Why overdiagnosis is failing the students it claims to help [PODCAST]

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At one university, the share of students receiving disability accommodations rose sevenfold in a decade. Is that progress? In this episode, health care educator and patient advocate Richard A. Lawhern argues that psychiatric overdiagnosis is handicapping the very students it aims to help, and that the research underneath much of modern psychiatry may not hold up. This episode is based on his article “Why psychiatric overdiagnosis fails the students who suffer,” published on KevinMD. You will hear why he says a rise in student diagnoses reflects misallocated help rather than real need, how the replication crisis has undercut studies that shaped the field, and why critics like Allen Frances have questioned the expanding reach of the DSM-5. He also lays out where he thinks families harmed by misdiagnosis may have recourse. Hear the case he makes for why the science behind these diagnoses may not hold up, and what he thinks families can do about it.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Richard Lawhern, patient advocate. Today’s KevinMD article is “Why psychiatric overdiagnosis fails the students who suffer.” Richard, welcome to the show.

Richard A. Lawhern: Thank you very much. I appreciate the opportunity to speak, through you, with an audience that is at least equal parts, probably more than equal parts, clinical professionals, journalists, and health care patients.

I am, as you’re aware, and as many of your readership are aware, a health care educator with about three decades of experience in the field and somewhat over 400 published papers.

I maintain a very large network. It’s a way of being aware of what’s going on in health care. And the network popped up with an article recently in The Boston Globe by a gentleman by the name of Adam Omary. Adam did an article titled “The Disability Accommodation Trap on College Campuses.”

Kevin Pho: I think I read that article.

Richard A. Lawhern: It was quite well done and well-referenced, as a matter of fact. And what he basically wanted to communicate is that, as was reported in The Harvard Crimson in December of last year, the share of Harvard undergraduates receiving disability accommodations rose from roughly 3 percent in 2014 to 21 percent in 2024, which is a sevenfold increase in a decade.

Now, for me, that observation and his further commentary were a little disturbing, because 40 years ago one of my daughters was among that 3 percent or less who were diagnosed with a disability, specifically dyslexia. She had inherited dyslexia from her grandmother through me, but it had skipped my generation, and I was not really certain that the label would have applied.

When it was discovered, she was homeschooled by her mother from sixth grade through high school, admitted to a junior college, and then to upper-division status at a branch of the University of California. And she was one of those who benefited from what are now called accommodations. She was granted extra time in some of her examinations and was exempted from reading aloud in some of her classes. Those were not large accommodations by any means, but they were part of her educational program.

Now, when I read something like the article by Adam Omary, I am particularly alarmed, because I think it may incorrectly cast a shadow over others like my daughter who are very bright but simply have a disability in the way they process information.

She was a very bright lady. She in fact graduated from the University of California cum laude in English, and when she left her employment 12 years later to start her family, she had served as an assistant vice president for network services at a multi-branch community bank. In fact, not only had she served in that capacity, she was at the time an assistant network administrator for the Federal Reserve Bank in San Francisco. Now, you don’t get to such positions by patronage or by being dumb, that’s for sure. She’s not a dumb lady. She’s very bright.

But Dr. Omary offers a very important context for the article, and on this I’m going to quote him: “No one wants to be accused of indifference to suffering, but overdiagnosis is not compassion. It teaches a generation to mistake the ordinary difficulties of being young for evidence that something is clinically wrong with them, and it dilutes resources and attention, and takes attention away from the people who need the most.”

And as a health care educator, I am entirely in agreement with this observation. But I’m also going to suggest that Omary did not take his observation quite far enough, because this article is occurring in the context of an enormous, I think you could say, earthquake in public perception of the entire fields of psychology and psychiatry.

Those fields are now in crisis, and it’s a crisis of credibility, and they are in crisis for very good reasons that most people are not generally aware of. And let me quote again from a few other sources that suggest this.

Let us take a for instance. One of the books that was very formative for me was published, let’s see, something on the order of 1973. I’m going to say that it was 1973. It was by Martin L. Gross, and the title of it is “The Psychological Society: The Growth and Failure of Modern Psychology and Psychiatry in the Psychological Generation.”

It was a very startling book because, among other things, it summarized studies that went as far back as the 1950s that demonstrated a very alarming characteristic of psychiatric treatment in institutions. Specifically, it reported the results of several studies that did a kind of double-blind analysis on the effectiveness of several types of psychiatric therapy in resident facilities.

A group of patients were separated into two subgroups. One of those groups was admitted to resident status for six months, basically to a bed at an institution, based on an evaluation that suggested that they were in some way profoundly depressed. That group was in turn divided into three groups. One of them experienced Freudian psychotherapy or psychoanalysis. Another experienced Adlerian psychoanalysis, and another group work.

That group, after six months, was asked, “Has your depression improved?” And 90 percent of the group reported that yes, indeed, it had. There was no significant statistical difference between the three forms of therapy.

But here is the real kicker. The group that was wait-listed was also asked the same question, and they gave the same answer in the same prevalence. Ninety percent of those who were wait-listed said that they too had significantly improved in their levels of depression.

We really need to think about that in the context that Omary has established, because what that observation, among many others, is telling us is that the people whom we trust to assist our youth, and to assist us old folks when we feel we need it, in dealing with depression, in dealing with anxiety, in dealing with issues that basically hamper our ability to live and to enjoy lives of something other than quiet desperation, those people have not made the case for their methods.

And this is not the only issue that arises, as I’ve mentioned in the article that we’re working from. Anyone who is going to potentially study this field also needs to study some recent efforts by analysts to evaluate whether the studies that are considered to be seminal, and by that I mean really game-changing, in the practice of psychology and social psychology and psychiatry hold up when they are re-performed by groups different from the groups that originally performed and published them.

Now, by any other name, this is called the quote-unquote “replication crisis.” And it is a crisis because what it reveals is that when teams of investigators attempt to duplicate the results of the original studies that go back probably 20 years or more, and which have shaped the entire practice of psychology, psychiatry, and social psychology, when groups tried to do that with 100 studies, in 65 percent of those studies the results didn’t replicate.

In other words, using their best understanding of the trial protocols that were used in evaluating these methods, the independent study group arrived at the understanding that the studies really were not supported by the data that was processed. They just didn’t replicate. And worse, even among the approximately one-third of studies where there was some replication, the statistical significance or strength of the findings was much lower than claimed by the original investigators.

Omary’s article illustrates that resources are being misallocated for people who probably would do just as well without them. It also suggests that we may be crippling an entire generation of people by subjecting them to favoritism with the best of intentions, and essentially subjecting them to proposals about the nature of human psychology that are simply false.

As a clinical educator, I see this operating in a different framework all the time.

Kevin Pho: So in terms of the diagnoses that Omary writes about, you are implying that some of them, not only because of the historical context of psychological studies, may be in question. Those diagnoses that some students are getting may be in question.

Richard A. Lawhern: Yeah, I think they’re more than in question. I think that students are actively being handicapped by overdiagnosis rendered by psychiatric and psychological professionals.

Now, this is a general statement about a problem that has a great many dimensions to it, but one of the things that we’re realizing now is that the people whom we trust to be experts on the management of life difficulty, which is really what a psychiatrist or a psychologist does, the people whom we’ve trusted are not worthy of that trust.

We have facing us the likelihood that an absolutely huge number of studies that have influenced the practice of psychology and psychiatry need to be burned to the ground and done over by a different team with different assumptions, and a team that bothers to check its own results by doing a step-by-step analysis of methods before they ever go to print.

There are families who have reason to believe that their kids have been actively injured by misdiagnosis. There are other families who are really desperately seeking help that psychiatric care probably isn’t going to give them. They might do just as well working with a life coach. They might do just as well working with someone who is certified as a marriage and family counselor, and counseling is a very different operation than psychiatric care.

Kevin Pho: Now, there must be some data that shows some of the benefits of some of these psychiatric studies. Are you just putting them all in one bucket?

Richard A. Lawhern: So far, and this is one of those places where I have to say as far as I know, nobody has put the whole thing in one bucket yet. The closest I’ve ever seen was Martin L. Gross, and he did this particular job now 50 years ago. His book, by the way, is still available as a used book from Amazon. You can look it up: Martin L. Gross, “The Psychological Society.”

The point I’m trying to make, and the point that I hope that other people will regard, is that there is a counter-revolution brewing now. And it’s brewing, among others, among people who have excellent credentials to be critics of the current trend.

One of those people is a fellow by the name of Allen Frances. He was basically the crew chief who supervised the development of the diagnostic and statistical manual, version five. He is also one of its sharpest critics. And the book that I suggest that people consider, that he authored, was “Saving Normal.”

It is a fascinating look at the tendency to over-psychologize normal adjustment issues that we encounter in adolescence and young adulthood, and older adulthood as well. Because what he says is basically that the DSM-5, as the standard that is used in diagnosis, essentially expanded the range of possible toxic diagnosis significantly without in any way assisting in generating better health, mental health or otherwise.

And from someone like Allen Frances, who is certainly qualified to make that judgment, this is a very damning indictment, and it’s one that should prompt public health policy change and action. We need to seriously reconsider a great number of the published papers that are used to justify therapies for young people that probably don’t work any better than a wait list.

Kevin Pho: Now, can you tell me where we go from here? What are the plausible paths forward?

Richard A. Lawhern: One of the possible actions here is that families that have had problems with a child not getting appropriate support have a basis for legal action. It’s a rather tenuous one. But families where a child has suicided while under treatment have an excellent case for requiring that a state board reexamine the credentials and practices of the treating physician in those circumstances, to assess whether in fact he was using methods that in fact work.

The state board process is set up to do that, both with clinicians who treat pain and with psychiatrists and psychologists. But people whose families have been damaged by these kinds of influences have a definite, I think potentially highly effective, means. I haven’t yet seen evidence that the lawsuits are happening, but I think we’re right on the hairy edge of a wave of them that respond directly to the kinds of influences and issues that were raised in The Boston Globe just a few days ago.

Kevin Pho: We’re talking to Richard Lawhern, patient advocate. Today’s KevinMD article is “Why psychiatric overdiagnosis fails the students who suffer.” Red, let’s end with some of your take-home messages to the KevinMD audience.

Richard A. Lawhern: Pertaining to this article, we are very much involved in referring people to competent physician care who need it, and we will make every effort to be sure that anyone who contacts us requesting that kind of referral is treated on a priority basis.

Kevin Pho: Richard, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Richard A. Lawhern: Thank you for having me.

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