The man who twirled with rose in teethHas his tongue tied up in thorns His once expanded sense of time and Space all shot and torn See him wander hat in hand - "Look at me, I'm so forlorn - Ask anyone who can recall It's horrible to be born!
-Bruce Cockburn, from song "Shipwrecked at the Stable Door."
I found the discussion around my recent post about treating colds very interesting. Sick people come to the office to find out how sick they are. Most people don't want to be sick, and when they are sick they want doctors to make them better.
Some people want to be sick, and some doctors want to make people sick. I am not talking about hypochondriacs - people who worry that they may have disease and become fixated on being sick. I am not talking about malingerers - people who pretend to be sick so they can get medications. I am talking about the slippery slope of defining disease.
"I lost my job and have felt depressed ever since."
"My son won't obey me."
"I'm just tired and have no motivation."
"My daughter's having trouble in school."
The definition of disease versus normal has become a big issue recently. A recent study found that over 50% of Americans are taking regular medications. In the eye of the hurricane of this controversy is the DSM-5, the new manual for the definition of mental illness. John Gever, of MedPage Today explained in a recent article on KevinMD that the criteria seem, in the eyes of many, to shrink the definition of a "normal" person. The motivation to put a label on normal people, he explains, has various motivating forces:
It’s true that drug companies often do little to discourage off-label use of psychiatric drugs and sometimes encourage it. It’s also true that many doctors throw medications at patients who might do better with other treatments or no treatments. (That’s true for many somatic conditions too, let’s not forget.)
But not many people are plucked off the street to have psychiatric labels stuck on them. Most often, people get a DSM diagnosis because they were distressed enough to see a doctor.
That’s the key word — distressed. These are people who aren’t happy and who want to feel better. Or their children are unhappy and having trouble at school. Either way, they’re seeking help.
You might argue that life isn’t a bowl of cherries, and I’d agree with you. But then I’d point out that being somatically unhealthy is normal too.
Gever argues that this may not all be bad, countering the complaints against the DSM-5 by pointing out that it's not all bad for people to seek help.
I agree with his argument, but only to a point. Here's the rub: I am the person these people come to see; I am the one who makes the first determination of "sickness," not the psychiatrists.
What makes all of this even more difficult is the belief by people (and doctors) that any disease or disorder should be treated. When I first started in practice I prescribed antidepressants for anyone who asked. I figured that if they were bad enough to come to the office for this, they must need it; and the medications did improve their depression. The same thing was the case with attention deficit disorder, liberally giving medication to children as long as they qualified using psychosocial testing. The medications worked here as well.
But one thing happens as you get older: you get to see a lot more living. I noticed that everyone has pain, both emotional and physical, and noticed that those with the pain weren't necessarily the unhappy ones. Life is hard and pain is normal. There are always things to be anxious about and things that make people depressed. Am I actually helping people when I pharmacologically treat the school of hard knocks? If I put a bubble around a child to protect them from germs, what would happen to their immune system? I'd be preventing illness in the short-term, but the long term result would be weakening their ability to live in a harsh environment. Am I doing this by putting a pharmacological bubble around them?
When I look back on my childhood, there is no doubt that I had ADHD. I spent so much time in the principle's office that when they were painting the walls, they asked me what color I wanted. I also have no doubt that I would have been medicated for ADHD. I was an underachiever, I was insecure about my ability, and I was a major trouble-maker. But since I grew up in the 70's, I was not medicated. The result? I'm doing OK, actually. I found a job that fits my short attention-span perfectly and am successful by most measures of the word. Some of that success, I believe, is due to my need to fight through my weaknesses.
Rough seas make good sailors.
I understand that my story does not negate the use of medications for ADHD. I prescribe them for many kids in my practice, and believe there is good reason to do so. But I don't do it without wondering how many am I helping, and how many am I hurting. I had no label; I was just "rambunctious." I wonder if protecting kids from bad grades or from the principle's office is actually a bad thing.
And the requests for medications to ease the hardship of life have increased, and are increasing at a high rate.
"I keep losing my temper at work and am going to lose my job. Can Dr. Rob give me a medication for that?"
"I can't stop eating, so will Dr. Rob refer me for lap-band surgery?"
We even had a patient come in with the following request: "Could you give me a medication to help me make better decisions? I keep making bad ones and they are wrecking my life!" The doctor thought to himself, "If I had a medication like that, I'd put it in the water in Washington DC."
Nobody is normal, really. Normal is just the average for a world of dying people. Medicine won't fix life. It won't make us happy all the time. It can numb pain, but is that necessary? Is that good? Do we really think we deserve a life without pain? Do we really think a life without pain would be better?
Again, I am not saying that we shouldn't treat; my actions betray my belief in the benefits of medications.
But sometimes I wonder where we will draw the line.
Sometimes I wonder if we will draw a line.