Thursday, January 23, 2014

Everyone is pixilated but me and thee, and I wonder about thee

kw: book reviews, nonfiction, psychology, psychiatry, standards, diagnostic procedures, polemics

The quaint country saying that titles this post may soon become reality, except that people in very official capacities will be enforcing it. Not a moment too soon, Allan Frances, M.D., who chaired the DSM-IV task force, has written Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life.

DSM refers to Diagnostic and Statistical Manual of Mental Disorders. Editions I and II, released in 1952 and '68, were innocuous, and defined criteria for diagnosing a few dozen psychiatric syndromes. DSM-III (1980) and -IIIR (1987) greatly expanded the reach of psychiatry. Seeing how the diagnoses were being abused and expanded into "normal" territory, Dr. Frances tried very hard to establish standards for DSM-IV that would alleviate the problem. He didn't know the hydra-headed monster he was up against! The first direct-to-consumer drug advertisements aired in 1983, just over 30 years ago. By the time DSM-IV was released in 1994, drug companies had a 12-year head start inflating diagnoses, psychiatrists were also eagerly ramping up their business, and family physicians were beginning to get in on the largesse afforded by official recognition of a host of "afflictions" that were formerly considered within the spectrum of normal, or at least, ordinary, behavior and experience. Most of those diagnosed under the new guidelines will be, not the truly ill, but the "worried well."

My own experience with this has been rather peculiar. DSM-IV introduced Bipolar II (BP2), for persons with hypomanic (less manic than full-blown mania) episodes alternating with depression. In 2002, in the aftermath of a serious personal crisis and loss of a valued friendship, I could not shake off persistent depression after several months. My family doctor at first recommended an antidepressant. I tried several and the third try was Zoloft. When I saw him a few weeks after starting Zoloft I was bouncing off the walls. Now he said it might be BP or BP2, and sent me to a psychiatrist for a definitive diagnosis. BP2 it was, and after some counseling and trying a couple of anti-epileptic medications, I decided to learn to live with it. I could not find a doctor willing to prescribe Dilantin, which I had already learned is the most effective anti-epileptic to use for BP or BP2. It is old, off patent, and thus denigrated. Nobody seems to care that it works.

A few years later, after another depressive episode that included some suicidal ideation, yet another psychiatrist prescribed Abilify. It is very expensive, but it seemed effective. I noticed my weight gradually rising, so after a few years I stopped that, and I have determined that is that (I subsequently also lost 20 lbs; losing weight is a great antidepressant). I have cognitive methods to deal with my moods. Prior to 1995 I'd have received the "paid friendship" of a counselor as the only therapy, and it would have been sufficient. I'd have saved a few hundred dollars, and my insurance company would have saved 20+ thousand. By the way, my experience with psychiatrists who will accept an insurance plan such as Compsych is that they are really bottom of the barrel. I could never afford a "real" shrink, but brief contact with one or two made me realize how bad those I'd seen really were.

That thought brings me to a late section of the book, in which Dr. Frances recommends a few things. One is expanding the number of psychiatrists. Who recalls when the baseball leagues were expanded? What happened? The average level of play went down. Think about it. Major league baseball could only accommodate a few hundred of the very best players. The cutoff was arbitrary, limited by salary caps and other regulations. But there were, in minor league teams, players just a tiny bit less talented than the ones who'd barely made it into the majors. However, there were not several hundred at that level. Revising the leagues nearly doubled the number of players. Most of those added were well below star status. If we do encourage a great expansion of psychiatry in America, guess what the average newcomer will be like. Maybe a few will be really great, but not most. I must add that I do agree with many of the author's recommendations, just not this one!

Now with DSM-5 just released, which has much greater potential for diagnostic inflation and other abuses, it is squarely on our shoulders (we, the potential patients) to say "No!" to the attempts by drug companies and newly minted psychiatrists and newly empowered family doctors to redefine almost anything less than "I am perfect in every way every day" as abnormal and requiring treatment, the costlier the better. Here is my own short list:

  • I decided long ago not to allow a doctor to prescribe any drug that I had seen advertised on TV. Make that your New Year's resolution, in place of the ones you've already broken.
  • Make sure you have at least one or two good, good friends you can talk to when you are feeling bad.
  • Don't allow the schools to medicate your kid. A normal grade schooler is inquisitive and active and has a short attention span. The current definition of ADHD covers more than 75% of children! But only if we allow it.
  • If you do have a terrible affliction that time and talk ("watchful waiting") does not alleviate, then get help, but do not let your family doc prescribe Seroquel or something. Get referred to a psychiatrist and demand conservative treatment from the outset. The stronger drugs can have permanent debilitating effects, and if you use one that doesn't work anyway, you could find yourself in worse shape and with little effective help.
Well, this is a bit more scattered than usual. Read the book, it is an eye-opener.

I finished the book on the date of this post, but I am writing it 4 days later. I back date posts in such cases. I was out of state, and it always takes me a while to get over plane rides, but the trip was very good otherwise.

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