For a real eye-opener, click here and scroll down to the color-coded map of mental health medication use by US region. Who would guess we Illinoisans would be among the lowest-percentage group, given our $100 billion pension funding debt and our shiny new hedge-fund governor?
Scroll a little further for the prevalence of adult (and child) antidepressant use and the hits just keep on coming. Women lead the pack, with 21% age 20 and older taking an antidepressant. Ominously, steep increases are also seen in women 65+.
Perhaps you read the 11% figure published by CDC in 2012 even as your very own little white Lexapro was melting in your stomach, molecules of escitalopram drifting into your brain, doing something (who can remember what exactly?) to your serotonin.
Life wasn’t always this way
Recently mulling this situation, accompanied by my own psychopharmalogic agent de choix (Kim Crawford Sauvignon Blanc, 2014), I came to the realization that my professional career had followed psychiatry’s gradual change in trajectory from using virtually no medication (except for people with schizophrenia who were institutionalized) to this current 11% for SSRI antidepressants.
With a comparable percentage taking anti-anxiety meds (higher at O’Hare with announcement of weather delays), we’re talking an astonishing near-25% of the population swallowing one medication or another for psychic stress.
Before 1973, outpatient psychiatric treatment pretty much consisted of talk therapy, with the therapist role limited to psychiatrists. It took some years before psychologists and clinical social workers became significant players in the talk therapy field. Inpatient psychiatry was practiced on thousands of patients in long-term mega-hospitals like Manteno, where emotionless psychiatrists administering shock therapy virtually never talked to the patients. I visited such hospitals and once wrote a Health Tip about it. All in all, best not discussed on a full stomach.
There was little structure when it came to making a psychiatric diagnosis. The Diagnostic and Statistical Manual of Mental Disorders (DSM) was in its infancy and the diagnostic process was largely intuitive. Patients weren’t labeled with diagnoses and diagnostic numerical codes as they are now. But the weakness of intuitive diagnosis became apparent in the famous Rosenhan experiment, devised to check the accuracy of psychiatric diagnoses. This is a great story in the annals of psychiatry.
In 1973, psychologist David Rosenhan hired emotionally healthy people with good acting skills to present themselves at the emergency departments of a dozen US psychiatric hospitals and report that they heard voices. Each and every one of them was immediately admitted. Then, to everyone’s horror, they discovered they couldn’t get discharged unless they obeyed all the rules, took the prescribed meds for schizophrenia, and told a psychiatrist they were feeling better and the voices were going away.
Eventually, all the sham patients managed to get discharged. Rosenhan published his article in Science and within days it was reported in newspapers across the country. The public’s respect for psychiatrists plummeted.
But the second part of Rosenhan’s project made matters worse. A hospital publicly challenged him to send them sham patients, confident they could pick out the frauds. After 30 days screening 193 patients, the hospital declared 41 people to be Rosenhan’s actors. Rosenhan replied that he hadn’t sent a single patient and that the 41 “frauds” probably should have been admitted.
Clearly, the psychiatric profession needed to improve
Although the DSM had been around since the early 1950s, most psychiatrists felt it was vague and unreliable. After the Rosenhan fiasco, in 1974 psychiatrist Robert Spitzer headed a committee to revise the book dramatically into its current format. Psychiatric diagnosis could now be reached by therapists completing a relatively simple yes/no questionnaire, and if a certain number of “yes” answers appeared, viola, a diagnosis.
It was so easy that if patients themselves had had access to a computer, they could have virtually diagnosed themselves. In fact, today there are dozens of online psychiatric self tests created from the guidelines of the DSM.
Standardizing what is/what is not mental illness was not a bad thing in itself. One result was that mental illness came out in the open. Magazines ran “Are you depressed?” and “Are you anxious?” self tests, and if certain scores were attained, readers were advised to see their doctors. This was the start of group therapy. When a macho union pipefitter could open up about his panic attacks or obsessive thoughts in a circle of similar sufferers, the therapeutic effects could be very positive indeed.
Coincidentally, just as the Rosenhan study was shaking up psychiatric circles and the first comprehensive edition of the DSM was being distributed to psychiatrists, physicians nationwide began to feel more comfortable using medications like Elavil and Pamelor for depression and Librium and Valium for anxiety. And with the AMA blocking every change in legislation that might allow psychologists to write prescriptions, psychiatrists had total control over the management of mental illness.
40 years later
Today it’s primary care physicians (PCPs) who write most prescriptions for psychiatric drugs. When a new drug is introduced, legions of pharmaceutical reps swarm the offices of both psychiatrists and PCPs. If the PCPs hesitate because they feel ill-trained to diagnose mental illness, they can attend pharmaceutical company-sponsored educational boot camps where doctors learn to recognize mental disorders and start treatment without having to refer the patient to a psychiatrist.
It’s currently estimated that as many as 25% of Americans are taking psychiatric meds, with half using SSRI antidepressants and the other half taking antipsychotics for schizophrenia, stimulants for ADD, mood stabilizers for bipolar disorders, and/or anti-anxiety meds for generalized anxiety and panic disorders. These numbers all got a healthy boost with the addition of the newer-wave diagnoses, like social anxiety disorder, adult attention deficit disorder, post-traumatic stress disorder, and even internet addiction. These were simply non-existent in 1973 and most are treated today by combinations of counseling and medications.
Is anyone to blame for this state of affairs? To my mind, there’s no guilty party. Patients, having learned something about mental illness, seek help. Doctors are sincere in their desire to help. Most people can’t commit to lengthy counseling sessions and the pharmaceutical companies claim to be providing a relatively quick fix. If anything went sideways, it was the American public being fooled into thinking that normal variations of the human experience (sadness, anxiety, anger) are treatable mental conditions.
Now, in 2014, half (yes, half) the new patients I see either once took or are currently taking a medication for an emotional problem. When I ask why they were started on the drug, common responses include “I was breaking up after a long-term relationship,” “I lost my job and couldn’t find another,” or “My grandfather died.”
I want to tell them “This is life. If you don’t feel depressed when your spouse walks out, eviscerates your life savings, and leaves you homeless, you’re not human.” Recently I saw one patient who was twice blessed with an utterly satisfying job and a strong marriage. He had gone through a crisis, feeling melancholic, because he realized he was getting old and his job couldn’t last forever. Every doctor he saw recommended antidepressants, which he tried, but he hadn’t noticed any change and felt they were completely ineffective. He wanted to discontinue them but his doctors advised against it.
Is he, along with a large chunk of the 25% of Americans popping psych meds, being duped into feeling entitled to unrealistic emotions because everyone we watch on TV seems so fulfilled, so much better off than ourselves? Because we look at sitcoms with actors and audience alike laughing uproariously while we’re not? Claire Danes’ day job on “Homeland” is so much more interesting than ours. Guests on Oprah are so thin and rich and we’re not. And all that California sun!
But folks, I have news: relationships end, jobs vanish, your self-esteem will get whacked, and as a result, expect to feel sad. If you live long enough, your parents will die and you’ll be sad again. One morning as you’re heading for O’Hare, you’ll get anxious at the thought of being inside a tin can filled with explosive fuel five miles above Iowa. These are not examples of mental illness. These are perfectly normal responses to different life situations.
Maybe what we’re really seeking is numbness. If we really don’t want to experience life’s difficulties, this is what all the meds–SSRIs, mood stabilizers, anti-anxiety meds–do best. You may rather like feeling numb, but in fact many people who start taking psych meds abandon them quickly for this very reason. “I’m not myself,” “I feel like a zombie,” “I’m not crying, but I’m not laughing either.” Or, from a spouse, “My wife says she’s happier, but she’s not the person I married.” Or, from an artist, “My creativity has some sort of a fog over it. I’m giving back these meds.”
Maybe temporary numbness isn’t such a bad thing. My glass of Sauvignon Blanc, the marijuana in your freezer, one person’s Xanax, another’s Lexapro, the off-duty firemen quaffing a brew at Kelly’s Bar. There are moments when we all need to chill. My issue is that just because a life experience is less than pleasant, perhaps even a real emotional challenge, does not mean we need to pop a pill for it. I told the patient who’d been prescribed antidepressants because he was melancholic about growing old, “Yours is an existential issue. Taper the meds. Go meet a few of your friends at a bar and jaw it out together. You’ll find you’re not alone.”
A genetic step forward
This brings me to report briefly on the hottest topic in psychopharmacology. As you probably know, the clinical benefits of the various psych meds are notoriously unpredictable. A med that cheers up one person may do zilch for the next. The mantra of failed psychopharma is “Here, try this one instead,” as your doc reaches into her well-stocked larder of samples.
However, now that your forehead has been officially tattooed with your personal DSM five-digit psychiatric diagnosis (296.22: Major depressive disorder, single episode moderate; 300.01: Panic disorder without agoraphobia), today in your doctor’s office you can scrape the inside of your cheek with a cotton swab and send it off to Genomind, a new company that performs genetic testing. They’ll examine the specific genes involved in drug utilization and metabolism. From the results, your doctor will be able to tell you why your current drug isn’t working, and what drug, according to your genetic pattern, should cheer you up or calm you down.
I suppose the Genomind test is a good thing, though my enthusiasm is lukewarm simply because it encourages doctors to rely on tests rather than listen to their patients. At any rate, insurance companies seem to like it—anything to discourage people from seeing counselors week in and week out. Mental health 2014 style: use Genomind to find the right med and authorize enough refills for the remainder of the patient’s incarnation.
I know that this Health Tip will surely prompt some of you to remind me that I myself write SSRI ‘scripts. This is true, although I do encourage people to get off them or at least switch to St. John’s wort when they start feeling better. Or you’ll tell me how much you were helped by SSRIs, and I’ll agree, SSRIs having the highest patient satisfaction rating of any group of meds. That’s great, and I’m glad.
But let me end with a quote from one of the great science fiction films of all time, the original (1956) “Invasion of the Body Snatchers.” The speaker is Dr. Miles Bennett, the town’s GP (and it’s three decades before Prozac hits the market):
“Sick people who couldn’t wait to see me, then suddenly were perfectly all right. A boy who said his mother wasn’t his mother. A woman who said her uncle wasn’t her uncle…In my practice, I’ve seen how people have allowed their humanity to drain away. Only it happened slowly instead of all at once.”
David Edelberg, MD