Allen Frances

Author: 'Clinician's Survival Guide To The Chatbot Revolution'
Professor & Chair Emeritus, Duke Dept of Psychiatry
Chair, DSM-IV Task Force

[Allen Frances @AllenFrancesMD]

Road to hell is paved with good intentions & bad unintended consequences.

We included Bipolar-II in DSM-IV to reduce risk of antidepressants causing mania/rapid cycling in people with bipolar risk.

But Pharma promoted massive over-diagnosis & overuse of harmful antipsychotics.

[Allen Frances @AllenFrancesMD]

Biggest DSM IV error was adding Bipolar 2:
Pushed by Pharma & over-diagnosed by MD's, it led to harmful/unneeded use of antipsychotic meds. https://t.co/PSmWfn0Ukj

[Allen Frances @AllenFrancesMD]

Serious suggestion to improve psychiatric training & care:

All training programs & large scale providers should be required to run a lithium clinic for bipolar disorder & clozapine clinic for schizophrenia.

Not having these= neglecting the severely ill/treatment non-responders.

[Allen Frances @AllenFrancesMD]

In AI world, we need to radically change who gets into medical school.

All medical info is now readily available, but great clinical judgment is rare & the human touch is almost lost.

Being book smart is now much less important than having common sense & being people smart.

[Ash Paul @pash22]

Medical students admitted solely by grade point average show a narrow but highly prosocial personality profile
https://t.co/bK0S2NgpUf via @jarlebreivik et al

[Allen Frances @AllenFrancesMD]

Human emotional distress is ubiquitous. Psychiatric disorder is pretty rare. Conflating them causes big trouble.

30 yrs ago, wild fad psych diagnosis was promoted by Big Pharma/mostly done by the MDs.

Internet is now to blame & the loose self labelling is done by the patients.

[Allen Frances @AllenFrancesMD]

People with severe mental illness usually need meds- but always also need #psychotherapy & social work help.

But few therapists train in this work/few patients have insurance.

Beck's "Recovery-Oriented Cognitive Therapy for Serious Mental Health Conditions" is best solution.

[Schizophrenia International Research Society @SIRSGlobal]

🧠 Evidence-based psychosis-specific psychotherapies are recommended across the schizophrenia spectrum. However, training in these specialized therapies is often not mandatory for psychotherapists, leading to a fragmented field of expertise.
This large-scale survey of 1,382 psychiatrists and clinical psychologists in Switzerland assessed self-reported psychotherapy workshop attendance for psychosis. Nearly half of participants attended at least one workshop, although only roughly a third had attended as part of their mandatory psychotherapy training.

🔎 Social network analyses revealed that the overall psychosis psychotherapy training landscape remains highly fragmented and without clear training pathways. Popular workshops included cognitive behavioral therapy for psychosis and psychoeducation, but co-attendance rates between different workshop types rarely exceeded 10%.
Furthermore, attendance patterns differed significantly based on occupational roles (psychiatrists vs. psychotherapists) and therapeutic orientations (CBT vs. psychodynamic vs. systemic vs. humanistic), indicating inconsistencies in access.

💡 These findings highlight the urgent need for evidence-informed measures to address training gaps and promote guideline-aligned specialization pathways.

🔗 Read the full study:
https://t.co/ESstG6066h

#CBT #MentalHealth #Psychosis #PsychotherapyResearch

[Allen Frances @AllenFrancesMD]

If you consciously set out to develop the world's worst possible mental health non-system, you would come up with the absolute mess we have created in the US.

[Psychiatric News @PsychiatricNews]

The barriers that patients face when trying to access mental health care are numerous, including extensive wait times, limited in-network options, and ghost networks—in which insurance directories are padded with clinicians who can’t or don’t actually provide care. https://t.co/kB3DBjLQy7

[Allen Frances @AllenFrancesMD]

Cruel paradox:
We over-diagnose/over-treat worried well while neglecting the really sick.

Awful misallocation of resources started in 1980 with 2 unrelated events: 1)DSM-III
2)Community mental health centers defunded

If all are "sick", desperate needs of really sick go unmet.

[Medicating Normal @MedicatingNorm1]

"Normal human emotions are being diagnosed as disorders, according to mental health experts.

More than four in five mental health professionals believe that normal thoughts are being 'medicalised', with anxiety, depression, autism – and attention deficit hyperactivity disorder (ADHD) in particular – being overdiagnosed, according to a survey.

The majority of practitioners also think mental disorders are being 'glamourised' and that having a neurodevelopmental condition has become a desirable personality trait."

https://t.co/RxxoaV03IM

[Allen Frances @AllenFrancesMD]

Reagan definitely had terrible intentions when he stopped federal funding of community mental health centers.

& no powerful political leader since has cared enough to correct the criminalization of mental illness/support adequate community care/or correct shortage of housing.

[Kurt Belgard MD @Kurtbelgard]

Reagan played his part but he was one player acting in one act in what looks to me like a four act tragedy. Critical steps occurred before and after his federal career. No one had bad intentions. No one with the power to make decisions understood the consequences of their decisions.

My own take is that as asking for government money became more and more an economic foundation and socially acceptable to people in all ranks of society, the traditional acceptable objects, the weakest least able to care for themselves, got trampled in the dust.

Too many pigs, not enough tits. The weak piglet gets shoved out. In human terms it is the people who don't vote, can't work the system, can't make themselves into a cohesive political force who are shoved aside.

[Allen Frances @AllenFrancesMD]

Reagan destroyed care for people with severe mental illness by privatizing it.

Private systems care only about profit & cherry pick the easiest patients.

Result: People who really need treatment can't get it & wind up homeless or in jail.

[Deborah Geesling @DeborahGeesling]

Why do private psychiatric hospitals turn away complex patients?

A new psychiatric hospital opens, and families think, “Maybe now there will be help.”

But what if your loved one needs constant supervision? What if they have a medical condition that requires extra nursing care? Dr. Carol Olson explains why more beds don’t necessarily mean more access for the people who are most ill.

Then where do they go? That’s the question I can’t leave alone.

In Episode 3 of Mama Bear Diaries, we talk about who our system can serve, who it struggles to serve, and what it would take to close those gaps.

[Deborah Geesling @DeborahGeesling]

Why do private psychiatric hospitals turn away complex patients?

A new psychiatric hospital opens, and families think, “Maybe now there will be help.”

But what if your loved one needs constant supervision? What if they have a medical condition that requires extra nursing care? Dr. Carol Olson explains why more beds don’t necessarily mean more access for the people who are most ill.

Then where do they go? That’s the question I can’t leave alone.

In Episode 3 of Mama Bear Diaries, we talk about who our system can serve, who it struggles to serve, and what it would take to close those gaps.

[Allen Frances @AllenFrancesMD]

Reversal of fortune:
In 1960s/70s, US led world in creating humane, community based treatment of severe mental illness.

Under Reagan, US began defunding mental health/funding prisons/forcing homelessness.

US is now worst place in world to be mentally ill/Trieste & Aviles best.

[juanjomjambrina @juanjojambrina]

@AllenFrancesMD Come to Avilés, Allen. Despite the difficulties and scarce resources, we are still holding out.
ACT Team, Crisis Resolution Team and AcT for Youth People: Tranvía Team: Transition to adulthood from childhood; only for SMD under 25 years.

Tranvía: Transición a Vía Adulta

[Allen Frances @AllenFrancesMD]

What would a good country do for people with severe mental illness:
1)Build affordable housing, not data centers
2)Spend $$s on treatment, not jails
3)24 hr crisis teams, not cops
4)Community mental health centers, not waiting lists
5)Clozapine/lithium clinics, not neglect

[Allen Frances @AllenFrancesMD]

When I started psychiatry 60 yrs ago, 500,000 patients were warehoused in disgusting state hospitals.

Things now much worse:
1)Only 100,000 psych beds
2)1/2 severe patients are untreated
3)400,000 in jail
4)500,000 homeless

Richest country in world has very worst psych care.

[Allen Frances @AllenFrancesMD]

US criminalization of severe mental illness breaks my heart & boggles my mind.

Graph shows magnitude of problem, but nothing can convey the suffering.

Our patients are sicker than rest of world because we make their lives so miserable.

[Tyler Black, MD @tylerblack32]

To wit:

[Allen Frances @AllenFrancesMD]

Any country that copies US model of medical or psychiatric care is doomed to disaster.

[Dr LG @subversivepsych]

What will happen in the UK if the Right Wing get in.
They will pursue an American healthcare model.
It’s already bad but it could be worse.

[Allen Frances @AllenFrancesMD]

When I started psychiatry 60 yrs ago, 500,000 patients were warehoused in disgusting state hospitals.

Things now much worse:
1)Only 100,000 psych beds
2)1/2 severe patients are untreated
3)400,000 in jail
4)500,000 homeless

Richest country in world has very worst psych care.

[Awais Aftab @awaisaftab]

There is a tremendous need for inpatient psychiatric care. Patients & families are desperate for therapeutic inpatient treatment with psychological support that offers them dignity, privacy & respect, but what they often experience instead is traumatizing & dehumanizing. (1/3)

[Allen Frances @AllenFrancesMD]

BIOLOGICAL REDUCTIONISM IS DUMB

PSYCHOLOGICAL REDUCTIONISM IS DUMB

SOCIAL REDUCTIONISM IS DUMB

SPIRITUAL REDUCTIONISM IS DUMB.

SIMPLE ANSWERS TO COMPLEX PROBLEMS=WRONG

Psych disorders have complex interacting causes & often require comprehensive/flexible/integrated treatment

[Allen Frances @AllenFrancesMD]

Great ? from @PatMcGorry:
How come there's some specificity of treatments for psych disorders when there's no known specificity of causes.

My view: Psych disorders may be too complex for us to understand, but not too complex for us to treat.

True for most diseases in medicine.

[Allen Frances @AllenFrancesMD]

My opposite view:
That 100s of genes are weakly/nonspecifically related to many different psych disorders means its time to admit psych genetics is a flop-has little to diagnosis/practice.

DSM differential diagnosis, tho limited & flawed, remains crucial for treatment planning.

[Allen Frances @AllenFrancesMD]

My opposite view:
That 100s of genes are weakly/nonspecifically related to many different psych disorders means its time to admit psych genetics is a flop-has little to diagnosis/practice.

DSM differential diagnosis, tho limited & flawed, remains crucial for treatment planning.

[Allen Frances @AllenFrancesMD]

I predict:
1)Soon almost everyone will depend on AI as coach/therapist
2)Human therapists will have narrower niche treating more severe problems
3)Many training programs/therapists will be too slow adapting to shift
4)AI will integrate therapy/ending competition among schools