Saving Normal: An Insider's Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life

I teach classes on my research on Big Pharma. The classes are "Big Pharma: Pulling Back the Curtain on the Business of Healthcare". This book has been invaluable to my research on Big Pharma. People in my classes are astonished to find out what goes on behind that curtain. Dr. Allen Frances is one of my newest heroes!! He tells it like it is.This country spends more on prescription medicine than any other country. Direct to consumer TV ads are out of control. Showing only how wonderful you will feel after you take their drug while the rapid voice over gives non-stop difficult to grasp and even more difficult for any non-medical person to understand side effects of these drugs. We take something as simple as shyness and turn it into mental illness.Dr. Allen reports:"We should not be making patients of people who are basically normal and ignoring those who are really sick. Psychiatry is certainly not alone in its overreaching—we are just a special case of the bloat and waste that characterize all of U.S. medicine. Commercial interests have hijacked the medical enterprise, putting profit before patients and creating a feeding frenzy of overdiagnosis, overtesting, and overtreatment. We spend twice as much on health care as other countries and have only mediocre outcomes to show for it. Some of our citizens are harmed by too much medical care, others by shameful neglect. Medicine and psychiatry both stand greatly in need of taming, pruning, reformulation, and redirection."Frances, Allen. Saving Normal . William Morrow. Kindle Edition.We are lead to believe by the D to C commercials that if we are tired, grieving or worried about some situation we find ourselves in, that we may be mentally ill and in need of medications...lots of medication. One commercial lately touts a medication as an "add on" for your depression medication!! They talk about "If your depression still doesn't go away after being on medication, you should ask your doctor about adding XXXXX." OMG! How much medication can we take? Should we take? We've run amok of medication as the answer to all life's problems!!! Some times life just sucks! Sometimes we just have to bear up under difficult circumstances. We are resilient creatures! We need to give ourselves credit and understanding that we will come out of whatever our condition is at the moment. Everything today must be fast! Fast download speed, fast food, fast result, etc.As Dr. Allen says in this book we need to treat those people who are actually mentally ill and allow those who are not to work out their issues with a shoulder to lean on, someone to talk to and with empathy. We should not rush to find the right freaking pill!"Real psychiatric disorders require prompt diagnosis and active treatment—they don’t get better by themselves and become harder to treat the longer they are allowed to persist. In contrast, the unavoidable everyday problems of life are best resolved through our natural resilience and the healing powers of time. We are a tough species, the successful survivors of ten thousand generations of resourceful ancestors who had to make their precarious daily living and avoid ever-present dangers far beyond our coddled imagining. Our brains and our social structures are adapted to deal with the toughest of circumstances—we are fully capable of finding solutions to most of life’s troubles without medical meddling, which often muddles the situation and makes it worse. As we drift ever more toward the wholesale medicalization of normality, we lose touch with our strong self-healing capacities—forgetting that most problems are not sickness and that only rarely is popping a pill the best solution."Frances, Allen. Saving Normal . William Morrow. Kindle Edition.I love the section on ADHD!! OMGosh we over-medicate children because they are full of energy and we demand they sit still.Dr. Frances: "ADHD is spreading like wildfire. It used to be confined to a small percentage of kids who had clear-cut problems that started at a very early age and caused them unmistakable difficulties in many situations. Then all manner of classroom disruption was medicalized and ADHD was applied so promiscuously that an amazing 10 percent of kids now qualify. Every classroom now has at least one or two kids on medication. And increasingly, ADHD is becoming an explain-all for all sorts of performance problems in adults as well. How could this possibly happen? There were six contributors: wording changes in DSM-IV; heavy drug company marketing to doctors and advertising to the general public; extensive media coverage; pressure from harried parents and teachers to control unruly children; extra time given on tests and extra school services for those with an ADHD diagnosis; and finally, the widespread misuse of prescription stimulants for general performance enhancement and recreation. The most obvious explanation is by far the least likely—that the real prevalence of attentional and hyperactivity problems has actually increased. There is no reason to think the kids have changed, it is just that the labels have. We now diagnose as mental disorder attentional and behavioral problems that used to be seen as part of life and of normal individual variation. The most convincing evidence of this comes from a large study with a particularly disturbing finding. A child’s date of birth was a very powerful predictor of whether or not he would get the diagnosis of ADHD. Boys born in January were at 70 percent higher risk than those born in December simply because January 1 was the cutoff for grade assignment. The youngest, least developmentally mature kids in the class are much more likely to get the ADHD diagnosis. The birthday effect was almost as influential in girls. We have turned being immature because of being young into a disease to be treated with a pill.3,4,5"Frances, Allen. Saving Normal (p. 142). William Morrow. Kindle Edition.Frances, Allen. Saving Normal (pp. 141-142). William Morrow. Kindle Edition.I HIGHLY RECOMMEND THIS BOOK!

First, I highly regard Dr. Frances’ efforts in composing this book, as he is thereby confronting a lot of vested interests. His “Insider’s Revolt”, per the book’s subtitle, is quite evident and most appreciated. Moreover, I believe that his efforts epitomize the highest ideals and ethical standards of the medical profession. As he states, he is concerned not only with saving normal, but also with salvaging the credibility/efficacy of psychiatric medical practice in a broader sense (e.g., including general practitioners). From my perspective, however, I also believe that he could have developed and presented his case more effectively. He would seem to have marshaled his major points rather well, but he could have organized them more coherently and supported them with greater depth.Quite generally, Dr. Frances notes that “we have not figured out ways of translating basic science into clinical psychiatry...The expectation that there would be a simple...neurotransmitter...explanation for any mental disorder turned out to be naive and illusory” (p. 10). Accordingly, it would have been desirable for the book to include some ample treatment of neuronal/synaptic intricacy to drive home how severe the lack of requisite knowledge is regarding mainline psychiatric prescription drugs. A sound relevant scientific basis for configuring and administering psychiatric drugs simply does not exist.The essence of this major deficiency might have been explained as follows: the few neurotransmitters that are mimicked by many of these drugs are but an exceedingly small number of the agents active in various synapses throughout the human body. And synapses typically contain a wide assortment of different neurotransmitters coincidentally active. Consequently, the intricacy of the myriad of ongoing interactions within any given synapse is essentially unfathomable now, even at the leading edge of neuronal research. Only the coarsest of neurotransmitter effects are known, and then only on a poorly controlled and grossly observed basis. See Valenstein’s “The War of the Soups and the Sparks” for an accessible account of how formidable and obscure these synaptic operations remain. In consequence, the extant knowledge of synaptic interactions provides no adequate scientific foundation upon which to configure and administer psychiatric drugs.Moreover, on page 173 Dr. Frances offers a more general and truly alarming assessment that implicitly encompasses the foregoing neurotransmitter commentary. Rather bluntly, he asserts that “Psychiatry’s research revolution is...in a deep rut when it comes to progress in clinical diagnosis and treatment. There has been no real advance in diagnosis since...1980, and no real advance in treatment since the early 1990s.” Alas, this contention does not receive a focused or coherent elaboration anywhere in the book. It would seem though that this appraisal accords with the continuing poor scientific basis for commonly prescribed psychiatric drugs. The book should have dealt with this matter head-on. Also, his assessment above would seem to prompt consideration of other crucial issues. What is being taught in medical schools? What impact does curriculum have on the psychiatric practices that he disparages? After all, “Eighty per cent of prescriptions are written by primary-care physicians” (p. xv).The evident overtreatment of purported psychiatric disorders (as listed in the latest Diagnostic and Statistical Manual, or DSM) effectively results in the medication of many essentially normal patients who are victims of intentionally False Positive diagnostic criteria and thresholds. Note the book’s commentary on “DSM-5's highly subjective and catch-all criteria” (p. 195). Such cases of unwarranted prescriptions dilute treatment of needful patients, and yield side effects among the False Positive ones. Those side effects prominently include increased propensity for obesity, diabetes, and heart disease. Throughout the book, the author states that the DSM’s disorder categories in many cases effectively prescribe/trigger “epidemics” as practicing physicians adopt its incipient new “fads” in diagnosis and medications. Moreover, such diagnostic inflation spans all DSM disorders, so that now about one in five adults in the US is taking some kind of psychiatric drug (p. xiv). Much to Dr. Frances’ credit, he recommends a six-step diagnostic protocol (p. 222) to reduce this treatment binge, while better serving the truly needful.Another driver of diagnostic inflation obtains from government or insurance benefits requirements. Specifically, a diagnosis is typically required to ensure benefits, and hence of the physician’s being paid. Hence they are motivated to up-diagnose to safeguard their remuneration. The author notes for example that veterans’ post-traumatic stress disorder (PTSD) is over-diagnosed for that reason, while some ailing veterans opt to tough it out and live with untreated afflictions. Hence, PTSD is both highly overdiagnosed and undiagnosed (pp. 85, 157 & 159). In part for such reasons, it is not surprising that “Since 2005 there has been a remarkable eightfold increase in psychiatric prescriptions among our active duty troops...and hundreds die every year from accidental overdoses.” (p. xv). In the context of side effects, I wish that Dr. Frances had explored the possible correlation between high suicide rates among service personnel and their pervasive use of prescribed psychiatric drugs. Note how often the drug advertisements on TV issue warnings about suicidal feelings that may accompany the taking of certain drugs. Surely, there must be some study of that nature, albeit one perhaps deliberately kept from the American public.Finally, the book closes with recommendations to remediate the excessive or unwarranted prescription of psychiatric drugs. Background for these recommendations is well developed in the book, with the note that the various influences/contributors regarding diagnostic inflation tend to work in concert. Of course, the large pharmaceutical firms (Big Pharma) dominate the drug promotion coalition. Moreover, these factions have no significant organized opposition. The following synopsis of recommendations is in part taken from pages 210-211:1. Curtail Big Pharma’s direct-to-consumer advertising2. Eliminate Big Pharma’s subsidies to professional organizations & personnel3. Eliminate Big Pharma’s sponsorship of consumer advocacy groups4. Relax VA and health insurance diagnosis stipulations to qualify for benefits/coverage5. Prohibit the political, regulatory & bureaucratic personnel from migrating to the pharmaceutical firms with which they have had dealings until at least three years lapses.In sum, the message of this book is of first importance, but in my view at least, the focus and impact are diluted by repetition (e.g., virtually the same descriptive pattern/content for each disorder addressed) and extranea (e.g., marginal value of anecdotal case histories), as well as by incompleteness (coverage lacking on pivotal topics as noted above). The writing per se is alright, but I nevertheless found the book wearisome to continue reading. Still, I am glad that I did, as I am very thankful for the “Insider’s Revolt”.

This book cured my ADHD!! I'm not even really joking. There's a brilliant passage where he describes his own distractedness, which easily beats anything I experience, and argues that this is a part of normal human variation, just like having people who are very shy and cautious, people who fixate on special topics etc. Humans have evolved to have different traits as it helps the tribe to have a individuals with different tendencies -- explorers, worriers, rememberers etc. He thinks that the bar for what counts as mental disorder has been set too low. Your distractedness and impulsivity should be seriously disabling to get an ADHD diagnosis, and in many cases it clearly is. But not in mine. So after a year and a half struggling to digest the implications of getting diagnosed, I now consider myself cured, or at least misdiagnosed. What a relief. Now on with the rest of my life.Also, it's a really good and quite alarming analysis of how the DSMs, including the one he led, have opened huge spaces for Big Pharma to market psychiatric drugs to people who are at worst eccentric.ADHDers can't really complain. Imagine being a kid or retirement home resident stuck on risperdal or abilify. Shocking.

Despite his protestations, the author seems to have played a major part in creating the problem of diagnostic hyperinflation in mental illness. The DSM (Diagnosis and Statistical Manual) is psychiatry's bible in terms of defining what is and what is not a mental illness. The author chaired the task force that created the DSM 4. This has only just been superseded by the DSM 5 which the book brilliantly critiques.The author cites as evidence for diagnostic hyperinflation (amongst many other statistics) the fact that about half of Americans will be diagnosed with a mental health problem during their lifetime. Of course, this situation pertained under the DSM that he chaired the production of. The DSM 5 has only just been released and so cannot be blamed for this sort of historical fact.No doubt the DSM 5 will make things much worse and Frances explains why.Frances is a fantastic writer, hugely erudite and very entertaining.It's great that he has come over from the dark side!

What an engrossing read! So many fascinating insights into the history of mental healthcare. If we lived in a more enlightened future we'd be looking back to our present with mixed feelings of horror and nervous laughter. The author, himself a leading psychiatrist and chair of DSM4, details how Big Pharma, Politicians, the media/advertising and then of course grossly under- qualified primary health carers and then psychiatrists are all too eager to don the garb of expertise, deploy one or two of the catch all DSM trendy diagnoses and quickly dish out whatever drugs are a la mode, regardless of the many crucial factors which need to be taken into account when making diagnoses. At the end of the book he gives several typical examples of such misdiagnosis and any normal person can only feel compassion for the traumas these normally flawed people were subjected to. One of the major points is that unfortunately neuroscience isn't anywhere near advanced enough to explain such things as 'chemical imbalance' so in the meantime big pharma is free to experiment and profit from the millions of people who have problems they have difficulty in resolving alone. Actually most of these people just need someone to take time to understand their predicament and provide support. There is no doubt that there are the really unfortunate people who do have a real mental illness and medication can alleviate some of the more distressing symptoms. But again it seems to me anyway that there isn't any conclusive science behind these meds; rather they have been evolved through trial and error and just seem to work. In the final analysis all this has to stop - there needs to be ALOTmore human understanding and care (people time HAS to be made) and as the author suggests careful procedures HAVE to be put in place before any medication is given. Personally I think all parents should read this book mainly because of the disturbing trends in child diagnosis and the possibly horrific consequences of misdiagnosis and harmful medication. I hope this book will be seen as the beginning of a new dawn in mental healthcare.

First class book, clarifies why we shouldn't regard mental health issues as illness (pathology) rather as a response to environmental, social, economic and cultural issues.

Interesting text, it is clear the author certainly questions the "establishment" and its adoption of medical models as default!