DIAGNOSIS INFLATION

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Episode Transcript

(00:00):
Welcome to the Psychological Theories Podcast.In this podcast, we take a journey
into the human mind with one psychologicaltheory at a time. So let's begin.
Welcome back everybody. Well, todaywe have a great guest, doctor
Allan Francis. If you haven't heardof him, you're going to hear about

(00:21):
him today. He's an American psychiatrist. He's currently Professor and Chairman Emeritus to
the Department of Psychiatry and Behavioral Sciencesat Duke University School of Medicine. In
addition to that, you might wantto follow him over at Twitter. Alan
Francis. It's a L. L. E. N. Francis is f
R A N cs MD. AlanFrancis, MD is the author of two

(00:42):
great books, one called Twilight ofAmerican Sanity, a Psychiatrist analyzes the Age
of Trump, and another book thatI really love. We're going to be
talking about saving normal, so we'regonna look at diagnostic inflation today. If
you're not familiar with it, youwill be after today's discussion. By the
way, you can also catch doctorfrancis great podcast and hoighly recommend, especially
if you're a graduate student in counselingor therapy. Co catch Talking Therapy with

(01:07):
Doctor Goldfried and Doctor Francis. It'sreally a great podcast. Or get started,
you know what to do. Makesure to share, subscribe hit that
I like, butud you don't likeit, that's not like any more time.
Welcome to the show, Doctor Francis. Welcome sir, Good morning,
Good morning. You know this hasbeen so interesting reading your books. And
I want to start off with thisbecause I want to get your your thoughts

(01:29):
on this because when I lecture inthe class, we start off with a
video with doctor Saz, doctor ThomasSas, and I'm seeing some parallels a
little bit because he was really concernedwith the how would you say, loose
definitions with the broadening of the umbrellacapturing too many people. And I know
he probably has a little different mindbent than you did in regards to that.

(01:49):
But what did you think about Saz'swork? Well, I have a
great story about that. Tom Sasand I had dinner in the mid seventies
and he was at that point Ithought, half right and half completely wrong.
He was half right in saying thatmany people were being overdiagnosed as a
psychotic and schizophrenic, being warehoused interrible state hospitals. He was half wrong

(02:15):
because he said all diagnosis was amyth and that we should give our patients
complete freedom to do what they feltwas right, including suicide, and all
labels caused more harm than good.So I looked at him and I said,
Tom, suppose it's your son andhe's psychotic because of taking medication for

(02:38):
the cortisol, medication that can drivepeople nuts, taking it for medical illness,
and he wants to kill himself?Are you going to let him kill
himself? And Tom looked at meand he smiled a crooked smile and said,
Alan, I'm a father first anda libertarian second. So I felt

(02:58):
that that Tom and the people ingeneral, the anti psychiatry movement, which
he was an important father of,that the anti psychiatry movement that says all
diagnosis is wrong all psychiatric treatment ismore harmful and helpful. I think they're
out to lunch and dangerous at thesame time. I'm equally distrustful of people
who are just promoters of psychiatric diagnosisand recommend medication for everyone. That medicines

(03:24):
that are enormously useful for the feware harmful when they're prescribed carelessly for the
many, and that we should usepsychiatric diagnosis, shouldn't use it clinically when
it's useful, but not worship it. DSM is not a bible, it's
a clinical guide. And I equallydistrust people who just do DSM diagnosis and

(03:46):
don't get to know their patients beyondthe diagnosis, as I distrust people who
say that all diagnosis is useless.That's really fascinating. You had dinner with
them, you said, yeah,yeah, it was an interesting character.
Well, he was very different inperson than he was when he was on

(04:08):
stage. Oh was he? Yeah. He came across on stage as this
angry guy who's against everything, andpersonally he was much more reasonable, much
more He was much more moderate thanthe Saussians. That seems to be a
pattern for a lot of these individualsthat go on camera these days, and
also for leaders to maybe be moremoderate than followers. Oh that's interesting,

(04:30):
that's an interesting analysis. Let's goover. So tell us a bit about
your book in regards to this.What motivated you to write it. I
know you talk a lot about itin your podcast about your issues with DSM
four When you were at the headof the joint task force over there.
But what did you What did youto write the book? Well, the
impetus to write it started right withbeginning my beginning current psychiatry, in that

(04:56):
we terribly this was in the midsixties late sixties, terribly overdiagnosed people as
schizophrenic, and we gave people waytoo much medication. And so from the
very beginning of my career I wasworried about the fact that although diagnosis and
psychiatric treatment could be very useful whendone carefully, it could be very harmful
when done carelessly. I wrote apaper I guess it's forty two years ago,

(05:19):
and no treatment as the treatment ofchoice that I saw in my political
practice and supervision that many patients actuallygot worse than therapy, and it was
very important not to do harm,the hippocratic osis first, do no harm.
So shortly after that wrote a bookcalled Differential Therapeutics, Who do we

(05:41):
treat and how do we treat them? That we shouldn't have a hammer and
be seeking nails. I think thereason I was appointed head of the DSM
four Task Force was because I hadthis conservative feeling about diagnosis. The system
had expanded greatly after nineteen eighty andDSM three, that many people would not
have considered psychiatric patients when they fellasleep before the publication of DSM three would

(06:04):
have been considered psychiatric patients the morningafter when it was published. And some
of this was useful that people weregetting psychiatric labels that described what was previously
suffering they didn't understand, and theygot treatment for conditions that previously were not
described and were useful to describe,like PTSD. But there were also people

(06:27):
who were getting unnecessary diagnosis as thesystem loosened the criteria for being mentally ill,
as there were more and more diagnosesavailable in the DSM, as the
standards for making the diagnosis were loosenedfor each of the categories, many people
who were mildly distressed transient problems thatwould get better on their own were being

(06:50):
labeled with a diagnosis. And onceyou get a psychiatric diagnosis, it can
haunt you for life. It's veryeasy to give a diagnosis, it's very
hard to take it back. I'vealways said that psychiatric diagnoses should be written
in pencil, because unless you're reallysure of something, you shouldn't be stating
it. And it's very hard tobe sure of a diagnosis after one visit

(07:12):
or even a couple of visits.So the effort I had in DSM four
was to put a halt to thegrowth of the system. We established a
very high standard for making changes.There had to be thorough literature reviews,
data re analyzes, field trials,and we were hoping to stop the rapid

(07:33):
increased in the number of diagnoses andto reduce the threshold kind of inflation that
made it easier to get the existingdiagnoses. We succeeded to an extent.
There were ninety four proposals in DSMfour for new diagnoses, and we accepted
only two, but both of themresulted in fads of excessive diagnosis that there

(07:59):
was a fad of We added aspergersas a form of much milder autism,
and we did careful field trials thatsuggested that this would increase the rate of
autism by three times. Within justyears, the rate of autism increased by
forty times, and now the rateis like one in forty where it used

(08:20):
to be one in three thousand.There's been this tremendous increase in the rate
of diagnosis of autism. It's notthat the people have changed so much.
It's the way we assess them that'schanged. And many people who were maybe
normally eccentric have particular hobbies and interests. Nerdy who would have been considered normal

(08:43):
and probably should be considered normal,are now considered to have a mental disorder,
and although that for some people isthe kind of badge of honor,
for many others is stigmatizing and troubling. Similarly, we ended bipolar two and
that led to for good reasons,if you're interested, we get of them.
But it led to a tripling inthe number of bipolar patients compared to

(09:05):
the number of unipolar patients. Andthat was a good thing in the sense
that people who previously might have beengiven antidepressants that would make them have more
episodes of mania covered them. Buton the other hand, the drug companies
pushed the idea that antipsychotics were goodfor bipolar disorder. They pushed bipolar disorder,
and so many people received antipsychotics theyshouldn't have had. This is a

(09:28):
very long winded answer to say thatfor a very long time, I've been
concerned about the proper use of psychiatricdiagnosis, seeing it as essential for the
management and for the helping of peoplewho with severe illness, but worried that
the fuzzy boundary was normal. Manypeople get diagnoses and treatments that may do
them more harm than good. No, I think it's great. You wiped

(09:52):
out a bunch of questions I havefor you that answer, which is good.
And that's the interesting thing about fadsand psychologist. I think you mentioned
it before and therapy. I hadn'tthought about it, but then almost everything
in society has some kind of fadthat pops up all of a sudden and
everybody go, oh, look atthis, this is something new, and
it seems like we're susceptible to itobviously as well, which would really be

(10:13):
fascinating to me. But I guessone of the things I read yesterday,
I don't know if we saw ifthe UK had called for a reduction an
antidepressant prescribing because they said it wasway too high. Do you think it's
trying to go the other way now, or the pendulum or some people are
seeing it, or is this kindof an anomaly over there in the UK?
Oh? No, we're worse thanthey are in terms of the rate
of overprescription. Antidepressants. Eighty percentof antidepressants in the US are prescribed by

(10:39):
primary care doctors. It's usually doneafter a twelve minute visit. The individual
is probably coming on the worst dayof their lives, often with fairly mild
and transient problems related to a recentstress, trouble at work, trouble in
marriage, divorce, trouble with kids, things that usually you will get better

(11:00):
just with time mutchful waiting. Butin order to get paid for the visit
and in order to get the patientout of the room happy, the primary
care doctor will often prescribe an antidepressantas if there's no risk attached to that.
The trouble is there are risks attachedto the antidepressant, and one of
the problems is that if you starta pill on the worst day of your

(11:26):
life, even if the pill isjust a placebo, you're going to get
a feeling that the pill made youbetter. If you get better within a
couple of weeks, and very oftenit won't be the pill that made you
better. It will be time reductionof stress placebo effect. But once you're

(11:46):
on the pill, you're not goingto want to stop it because you feel
better and you're afraid that if youstop it, you'll get worse again.
So for a percentage of people stayon medicine for years, decades, sometimes
a lifetime, but they didn't needto first place. And what makes this
even more poignant is that the medicinesoften have withdrawal effects. So if you

(12:07):
try to abruptly stop the medicine,you begin having withdrawal symptoms, but it's
very easy to confuse these with arelapse of the original condition, and so
people will stay on the medicine toavoid withdrawal symptoms. We teach people how
to prescribe, and any moron canprescribe medicine. We don't teach people carefully
how to deprescribe medicine, and deepprescribing requires slow reduction in dose over a

(12:35):
fairly long period of time. Butstopping any psychiatric medicine quickly is likely to
lead to withdrawal symptoms. And soI think that both in England here most
of the developed world now, thedrug companies have permeated primary care also have
convinced psychiatristies the medicines too liberally,and at this point it would be wise

(12:58):
to reduce the use of medications formilder and transient problems. At the same
time, we have the opposite problem, the terrible crul paradox is that people
who have mild problems are way overtreated, whereas people who have severe problems have
great trouble getting medication at all.We currently have six hundred thousand people homeless

(13:20):
or in jail because they have severepsychiatric conditions and couldn't get treatment. So
what we need to be doing isensuring much more careful prescribing, slow prescribing,
often deep prescribing for people with mildto moderate and more transient problems that
are stress related, reactive to theirlives. At the same time, we

(13:41):
need to be greatly increasing the accessto treatment for people with severe psychiatric issues.
Currently, when in many of thebig cities you walk out doors,
you're going to see a homeless person, and there's one chance in three that
that homeless person is homeless partly becauseof a mental illness. That's so true.

(14:01):
That's so true. By the way, again, folks, we're talking
to doctor Alan Francis. You canfind them on Twitter Alan Al E.
N. Francis frin cs MD,Alan Francis MD over at Twitter. You
know, I guess I'll put thesetwo questions together. Do you think diagnostic
inflation has also increased due to thewe're rulling one of two countries in the

(14:22):
entire world that advertises directly to theconsumer with the pharmaceutical companies. And do
you think GPS are also a littlebit responsible? I hear a lot of
GPS when when patients go in theykind of sometimes will give certain types of
psychotropic medications like tic TACs. Doyou think either one of those two contributes
or well both, I think andthey're related. As I said before,

(14:46):
eighty percent of all psychiatric drugs areprescribed by GPS. Eighty percent, it's
ninety percent. Of The benz ofthe anthipines and bendz of the azipines should
almost never be used for psychiatric problem. The risks of addiction and all the
problems associated with addiction is so great, the benefit of ends of the acipins
and psychiatry so little. I saythey should never be used. The anti

(15:11):
depressions eighty percent primary care doctors,the ADHD stimulant drugs sixty percent prescribed by
non psychiatrists, and even the antipsychoticshalf of them prescribed by primary care doctors.
So the biggest problem with diagnostic inflationand with overtreatment with psychiatric medications clearly

(15:31):
in primary care practices, not byaccent. The drug companies discovered they can't
directly advertise their drugs, so youdon't see the drug companies, and now
they don't advertise. This is aproblem in the past that lingers in the
present. But when they were advertisingreally heavily, which they did remarkably heavily

(15:52):
until the patents started running out,When they advertised heavily on TV, on
magazines and networking, they were tryingto convince people about diagnosis, not about
their particular product. The theory wasif you could increase the pool of people
who had to diagnosis and then saidask your doctor, that that would by

(16:15):
itself result And they were right.It turns out that if you do a
commercial for a psychiatric drug and wouldask your doctor, and the commercial will
never be about the drug. It'llalways be about diagnosis. You know,
it will be educating the public aboutbipolar disorder, educating the public about ADHD.
When someone asks the doctor for medication, they're twenty times more likely to

(16:38):
get it, twenty times to getit. So the idea is you brainwash
like for ADHD, you brainwash patients, you brainwash parents, You brainwash teachers
to ask doctors to solve problems.And the minute you ask, oh,
do I have ADHD, the oddsof getting an ADHD medication jump by twenty

(17:03):
times, so they are inundated.The media in an effort to sell psychiatric
ills as a way of selling psychiatricpills, and diagnostic inflation would largely generated
by drug companies. You know,it's so interesting because it reminds me a
lot when you start school. Maybeyou went through this as well. I

(17:26):
know I did. Most people dowhen they go through like abnormal psych they
start thinking they have all the disordersthat they're reading about, like oh I
have generalizing oh I have this,and then they realize it isn't because I
guess they just use that tactic.How interesting The idea is that before making
a diagnosis, it's not just amatter of meeting the specific symptom criteria for
that diagnosis. There also is supposedto be an evaluation of clinical significance.

(17:52):
There is the person's the aggregate ofthe person's symptoms rise to the level of
severity and pervasiveness to cause significant enoughdistress or impairment that we should be giving
a diagnosis of mental disorder, andthere's always a risk benefit when you give
a diagnosis. Are the possible benefitsof getting this diagnosis because the symptoms are

(18:15):
sufficiently severe clinically significant distress or impairment, it's worth giving the diagnosis and worth
treating it. Or are the risksmore important than the benefits when you're talking
about severe psychiatric illness? Is noquestion in the world the benefits of the
diagnosis are overwhelming. The risks arethere, but the benefits are overwhelming.
The more you get towards the fuzzyboundary with normal, the more likely it

(18:37):
is that the benefits will be slightbecause time, by itself support reduction of
stress placebo effect. All have workingin the direction of this will get better,
whereas the risk then proportionally seen,are much more important in evaluating whether
to give the diagnosis, whether itbe in the treatment. And what we

(19:00):
have in America is this crazy paradoxwhere if someone comes into a primary care
office complaining of distress of everyday life, they're very likely to get a pill
as a way of getting them outof the office happy. So we have
this huge over diagnosis and overtreatment ofthe worried well and the mildly psychiatric,

(19:21):
who might do better with watchful waitingand psychotherapy. At the same time,
the severely alerted neglected. There's notreatment for them. They don't have insurance,
they're neglected, they're on the street, they're in jail. And what
we should be doing is providing lessdiagnosis and less treatment for the mildly people
with mild symptoms, they're transient,likely to go away, much more treatment

(19:42):
and diagnosis with people who have severeillness. We have everything up backwards.
Not too surprised by the way.Again we're talking to doctor Alan Francis.
The book is called Saving Normal andInsiders Revolt against out of Control Psychiatric Diagnosis
DSM five, Big Pharma, TheMedicalization of Ordinary Life. If it's a
fabulous read, if you have anybodywho's got psychiatric issues, you, yourself,

(20:04):
or anything, I really recommend readingthat book. If you're a student,
highly recommend it. Doctor Francis.I do have a few questions left.
I wanted to get to here.You know, you mentioned something about
the clinical significance of the diagnosis,and it reminds me of GAFF, and
I got that has to ask youthat question what happened to that thing?

(20:25):
Because I always liked GAFF the Globalassessment functioning. Do you know why they
took that out? Yeah? Itreally stupid and maybe too technical to spend
much time on. But the DSMthree and four were a multi axial system,
so most disorders would be rated inACCESS one. Personality disorders be rated
on access to an Access three wouldbe the medical conditions that needed to be

(20:48):
attended to. Access four was forlevel of stress, and access five was
level of functioning. DSM five wascompletely wrong headed in many things, and
one of those was in feeling thatthe system would differentiate psychiatry from the rest
of medicine, and so they insteadof realizing that the more information you have

(21:08):
about the patient, the more roundedwill be your view of them and the
more specific the treatment, they threwit out just to try to be close
to the rest of medicine. Ohman, that frustrated me. I wanted
to get your opinions on some ofthese other questions because I thought there were
interesting thoughts. But one of themI was reading about the issue about bereavement

(21:30):
disorder being kind of minimized and theyswitched it, and I guess kind of
like the Asperger's the thing. Itsounded like a little bit to me.
Any thoughts on that one, Uh, yeah, I have a lot of
thoughts on this. I think thatthere's no uniform way of grieving. There's
no expiration date on the love youfeel for someone once they die. Grieving

(21:52):
is a universal in mammals because theability to attach, which is the specific
behavioral characteristic of mammals, means thatthe price you pay for that attachment,
for that love is grieving. Andgrieving goes on in many, many species.
It's not as specifically human feature,it's in a million features. So
grieving is part of the human condition. This may be one of the most

(22:12):
essential things about the human condition,is that we love and we grieve.
That's part of our mammalian endowment.How do you distinguish between normal grief and
major depressive disorder is the diagnostic issue, and the dsms up until DSM five
were very careful to say, don'tconsider the symptoms major depressive disorder if they're

(22:37):
happening in the context of the lossof a loved one. That the same
symptoms that might qualify for a majordepressive disorder if it was outside the grieving
experience, shouldn't necessarily counter its majordepressive disorder. If someone's lost their luck
one two weeks ago, that itreduces the dignity of their loss and their
need to grieve. To say,Okay, you have major depressive disorder,

(22:59):
take two peers and you'll be fine. It doesn't work that way. What
DSM five was to blur that distinction, to make it much easier to give
the diagnosis of major depressive disorder,in effect medicalizing normal grief. And there
were many other ways of dealing.There's some people who suffer pervasive, severe
symptoms for way longer than make sense, and it can be dangerous for them

(23:22):
during the grieving period. They shouldget the diagnosis, but that should be
reserved for the special case. WhatDSM has done has made it very easy
to give the diagnosis of a mentaldisorder for people who are having perfectly normal
grief. That's true. I feltexactly the same way. I was thinking,
Wow, this really opens up anotherdoorway for medication purposes. I guess

(23:45):
exactly. Let me there was apurpose. I interviewed a lady. I
apologize, I can't remember her nameshe was. I think it's doctor Fox.
I can't remember. She was fromthe UK, she came over here
to the US and she was specializingin borderline. By the way, way,
I loved your episodes with doctor Goldfriedon Marshall Linahan again talking therapy on
podcasts. We want to catch that. They got some great ones there.

(24:08):
She made an interesting comment that Ihadn't heard about before, and she was
saying, there was a small movementand I don't know, I can't remember
if it was the UK or here. I've only having three types of diagnosis,
and maybe you've heard of it.She said, it was only externalizing
disorders, internalizing disorders and psychosis,and you can blend them all together,
you can have individual ones. Anddid you ever hear that? Well,
sure, there's been a constant kindof push and pull between splitters and lumpers.

(24:37):
Splitters and DSM is a splitter system. Never see a new diagnosis they
don't like. They keep on dividingthe diagnostic pie into smaller and smaller slices.
Lumpers say, oh, it's onebig thing, just one mental disorder,
or two mental disorders and three mentaldisorders, and as in most polarizations,

(24:59):
both sides your actions wrong. Itdoesn't make sense to make a new
disorder of every aspect of the humancondition. On the other hand, you
lose very valuable information when you reduceall the diagnostic system to three or four
different conditions, because there's a tremendousamount of information when you give a diagnosis.
It's never sufficient to decide on thetreatment, but it's often necessary that

(25:25):
the psychiatric diagnosis describes how people arelike other people with the same problem.
You need to go further in aformulation to see how they're different, but
the information about how they're alike.You need to know someone has a panic
disorder, that tells you something.You need to know if someone has obsessions,
if someone is psychotic. These aredistinctions that aren't the people within each

(25:47):
of them will be very different.There'll be a lot of heterogeneity within each
category of the system. But onthe other hand, they'll be very much
alike in certain aspects of course andtreatment planning. So anyone who has a
strong position war or against psychiatric diagnosis, anyone who's a true believer worships the
DSM as a bible is wrong.Anyone who says the diagnostic system is useless.

(26:08):
I don't use it. I don'teven know it. They're wrong.
I only trust clinicians who know thesystem but use it rather than worship it.
Well, I'll tell you changed.It's something amazing just to talk to
you and hear these things fleshed outbecause your history and experience with it is
so amazing. Let me go withthis up IC the eleven. When I

(26:29):
look over at Europe, to me, it's always fascinating to see how different
countries diagnose and it's just so crazybecause we're all humans, but yet there's
really differences there and maybe it's socialconstructs. I don't know. But what
are your thoughts about ICD eleven.Is it better or worse? I see
the eleven is even worse than DSMbecause it's even more inclusive. So the
reason why these systems are overly inclusiveis that there are groups of experts who

(26:53):
have a pet diagnosis. If you'veworked in an area, you've done research
on it, you run a clinicspecializing, you become to love your diagnosis.
You lose perspective. You tend tothink it's the most important thing in
the world, and you're sure itshould be in the diagnostic system. I've
worked with thousands of experts. Theynever come to you and say, you
know, my diagnosis is overly broadin its definition and too many people are

(27:17):
getting the diagnosis. They always complainthat the person they missed who should get
the diagnosis. If the system doesn'tinclude the diagnosis, they're begging to get
it, in partly because it makesit easier to get grants, easier to
get insurance coverage. So experts can'tbe trusted to make final decisions on their
diagnosis. Both d SM five andICE the eleven gave far too much power

(27:40):
to the experts, and if anexpert pushed hard enough to get their diagnosis
in, it got in. Theexperts never know, never worry about unintended
harmful consequences. They always focus onlyon the benefits. So in doing a
risk benefit analysis, if you're anexpert in the disorder, you see all
the benefits of including it, youdon't understand the risks. And most diagnoses

(28:04):
have their worst manifestations used outside ofthe field of the expert in primary care.
So a diagnosis like grief profound griefthat is switched to major depression,
I don't worry so much about theexperts and grief who suggest it. I
worry greatly about the primary care doctorwho doesn't understand it and only has fifteen

(28:26):
minutes for the patient. So thesystems, both of them, both SM
five and I see the eleven,are way over inclusive, and people using
both symptoms systems should be very carefuland cautious in making diagnoses. It's always
better to underdiagnose than overdiagnose. You'reusually incorrect in your initial impression that you

(28:51):
will almost always think of patients asbeing more seriously ill than they really are
because you're seeing them on the worstday and then the best of all possible
worlds. People would I'm actually speakingto insurance companies now that it would be
the become interest of patients and inthe interest of insurance companies and also clinicians
if you didn't have to make adiagnosis on the first visit to get paid

(29:15):
for it, if you had threefour to five sessions for evaluation, many
people would get better during that period, would not get the diagnosis, not
get the unnecessary treatment, and itwould actually not only be better for the
patients, it would be cheaper forthe insurance companies. Oh so true.
It's such a lot of pressure forthe therapist as well, sometimes because they're
sitting there going I got to giveyou something. I got to give you

(29:37):
something, and it drops to adiment disorder, and it would be a
lot better to say, you know, let's take the time to really understand
this, and a careful evaluation isoften by itself cured. But sometimes they
don't even say anything to you inthe first session they really talk, or
they talk about everything else besides that. It's really difficult. Yeah, do
you try to see I got twoquestions I want to buying together because I

(30:00):
think they're connected, and trying seewhich one I throw it to first.
Well, there's Keith Connor. Iguess my last this one. First,
it seemed that Hugh I guess theycalled him the father of Adhd. He
seemed to show some regret at theend of it. Do you think he
fell prey to I see it everywhere, I see Adhd everywhere, and then
all of a sudden he realized,oh shoot, they ran with this thing

(30:22):
way too far. What do youthink about him? Well, Keith and
I were good friends and we wrotehis obituary together shortly before he died,
so Keith and I wrote his obituaryin the British Medical Journal, and he
wanted to do that as a warningfrom the grave to take seriously his concern
that the true rate of ADHD isprobably best considered to be about two or

(30:45):
three percent. The rate in theUS is recorded now is about ten percent.
He thought that the diagnosis is remarkablyuseful when you used well, but
more harmful and helpful when you usedas carelessly as it was being used.
And no one knew more about ADHDthan kids. One interesting anecdote, and
I think I'm going to have tostop. One of the most robust findings

(31:08):
in all of psychiatry and psychology isthat the birthday of a person is the
best predictor of whether they'll get ADHDdiagnosed in their childhood. And the reason
for that is that the youngest kidin the class, especially boys, can
be almost twice as likely as theoldest kid in the class to get the
diagnosis. So what that means isimmaturity is being turned into a mental disorder.

(31:33):
That the most immature kid in theclass to the youngest one most actly
likely to act up a bit.And in schools that have too many kids
in the class, the teacher willidentify that kid as the one who's hyperactive,
hyperactive because he's the youngest kid inthe class. Get the diagnosis and
get the medicine. So the proofshave none in about ten countries, millions

(31:55):
and millions and millions of kids.It's a very robust proof that ADHD is
being wildly overdiagnosed. And I thinkthat the important message for your clinician listeners
is that they shouldn't jump to diagnosis, that they should evaluate everyone carefully enough,
over enough time, and if youhave to make a diagnosis on the

(32:20):
first visit, make it the leastsevere diagnosis. You can always work your
way up. It's very hard towork your way down for patients. I
think it's important to be in foreignconsumers to not accept diagnoses without checking it
out yourself, with yourself, withyour family members, and don't just jump
to get an antidepressant, and certainlydon't just jump to get xenax or benzodiazepine.

(32:47):
When you visit your primary care doctor, that you should make the assumption
the doctors are over using these meds, and be very careful judges yourself about
whether it's worth the risk of takingthem problem, go ahead and this will
be the end. On the otherhand, for people who have severe psychiatric
problems, only about a third ofthem get treatment, and we as a

(33:10):
society need to do a lot better, need to provide community access to care,
need to have crisis intervention teams.So as a society we need to
do is protect people from diagnoses andmedicines they don't need, but make it
a lot easier for people desperately doneed, because they'll wind up in jail

(33:30):
or on the street that they getthe treatment in the housing that they do
need. And I appreciate the timeto be with you this morning. Likewise,
thank you very much. That wasdoctor Francis a incredible discussion. Hopefully
you enjoyed it as much as Idid. We learned a lot and you
know what to do. Folks.Make sure to share, subscribe and hit

(33:52):
that like button. You know welike it. Go check out that Alan
Francis MD on Twitter. You canalso catch to catch his books Saving Normal.
Thanks everyone for listening.