Saving Normal by Allen Frances, M.D. (2013, HarperCollins)
On page 252 of the paperback edition of this book, Dr. Frances delivers his most-enduring and important message:
Fads cause careless [psychiatric] diagnosis. Clinicians should buck fads, not join them. Wrong diagnoses can do enduring harm that comes with no automatic expiration date. It is almost always better to underdiagnose than to overdiagnose.
This excerpt also exemplifies two of my frustrations with the book. First, it is one of the few examples of such a direct, clear statement (pointed at the correct audience – the diagnosticians). Second, it appears on page 252, not on page 1 where it belongs.
Ultimately, the most disappointing books are the ones that you fully expect to enjoy and yet you finish the book feeling completely underwhelmed. I expected to like this book because, although I have no training in psychiatry or clinical psychology, I have long been interested in the history of science and medicine and I teach subjects closely related to these fields (Neuropsychology and Physiological Psychology). I also teach two courses – The Limits of Rationality and The Psychology of Eating Behavior – in which we deal with how medical fads get started, how people’s reasoning can go astray, how people (even smart people) come to believe weird things.
In the Limits of Rationality course, we discuss the long-standing medical practice of blood-letting. The Greeks gave us both this practice and the Hippocratic dictim that medical doctors first must do no harm. In their book Trick or Treatment, authors Singh and Ernst provide a riveting first chapter in which they posit that aggressive blood-letting led to the early death of President George Washington – a treatment initiated by doctors who were desperate to cure the beloved man. In the Neuropsychology course, I discuss the history of prefrontal lobotomy, a surgical procedure to treat psychosis that earned its inventor a 1949 Nobel Prize. Over a period of 15 years, as Elliot Valenstein describes in his book Great and Desperate Cures, surgery to treat psychosis (and eventually other problems that would today be called depression, bipolar disorder, PTSD, ADHD, OCD, and personality disorder) went from being nonexistent to being performed as often as possible.
One of the reasons I present these histories is to ask my students the question: could this happen today? We all have a tendency to think of these and other treatments (cold water baths, insulin shock, trepanning, and so on) as being relics of the past, as emerging from a time when we didn’t know any better. Sure, there are any number of foolish beliefs today – astrology, reiki, homeopathy, acupuncture, reflexology, iridology – but surely not in accepted medical or psychological practice. The hidden assumption is that we know better now, or that we at least have elevated our standards to such an extent that we would never sanction a dangerous procedure without ample evidence of its effectiveness. Both of these assumptions are unjustified.
This is where Saving Normal by Dr. Allen Frances enters the picture. Dr. Frances was a “thought leader” (to borrow an annoying phrase he overuses in the text) in psychiatry who organized the Diagnostic and Statistical Manual-IV published by the American Psychiatric Association in 1994. The DSM (beginning with the third volume) emerged in the 1980s as a major tool in psychiatric diagnosis, and thus its contents are highly relevant to diagnosis and treatment of mental illness. Each edition of this manual emerges from a years-long project to poll experts and assess the published literature to answer questions like: How broad should the definition of autism be? Should internet addiction be classified as a mental disorder?
Frances argues that, with each volume of the DSM, the number of things that can constitute a diagnosable condition have only increased. Worse, many trends in our society work against his advice above that underdiagnosis is preferable to overdiagnosis. In order to receive assistance and treatment reimbursement, insurance companies and government agencies require a diagnosis. This places a perverse incentive on both the physician and the client to receive a label, even if that diagnosis is inapt or premature.
Frances cites another subversive force: Big Pharma. Indeed, Frances’ focus on the insidious role of drug companies is one of the big disappointments in his book. Frances almost sounds tinfoil hat paranoid about pharmaceutical companies, to such an extent that, despite my own concern about diagnostic creep, I’m tempted to diagnose Frances as suffering from Pharmaphobia.
There is no question that the ease on restrictions in the 1990s allowing direct-to-consumer advertisements of psychiatric medications is an important factor in the current state of psychiatric (over)diagnosis. Frances’ most-compelling ammunition for this concern comes on page 96 where he gives us a full-page table of the multimillion and even billion dollar fines that have been assessed to the Eli-Lilly, Johnson & Johnson, and Pfizers of the world (most since 2010), often for the promotion of off-label uses of an approved drug (an illegal way to broaden their consumer base). Because these drugs are now so overprescribed and lucrative, the drug companies can easily afford to absorb these fines as the cost of doing business. Even a hundred million dollars amounts to nothing more than a “rounding error” in their balance sheets (to borrow another phrase Frances is in love with). Indeed, I was stunned to learn that Abilify, a drug with extremely creepy TV ads, was approved originally not as an anti-depressant, but an antipsychotic. Since schizophrenics make up less than 1% of the population, but since everyone feels depressed to a greater or lesser extent, Bristol-Myers Squibb pursues the much larger market in their ads.
Again, there is no question that the pharmaceutical industry is a player in pathologizing normal behavior, and clearly deserved a chapter in Frances’ book. Instead, however, concern about the industry appears in every chapter, and that overemphasis left me cold for three reasons. First, it was undignified – Frances comes off a bit as a conspiracy theorist, rather than the well-credentialed, impartial scientist-practioner I wanted to see him as. Second, knowing the history of blood-letting and lobotomy as I do, I knew that what is happening today is not a new problem requiring us to seek a new villain. Frances clearly sees a strong correlation between rates of diagnosis and, for example, money spent on direct-to-consumer ads for pharmaceuticals. I see a very old problem that stretches back to Hippocrates with a few new actors on the stage but the same old connecting theme, explored so well in books mentioned above by Valenstein and Singh & Ernst. It’s a problem of how we reason about facts – poorly – examined in another wonderful book called Thinking – Fast and Slow by Nobel Laureate Daniel Kahneman. Third, while Frances does attempt to cover all sides of the issue, one can’t help but feel that far too much print is spent on the pharmaceutical companies, and not enough is spent on those most guilty: the psychiatrists, psychologists, and general practitioners.
There’s a 3-way interaction at place in the overdiagnosis of mental disorder and overprescription of psychiatric medication. You have the drug companies, who advertise directly to the consumer (“Ask your doctor…”) and who provide excessive inducements to doctors and medical societies in the form of free samples and free seminars and the paying of doctors for speeches, research, and testimonials. You have the clients, who do indeed “Ask their doctor” and who may not feel satisfied without a diagnosis and prescription. And you have the health care provider, who is the one who makes the diagnosis and orders the prescription.
All three agents are culpable, in addition to the culpability of other players (like the FDA, the insurance companies, the media). But who is most culpable? Who is most-able to stem the tide? While drug companies can be sued and can be legislated against (I’m certain Frances would like to see the direct-to-consumer advertisements eliminated), they are best viewed as part of the backdrop of modern society that must be taken into consideration. They do what they do – they seek a profit. They are made up of people, but they aren’t people – they can’t be moralized to or reasoned with. If one’s body is beginning to sag one doesn’t outlaw gravity or try to reason with the pull of the earth, one goes to the gym. Pharmaceutical companies are to blame like gravity is to blame – definitely a big part of the problem, but naive to imagine they are part of the solution.
The clients are also culpable. We are gullible – we believe the TV ads, we believe the testimonials of our friends and neighbors. We are impatient – we don’t want to wait for a diagnosis or for time to heal the wounds it can heal. We are emotional – worry about our own health or the health of a loved one can blind us to other considerations. And we are uninformed – we don’t have near the knowledge that the experts have, though the experts should admit they don’t always have near the knowledge they need (because no one does, yet). We’re dealing again with gravity though – this is human nature, it has always been human nature, it is the problem that led to the popularity of lobotomy and homeopathy and blood-letting and accusations of witchcraft. Looking for the solution in more-informed consumerism (chapter 8 of Saving Normal) is also naive. It’s not going to happen for most people who aren’t dealing with a “true” mental disorder, to say nothing of asking someone truly wrestling with schizophrenia, generalized anxiety disorder, or major depression.
And so we are left with the health care professionals. We trust them – we pay them – to give us the benefits of their experience and their expertise. We rely on them to do for us what we cannot do for ourselves. It is them who write the prescriptions. It is them who check the diagnostic boxes on the insurance forms. It is them who accept the speaker’s fees from Big Pharma, and who pass along their free samples to clients. It is them who make a diagnosis on the first visit, when the client is likely to be most distressed and when the practitioner has available the least information.
To his credit, Frances does place much of the blame there, and even with himself (he regrets certain decisions in the production of the DSM-IV and tells stories of misdiagnosis from his own career as a practitioner). The quote I began with shows Frances at his best, clearly targeting his colleagues with blame (though the paragraph does end with another reference to the drug companies which waters down even that good advice). His advice in a section called “Stepped Diagnosis” is on the right track, as is his chapter on the best and worst of psychiatry. His advice to delay diagnosis to later appointments, to carefully consider current stressors in a client’s life that may reduce with time, and to carefully rule out substance abuse and side effects of prescription medication were right on target and, if adopted, would certainly alleviate some of the crisis. But all these admonitions are stretched too thinly in a book that is about 50% too long. Although retired from the profession, he too-often seems unwilling to call out his former colleagues, hiding behind unnamed “thought leaders” working at “prestigious universities” and pseudonyms rather than giving us a good history with names and dates of diagnostic fads gone astray. (In fairness, Frances does not want to give ammunition to the anti-psychiatry crowd, such as the Scientologists; Frances believes in the profession and wants to strengthen it. Admittedly, this is a difficult balancing act.)
Finally, the book is disappointing because Frances is clearly not a writer. The book is badly organized and rhetorically less effective than it could be given the central truth of Frances’ position. Rather than start the book with one of the bad diagnosis stories of chapter 9 (chapter 9!), or one of the analogous medical fads from history (as Singh & Ernst did with the blood-letting of George Washington and the forced labor of suffers of scurvy), Frances begins with a tedious and rambling attempt to define the word normal. The first three subheadings in the book are “How does the dictionary define normal?”, “What does philosophy say [about normal]?”, and “Can statistics dictate normal?” I am forced to believe that there was no editor for this book or the editor had been prescribed a stimulant and thought this would make for a gripping opening (talk about your delusions of grandeur). In all this philosophizing about the definition of normal, he never really challenged his readers with a borderline case, or put us in the head of a diagnostician to help us appreciate why two clinicians might disagree.
Rather than get us closer to the point, chapter 2 takes us even further from it. We are given a superficial and almost random history of ideas about medicine, discussing spirits, priests, and shamans, but missing so many more vivid and relevant examples – witch trials, blood-letting, scurvy, homeopathy, lobotomy. Curiously, more interesting history is left to a later chapter, when we finally learn about the diagnostic crazes of neuroasthenia and hysteria and the more modern (but underexplored) explosion of multiple personality disorder. So much of the history Frances chose to present could have been scrapped in place of a deeper discussion of the chapter 5 topics of autism, ADHD, bipolar II, and childhood bipolar disorder. I did learn a lot about these topics, but a more skillful writer, I think, would have been better able to relate the horrifying consequences of overdiagnosis of these categories.
After all this, there are still pages I would consider assigning in my classes. That I can’t recommend the book as a whole is frustrating, because the author is credentialed, the message is incredibly important and relevant for our student population, and some – but just some – of the vignettes are powerful and compelling. When the 75-page abridged version comes out, we might really have something. Put chapter 9 first, kill chapters 1 and 2 and most of 4, and collect all the complaints about Big Pharma in one chapter and be done with it. That would be a better way of Saving Normal.