Judith Warner has some insightful essays in the NYT column, pertaining
to the long-raging question about whether psychiatric patients are
style="font-style: italic;">overmedicated or
style="font-style: italic;">undermedicated.
One of the essays addresses the question directly:
href="http://warner.blogs.nytimes.com/2008/02/14/overselling-overmedication/">Overselling
Overmedication
Judith Warner
February 14, 2008
...In the book, Barber
argues that Americans are being vastly
overmedicated for often relatively minor mental health concerns. This
over-reliance on quick-fix medication is numbing our nation and dulling
our awareness of real and pressing social issues and of
non-psychopharmacological therapies and treatments.
Barber is hardly alone these
days in this line of reasoning. The
notion that American children and adults are being over-diagnosed and
overmedicated for exaggerated or even fictitious mental disorders has
now become one of the defining tropes of our era.
despite the fact that href="http://www.surgeongeneral.gov/library/mentalhealth/chapter1/sec1.html#approach"
target="new">government research has repeatedly
shown that most adults and children with mental health issues don’t
get the specialized help that they need...
...contrary to received wisdom, the United States is not
a world
leader when it comes to the use of psychiatric medications. (The U.S.
is “’in the middle’ relative to other
countries, and is not an
outlier,” a study from M.I.T’s. Sloan School of
Management, cited by
Kramer, showed last year.)...
Her next essay examines the questions of how and why we developed a
national myth, that people -- particularly children -- are
overmedicated.
Judith Warner
February 21, 2008
At the end of my last column, I wondered about the purpose served by
the narrative of the disastrously overmedicated American.
I’ve been pondering this question as it relates to children
for the better part of the past four years.
Recently, in search of an answer, I was re-reading
“Huck’s Raft: A History of American
Childhood,” by the Columbia University historian Steven
Mintz. In the book, Mintz identifies a “pattern of recurrent
moral panics over children’s well-being” that has
emerged at varying points in our history, and dissects how these
episodes mask other diffuse worries Americans have been either unable
or unwilling to directly articulate.
“Children have long served as a lightning rod for
America’s anxieties about society as a whole,”
Mintz writes...
...I couldn’t agree more. And I believe it’s these
fears, this worry, this adversarial attitude and this bad conscience
that keep the narrative of the overdiagnosed and overmedicated child
alive...
Ms. Warner makes some very good points. I won't
elaborate on her arguments here, because she does a perfectly good job
of presenting her case.
What I would add is a subtle point that, it seems, is overlooked in
discussions on this topic. This is something that frequently
causes confusion when it comes to interpreting information about
medication (all medications, not just those used in psychiatry.)
The information we have comes from studies. Mostly, those
studies are done on populations. But populations do not come
in for treatment; individuals do. Doctors generally do not
treat populations; they treat individuals. Populations do not
ask their doctors about medication; individuals ask those questions.
But when individuals ask those questions, the answers they get do not
pertain to the individual. Rather, the answers pertain to the
average in a population of individuals who have been the subjects of
research.
So, when we ask if "people" are overmedicated, what we learn is that
there is no evidence that the percentage of the population receiving
medication is not suspicious. The absolute numbers are large,
and they are increasing. To some, the absolute numbers are
alarming. But the absolute numbers do not tell us anything
interesting.
Granted, there are people who do look at the proportions, and still
find them alarming. It is hard to know what to make of that.
I have some speculations. For one, it may seem contrary to
one's experience, to hear that 10 to 15% of the population has a
problem with serious depression. If true, that would mean
that during your typical trip to Wal-Mart, you would see several people
with depression. But the last time you went, you did not see
style="font-style: italic;">any.
Therefore the statistics must be wrong. Something
like that.
Another thing is this: most people experience their brain as a pretty
reliable organ. It does not seem to make sense that so many
people would have problems with it. But consider this: the
human brain is the most complex organ in the body. Indeed, it
is the most complex entity in the known Universe. Is is any
wonder that a high proportion of people have problems with it?
Anyway, back to the point. Studies show that the population
is not overmedicated. Does that not contradict some people's
experiences, seeing themselves or their loved ones taking multiple
medications, high doses of medications, suffering ill effects from all
those pills? Ah. That is a different question.
That is a problem experienced by individuals. If
you merely look at what percentage of the population is taking
style="font-style: italic;">some medication,
you will not find out how many people are taking
style="font-style: italic;">too much
medication.
Plus, there is another issue. Some people will be
overmedicated temporarily, when they are started at a dose that is too
high for them, or the dose is increased too rapidly, or when
incompatible medications are mixed. But, that should not go
on for long. Sometimes it does, granted, but the temporary
situations sometimes are a necessary part of an ongoing process.
Or they are not necessary, but are identified and corrected.
The main point is this: just because studies show that the population
as a whole is not overmedicated, that does not mean that there are not
individuals who are. How common is it? I don't
know. My suspicion is that it is all too common.
Some instances are transitory, or unavoidable, but it still
is a problem.
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I find it particularly alarming that children are prescribed some of these drugs. How much is truly known about how various psychiatric drugs affect the development of the brain? If a fifteen-year-old is put on a regimen of SSRI inhibitors, how will it affect him down the road? If he's on them long enough, will he experience any adverse effects when he's thirty-five or forty? For that reason, I think that physicians should be extremely sparing in prescribing psychiatric medication to children.
I suspect that there is a good deal of over-medication when it comes to drugs like anti-depressants. If a patient goes in to his primary care physician and indicates that he's been going through a bad stretch emotionally, he will likely be offered a prescription for Prozac, or some analog. I had an experience like that myself. Several years ago, I went in for an annual check-up. My physician asked me how things were going. I said that they were going okay, but that I hated my job. She immediately asked me if I wanted a prescription for Prozac. I had the good sense to say no. Her response was, don't you want to feel upbeat about things? From talking to friends, that's not an uncommon experience. I suspect that drug-company reps push some of these drugs to primary care physicians as feel-good medications.
Thanks for pointing out what always gets lost in these "Pills: Threat or Menace?" types of stories. A lot of people who need effective antidepressant medication don't get it, for a variety of reasons, one of which is the prevailing notion that we are "medicalizing" life's normal emotions, such as shyness and sadness. This is pretty much nonsense, and really only restates the obvious: Antidepressant and anti-anxiety meds are meant for the people who really need them, not for "cosmetic" psychology, and a medicine that works for one person may not be effective for another.
One point that often seems to be overlooked is that if a patient finds these medications to be ineffective, or that the side effects outweigh any benefits, the medication is usually discontinued. Concerns of overmedication seem to presume that patients will continue taking, and physicians will continue prescribing, medications which are either ineffective or have adverse effects.
With the antidepressant percentages, one possibility is not that there is overprescription, but rather that PCPs are often prescribing them for depression/dysthymia that is comorbid to another untreated condition (ADHD is a good example) or else misdiagnosing depression in patients who present with superficially similar symptoms (bipolar disorder, for instance). Adding these cases to the prevalence rate of unipolar depression, and maybe adding in a few cases of dysthymia and anxiety, and the figures probably make sense without having to imagine any massive levels of "overprescription."
In response to ChuckO's comment:
I find your story a little difficult to believe. I thought MDs had to screen people before prescribing them an anti-depressant. My physician asked me a list of questions when I told him I was feeling unhappy. Only then did he prescribe anything. I suppose different doctors could do things differently, but I doubt that most physicians would prescribe an anti-depressant without checking to make sure the patient needs it.
Two points -- people with mental problems have to be pretty darn sick before they are obviously ill to a casual observer. The fellow walking down the street arguing with the fairies (and losing) is only the most evident of 50 or 100 others struggling with mental disabilities. I've had three friends die of depression, who were still working and coping with their lives right up till the day they committed suicide.
Second -- Being misdiagnosed is a problem, but being undiagnosed and untreated is probably worse. If you're misdiagnosed, at least someone knows there's a problem and is watching.
My husband was depressed and over medicated with different ani-depressants. He ended up committing suicide. Every time he told the doctor he felt more depressed or anxious the doctor gave him more medicine. Medicine for depression, to go to sleep, to stay sleep.
The doctor knew he carried a gun, but never mind, gave him more narcotics!!!!!
Those who feel sad for no good reason are clearly sick. Those who feel happy for no good reason are even sicker.
The present article explores the novel hypothesis that patients who feel well are, in fact, patients who need treatment...
Asymptomatic Depression:
Hidden Epidemic and Huge Untapped Market
http://www.bonkersinstitute.org/asymptomatic.html
"Psychiatry is to medicine what astrology is to astronomy."
~ Leonard Roy Frank
Bonkers Institute for Nearly Genuine Research
www.bonkersinstitute.org