But from the insurance companies’ perspective, isn’t it cheaper for patients to take pills than to go into psychotherapy?
Frances: No it’s not. It just seems more costly because there’s more upfront expense. A patient may need reimbursement for 12 therapy visits over three months. But if you step back and think about a lifetime of being on unnecessary medication, which could have been avoided if psychotherapy had been the initial treatment, the lifetime costs are much less to keep people away from medication.
The trouble is insurance companies usually have year-to-year contracts, so they’re not thinking about the trajectory over the lifetime of the individual. They’re thinking about how they can reduce costs in this quarter, and that leads to decisions that are neither economically smart for people nor good for them clinically.
Another prominent critic of DSM-5 has been Thomas Insel, the director of NIMH, who announced that they weren’t going to use it as the template for funding psychiatric research. What do you think of that decision?
Frances: I think it makes absolute sense for NIMH to try to develop simpler questions and, instead of studying heterogeneous DSM diagnoses, to find simpler dimensions for study. So I’m completely on board with the decision. But I was tremendously against the way it was announced, and the overall stress at NIMH, which is overpromising biological advances in psychiatric treatment. We’ve gone through 30 years of an amazing revolution in neuroscience and genetics. But so far, that’s contributed not one iota to caring for a patient. We don’t have a single biological test for mental illness, and our treatments are no better than they were 60 years ago.
The fact is that the brain is the most complicated thing in the universe. We shouldn’t expect quick hits in understanding something like schizophrenia. Schizophrenia won’t be one disorder: it’ll be hundreds of disorders, many different causes that have a common pathway. It’s going to be the task of lifetimes of researchers to tease all this out.
NIMH is promising quick results when we know from the past 30 years it can’t deliver them. Meanwhile, we have a million psychiatric patients in prison because they didn’t get adequate care in the community and don’t have a place to live. A million psychiatric patients were discharged from psychiatric beds in the last 50 years, and a million prison beds—the exact same number—were added for psychiatric patients. This is a shame. NIMH should be in the forefront of trying to help patients now, not overpromising for patients in the future. We need to do biological research, but we also need to be doing research into health services, social context, psychological factors—and NIMH has made itself into a brain institute.
Do you see any indication that the processes leading to diagnostic inflation are changing?
Frances: The drug companies and the health insurance industry have a lock on Washington, DC. But 25 years ago, Big Tobacco ruled the roost: they owned Washington. Who’d have thought they’d eventually be restrained in the way they have? The single thing that would most transform the public health of this country and save us billions of health dollars would be to control drug company marketing. Only in this country can they advertise to consumers. The freedom to distort the medical enterprise through advertising to consumers is unbelievable. The marketing to doctors is distorting the medical enterprise, and the American Journal of Medicine agrees with me.
The DSM system needs to be tightened. DSM-5 is an absolute step in the wrong direction. No one needs to use DSM-5 unless your institution requires it. I think we should take the DSM system out of the American Psychiatric Association (APA). It shouldn’t be that a small psychiatric association controls something that has such an enormous impact on so many societal decisions. You need people who have expertise far beyond psychiatry to determine the long-term consequences of these decisions. You can’t trust the experts in the field. Of course, you need their input, but you can’t have them calling the shots. I think the new drugs in psychiatry are much less dangerous than the new diagnoses. We spend a lot of time making sure the drugs are safe and effective, but no time making sure that new diagnoses are safe and effective.
We need something like the Food and Drug Administration for our field, a broader regulatory mechanism that’s not within the purview of one psychiatric association, particularly because the APA has tremendous financial conflicts of interest. They spent more than $25 million on DSM-5. (We spent $5 million on DSM-IV.) They expect to make hundreds of millions of dollars. The whole thing shouldn’t be a commercial venture. It should be a public trust. At the same time, we need to focus attention away from coming up with more diagnoses and on the whole mental health enterprise, and those people who are suffering greatly, the people who really need help but aren’t getting it.
Allen Frances is author of Saving Normal and leading DSM-5 critic