Friday, April 05, 2013

Cosmetic Psychopharmacology?

We read everywhere that psychotropics are over-prescribed.  The DSM guidelines have pathologized normal reactions and  DSM-V promises to make this even more so.  For example, over 11% of children are now diagnosed with Attention Deficit Disorder.  Our friend, Dr. Mojtabai, tells us that many patients who are given antidepressants by primary care doctors don't have a psychiatric diagnosis, our colleague, Dr. Frances (and many others) doesn't want normal symptoms of grief to be diagnosed as major depression after 2 weeks of symptoms, and our readers have written in saying that there are effective psychotherapeutic treatments for schizophrenia.

Why the push to give so many people a diagnosis, and then a pill?

I'll venture some guesses here.  These are only guesses:

~ Psychiatric disorders were previously under-diagnosed and with the broadening of diagnostic categories, and the promise of relief, more people go to the doctor seeking these diagnoses.  In order to get a diagnosis of ADD, you have to point out the symptoms to a doctor -- a doctor doesn't just know that you can't concentrate, focus, and lose things all the time (to name a few symptoms) and if you think this is normal, you won't tell the doctor your problem.  So greater public awareness and desire for diagnoses and treatment.
~A desire to blame problems on biology and therefore not have to own them.
~Treatments with fewer perceived side effects.  Many people have no side effects to the medications, and so the risk/benefit tradeoff is low.  I left it as "perceived side effects" because some of the treatments include risks that may not initially be felt as such by the patient, such as the risk of addiction or of metabolic problems which may not have obvious symptoms.  But some people truly get benefits from medicine with no untoward side effects.
~A push by the pharmaceutical agencies to sell their wares to doctors and consumers.  Funny, we have villainized physicians who let drug reps give them pens or feed them sandwiches or pay them thousands to peddle their product, but it's fine that drug companies now advertise direct-to-consumers in 30 second bytes.  I'll leave that one for another day.
~Sometimes these medicines work and provide tremendous relief and then they become their own advertisement.  My friend feels great on Drug X and I want some, too.
~Who doesn't like a quick fix?  I believe medications work best in combination with psychotherapy, and it's not an either-or proposition.  Some people get all the way better by simply popping a pill, others don't get better with all the drugs and all the psychotherapy there is in the world. 
~While a trial length for medications is clear, we don't have a definitive time frame for how long one needs to go to therapy.  Do you get better after 4 sessions or 4 years?

That's for background.  Now for today's blog post:

So with a push to accurately diagnose, and to reserve treatments for only those who meet diagnostic criteria, I'm going to ask a question: What's wrong with cosmetic psychopharmacology?  Why is a problem to give someone who doesn't meet criteria for a disorder a pill, provided the patient comes looking for help (I don't advocate sending psychiatrists to knock on doors), provided they are made aware that the medication has risks, provided the patient has some form of free will and can stop the medications at any time?  And given the fact that "meeting criteria" is about diagnoses that are decided by a committee and not based on something hard and fast and scientific, for example the presence of a large tumor.  The issue, of course, gets sticky when the treatment includes medication with the potential for addiction, but let me give you some examples, and you can comment as you will.  Keep in mind, I'm asking to be provocative, not to say it's fine.

~ A patient comes in with 4 weeks of  profound sadness, feeling hopeless and suicidal.  There are no neuro-vegetative symptoms (meaning no change in sleep/appetite/sex drive) and he's a couple of symptoms short of "meeting criteria" for Major Depression.  There are no clear precipitants to the episode, both parents and one sibling have had treatment for depression, and the patient is willing to come for therapy, but he's also requesting medication.
~ A patient requests a single tablet of Valium (or any of it's relatives) to take before a flight.  The patient has flown before and gets very anxious, but has no psychiatric diagnoses.  His flight is next week and he has neither the time, funds, or propensity to undergo desensitization training.
~ A college student comes in requesting a prescription for a stimulant.  He has been taking a friend's and finds it to be very helpful.  He only takes it before exams or to write papers and he feels it gives him an edge he wouldn't otherwise have.  He has no history of addiction, no blood pressure problems or arrhythmia, he is requesting a low dose and only wants a small supply.
~ A woman is a wreck 2 weeks after her mother dies.  She has every symptom of depression and wants medication.  She understands that her symptoms are from grief, but she wants to see if a medicine might help mitigate some of her misery.
~ A gentleman with a family history of Alzheimer's has noticed some age-related changes in his memory.  A neurologist has told him that he doesn't not have Alzheimer's disease.  He wants to start Aricept as a prophylactic medication in the hope that if he were to get Alzheimer's disease, this would slow it's progress.
~ A man took an SSRI for a single episode of depression and made a full recovery quite quickly.  During the episode of depression, he was seen weekly for psychotherapy, since then he has come in for monthly sessions.  After a year, his psychiatrist took him off the medication.  He has not had a relapse and is doing well, but is requesting to resume the medication because he just feels better on it, but can't articulate why other than to say he feels calmer and more resilient.   He has no side effects to the medication, and it does not make him complacent or unmotivated.
~ A patient has trouble sleeping and wants Ambien to take once in a while.  Then he wants Ambien to take every night. It helps him sleep and he has no side effects from it.
~ A patient has trouble sleeping and has a history of addiction.  The psychiatrist is worried about starting Ambien or a benzodiezepine.  The patient did not have a good response to trazodone or benedryl.  His insurance won't pay for Rozeram.  He found Seroquel to be helpful, his insurance will pay for this, and he understands that it might cause weight gain and metabolic issues, but he's young, healthy, slim, exercises regularly and willing to take the risk with monitoring of his weight and labs, but it's not indicated as a sleeping pill. 

Go for it.