Interview with Dr. Allen Frances

Okay, hi. I'm Dr. Joseph Woodring. And, um, for today's interview, uh, it's my pleasure to say that we've got Dr. Alan Francis here. Um, Alan Francis, he was the chairman of Duke Psychiatry, and he also led the team that wrote the DSM-4. Um, I would say it's fair to say that, uh, Dr. Francis has been at the center of establishment psychiatry, and he's also a respected leader, kind of, you know, within that field.

About 10 years ago, he started to very publicly raise attention about some of the limitations of our current mental health system, uh, first by talking about the DSM and the way it's misused, but also generally about the different kind of incentives that have led to, uh, you know, sub-optimal mental health care in the US. So, um, we're going to have a discussion about specifically about benzodiazepines and antidepressants. And, um, on that note, I'm going to turn it over to to Dr. Francis, who's going to tell us a little bit about, um, the history of these medications and how they they came to be used. So, thanks for being here.

Yeah, well, I was part of the new wave of psychiatrists in the '70s that were thrilled when the benzos of the azepines came on the market because they seemed to be so all-purpose, helpful, wonderful for detox. The hope was that they could be a replacement for alcoholism with many fewer side effects. And then I came to realize very quickly when I ran a drug and alcohol program that the patients who you switched to benzodiazepines wound up taking more alcohol and more benzodiazepines together and got into lots of trouble. And I realized in the early '70s that this was a very dangerous medication.

I think people need to understand why they became so popular. Why are benzodiazepines so popular? So currently, in the U.S., 4% of people, 4% of the general population of the U.S. is on the benzodia- 15, 8% of the population of geriatric patients, elder seniors, is on a benzodiazepine. And that's particularly striking, twice the the general population rate in elderly, because it's so dangerous in the elderly with falls, memory impairment, confusion, delirium, all tremendous risk factors in the elderly.

Why are these medicines so popular? Well, the first, the first villain in this piece is Arthur Sackler. You know, people are probably familiar with the Sackler family's villainous role in promoting the opioid, horrible epidemic that's now completely out of hand with the introduction of fentanyl. The Sackler family has been an absolute tragedy in American history, and the opioid epidemic is only the latest example of this. Sackler, during medical school, worked for a Madison Avenue advertising company. He bought the company, um, early in his career, and he became the advisor to, um, Roche, which produced both Librium and Valium, in terms of their advertising. And he invented most of the horrible tools of drug company advertising during the '60s and '70s: the idea of having thought leaders, of having advertisements, beautiful, detailed people to visit doctors and push the product. And most importantly, the idea that the psychiatric medicines should be used by everyone, not just psychiatric patients.

So he developed an advertising campaign for Librium and Valium that emphasized the fact that these were anti-anxiety drugs that helped everyone. You didn't need to have a psychiatric disorder to benefit from them. And they emphasized the relative safety and the enormous efficacy. And the drugs quickly became among the best-selling drugs in America, very quickly, and very soon after that, best-selling drugs in the world. So the original sin of the benz of the azepines rests with the Sacklers, goes back 50 years now.

The, um, the second edition of this was with the introduction of Xanax. And I think it's '86 or '87. And I actually saw some of the early data that was being produced by an international collaboration of researchers on Xanax. And it turned out that the, um, the dose that was used for panic disorder that was effective for panic, so it was very close to an addicting dose. From the company's perspective, this was shockingly a good thing, not a bad thing, because it meant that the people who used the medication for panic disorder would essentially be hooked on it, and they would be lifetime customers.

And in my view, the, um, the indications for, um, the use of benzodiazepine are vanishingly small in psychiatry. The only uses of benzodiazepines that are worth the enormous risks are in catatonia because it has a dramatic effect in improving catatonic patients, so does ECT. But benzodiazepines are dramatically effective in catatonia, but that's a relatively rare condition. It can be useful and is useful in detox. It's useful in some neurological conditions. It's useful maybe in some emergency situations where there's a need to instantly reduce agitation. It might be useful for the first few weeks in panic disorder until the SSRI or the psychotherapy kicks in. But the risks are so high of patients becoming hooked on it that I would see that as a basically a risk-benefit ratio I'd be very unwilling to take for most people.

So by and large, you have a medication that's very popular. Patients love it. It's like being able to get the relaxation from drinking alcohol in a pill form. It's very popular. It works in terms of immediate short-term benefit, but the long-term ridiculously high risks are never considered during the initial period of prescription. And the worst part of the story is that 80% of the benzodiazepines are prescribed, at least 80% of the benzodiazepines are prescribed by primary care doctors, not by psychiatrists. And they usually prescribed after about a 15-minute visit. The way the most important thing for doctors in America these days is getting the patient out of the office quickly. The easiest way to get a patient out of the office quickly is to give them a benzodiazepine because the medicine will make them feel better in the short run. And the long-term considerations, all the risks that come with addiction and overdose, are ignored by the primary care doctor because he doesn't have time to think about that. He has the compelling injunction from his boss to get the patient out of the office very quickly. So patients are never educated about the risks, are always, um, plugged into the benefits. In the long run, that's led to the disastrous situation with millions and millions of people on medicine that they can't stop. It's very hard to stop benzodiazepines. It's a very long, very, um, dangerous withdrawal period unless it's done under careful supervision. It has to be done very slowly over months in most cases. And so we have the situation where millions and millions, and maybe tens of millions, of people are on medication that they no longer need, no longer benefit from, that has all of the risks of dependency without any of the benefits of efficacy.

Yeah, thank you for that overview. Um, I want to pick up on a thread there. You know, you, this is something you've spoken about at length before, but, you know, we, it's, it's, it's that thing you said about, you know, the incentive being to get the patient out of the doctor's office, uh, kind of as quickly as possible. And, you know, certainly that was my experience when I was going through training, and it's been something that I've seen recently. You know, whether it's the way, um, uh, psychiatrists are reimbursed for treatment. I mean, it's, you get more, uh, reimbursement if you do four 15-minute visits as opposed to say, doing a 15-minute med check and then combining it with, you know, 40 minutes of psychotherapy or something like that. And so, I mean, that, that is also effective. There's also things like RSUs, which, uh, um, these incentives given to physicians to kind of see patients over their typical quota, and then they get bonuses at the end of the year for that. And, and, I mean, I mean, that's something I'd like to get your perspective on because I feel like when that Dove, that kind of incentive model to see people in shorter periods of time is kind of, um, led up with things, you know, you know, uh, kind of combined with things like the DSM, you don't really get, I guess, physicians who are really getting to know their patients in the context of the stresses in their lives. You know, it becomes almost this searching for, um, you know, what, what symptoms do you have? And okay, you have these symptoms, and now we have a drug that meets that indication. And then, like you said, you know, it's prescribed and they kind of leave. So, yeah, I'd like to get your, your perspective on, you know, how you think psychiatrists practiced in the U.S. today, and I guess what you think of the, are the key, the main drivers of, of the way it's practiced?

Again, psychiatry is only a small part of the problem. But at least 80% of the medications are prescribed in primary care. So even, even if we had perfect psychiatric practice, it would not even begin to touch the magnitude of the over-prescription and and careless, uh, use of medication, particularly the benefits of the azipines, which have so little utility in our field. I think that, as you, as you mentioned, all of the incentives are in the wrong direction. Um, any juror can write a prescription, and many do. And particularly if you only have 15 minutes with the patient and you never get to know their problems, the context of their problems. Most of the problems people present with in primary care, and many of the problems that people present to the psychiatrists, are more psychosocial than they are biological, that are related to current stress, loss of support, breathing, financial distress. Social and psychological problems are an enormous driver of people to want some sort of pill solution to a problem that often doesn't lend itself to to chemical agents. And it takes much more time up front to be able to talk to people, to get to know them. Hippocrates said it's more important to know the patient who has the disease than the disease the patient has. That in order to understand the psychological and social context of a given symptom, you have to know the person. And that requires time and expertise. In order to write a prescription, you just have to have the, um, the MD and the ability to, to say, I'm going to give you this medicine. You don't have to get to know the patient. You don't even have to know the medicine very well. And so many prescriptions for psychiatric medications are written by people who are not very well trained in psychiatry, and even if they are, have very little time, certainly not enough time to get to know the person and explain the other options. For most mild to moderate problems, particularly transient ones that patients present with, time, watchful waiting, and, um, placebo effect, um, are much more powerful than any active, uh, useful efficacy from the medication. So for most mild to moderate problems, talking to people, getting to know their situation, providing advice, support, reducing stress, simple psychotherapeutic techniques will be far more useful than medication in the long run, far less expensive. Once you're on a benzodiazepine, there's a very strong pressure based on tolerance to increase the dose. And as those gradually rise, often it'll be very gradual, and over many years, the ability to get off the medicine becomes less and less, and the symptoms that arise from deprescribing more and more risky. So that people are trapped, often into a lifelong dependence on medication for transient stress-related, environmental, and psychological problems that would have been dealt with much more efficiently with a a good evaluation, psychoeducation, and psychotherapy at the outset. Medication is the easy, cheap thing to do in the short run that turns out to be very, very difficult and expensive in the long run.

And would you extend that same kind of, um, uh, train of thought to the use of antidepressants for, you know, mild to moderate depression as well?

Yeah, I think that the antidepressants became remarkably popular with the advent of of Prozac. And again, same time, around 1987, with, uh, the, the notion that they didn't have the, uh, difficult side effects of the older antidepressants, although they have their own package of side effects. And at the beginning, it wasn't really clear that they had withdrawal symptoms. It's become increasingly clear that for many people, it turns out that a very large percentage of people who started antidepressant stay on it for a long period of time, this despite the fact that most of the people who seem to get a benefit from the antidepressant for mild to moderate problems are probably placebo responders. So if you have a mild to moderate short-term depression, the odds of a placebo response are over 50%. The odds of a drug response are maybe 60 to 70%. There's very little added advantage of the active ingredient in the medication when you're dealing with mild to moderate depressions. Most of the response has to do with the passage of time and the expectation of recovery. But if you start a medicine at the beginning of your, at the end of a visit with your primary care doctor or psychiatrist for a transient depression, and you get better in three weeks, you don't know that you got better because of time and placebo effect. You think you got better because of the medication. And many people will stay on medication for many, many years, sometimes decades, that they may not have needed, but have a great deal of trouble getting off. They have attributed the response to the medication when it was really just time. But once you're on the medications, particularly if the dose is significant and it's long-acting, the, um, efforts to, to stop the medication may lead to withdrawal symptoms, which are often misunderstood as being part of the original problem, a return of the original depression, not seen as a withdrawal symptom from reducing the dose of the medication. So that people get trapped in medication that may not have been needed in the first place, becomes necessary as time goes on because of its withdrawal effects. And since the art of deprescribing is very rarely taught anywhere in medical school or medical training, doctors are trained to prescribe. They're constantly thriving. The art of sunsetting medications is very rarely taught, very rarely learned, and most physicians are not good at sunsetting medication. It requires great skill. Requires almost no skill to prescribe a medication. It requires very great skill to de-prescribe a medication. It has to usually be done very slowly, under careful supervision, especially in the benz of the azipines. There are considerable risks of of really tragic withdrawal symptoms unless it's done carefully and well and under supervision. And so we have a situation with both the benz of the azipines, the antidepressants, to a lesser degree, but significant degree, also with antipsychotics. The medication that may not have been needed at the beginning becomes needed because of its withdrawal symptom effect. And we don't have enough people trained and have the time in order to help people get off medications. It's too easy to get on medications at this point. There's too little help in getting off them.

Yeah, and it can, it really leads to some terrible places. I mean, we, we treat some patients who, you know, just like you said, maybe, you know, 20 years ago or something, they moved, moved states, and they were stressed at the time, and they got placed on something. And then, you know, kind of needlessly, the medication, you know, was continued for, you know, like a decade until they eventually reached tachyphylaxis, which is essentially just dependence on the medication. It stops losing any kind of therapeutic effect it was having. And instead of, you know, I guess the prescriber at the time doing a, you know, a history and maybe putting together a plan to withdraw because that sometimes improves the problem when people find themselves very kind of blunted when the medication has, of course, this level of dependence. Instead of doing that, they get, they get started on an antipsychotic medication. And then that can really lead, lead to a lot of other problems. And that's usually where, I guess, people, people tend to find my clinic and we start untangling things. People are in polypharmacy. That, yeah, the tendency is to whenever there's a new problem, a new symptom, or an insufficient efficacy with the symptoms that were originally the the indication for the first medication, instead of carefully withdrawing one medicine and beginning another, maybe in tandem, gradually, the tendency is just to add the new medicine. And at this point, it's not uncommon for people to, to present with three, four, five medications. This is absolutely, um, no literature on polypharmacy except for a few conditions like bipolar disorder where it's important to have both mood stabilizers and antidepressants. But by and large, most of the polypharmacy that is so common in practice today is is unmoored to any research findings. It's very hard to do. It's hard enough to do studies of one drug versus another drug versus placebo. It's almost impossible, isn't possible to do studies that have two drugs versus one drug or three drugs versus two drugs versus one drug. Too many cells, too complex the clinical presentations. So most of what passes now for polypharmacy is really just, um, occasionally, occasionally it's careful customization. Yes, patient needs. So there's some combinations, cocktails that particularly skillful clinicians and very cooperative patients work out that works when nothing else works. There are some people for whom polypharmacy is helpful. But by and large, most polypharmacy these days is mindless and excessive. And I think that for many people, the, um, reduction in medication done gradually is the key that they're getting better. That many people present any new symptom that I see in anyone, the first thought I have is medication side effect. The, so common medication side effects are so common because medications are so ubiquitous. Combinations of medications given out so carelessly. As people age, they get less good at clearing medications, metabolizing them, so that the, whenever you see a symptom in anyone, the first thing you should be thinking about is medication side effect. But that's not the case. And what usually happens is that there's a chasing of each new symptom. And when a person presents with a symptom, let's add a medicine, rather than thinking about the fact that maybe that symptom is actually caused as a side effect of the package of medicines the person is already getting.

I want to ask you, I guess, a personal question about about, you know, how you came to start seeing, you know, thinking, could this be a side effect? From my experience, I guess, going through training, and I guess, you know, I still work in emergency room settings and in hospital settings doing this, and and that, and that is definitely not, you know, the primary diagnosis that I'm seeing on a lot of notes from clinicians, or at least a prof, you know, a differential, you know, consider this, the medication side effect. Where in your career did, when about in your career, did this, um, start to emerge as saying, hang on a second, you know, a lot of these problems are medication side effects? Was this early on? Was this mid? Was this late? When did you come to that realization?

Pretty early on. First off, as I mentioned before, I became quickly disillusioned with the benzodiazepines in the early '70s. And then I was in charge of the outpatient department and the emergency room at Payne Whitney Cornell in New York. And so, so many of the catastrophes caused by medication in our clinic that I actually wrote a paper in 1982 called "No Treatment as the Treatment of Choice."

I have to rate that. Yeah, yeah. Many people, it turned out that the treatment itself was doing more, more harmful good. I became aware of the problem early from having responsibility for so many patients in clinical practice. And then I was worried about the DSM. I started working on the DSM-3 in '77. I saw it proliferate diagnoses, became very concerned that the proliferation of diagnoses was leading to a proliferation of over-medication. The drug companies were very active in psychiatry around that time because it was at that point probably the most profitable of all the medications they were producing. So they were advertising like crazy. The DSM was expanding the system. Patients were receiving medications at multiples. The rates of medication use went up three, four, five times during the '80s and '90s. So it seems, it seems like it was a runaway train. And, um, I thought, it's my responsibility to do my best to contain it, although it turned out to be an unsuccessful effort.

Yeah, I wanted to, I want to shift gears now. I mean, you know, in your book, "Saving Normal," but also in a lot of keynotes, you speak and write beautifully about, um, cultural influences in, uh, in the U.S. that, uh, that I think are unique. I mean, they may also be happening, they probably are happening in other parts of the globe. And I guess it's, it's this idea of, um, I guess disease mongering is how it's talked about from, from, I guess, whether it's the medical affairs units of different companies where they put out these campaigns to almost raise awareness about the prevalence of say, depression and anxiety, and, you know, how serious it is. And, um, I guess the way we see this on the ground, psychiatrists, oftentimes there's patients coming into our office with the expectation of getting a medication, saying, I have a mental illness, you know, I need this treatment, it's serious. And, you know, there's almost this implicit thing there, you know, if you were to go against this, oh, you know, you're, you're lacking compassion, or you're almost, um, stigmatizing, you know, the severity of the problem. I'd love to get your thoughts on, uh, on on that because I mean, I think that is a very hap, very heavily happening in the U.S. and not, not quite so much in other places.

The U.S. has, where I put, is the U.S. is the worst place in the world to have a severe mental illness because we completely ignore, almost completely ignore people with severe psychiatric conditions, relegate 600,000 of them to jail or living homeless, provide almost no care for them, and, and, um, almost no housing, no decent housing. So that we have a population of individuals with clear-cut psychiatric illness that could be well treated if only there were the resources in the community to treat them, in places for people to live. At the same time, we're terribly over-treating the worried well and the mildly ill by medicalizing the problems of everyday life. And one of the problems for psychiatry is that it used to be that psychiatrists were doing the initial evaluations and would have enough time to think about not just the biological component, but also the psychological and social, have enough time to talk to patients, educate them, enough time for watchful waiting. You didn't have to make diagnoses in the first visit. You didn't have to begin treatment right away. With the advent of managed care and insurance company supervision of care, lots of the responsibilities of psychiatrists were switched to less expensive professionals at the front door. And increasingly, psychiatrists were seen as a last resort, and the major purpose it was to prescribe medication for patients who need meds. So the patient wouldn't be seen in a setting where all of the factors, the psychiatrist is often downstream, not seeing the patient at a point where all the factors are being considered, but often called on for a quick consultation to write the medication. And in many settings, the psychiatrists are employed, really these pill pushers, the end of the line consultation. I think we as a profession have to resist that. We have to have our first obligation be to the patient, not to the organization. We have to spend enough time with each patient to make sure that what we're doing makes sense. We have to consider the psychological and social contextual factors that go into symptom production. We have to consider the fact that medication may be causing the problem, it's not necessarily the solution to the problem. We have to spend more time with patients. That unless we get to know our patients, if we see our role as, ah, I see on a checklist that these are the symptoms, and therefore I'm going to prescribe this new medication, and I'm going to get this all done in 15 minutes, we're going to be doing a disservice to the patients. And ultimately, it's a stupid, economically stupid, as well as clinically, um, misguided way of approaching care because the short-term cheap thing to do, which is to write a prescription, is in the long run much more expensive for the patient, for the treatment system, and for the society.

It's true. I want to ask you, well, uh, now about, you know, in, in, um, in the U.S., at least, there's not a lot of, uh, like, uh, psychiatrists, I would say from my perspective, you know, questioning the way things are done. I mean, you, you kind of very vocally emerged on the scene about 10 years ago, and I want to get your perspective on, and maybe there are, maybe maybe there are other American psychiatrists you could point to who are also sounding the alarm about this, who have maybe the platform that you have, being, um, so prominent in the field. But, what's your understanding of why there aren't more, um, psychiatrists out there, talking about these types of issues, you know, the, you know, the problems with the mental health care system?

Well, I think, uh, psychiatry is not a powerful profession. We're mostly, um, not in control of how we practice. You know, there are some people who are still in private practice, but probably the majority of psychiatrists now are on salary or contract of one sort or another. Uh, the ability to, um, to speak out against one's own livelihood is limited. I had the luxury of not depending on practice for support, um, and I spoke out way too late. I mean, I think I wrote papers like "No Treatment as the Treatment of Choice" as early as 1982, but I did not use the bully pulpit of DSM-4 to make these issues clear. I made clear that I thought that there was diagnostic inflation, and we were very explicit about the fact that we, we would not increase the number of new diagnoses. There were 94 suggested new diagnoses for DSM-4, we accepted only two. But I didn't say, um, that we should reduce the system because if we were going to be data-based, it's very hard to eliminate things if you don't have evidence to prove that they, they are harmful. I don't think I was nearly vocal enough. I was vocal about being conservative in DSM-4, but I don't think I was nearly vocal enough about the plight of the severely ill or the, um, the very great harms of over-diagnosis. I didn't use a public forum that came only latest. I have regrets. I mean, I think I should have been a much more advocate, stronger advocate, both for the needs of the severely ill and for the harms that are done and consequential harms that are done from over-treatment. If I was a little too late and maybe too little. And, um, well, I think I'd probably speak for many people. And just that, just kind of grateful for what you did because I think I mentioned previously, you know, when I, when I read, you know, "Saving Normal" when I was a resident, resident, it gave me a whole new kind of perspective on on psychiatric diagnosis, and I think it really changed me as a clinician for the better. So I would just say, you know, um, yeah, you know, uh, your work is, you know, is greatly appreciated.

Um, I want to ask about, you know, what happened after you came out publicly and started saying things that were more critical about the way psychiatry was practiced? I mean, were you, um, you know, were you ostracized by some people? Were you quietly embraced in private circles for saying things that everyone had been thinking? What was, what was that like for you with the, I guess, all of those professional colleagues?

Yeah, I mean, I lost friendships. Um, I've gained others. Um, yeah, I don't think that's too important. I think the issue is that, um, we still have 600,000 people who were sleeping on streets or living in dungeons. When Biden considered having an infrastructure program that would help not just on physical infrastructure, but on, uh, social infrastructure, the administration did not even consider the fact that mental illness is so underfunded as an infrastructure project for the future. So I would say that my impact has been pretty small. I think it has, the book has had a significant impact on a large number of people like yourself. I know that I hear that all the time. I give classes and lectures and stuff, and everyone who comes loves the book and it changes, exactly what you said. But how much it's actually changed systemically the disaster that is American mental health care, I would say that that's pretty small. People, I'm sure it's helped individual patients, but the system is as bad now as it's ever been.

Okay, I was going to ask you, is there anything to be hopeful about? You know, any kind of, um, movements, you know, whether whether it's to try and, uh, get insurance companies to place more value on, you know, maybe longer, you know, psychotherapeutic counseling, you know, with practitioners, or maybe some other aspects? I'm not aware of anything to be hopeful of in terms of the way this is changing.

About, I think that, um, there won't be any sudden breakthroughs in psychiatry. The brain is the most complicated thing in the known universe. There are no simple answers. The drug companies have stopped doing research on psychiatric drugs because there are no magic bullets that are going to be discovered in probably for decades, if ever. So I think that the question is, will care be improved? I think that the, um, efforts of patients has been very useful in emphasizing the importance of deep prescribing. That the various groups that have developed to point out the risks of taking antidepressants and benzodiazepines, and to a lesser degree, antipsychotics, that pointing out the need to, to be very consumer-oriented before starting, to be an informed consumer before starting, to be careful in deprescribing. I think that physicians are becoming more aware of this. It's written about much more recently. The British Society of Psychiatry came out with a very strong statement about the risks of antidepressant withdrawal symptoms, which had been denied for many years. So there's encouragement that people are becoming more consumer-oriented and aware of the risks of medication. There's much less, there isn't drug advertising now for psychiatric drugs because they no longer have patent protection. That's a good thing. But in terms of a systemic change, particularly in the U.S., in how primary care doctors prescribe medication, a systemic change in giving psychiatrists more time to get to know their patients, a systemic change that would bring out the psychiatric patients who are prisoners and get them back in the community where they belong, a systemic change to deal with these problems of the homeless, I'm not too optimistic that any of these are quickly going to happen. I think that individual practitioners have to not give up hope. I mean, I think that there isn't great hope on the broader sphere that we're going to have a political and sociological, uh, reawakening in America to our responsibilities to the severely ill, reawakening to the awareness that primary care medicine is being practiced in just the worst way possible in the U.S. I don't see that happening in the short run. But I think for individual practitioners, it's important that at the end of their career, they not feel as I sometimes do that I should have done a lot more. That it's important for an individual practitioner to maintain hope and the integrity of our calling, to not do things that are wrong just because the system says they have to be done that way, to get to know patients, to not prescribe in the reflex sort of way, to become an expert at deprescribing medication, and to continue seeing very sick patients, not to run away from them.

Dr. Francis, um, I think this is probably a good time to wrap. I've, I've gone a little over time, but, you know, I just, I so appreciate you taking the time to, to speak with me and talk about what I think is a really, really important issue. So, yeah, your effort to stem the tide and to do the right thing and to help others to, to learn what's most appropriate care, educating both clinicians and patients to avoid the risks of over-medication for those people where medication may be more harmful than helpful, to and educate people about how to get off medication because that's so important. And I think we all also have to recognize our, the importance of our constantly advocating for the severely ill. We shouldn't be possibly if they're not able to have a place to sleep at night off the streets or if their bed isn't a person. And,

Very true. So, yeah, thank you for those kind words. I mean, I'd love to have you on again sometime in the future if you'd be interested. And, and topics emerge where you could lend your expertise. Yeah.

Okay. Thank you. Thank you so much. Bye-bye.