"...manufactured epidemics of mental illness." - Psychiatry's 'bible' rolls out...

By Sharon Kirkey, Canwest News ServiceApril 26, 2010 As Dr. Allen Frances read through the list of proposed changes to psychiatry's bible of mental sickness, alarms started ringing in his own mind.

``I was surprised,'' the renowned U.S. psychiatrist says, ``that the proposals managed to be much worse than my most pessimistic expectations.''

By the time he was finished reading, Frances had calculated that the recommendations contained within the first draft for the fifth and latest revision of the Diagnostic and Statistical Manual of Mental Disorders - a hugely influential book used daily by doctors worldwide, psychiatry's official classification of all the ways humanity can go ``mad'' - could unnecessarily trigger wholesale ``epidemics'' of mental illness and expose millions more adults and children to potentially harmful psychiatric drugs.

Frances, more than most, knows the kind of surprises that may be lurking.

Rates of bipolar disorder alone jumped 40-fold in the U.S. after the definition was broadened to suggest that children don't have to experience the typical manic symptoms seen in adults to be diagnosed bipolar - and that depression in kids can be a persistent irritable mood.

``Most of this was not our fault,'' says Frances.

Rather, he blames ``a runaway fad led by thought leaders and pushed by drug companies and advocacy groups.''

``We were remarkably conservative and very careful. We laboured very carefully not to have surprises, not to have unintended consequences,'' says Frances, former chair of the psychiatry department at Duke University's School of Medicine in Durham, N.C. He's now a professor emeritus at Duke.

But once a diagnosis gets out of the bottle, he says, ``it spreads like wildfire in ways you could never imagine.''

This psychiatrists' bible is in the midst of its first major rewrite in 16 years, coming at a time when anti-depressants, tranquillizers and other psychoactive drugs have become the second most-prescribed drug class in the country, second only to cardiovasculars, according to prescription drug tracking firm IMS Health Canada.

Across Canada, pharmacies last year dispensed 61.2 million prescriptions for psychotherapeutics, worth nearly $2.4 billion.

Increasingly, some of the most potent, mood-altering drugs are going to children. Between 2005 and 2009, the number of prescriptions for ``atypical'' or second-generation antipsychotics for children under 13 more than doubled, according to IMS data provided to Canwest News Service. Nearly 700,000 prescriptions for atypical antipsychotics were dispensed for kids under 13 last year.

None of the drugs - which can cause rapid weight gain, increasing the risk for diabetes and other metabolic conditions - have been approved for use in Canada to treat any conditions in children under 18. Instead, doctors are prescribing them ``off label'' to hundreds, possibly thousands of children, amid growing concerns about the potential effects on a child's brain and social development.

In B.C. alone, the prescribing of newer antipsychotics to children under 14 shot up tenfold between 1997 and 2007, according to researchers with the Therapeutics Initiative at the University of B.C.

The changes being proposed for the manual of mental illness - whose sales since 2000 have topped $40 million - would create even more patients for whom psychoactive drugs can be prescribed.

And an entirely new category of mental dysfunction called ``behavioural addictions'' would be created, with gambling as the single, sole disorder for now, but with Internet and sex addiction recommended for inclusion in the appendix as conditions worthy of further study....

Lane says most men, as well as a considerable number of women, would recognize themselves in the criteria for hypersexual disorder. ``It's an extremely alarming precedent to see psychiatrists trying to legislate what are normal sexual desires and how often we should experience them.''

One of the most controversial proposals calls for the establishment of a new condition called ``psychosis risk syndrome.'' The goal is to identify young people at risk of developing a psychotic disorder, such as schizophrenia, and intervene early.

Critics say there are many reasons why teenagers behave strangely, and that eccentric behaviour could be enough to tag a teen as ``at risk of psychosis,'' even when they aren't experiencing frank hallucinations or delusions.

``The DSM-5 says, `Ah, no. These people probably have a precursor of schizophrenia, so we'll treat them prophylactically with powerful antipsychotic drugs in the hope of forestalling the eruption of serious illness that we know to be almost inevitable.'''

But even in the most skilled hands, studies suggest only 20 to 35 per cent of people who get the diagnosis go on to develop frank psychosis.

Meanwhile, Frances worries that the ``false positive'' rate could run as high as three to nine adolescents wrongly diagnosed at being at risk for psychosis for every one correctly identified.

Worse, many of these misidentified youth would be prescribed antipsychotics that can cause one pound per week of weight gain, a greater risk of diabetes and ``likely reduced life expectancy,'' he says.

``I think about 400,000 (American) kids are already on these meds,'' says Frances, adding pre-psychotic risk and temper dysregulation would ratchet it up even further. The more behaviours the DSM medicalizes and the more disorders added to psychiatry's official nomenclature, the bigger the market for psychiatric medications grows.

The first DSM, published in 1952, was a skinny, 132-page spiral-bound booklet containing 128 disorders. Its current edition, published in 1994, lists 357 disorders, and runs 886 pages.

``There's something wrong with that,'' says Dr. Frank Farley, a past president of the American Psychological Association.

``We're seeing too many quote-unquote disorders lurking simply in the extremes of behaviour. We see some extreme of behaviour and we decide it's a `disorder,' that it's out of order with something, that it's not normal,'' says Farley, an Edmonton native who's now a psychologist at Temple University in Philadelphia.

``Are we going to force human behaviour into a kind of `normal' category that, let's face it, is ill-defined? What is `normal' behaviour? That's ground zero. That's job one, to clearly define what is normal, before you start saying what's abnormal.''

There is no reliable biomarker or blood test a doctor can point to and say, `This person has a psychiatric illness.' And so, not one biological test is ready to be included in the DSM, says Frances.

The challenge is finding which diagnosis, according to the criteria, is the best fit. (Insurance companies require a DSM code before they will authorize reimbursement.)

Lane, of Northwestern, questions whether achieving normalcy is doable with so many behaviours now viewed as disorders according to the DSM. ``Is it possible to live a normal life without bumping up against one or more of them?''

In their book, Making Us Crazy; DSM: The Psychiatric Bible and the Creation of Mental Disorders, Herb Kutchins and Stuart Kirk say the manual is intended to describe symptoms of mental illness that can make life devastating for individuals and their families.

But the guidebook goes further, they say, ``by defining how we should think about ourselves; how we should respond to stress; how much anxiety or sadness we should feel; and when and how we should sleep, eat and express ourselves sexually.''

The tome, Kirk said in an interview, has led to manufactured epidemics of mental illness.

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