Monday, July 19, 2010

designer brains for all!

So let me say up front that this is a Rant, one inspired by the fifth young go-getter this week to walk across my threshold demanding I diagnose him with AD(H)D and prescribe him Adderall to get him through his dissertation/term paper/research proposal/whatever.

In my (not so) humble opinion, AD(H)D is not so much a disease (in the sense of a physiologic malfunction) as an unfortunate interaction of personality x environment. Certain personality types just don’t do well with being required to sit in a chair for 8 hours a day. A lot of those same people would probably do phenomenally well at running around outside spearing buffalo, (see Kuo and Taylor), but sadly for them, that’s not the environment in which they find themselves.

So, we have medication that can alter these people’s brains so they conform more acceptably to the society where they do find themselves. We could have another very long and involved discussion about whether that’s a good choice or not but my feeling is, if a pill is the difference between good function and borderline or poor function, then please, weigh the pros and cons and make your own decision. It’s your brain. Not my business to dictate whether you ‘need’ it or not.

What I really don’t like is the cultural apparatus that is telling us the suboptimally attentive have a Disease, because the only legitimate reason to take a drug is if you have a Disease, and therefore that these people who take stimulants so they can function more effectively at work or school must have a Disease, because that is the only socially acceptable way that they can take their medication.

And what I really, really don’t like is that as a physician I am being put in the middle of this. I am being told that the only way these people can have their medication is if I diagnose them with a Disease and prescribe them the medication to Treat it. There’s no box to check that says “This could help you do better than you are doing now, and I don’t mind if you take it, so long as you understand the risks and benefits.” There’s only the Disease box and the No-Disease box. And I can’t give out the drug unless I check the right box.

The thing about treating this Disease with stimulants is that, in the right dosage and formulation, they are going to be performance enhancers for *most people.* How many thousands of students and professional writers have used a jot of speed to get them through that important deadline? I’m currently working in our university’s student health center, where I see a lot of people who are coming to me for stimulants so they can make their already excellent function even better. I honestly do not mind if people want to take brain-altering chemicals to help them write their papers – I’m swigging a bolt of caffeine as I write this post – but I do get a squicky feeling when I’m asked to write a doctor’s note about their ‘disease’ and a prescription so that they can ‘treat’ it.

So in my perfect world there would be public recognition of the wide latitude of uses for psychotropic medications, the terribly broad and nonspecific symptom clusters that constitute what we refer to as psychiatric disease , and the many reasons why people might want to take a drug that improves their ability to get their work done (see interesting perspectives on this from Nature and the Guardian) - even if their current abilities are well within the broad range of normal. Will the public accept the availability of a smorgasbord of designer psychotropics for your business and recreational neuroenhancement needs? Maybe, maybe not. But please, let’s stop putting doctors in the middle by maintaining the fiction of a ‘disease’ for which stimulants are the ‘cure.’

Saturday, July 3, 2010

family matters

Mrs U first came to my attention some time after the birth of her first child. She was a stately woman, dark and slender, dressed always in brightly colored robes. Her husband brought her to see us because she had stopped speaking. Ever shy, he reported that she'd become gradually more and more taciturn, and at the time of our first meeting she hadn't said a word in several weeks.

At first we were uncertain of the cause. Was she so depressed that she had withdrawn entirely? Did she perhaps have a medical issue, such as insufficient thyroid activity or a vitamin deficiency? Mrs U's thyroid levels, as well as the rest of the blood tests we ran, were entirely normal. We started her on a small amount of an antidepressant, and soon added an antianxiety agent. She started speaking again, though she still had periods of mutism, often when she was stressed or upset.

Around this time, Mrs U and her family took a trip home to Africa, to visit her large and close birth family. They spent several months there. When they returned, Mrs U was a different woman. She smiled pleasantly, laughed at her recollections of her trip, planned eagerly for some classes she intended to take. She remained somewhat shy but the episodes of speechlessness had vanished.
"I could see her getting better by the hour on the plane trip over," Mr U told us. "It was amazing, Doctor. In the airport on this side she seemed anxious, terrified, looking here and there, speaking little. As the hours on the plane passed she began to smile a little. By the time we reached her childhood home she was almost entirely herself again, so that even her own mother could barely notice anything amiss!"

We smiled and nodded, happy to see Mrs U doing so well. She weaned, uneventfully, off her antianxiety medication, though she continued to take the antidepressant. Things remained this way for several months. Then, slowly, she began to deteriorate again.

Her eye contact was the first sign. Though always retiring of manner, when well she met my eyes in conversation, with an occasional frank and open smile. As time passed, though, her eyes began to slide past me even as she answered my questions. They would be fixed on the floor, or out the open window. She maintained our conversation appropriately. Nonetheless she seemed to be elsewhere. I filed that under 'to be kept track of' in my mental cabinet.

Soon after that I began to receive concerned calls from Mrs U's husband. She had begun to say strange things. One day she was convinced that she should leave her husband for a stranger she had seen on the street. Another day she became obsessed with a cartoon she had seen on the television, referring to it over and over. She was unable to keep up with her classes and had to drop them. However, she
always said her mood was fine. She didn't seem anxious or sad in the least, only... strange; and increasingly so. She continued to care for her son ably and with great patience, according to her own word and to her husband's observations. Our original diagnoses of depression and anxiety seemed less and less satisfying.

Ultimately things came to a head when Mrs U began to have frank hallucinations, horrible ones of vermin in her mouth and people under the stairs. That sealed her diagnosis as a psychosis of some form. We started her on an antipsychotic and slowly, things started to improve.

After a couple of weeks of treatment the floodgates opened. Though she'd never before put more than ten words together in my presence, she was fluently talkative. She revealed that she'd been having horrific religiously themed nightmares for a year. Voices of people in her house. A chip implanted in her head. CIA cameras hidden all around her. All very, very classic psychotic symptoms.

I felt silly that I hadn't recognized this before. Mrs A, in her early twenties, was the right age for a first psychotic break. It's very common for schizophrenic patients in the throes of their illness to withdraw completely from the world, unable to give voice to the phantasmagoria in their heads. Easy to recognize after the fact; but since social withdrawal can also reflect depression, anxiety, and other common woes, things are not always clear in the moment.

She did reasonably well on her antipsychotic, though she was still somewhat odd. She would laugh at inappropriate moments and stare vacantly through the window when you talked to her. Her husband was frustrated with our inability to return his wife to her old self. We were frustrated with it as well.

Shortly after starting the antipsychotic, Mrs U took another long trip to her home country. Once again, her symptoms improved. Although she was not able to wean off her medication, she appeared to recover a good deal of her old personality. She was able to interact normally with her family and friends and handled her domestic duties without difficulty. Ultimately her husband decided that his family was best served by staying in their home country. As of this writing Mrs U remains well.

Mental health and mental disease are defined largely by functional capacity. If a person can live, love, and work, we consider him well. But the level of function required for love and work may differ radically from society to society. The 'basic capacities' required to live among secure and supportive extended family, and perhaps do some simple labor under supervision as necessary, are quite different from the 'basic capacities' required to live alone, maintain employment, and manage personal finances complete with lines of credit and other pitfalls.

Schizophrenic patients exist at all levels of functioning, ranging from those who require ongoing institutionalization to extremely high-functioning and high-achieving individuals. The differences among them may be partly due to severity of disease and to innate psychological reserve, but are also strongly dependent on the environment surrounding each.

Over the past six decades, the increasing availability of medication for psychiatric illness, along with factors such as social change and cost concerns, have led to the deinstitutionalization of the mentally ill. In the US, where strong and supportive extended families are not the rule, this has often led to the need for a sort of wraparound care, where a cadre of social workers and psychiatrists helps to guide each patient through the complexities of daily life. In the crudest sense they are functioning as a paid family - much as we in the US have outsourced other former family domains such as child care and elder care. This outsourced domestic work then counts as part of the GDP, and to the economic might of the nation. What isn't clear to me is whether - acknowledging such clear improvements as the reduction in social stigma that attaches to mental illness - such a solution is a gain overall for the mentally ill themselves.