an acute reaction to overwhelming environmental stress.” (p 48)
Of particular note are the phrases: “… in individuals without any apparent underlying mental disorders…” and “… overwhelming environmental stress”, both of which suggest that the reaction in question is essentially a normal and reasonable response, even if the response is severe.
In DSM-III (1980), the section title is Adjustment Disorders. So the problems in question have “progressed” from reactions (DSM-I) to disturbances (DSM-II) to disorders (DSM-III). And, of course, in psychiatry, as in general medicine, the term disorder is essentially synonymous with the term illness. So, by 1980, these problems had become full-blown psychiatric illnesses (presumably “just like diabetes”). Here’s the DSM-III definition:
“The essential feature is a maladaptive reaction to an identifiable psychosocial stressor, that occurs within three months after the onset of the stressor. The maladaptive nature of the reaction is indicated by either impairment in social or occupational functioning or symptoms that are in excess of a normal and expected reaction to the stressor.” (p 299)
Note the introduction of the word “symptoms”, a critical step in the spurious medicalization process.
Adjustment disorder with depressed mood is described as follows:
“This category should be used when the predominant manifestation involves such symptoms as depressed mood, tearfulness, and hopelessness.” (p 301)
Again, notice the word “symptoms”.
The entries in DSM-III-R are essentially similar to those in DSM-III.
In DSM -IV (1994), adjustment disorder is defined as follows:
“The essential feature of an Adjustment Disorder is the development of clinically significant emotional or behavioral symptoms in response to an identifiable psychosocial stressor or stressors.” (p 623)
Again, note the use of the word “symptoms” and “clinically significant”. Also note that the focus has shifted from the nature/severity of the stressor to the development of clinically significant “symptoms”.
The progression to illness status continued in DSM-IV-TR (2000).
“…a reaction to a stressor that might be considered normal or expectable can still qualify for a diagnosis of Adjustment Disorder if the reaction is sufficiently severe to cause significant impairment.” (p 679)
So the fact that the individual’s reaction might be entirely commensurate with the stressor is not relevant.
“Adjustment Disorder has been diagnosed in up to 12% of general hospital inpatients who are referred for mental health consultation, in 10%-30% of those in mental health outpatient settings, and in as many as 50% in special populations that have experienced a specific stressor (e.g., following cardiac surgery). Individuals from disadvantaged life circumstances experience a high rate of stressors and may be at increased risk for the disorder.” (p 681)
The entry in DSM-5 (2013) is essentially similar to that in DSM-IV-TR.
The point of all of which is that within the successive revisions of the DSM there has been a clear and persistent agenda to fallaciously present situational depression as a bona fide illness.
So Dr. Frances’s attempt in the CNN interview to distinguish between people experiencing “situational depression” and people who are “really ill” is very misleading. Within the psychiatric hoax, situational factors (even including bereavement) are irrelevant to the question of whether the person is “really sick”. And this is no accident. This has been one of psychiatry’s primary agenda items for the past forty years. And, it should also be noted, it is not a finding of fact. Rather, like everything else in the psychiatric hoax, it is a matter of fiat. Psychiatrists say so; therefore it must be true.
In addition to all this, the nine criteria items are hopelessly vague and subjective. Anyone consulting a psychiatrist concerning feelings of depression can be shoe-horned into a “diagnosis of depression” without much difficulty, and almost inevitably drugs will be prescribed to “treat” the “brain illness”. This is the situation that psychiatrists have deliberately, systematically, and self-servingly created. For Dr. Frances to blame this state of affairs on pharma is not credible. Certainly, pharma was a staunch ally to psychiatry in the nefarious endeavor. But not one inch of progress could have been made on this drug-pushing bonanza without psychiatry’s firm and unremitting commitment. Pharma did indeed provide generous funding, of much of which Dr. Frances himself deigned to partake, but at every juncture, psychiatry, with eyes wide open, called the shots, eliminated the concept of exogenous depression, formalized the so-called cause-neutral criteria, pretended that they had identified a brain illness, and banked the checks. And they continue to perpetrate the hoax to this day.
. . . . . . . . . . . . . . . .
CA: “So what is your solution, then to this over-diagnosis crisis? Not, I don’t just mean for doctors to have more time, but people, how should individuals be sensitized and made aware of this problem?”
AF: “Well I think you’re doing that, and I’m trying to do that with this program. I think that there are several things that need to be done. The first and most obvious is that we need to tighten the diagnostic criteria for how physicians and people regard clinical depression. We need to tame the pharmaceutical industry. They should not be advertising directly to consumers. That happens only in the US and New Zealand, and both countries have remarkably high rates of antidepressant use. We need to convince the insurance companies to allow primary care doctors to get to know their patients, so that their only recourse is not writing a prescription. And most of all we need to inform the public to be more afraid of medication and less afraid of their emotions and of illnesses. I think that the overwhelming clinical experience and research finding is that most people with transient, mild depression will do very well on their own, and people should trust to their own resources, get support from their family, get psychotherapy way before they consider medication. The medication should be the last resort for people who have severe, chronic depression. It shouldn’t be the means of treating the aches and pains of everyday life.”
There are several noteworthy points in this response.
Firstly, note the phrase “clinical depression”, a vague term, used extensively in psychiatry to convey the impression of illness, but without any supporting evidence. There is no APA diagnosis called clinical depression.
Secondly, Dr. Frances is calling for the tightening of “diagnostic criteria”, but note the wording: “we need to tighten the diagnostic criteria for how physicians and people regard clinical depression.”[Emphasis added] Specifically, he’s not calling for a tightening of the DSM criteria, but rather for a change in how GP’s and the public view depression. In other words, there’s nothing wrong with psychiatry and its so-called diagnostic manual; it’s the GP’s and the “patients” again!
Thirdly, his contention that “we need to tame the pharmaceutical industry” rings hollow in the light of psychiatry’s long-standing hand-in-glove relationship with pharma.
Fourthly, Dr. Frances contends that the GP’s “only recourse” is to write a prescription, because “the insurance companies” won’t “allow” them to get to know their patients. Apart from the extraordinarily condescending tone, this contention of Dr. Frances’s ignores the reality: that GP’s prescribe psychiatric drugs in the way that they do, and in the quantities that they do, because they have received the message from psychiatry that this is not only right and proper practice, but is also necessary to combat this “illness” which has – according to psychiatry – reached epidemic proportions world-wide. Psychiatry has actually created the situation where a GP who does not routinely assess for depression and does not prescribe drugs when reports of depression are presented, is rendering him/herself liable to malpractice action. Coupled with which, psychiatry’s routine but false assertions that the drugs are “safe and effective”, and their stubborn resistance to any suggestion to the contrary, has fostered the very culture of misplaced complacency that Dr. Frances here laments.
Fifthly, Dr. Frances’s assertion that ” we need to inform the public to be more afraid of medication and less afraid of their emotions and of illnesses” is too little, too late. This is especially the case in that psychiatry for the past five decades has poured resources into the opposite message: that all significant problems of thinking, feeling, and/or behaving – including bouts of sadness or despondency – constitute brain illnesses; that psychiatry has the protocols to diagnose these “illnesses”; that failure to professionally treat these “illnesses” will entail multiple dire consequences, including possible suicide; and that psychiatric drugs – often to be taken for life – are the treatment of choice.
Much of what Dr. Frances says is sensible, but it would be a good deal more convincing if he would lay the responsibility for the present state of affairs squarely where it belongs: on psychiatry, its disempowering labels, and its destructive “treatments”.
AND FINALLY, A SUGGESTION
I suggest, in all sincerity, that Dr. Frances abandon his attempt to absolve psychiatry from blame in these matters, and that he join the anti-psychiatry movement. Dr. Frances’s present exculpation mission is doomed to failure because psychiatry is indeed the primary culprit, and it is only within the anti-psychiatry movement that Dr. Frances will find uncompromised congruence with his present desire to expose the excesses which he so clearly deplores.
I realize that many of my readers will greet this suggestion with a measure of skepticism, and some, even, with hoots of derision. But wait!
In August 1983, Dr Frances co-authored (with Katherine Shear, MD, and Peter Weiden, MD) a short article in the Journal of Clinical Psychopharmacology. The article is titled Suicide Associated with Akathisia and Depot Fluphenazine Treatment, and presents case reports of two men who had killed themselves shortly after receiving injections of depot fluphenazine (Prolixin), a neuroleptic drug. One of the men jumped from a rooftop; the other jumped in front of a train. Of course, two case studies don’t prove a causal link, but here’s what the authors concluded:
“Although we cannot be sure that akathisia caused the deaths of our patients, akathitic symptoms seemed to be immediate precipitants of suicidal behavior.”
Although this formal conclusion is worded cautiously, the text of the paper leaves us in little doubt that the unbearable nature of the neuroleptic-induced akathisia was the proximate cause of the suicides.
Evidently Dr. Frances took this matter to heart. Eleven years later he introduced the proposed diagnosis neuroleptic-induced akathisia in DSM-IV (1994). The problem was described in detail, including the observations that “in its most severe form, the individual may be unable to maintain any position for more than a few seconds” and “akathisia may be associated with dysphoria, irritability, aggression, or suicide attempts.” Prevalence was estimated to be 20%-75% of people taking neuroleptic drugs. The entry ran to two and a half pages. (p 744 – 746)
However, in DSM-5 (2013), the name of the problem was changed to medication-induced acute akathisia. The entry was reduced to four and a half lines, and there is no mention of irritability, aggression, suicide attempts, or prevalence. (p 711)
So here are two questions that Dr. Frances might want to ponder. Why did the APA, in the drafting of DSM-5, choose to suppress the critically important information in his earlier article and in his DSM-IV proposal? And why does he himself continue to defend a profession that would put its own guild interests ahead of client safety in such a blatant and unabashed fashion?
I suggest the time has come for Dr. Frances to jump ship. Psychiatrica, the siren that seduced him in his youth, has led him into the twin eddies of error and self-justification, and increasingly shows herself as the destructive monster that devours the people she purports to serve. It is time for Dr. Frances to come over to the right side, and to put his pen and his inside knowledge to good purpose.