Tuesday, April 15, 2008

This is your character...this is your character on antidepressants

Most of my patients, who are adults, developed their psychiatric problems after they had a pretty clear idea of who they were as individuals. During treatment, most of them could tell me whether they were back to their normal baseline.

Julie could certainly remember what depression felt like, but she could not recall feeling well except during her long treatment of antidepressant medications. And since she had not grown up before getting depressed, she could not gauge the hypothetical effects of antidepressants on her emotional and psychological development.

Dr. Richard A. Friedman has written for today's Science Times about a generation who has built their character and their knowledge of themselves while always on psychotropic medication. We would not think twice if Julie grew up with congenital high blood pressure, that was untreatable through diet and exercise, about medicating her. I think it unlikely that she or anyone would say what a loss it was that she didn't know her heart without that medication if it was protecting her internal organs from irreparable damage. With the brain, however, with the psyche, questions of self arise. We see the self as arising from the brain. However, a medication that slows the heart, regulates the diameter of the blood vessels or otherwise controls blood pressure would control our entire body's rhythm, with it our ability to be aroused in the general sense of the word, and no doubt our character would be affected by that too. I am being provocative with this example but using most medication requires serious risk assessment and there certainly there are risks when it comes to the different classes of antidepressants. Would you feel more latitude to not medicate someone in the case of garden-variety upper middle class neurosis or average teenage angst that you would with serious suicidal depression? I would say I would and yet how confident could I be that I can tell the difference? The use of psychotropic medication and understanding the usual short and long term risks of any medication is already a serious one, but adding this component of a drug being a component of ones formative experience complicates the issue. That is treated thoughtfully in today's article.


Dewey said...

I can tell you, as a person with a long-term physical illness, that you are completely correct about physical illnesses changing character, too. Chronic pain makes people testy, I can vouch for that. And chronic fatigue makes people spacy and sometimes poor communicators. Nausea will make people distracted, etc.

But I think that psychotropic medicines are way over-prescribed and blood pressure medicines, etc. are probably not. I think that is a key factor in this issue, one that can't be left out of any discussion about it.

However, having said that, I mentioned chronic pain above, and I also think pain narcotics are overprescribed, too. I had a minor surgery that required Vicodin for a whole two days, but do you know how much the doctor gave me, if you count up the refills? Almost three hundred pills! And he gave this to a previously narcotic-free patient with chronic pain. Way to create an addict, Doc! Fortunately, I didn't become an addict, but only because I was consciously aware of the possibility and worked to avoid it.

I also think that there are totally invented "disorders" that "require" psychotropic medication, which, once developed, has to be marketed to someone; if necessary, this group of consumers is created out of thin air. For example, I do not believe such a thing as ADHD exists, though maybe you, as a brain expert, will completely disagree. But as a teacher I have seen many, many kids put on amphetamines for ADHD, and I have never once seen it affect any of them in a positive way -- always in a negative way. You know, the way you'd expect a kid taking speed thrice daily to react. And since I keep the same students for 3 or 4 years, it's easy to observe changes in them over time. I also know that some of these medicines are continuing to be used in the US even though Canada (for example) has banned them as dangerous for kids (causing heart attacks). I think that ADHD is an invented explanation for the fact that we expect people at the most physically active time of their lives to sit still in desks all day. I think that our society has a lot of expectations about conformity, and this is also why other psychotropic drugs are so overprescribed. Why are nearly all kids diagnosed with ADHD boys, and white, and middle class or above? I am truly interested in your answer to that, because I can only see societal reasons for this. Oh, and pharmaceutical marketing reasons, though maybe those count as societal. If you have neurology reasons for that, I am definitely interested in hearing them.

I also consider "boderline personality" (what an awful name!) disorder to be "smart, creative female who was probably abused and pissed off about that" syndrome, but again, that is based on observation and personal experience with girls diagnosed this way (is there such a thing as a borderline personality boy?) and not on brain science, so please inform me if I'm wrong!

Ted said...

Hey Dewey! You bring up a lot of issues, hopefully I'll hit on all of them. I agree with you that there are confabulations between the need for medicines and the marketing of them that are problematic. It's an under regulated industry. The difficulty with psychological or developmental diagnoses is that they are a different animal from a diagnosis of something like high blood pressure or, say, measles. The medical model is dichotomous. You set a threshold (w/ blood pressure or diameter of a growth) or you detect the presence of a virus (as with measles) and then you have the diagnosis. However, with ADHD or borderline personality disorder or Asperger's Syndrome you have a bunch of scales that get numerically scored and then, if you're lucky, you have an observant and experienced clinician who spends a lot of time with the patient and makes a very thorough observation and finally goes to the DSM IV (diagnostic manual) and looks at the criteria for, say, ADHD and says 'ok, he has two symptoms from column A and two from column B, therefore he fits the inclusion criterion.' Really though any psychologist, psychiatrist or pediatrician can go right to the DSM and draw the conclusion from what they observe, if they choose to. However, developmental or personality related diagnoses, although they are forced to fit a dichotomous model, are really describing something that is on a continuum. We sometimes joke about ADHD 'does he really have it or is he just a 7 year old boy?' The thing is that a diagnosis in this realm is not a fact like having the measles virus, it's a tool. And as you have observed, it is societally driven. Addiction is a good example - caffein and nicotine are addictive, but they are not controlled substances. I can assure you there are people for whom the diagnosis of ADHD is a useful tool. More boys are diagnosed because more boys fit the current symptom profile, especially the more obvious symptoms - symptoms in that disorder come in three clusters - inattention, impulsiveness, and hyperactivity. There are also many common co-morbid conditions- mood disorders, substance use disorders, etc... Also, not all kids are on stimulants. Stimulants do not work for 25 - 30% of cases and then they can be given a whole host of other drugs from Strattera to anti-depressants to antihypertensives, each can be more effective (or have fewer side effects) for a different subset of legitimate diagnoses. You probably see more white, middle-class cases that you know of because those are the most frequent consumers of healthcare. But my lab is in Harlem and I have seen plenty of ADHD, Tourette's, depression, Aspergers, and ASD in Hispanic and African American kids. In addition, this is a disorder, like so many others, for which we only have a phenotype (i.e. a bunch of symptoms that describe it) we can't as yet determine the underlying mechanism or mechanisms.
I really laughed when I read your borderline personality rant. It was definitely the diagnosis of the month for a while. Again, it's a tool - it can be very appropriate sometimes for labeling (when that is helpful), those categorizations help predict which treatments are likely to be more effective and what risks the person is likely to face.
I also think that the doctors or psychologists that are diagnosing are as susceptible to prejudices, fads, and heuristics as the rest of us slobs. When a new diagnosis is devised or becomes popularized you are likely to see it more often because those giving diagnoses are likely to see it in their patients more often. One would hope that these professionals would be less susceptible to those kinds of influences than the rest of us. Atul Gawande argues in "Better" that the healthcare system should not be like every other system in delivering a quality of care that can be plotted on a normal curve. He argues that it should be abnormally excellent. But it ain't called a normal curve for nothing! There are probably periods of time that we go through where these conditions are over diagnosed. That why so many neuroscientists are searching for the physiological markers for these disorders. If they exist and are accepted, they could change the field radically, but probably not entirely.
Did I hit everything?