KELLIE NEWSOME: Did 9 out of 10 college students really develop a psychiatric disorder during COVID lockdown? In our final interview with Allen Frances, we try to restore some diagnostic boundaries. Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

CHRIS AIKEN:  I’m Chris Aiken, the editor-in-chief of the Carlat Report.

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

CHRIS AIKEN: On a good day, psychiatry follows the laws of science, but most of the time, it follows the law of unintended consequences. You give Benadryl, and it makes the patient stay wide awake. You give Modafinil, and they fall asleep. Or, like the time I advised a depressed patient to try smiling more often in social encounters. He came back and said that was the worst advice anyone had ever given him. When you're as depressed as I am and you try to smile, you just look like a freak. It scares people.

KELLIE NEWSOME: One such unintended consequence happened in the 1990s, when the APA launched DSM-IV just as the pharmaceutical industry was launching the largest crop of new psychiatric medications this world has ever seen. Allen Frances helped birth that baby, and he came to regret some of its effects. Where people once turned to community, faith, therapy, and poetry, they now turned to a clinical manual of mental disorders to understand the problems of everyday life, and there they found them, from overeating to social isolation, all with FDA-approved medications to pave over the suffering road.

CHRIS AIKEN: The best psychiatrists pivot when the law of unintended consequences strikes. When their patient calls with acute dysphoria and agitation after starting an antidepressant, they don't say, just give it more time. They stop the med and reevaluate the diagnosis. In 2013, as the new edition of DSM-5 was going to press, Allen Frances pivoted and wrote a book that changed the way I think about diagnosis: Saving Normal: An Insider's Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. Quite a title. Well, here is how it changed me, here is an example, the DSM is filled with all of these arbitrary cutoffs, like you need four days to have hypomania, two weeks to have depression, six months for generalized anxiety. But Frances explains that what is really at stake here is whether the disorder is self-correcting or not. The time frame is only a rough marker of that. So, let's say I get criticized at work, and I come home all down and dejected, and I spend the weekend in bed. I might not be my usual self here, but it would be a stretch to say that I have clinical depression after only three days of acting like this. But let's say it keeps on. I would hope that eventually, at some point, I would get so bored of this avoidant, isolated behavior that cabin fever would set in, and I'd desperately call a friend to go out. That is self-correcting. But what if I don't self-correct? What if staying in bed all day just feels good, feels better, and better because I'm less anxious, and I don't have to face my problems? Out of sight, out of mind. What if this goes on for two weeks, and I'm still staying in bed, acting depressed and withdrawn? At some point, we draw the line where the behavior is not likely to self-correct. This varies by person and culture. But DSM chose two weeks for depression, and I find this very helpful in practice because people with mood disorders have rough periods and down days, just like the rest of us. It doesn't always mean that they're having a new episode, and we can't always change their medication every time it happens. So, what do we do? 

KELLIE NEWSOME: In practice, I ask patients how long it’s been going on, but I focus more on what they’ve done to correct the problem, and I’ll ask them straight up if they think they’ll be able to shift – to pull themselves out of it by changing how they are living – or if they think they are permanently stuck, that’s a different question than just asking them how distressed they are. And I find most patients have pretty good instincts about this. If they’re stuck, they’re going to need something external to pull them out. That might be a med change, but it might be more frequent sessions along with a behavioral intervention. Sometimes, the patient is very distressed, but as they talk about the problem, they realize there is a light at the end of the tunnel, and they haven’t lost faith in their own ability to get to that brighter spot.

CHRIS AIKEN: When I interviewed Dr. Frances in 2022, we were all coming out of COVID lockdown, and with the pandemic came a lot of surveys showing alarming rates of depression and mental illness in the general public, like a survey that concluded 95% of college students had mental health problems during the pandemic, 95%! That sounds a bit like diagnostic overreach. So, I asked Dr. Frances what he thought of that.

ALLEN FRANCES: Well, I wrote a whole book called Saving Normal, and the theme in the book is that we should be very attentive and stop shamefully neglecting the needs of the severely ill and that we've been overdiagnosing people who have average, expectable emotional reactions to the difficulties of life. And the other thing is that epidemiological studies never count correctly. Epidemiology always miscounts because it's a telephone interview or a self-report thing on the internet that doesn't account for clinical significance. Having painful symptoms is not equivalent to having a psychiatric disorder; those painful symptoms have to cause clinically significant distress or impairment, and that can't be done in a self-report interview on the internet or by telephone lay interviewer. So, when you see the rates changing dramatically of anxiety and depression, that means that the population is appropriately more anxious, more depressed, grieving for losses of loved ones. But that's the human condition. That's not psychiatric disorder. When the society faces a major stressor, people are going to have emotional symptoms, but that doesn't make them mentally ill unless they have clinically significant distress or impairment. So, what I usually say is that human nature is very stable, ways of assessing it are remarkably unstable, changeable, and easily manipulated so that it looks like everyone's sick. The exceptions are, I think that we should expect more people presenting with brain fog because of either direct effects of COVID on the brain or autoimmune effects. We should expect more somatic symptom problems that aren't somatic symptom disorder. They shouldn't all be seen as psychiatric because they're a reflection of the effects and long-term effects of the virus, and we shouldn't always jump to a default psychiatric diagnosis for problems that we just don't understand very well. I think eating disorder has actually gone up, and I think that's a combination of the isolation of caused by COVID and the fact that there are very noxious internet support groups for having pathological eating habits. There's tremendous support and advice on the internet on how to become anorexic and how to be a good bulimic, and I think the actual rates are influenced by the toxic effects of the internet. I think that we're probably going to see a lot more people who are withdrawn from society as a result of looking at screens for a couple of years and becoming much more attached, and Meta, this new Facebook thing, absolute disaster for humanity in driving people to a virtual world and away from real human contacts.

KELLIE NEWSOME: Let’s pause for a preview of the CME quiz for this episode. Earn CME for each episode through the link in the show notes.  

1. Which therapeutic school does Dr. Frances invoke to argue against aggressive use of psychopharmacology?  

A. Freudian 

B. Hippocratic 

C. Behavioral 

D. Humanistic

ALLEN FRANCES: So, I think that by and large, most of the change in rates of disorder are due to misinterpreting, mislabeling, adaptable responses, anyone who's not afraid of COVID. Is in danger of not getting vaccinated and dying or hurting other people and their families. You should be afraid of COVID. Fear of COVID is not a mental disorder. Anyone who is grieving the loss of a loved one, the loss of a job, the loss of income, financial problems, by and large, these reactions are normal reactions and adaptive reactions—built in by evolution so that we respond to painful events. Will some people be thrown over the border towards real mental illness? Sure, and we need to provide more help for them, but we shouldn't feel that everyone in society needs help because once you spread yourself so thin, you can't take care of the people who really do need help, and the severely ill have been terribly neglected during the COVID epidemic, people's schizophrenia, twice the rate of death as the normal population, and we haven't devoted nearly enough resources to them. We shouldn't be thinking that everyone who has anxiety problems or sadness needs mental health treatment.

CHRIS AIKEN: Like I said earlier, your idea of homeostasis has helped me a lot in understanding whether someone has mental illness or not and what we need to do to intervene. How do you think that this idea of homeostasis, whether something is self-correcting or not, should influence how disorders get into the DSM?

ALLEN FRANCES: Well, I have another way of looking at it. I think that whether you're thinking about which diagnosis should go in the manual and which should be left out, or you're thinking about, should I be giving a mental disorder diagnosis to this person? I think the best way of looking at it is utilitarian. I don't think that there are good definitions in an abstract way that let's say, gaming disorder should be in or out of the manual. It's a question of will it help more people or hurt more people in the gaming disorder part of the manual, and with an individual person, it's will, over the long run, giving this diagnosis be more helpful or harmful. In the short run, the diagnosis makes the person who gives it feel better may make the patient feel better, but it can have stigmatizing impacts, reduced expectations on the part of the individual and the people around them, and massive overdose of medication. And so I like the idea of diagnosis being written in pencil, not to make a diagnosis on a first visit, if you possibly can avoid it, to keep an open mind that people will get better, that many people come to us on the worst day of their lives, and if you just watchfully, wait provide normalization simple psychotherapeutic techniques or regular psychotherapy that many people who appear to need a diagnosis won't need a diagnosis three weeks or a month down the road. Particularly, that is true in primary care. Psychiatry these days, we see people by referral who often have been selected for severity, but in primary care, many people are being diagnosed and given medication who don't really need it, and for most of them, the side effects of the medication over the long haul are much more dangerous and costly than whatever short-term gain they can get. Most people who present with transient problems that result from stress and don't have a long pre-existing history of more severe psychiatric disorder or chronic psychiatric problem, most of those people are going to do fine with time, normalization, watchful waiting, and simple increasing supports in their life, reducing stress in their life, and many of these people do a lot better than never getting a diagnosis. Partly because once a diagnosis is made, it tends to haunt people for life. 

CHRIS AIKEN: Patients who come to see us these days often live in a med-centric world, where medications are the answer to everyday struggles. How can we help them engage with your approach?

ALLEN FRANCES: It really is an issue of time. If the average GP is seeing a patient for 10 minutes, that patient's been primed to wanting something concrete out of the 10 minutes, and writing a script is the best way of getting out of the office happy. You're sort of condemned to having a 12% rate of antidepressants in the general population. If the GPs had more time and got to really know their patients, as Hippocrates suggested if they got to know people and not just treat symptoms and tests, they would be prescribing a lot less medication because they could say, why don't we look at this and see, yeah, you're up against a tough situation, now, anyone would feel bad. These things tend to sort themselves out with time, and with changes you can make and with help from the people around you, that's normalizing it. It's education. Let's see what happens over the course of the next few weeks, a month or two, we can always begin medication later, and even in psychiatry now, a lot of psychiatrists are forced to do 30-minute evaluations, and they don't have time to get to know the patient. The less you know the patient, the more you're going to do in Hippocratic terms, the more you're going to do harm, and part of the harm will be by overdiagnosing and over-treating, and to bring it a full circle, that's where Hippocrates started, on his island of Kos, worried about the fact that the competing medical school, a hundred miles away in Knidos, was overdiagnosing and over-treating. He was seeing the train wrecks from their treatment.

KELLIE NEWSOME: Hippocrates worked on the Greek island of Kos around 400 BC, and his approach to depression shares some things in common with what we do today. He was the first physician to use sunlight to treat disease. Built into his health retreat were solariums, or "Helios" sunrooms designed to promote physical and mental well-being. In the 1980s, Norman Rosenthal and colleagues at the National Institute of Mental Health rediscovered light therapy for seasonal winter depression. Later trials showed it works for bipolar depression, PTSD, and non-seasonal depression, and last month an analysis of 11 randomized trials in JAMA Psych concluded that bright light therapy successfully augments antidepressants even in the Spring and Summer, effectively doubling the remission rates compared to placebo therapy with a low-intensity light. Dr. Aiken keeps updated directions on his website, chrisaikenmd.com/lighttherapy, and he recently changed his top pick for a lightbox

CHRIS AIKEN: Thank you for joining us, Allen. And I've enjoyed your talking therapy podcast. Do you have any more books coming up?

ALLEN FRANCES: I'm done. Yeah, it's great that you're doing this. I think that you don't reach people with writing scientific articles. This is the way.

KELLIE NEWSOME: Allen Frances is a psychiatrist, psychoanalyst, and Chair Emeritus for the Department of Psychiatry at Duke. He helped build DSM-IV and then went on to challenge DSM in his 2013 book Saving Normal. He has a popular feed on X/Twitter, hosts the Talking Therapy podcast, and his latest book is Twilight of American Sanity: A Psychiatrist Analyzes the Age of Trump. Dr. Frances is the emeritus chair at Duke Medical Center’s Department of Psychiatry. Dr. Aiken is still posting one practice-changing study a day, and you can now follow him on the BlueSky app in addition to his usual feeds on LinkedIn, Twitter, and Facebook; search for Chris Aiken MD. Subscribe to the print edition of the Carlat Report and get CME credits and $30 off with the promo code PODCAST. Thank you for helping us operate 20 years free of industry support.