LS 102 - Our Medical Dependency with Dr. Allen Frances

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Welcome to the Longevity show, informing listeners on the important aspects of health, wealth, and happiness to ensure you live life to its fullest. With fascinating interviews with top authors and gurus in the field, along with the latest news in the science and technology of longevity, we're going to reveal expert advice and amazing secrets of living a longer.

And now, here's your host, Jason Hartman. It's my pleasure to welcome Dr. Alan Francis to the show. He is professor at Emeritus and former chair of Psychiatry at Duke University and former chairman of the DSM IV Task Force and author of Saving an Insider Revolts against out of control psychiatric diagnosis, DSM 5, Big Pharma, and the Medicalization of Everyday Life. He's been dubbed the most powerful psychiatrist in America during the 90s, and it's a pleasure to have him on today. Alan, welcome. How are you?

Well, thank you. Because I think it's very important to get this message out, and I think the only way society can change is people like you giving us an opportunity to discuss what I think is a real problem.

This is a real problem, and I'm so glad you came on the show to talk about it today. I mean, it seems like we've got a name for everything, that probably half of those things don't even need to be diagnosed with a name. And then, of course, when you give it a name, you can create a drug for it too, right?

Well, it's incredible. 25% of people in the United States would qualify for a mental disorder any given year, 50% lifetime, and 20%, one in five average, shows almost like one person per family is taking a psychiatric medication.

Say that again. One in five people are taking a psychiatric medication.

You got it.

That is insane. I mean, 20% of the population is taking a psychiatric drug. Wow.

Women over 40, 1/4, are taking antidepressants.

So 25% there. Okay.

Teenage boys, 20% get the diagnosis of ADD, and 10% are taking medication. And I could go on and on with numbers.

One of my prior guests, Alan, said this all started in the 70s when the drug companies were running out of customers for one reason or another, and they had to just come up with a whole new category.

Yeah, well, the first burst of medicalization of everyday life came with Valium and Librium. In the 70s, the drug companies realized that this could be the mother load, that psychiatric problems could be their. Their biggest revenue producers. It got much worse in the late 90s, the drug companies did an amazing thing. They lobbied for and received the right to directly advertise to consumers. Only New Zealand, amongst other developed countries, allows this because it's crazy. If you let the drug companies mislead consumers, they then go to the doctor's office saying, I need this. I have this diagnosis. I need this medicine. And if they do that, it increases by 20 times the likelihood they'll get the medicine. So what's happened is the drug companies have BR watch the consumers. They've lavished untold attention on doctors, all with the message that mental disorders are easily diagnosed, often missed, always caused by a chemical imbalance, and easily treatable with a pill. And the result of this is amazing profits for the companies. The antipsychotics a couple years ago, $18 billion a year. Antidepressants, 11 billion. The stimulant drugs for ADHD, approaching 10 billion. The companies are doing great in psychiatry. It's not good for the people who are taking unnecessary pills.

And I agree with you, and we're going to dive into that. But first, Alan, just kind of define the categories of. When you talk about psychiatric drugs, certainly we're all familiar with the SSRI category, which would include Prozac, Lexapro, those types of things you mentioned, the old ones, if you will, the 1.0 version, which is Valium. And what else did you mention? I can't remember.

How many categories of psychiatric drugs are there?

Well, basically.

The benzodiazepines, anti anxiety drugs. The most commonly used one now is Xanax or Alprazolam. It's almost always prescribed by primary care doctors. It's almost never a good drug to be taking. Very addicting. If people are on it, they should wonder why they're on it, but not try to get off quickly because it has very severe withdrawal symptoms, dangerous withdrawal symptoms. And that's the problem with a lot of the drugs that are taken that are unnecessary. They have withdrawal symptoms. So don't stop just because you hear on this program that you may not need the medication. You may get worse if you stop. The antidepressants, you're familiar with the antipsychotics, drugs like Zyprexa and Ristridal and now Abilify, Seroquel. These have become enormous profit centers for the drug companies. They're often prescribed liberally where they don't really belong, especially in kids and in old people. They shorten the life of old people. In nursing homes, they often make kids get real fat. And we already have an epidemic of childhood obesity. And with that comes diabetes and heart.

Disease and Alexa and a whole host of new potential psychological like self esteem oriented problems. Right.

I think the point here is that when the medicine is needed, and it is needed for maybe 5 to 10% of the population, it can be life saving, it can be wonderful. I'm not against medicine. I am very much against the careless use of medicine for fake diagnoses that are made often by primary care doctors. 80% of the medicines given in America, psychiatric medicines are prescribed by primary care doctors, usually after seven minute appointments under heavy pressure from drug sales people.

Heavy pressure from patients who've watched the advertisements. Good diagnosis requires time and expertise. Very often people come on the worst day of their life for the evaluation and if you just wait for a month, they'll be better. But once they start the medicine, they attribute the gain to the medicine and they'll often stay on something that's harmful, not helpful for very long periods of time for that reason.

First of all, explain the dynamics of. You mentioned at the beginning that the drug companies are lavishing attention on these doctors. And then you also mentioned that the doctors are under heavy pressure from the drug companies. How do they do this? I know it's not legal, but I'm sure it goes on anyway. You know, actually pay the doctors to recommend the drugs. What can they do? I have doctor friends, they say that golf tournaments are sponsored. A lot of the fun activities that go on at conferences and so forth. The tab is picked up by these companies. What are the dynamics of that?

Well, it's actually getting much better, Partly because of congressional investigations of the outrageous bribing of doctors to do stuff. But yeah, it's golf tournaments, fancy vacations, great meals.

Paying doctors to give talks. For a while they controlled all of continuing medical education. Every grand round speaker would be sponsored by a drug company. Pizza for the residents. Get them at a young age. They have pizza lunches every day. And the whole. It's a kind of brainwashing of the medical and shanghaiing of the commercialization of the medical profession. Fortunately, that's getting better. Now associations that were largely financed by drug companies are pulling away. The journals are becoming more independent. They were also very dependent on drug company advertising. The drug companies have been so outrageous that there's now a necessary kind of correction. And I think that the best hope is that we will have the same situation with drug companies that we had with big tobacco that they seemed to rule the world 25 years ago. They were whittled down to size with a David and Goliath battle. But David was right in that situation. Right made for might. I'm hopeful that the same thing will be true with direct companies.

And I'm glad you made the distinction, by the way, that some of these do help people and they are necessary. But the vast majority, probably 75% of the market, you know, as we're talking, those numbers are not necessary. They're massively over prescribed. And it seems to me, I'm a business person and one of the things that frustrates me constantly is the area of law in that lawyers are not required to specialize. And I always compare it to medicine. Doctors are required to specialize. You know, you're either a family practice or an internist or you're a brain surgeon if you specialize in psychiatry. That's the thing. It seems like we should take away the rights of the general practitioner to be prescribing these drugs. You should have to go to a psychiatrist, I think. Is that a good solution or not?

Probably not. Here's the problem. We have far too few primary care doctors. We're over specialized in America and it's the problem not just for psychiatry. It's a problem across all specialties. We need to have more primary care doctors, but they need to have more time with these patients and more training. So I think they're noble by and large. It's not that they're bad people, they want to do a good job. The problem is that they only get seven minutes per patient. They work like dogs, they're underpaid, and that's why we have so few of them. And I think it would improve medical care in this country immeasurably if we paid primary care doctors better and we gave them time to be with patients. They don't get to know their patients. They don't get to know them because they don't have time.

You know, that trend is going the opposite way with nationalized healthcare. Of course they're probably gonna be spending less time or knowing their patients less. That's a whole new subject that I don't really want to dive into, but you can comment on it if you like.

Different time.

Yeah, different time. Okay. All right, fair enough. We'll leave that one on the shelf. So there's too few primary care doctors is what you said. You didn't say there were too few psychiatrists.

No, no, I think that the issue for there'll never be enough psychiatrists to treat every human problem, make every diagnosis. So we're going to be depending on Primary care doctors, and I'm not against that. I am against their receiving so little training. I'm terribly against them being lobbied by drug companies the way they are. I'm sympathetic to the fact that the patients are forcing their hand very often and they have no choice. And I mostly want them to have more time and fewer. If the primary care doctors know their patients and have time to speak to them rather than just prescribe a pill and give them a free sample, I think we'd have better cure in this country. And certainly we have to re educate the public. Parents need to protect their kids from being over medicated, not think that every time they give a kid a medicine it's going to improve school performance. People need to realize that these medicines have harms as well as benefits. And unless you have a severe problem, you're better off not being on them.

Right. I couldn't agree with you more. And a lot of it has to do with just diet and exercise and good old basic stuff that'll just make you feel better.

Exercise is one of the best antidepressants I've ever known, one of the best antianxiety agents I've ever known. If you can just get people to start and to stick to it, it has amazing benefits. And that's actually been demonstrated in studies. It's certainly been proven true in my personal experience with patients. The hard part is getting people. But if people want a good antidepressant and their problem isn't a severe depression, the best antidepressant in the world may be exercise.

Yeah. Take a jog around the block and get those endorphins going, whatever it is.

For you, every single day, though, the main point is people don't do it.

Do it. Yeah.

Each person has to find his particular thing that he'll do and whatever it is, do it every single day.

You know, give us an example with maybe one of these drugs. Feel free to pick one. What goes on when someone takes one of these drugs? I know that the SSRI drugs, that whole category has been linked to suicide, maybe to these mass shootings, although that seems to be pretty suppressed in the media. I've talked about that in the past with other guests. What happens to people when they take these things? I mean, what does it do to them?

Well, you know, it varies with the drug, it varies with the dose, it varies with the person, varies with the circumstance. If someone has a psychotic illness and they don't take an antipsychotic, they're likely to stay very sick. The brain learns to have hallucinations and delusions and they don't get better and they get worse. My experience is that for people with psychotic illness, antipsychotics are wonderful, but they're being given out promiscuously often for fake bipolar disorder, for conduct problems in kids. And in situations where they're not clearly indicated, they cause the kid to get sleepy or the person to get sleepy, dopey, to gain weight. And the biggest problem with the current drugs is that the weight gains can be enormous. It can be 10% of your body weight in just 12 weeks. You can really blow up. So it's not just how you feel different, it's also the long term risk that maybe you're going to get diabetes or heart disease. We have less effective measures for risks and harms than for benefit. And so all of the risk benefit analyses that are done in deciding when a treatment is indicated tend to be skewed towards, oh, let's hope for the best, without really taking into account that often you have the unintended consequences of the worst.

What about the mass shootings and a link to these drugs?

Well, I think I have strong feelings about this, that we will never ever be able to predict who the mass shooter is. That we can pick out a group of people who are at high risk, but we will never be able to say which guy and when will he do it. And when we look for explanations, we'll always try to find an easy answer. And my personal feeling is that the best we can do is to provide easy access to treatment for people who have psychiatric problems. That's the best prevention. It's not going to catch everyone, but it will catch some. Many people won't go to treatment. Many people may not be helped by it, but it's the best we can do. And my feeling, I'm not sure that you share it, is that the easy availability to guns turns what might be a small murder situation into a mass murder. If we can't predict the mass murderer, the best we can do is try to make sure that people who have a history of mental illness or proclivity to domestic violence or substance abuse that they have a much tougher time getting their hands on guns.

Sure, sure that healthcare is a whole nother debate that we don't have time for. But the thing I wanted to point out, and of course, you know, this obviously, is that the drug companies are huge advertisers on all sorts of different media, whether it be radio, television, magazines, print media. I mean, they're just everywhere. They're all over the web. These ads follow you around the web. It's mind boggling how they're just everywhere. I just gotta think that these media companies are afraid to say anything bad. I've seen people and writings about how that's the thing all these shooters have in common is they're all taking these drugs. Now. It's a chicken and egg argument, but I just wonder about the COVID up. You know, you talked before about the doctors being pressured, the doctors being lobbied, sponsored. And this is another way that I think the truth of what might be, I'm not saying it is maybe nobody knows an issue. It's just not out there. You don't hear about it in the mainstream media. The debate always falls to gun control, but it never, you know, what pills is the guy taking? Seems like we'd want to know that.

I would be focusing on both, but I think it often is chicken and egg and often they're on medication because they had the violent problem in the first place. I think the larger issue is, yeah, they spend 60, $70 billion a year on marketing and lobbying for their drugs. They spend very little on real research. Most of the research it's done is me too. Stuff to try to get a longer patent and make the drug real expensive. Amazing new phenomenon, Hepatitis C drug that went out 1,000 bucks a pill. 1,000 bucks a pill. 84 pills are needed. That's going to be 84,000 bucks to treat someone. In Egypt, they negotiated a price of $900 for the 84 treatments. $84,000 here, 900 in Egypt. In Egypt they're making money. So they have a monopoly. This is not a free market. They have a monopoly over pricing that they've gained because of their control of the politicians. And we really need to break their monopoly over pricing. We need to make transparent. This is a situation where you need regulation. Because without regulation it's your money or your life.

The problem is with regulation you make the government bigger and then there's more chance for corruption. It's just, I can't believe that. I mean, in Egypt, is it really the same drug?

Exact same drug. We pay, overall, we pay at least twice as much for every drug as the rest of the world. And that's because in other countries the people who are buying the drugs have the right to negotiate. Here the drug companies talk to politicians into not giving.

The buyers the right to negotiate. It's a one way market and when health is concerned, it's like they have a gun at your head.

Yeah, unbelievable. I mean the Same is true with Wall Street. You know, I like to say that Wall street just owns the government and that's the way they commit all their crimes. And even if they're legalized crimes, they get the regulations they want passed. And keep in mind that those regulations, they help keep established players. They help them keep keep their monopolies or their semi monopolies, because new people can't enter the market. They can't afford the compliance.

I think the one thing that worked with tobacco was public outrage that finally overwhelmed the big bucks. And when you took the company's right to advertise outrageously and misleadingly away.

And you had a counter education campaign about the dangers of smoking. We used to have 60, 70% of our people smoking. Now it's fewer than 20%.

It's awesome. I know, it's great. It seems like a lot more people are still smoking in Europe and in other countries, which is awful. So Philip Morris went overseas when the crackdown happened here. Tell us about DSM 5. Does that pose a risk to children? First of all, tell people what DSM is.

It's a diagnostic system, and it sounds dry, but it's what determines who's healthy and who's sick, who gets treatment, what kind of treatment, and whether it's paid for by insurance or not. Very powerful in the courts and custody battles. It determines who gets disability and who gets school. Just become way too powerful in the world. And the problem with DSM 5, the latest version, is that it takes a situation where we have diagnostic inflation and threatens to make it diagnostic hyperinflation. It turns normal grief into major depressive disorder. It turns my forgetting of old age into minor neurocognitive disorder. It turns my overeating into binge eating disorder. It turns my grandchildren's temper tantrums into mood dysregulation.

And it makes it even easier to get attention deficit disorder for kids and especially for adults. So my concern is that we have a terrible situation now and DSM will be opening the floodgates rather than trying to correct the problem.

How new is DSM 5? The fifth version of it.

One year.

It's a year old. So we've had five of them. And when did it start? DSM was it in the 70s?

Okay. DSM 1 and 2, no one cared about DSM 3 was a big change. It introduced criteria for each diagnosis. And this means that people can agree on the diagnosis if they use the criteria. More important, it became a best seller. So DSM sells several hundred thousand copies every year, much More than there are clinicians. It changed the public discourse. People became interested in diagnosing themselves, diagnosing their wives, diagnosing their bosses. It influenced how doctors practice. And recently it's been very misused by the drug companies because they've learned that to sell of the pill, the best thing you can do is sell the ill. That selling the psychiatric diagnosis is the most effective way of pushing pills.

Who creates the dsm? A committee, I suppose. Right, yeah.

And I chaired the one for dsm, Ford. It's sponsored by a professional organization, the American Psychiatric Association. And this is a problem for all of medicine, not just for psychiatry. Most guidelines for diagnosis and treatment are done by professional associations that have an inherent conflict of interest. Sometimes financial, always intellectual. The specialists in any one area are not to be trusted in defining disorders in that area without external governance, because they'll always expand them. If you're a rheumatologist, you see rheumatological illness everywhere. The diabetes people have made it much more easy to get diabetes. The hypertension people, easier to get hypertension. If you believe in osteoporosis, everyone has osteoporosis. A woman who's 60 should have the same bone density as a woman who's 24. So we've had this tremendous expansion in diseases all across, not just psychiatry, all across medicine. And that means treatments. The drug companies and device makers and the people in the medical industrial complex just jump on every suggestion that there are several million more people who have the problem, and it makes their shareholders rich. But a lot of the people who get the diagnosis wind up being more harmed than help. The best example, prostate cancer. It used to be that a guy like me should be getting prostate tests every year. Now the recommendation is just the opposite. Unless there are risk factors, don't do it. Because even though lots of people die with prostate cancer, maybe 75% of men, in most instances, it's not what kills them. What may make their lives miserable is the treatment for a prostate cancer that wouldn't have caused them much trouble overall. In America, we over diagnose, over treat, but psychiatry is a special case of that. And I'm hopeful that we get wise to this, not just in psychiatry, but.

In all of medicine. Yeah, definitely. Very good point. Really, really interesting to understand this. You know, the last parting thought I'd like you to just address is it seems like a lot of the help or outrage, there's the famous Deep Throat from the Watergate conspiracy, said follow the money. It seems like the insurance companies would be Bugged about this. Right. They don't want to spend a lot of money on paying for these drugs that are unnecessary. Right. Why aren't they outraged?

No, they don't. They actually are part of the problem in two ways. Insurance companies are the pastors, so they don't really care how much they spend because they're getting cut of the denominator. And they cause problems in two ways. One is they require a diagnosis to pay the doc on the first visit. And so doctors jump to diagnoses that often would be unnecessary if, as in the rest of the world, they had five or six visits to evaluate the patient before making a diagnosis. Many people who get a diagnosis now wouldn't have one if the doc was able to observe them for a month and the problems would go away on their own. Once you give a diagnosis and give a pill, the pill will be the thing that's carried forward, often in situations that are not needed. The other thing is that the insurance companies are very short term in their thinking. They don't take a lifetime course into consideration. They're thinking about the next quarter. And pills are cheaper in the short run. Psychotherapy is more expensive in the short run, but psychotherapy is a lot cheaper in the long run because people don't have to stay on the pills. So they should be financing pills a lot less. They should be forcing diagnosis a lot less. And in the long run, that would be cost effective, but they don't care that much about cost because in the long run, they get their profit off the top.

Yeah.

Wow.

This is amazing. This is just an unholy alliance in every direction. We've got iron triangles all over the place.

We have amongst the worst health care in the world and we're spending a fortune on it.

It's unbelievable. Yeah. And it's, you know, the pharma companies have hijacked the government just like Wall street has, you know, you know, it's the same story. All right, Alan Francis, thank you so much for joining us today. Give out your Twitter or whatever you want to give out, any resources.

Yeah, I guess the best thing, if people are interested in these questions, would be Alan Francis, M.D.A L O E N F R A N C e.

S M danfrancismd linenfrancismd on Twitter and Dr. Alan Francis, thanks for joining us.

Well, thank you. And thank you for spreading the word work.

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