Saturday, March 22, 2014

There's a Pill for That…Or Not

A few days ago, I read an article by Los Angeles-based psychiatrist Joseph Pierre titled "A Mad World" (thanks to Vaughn Bell over at Mindhacks for the link). Right off the bat, I was suspicious of the SEO link-baiting done by the Aeon editors: the title that appears on the web browser's title bar is not "A Mad World," but is "Do psychiatrists think everyone is crazy?", and the URL of the article ends in "have-psychiatrists-lost-perspective-on-mental-illness." Of course, Dr. Pierre likely had no control over how the publication chose to market his article; more on this later.

He does make some good points about how mainstream psychiatrists are not as bound by the DSM as some may think:
The truth is that while psychiatric diagnosis is helpful in understanding what ails a patient and formulating a treatment plan, psychiatrists don’t waste a lot of time fretting over whether a patient can be neatly categorised in DSM, or even whether or not that patient truly has a mental disorder at all. A patient comes in with a complaint of suffering, and the clinician tries to relieve that suffering independent of such exacting distinctions. If anything, such details become most important for insurance billing, where clinicians might err on the side of making a diagnosis to obtain reimbursement for a patient who might not otherwise be able to receive care.
However, reading through the piece gave me a very uneasy feeling. After thinking about it some, I think my discomfort comes from the author's uncritical acceptance of American consumerism, as illustrated by sections like this one:
Though many object to psychiatry’s perceived encroachment into normality, we rarely hear such complaints about the rest of medicine. Few lament that nearly all of us, at some point in our lives, seek care from a physician and take all manner of medications, most without need of a prescription, for one physical ailment or another.
Now, I love being a consumer as much as most other Americans. The convenience of being able to do just about anything ("There's an app for that") on a handheld device is incredible. But what happens when you mix healthcare and consumerism? You get commercials telling viewers to "ask your doctor about" lots of different conditions, whether it's chronic dry eye, low T, or whatever. We already live in a county where the costs of healthcare far outweigh the benefit in terms of life expectancy, so isn't the over-medicalization of normality worth lamenting, even if most people don't? And certainly when it comes to healthcare, the consumer is not always right, though doctors often give in and end up doing things like prescribing antibiotics for viral illnesses.

And then there was this passage, straight out of a pharma executive's wet-dream:
Pharmacotherapy for healthier individuals is likely to increase in the future as safer medications are developed, just as happened after selective serotonin re-uptake inhibitors (SSRIs) supplanted tricyclic antidepressants (TCAs) during the 1990s. In turn, the shift to medicating the healthier end of the continuum paves a path towards not only maximising wellness but enhancing normal functioning through ‘cosmetic’ intervention. Ultimately, availability of medications that enhance brain function or make us feel better than normal will be driven by consumer demand, not the Machiavellian plans of psychiatrists.
SSRI's have been around for over 25 years, and where are the safer medications? Has he not been reading the headlines? He continues with:
The legal use of drugs to alter our moods is already nearly ubiquitous. We take Ritalin, modafinil (Provigil), or just our daily cup of caffeine to help us focus, stay awake, and make that deadline at work; then we reach for our diazepam (Valium), alcohol, or marijuana to unwind at the end of the day. If a kind of anabolic steroid for the brain were created, say a pill that could increase IQ by an average of 10 points with a minimum of side effects, is there any question that the public would clamour for it?
Suppose we have a pill that could take away pain but has no side effects whatsoever, including constipation, sedation, deadliness in overdose, etc. Isn't it obvious that an emergent effect (whether or not you call it a "side effect" or not) is that people would be hooked on this pill, and it would have enormous street value? Perhaps I'm just old-fashioned, but I get the sense that side effects (e.g. passing out drunk, getting jittery from caffeine, becoming duller from chronic cannabis use) are nature's way of keeping us from going overboard with too much of a good thing.

Dr. Pierre states toward the end:
In the final analysis, psychiatrists don’t think that everyone is crazy, nor are we necessarily guilty of pathologising normal existence and foisting medications upon the populace as pawns of the drug companies. Instead, we are just doing what we can to relieve the suffering of those coming for help, rather than turning those people away.
Drug dealers can make the same argument, that they're just there to meet a consumer demand, relieve suffering, and increase happiness. Of course, with drug dealers it's easy to see that their products have very short-term benefits but cause long-term harm. While not nearly as extreme, I believe that if all we're doing is relieving suffering without helping patients recognize and change what led to the suffering, we are not truly helping them in the long run; we're just turning them into repeat customers. And suffering itself is not always a bad thing. In the field of child psychiatry & psychology, for example, we are increasingly recognizing how parents' efforts to protect their children from any suffering can lead to those kids having trouble being on their own or dealing with stress later in life.

I don't advocate turning people away, but I often emphasize to patients that feeling better is going to take significant time and effort on their part, and is not something I can just give them, which may not be what a good consumer wants to hear. Which brings me back to my first paragraph. I not only pointed out the methods Aeon used to market the article to consumers, but I also mentioned that Dr. Pierre works in L.A. This is not a coincidence, as L.A. is one of the epicenters of American consumerism. This article is emblematic of how consumerism operates and is a defense of it, by someone who may be too immersed in a consumerist culture to see its follies.