post by Bill Gardner
Anyone with a clinical or policy interest in mental health -- and this will include anyone concerned about US health care costs -- should listen to this lecture by Allen Frances on the problem of over-diagnosis in psychiatry (see also here).
Frances argues that too many people with mild to moderate mental distress are diagnosed with mental illnesses. This is harmful to people who are diagnosed in error, it is harmful to the 5% of the population with severe mental disorders who have less access to services, it is harmful to the nation because of the rapid growth of spending on psychopharmacological medications, and it is harmful to psychiatry as a discipline. The principal causes of over-diagnosis are the gradual loosening of diagnostic criteria over time, and the unremitting pressure by the pharmaceutical industry to exploit that looseness.
These are familiar criticisms. Nevertheless, this lecture is important for two reasons. First, Frances is an exceptionally lucid and expert speaker. The second reason is who Frances is and what makes him an expert.
Allen Frances is an emeritus professor of psychiatry at Duke, where he was also chair. More importantly, he was the chair of the task force that wrote the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV) and carried out many empirical studies to validate the diagnostic categories. This is probably the most important job in psychiatry. The DSM defines psychiatric diagnoses and is, as Frances describes, a central part of the problem. Frances is not a skeptic about the reality or importance of mental illness. The lecture is his account of the unanticipated consequences of his own work.