September 6, 2011

Primum non nocere

Primum non nocere.
First, do no harm.

The Hippocratic oath is recited by rising physicians upon completion of their medical training and signifies the demarcation point of accepting the responsibilities of a medical degree.  It is often oversimplified with the simple phrase: first, do no harm. Primum non nocere.   Although these words do not appear exactly in the oath, this notion of nonmalficience forms the cornerstone of medical ethics.  Nonmalficience is generally balanced with beneficence, which describes actions done for the benefit of others. A far simpler way to state this idea is as risks verse benefits.   In the notion of treatment, and especially pharmacology, this balance IS the guiding principal.  If the risk of a medication outweighs the benefit gained by taking it or is more noxious than the illness being treated, you don’t prescribe it; but if the illness is so odious that peril in the lack of treatment outweighs the potential treatment’s side-effects, the medication is administered. A typical case in point is with most chemotherapy for cancer.  Chemotherapy essentially works by targeting and killing fast growing cells. In addition to the cancer cells, other fast growing cells are in the hair and gut- thus, the more obvious (side)effects of alopecia and anorexia, the usual outward manifestation of the cancer victim’s private fight. Untreated cancers usually have a high death rate.  In general, most people find hair loss better than dying, so chemotherapy, in spite of, or actually because of, its toxicity, is usually administered.    Where this balance becomes much grayer is in the field of psychiatry and mental illness, and especially child and adolescent psychiatry.

Psychiatry has been called the impossible profession.  Likely for numerous reasons, the least of which is the whole moral notion of diagnosing mental illness/wellness itself, with its predication on a foundation of mental normality.   It operates in the hazy periphery. Practicing it, I agree. It is nearly impossible to truly understand what is really going on with someone else, even more so with a child who is still developing (as we all are, actually) or is pre-verbal. Certainly, we can get a rough idea as to whether someone is struggling with hallucinations or having paralyzing OCD – that is not the difficulty. We can make diagnoses and follow industry standards of care to get symptom control and “success.”  But to really understand someone comes much closer to the existential/philosophical than to the medical/pathological.  And unfortunately, the field of psychiatry has morphed into the field of psychopharmacology, where those essential questions of existence and self-understanding are bypassed in preference for a biological model of neurotransmitter inefficiencies and quick symptom control.

As I alluded to above, I am a practicing psychiatrist.   I prescribe a lot of medications. I am actually a believer in using psychotropic medications for the treatment of mental illness.  But these medications are being overused and likely abused by both practitioners and patients (and the pharmaceutical/advertising industry).   All are culpable in this offense. Much like modern society itself, our medical system often breeds and rewards a quick-fix mentality with insurance-mandated productivity needs which make a clinic function more like a factory, where, in a 15 minute visit, the provider is charged with “fixing” the broken child. Falling into line with the industry standards of care, prescribers often jump to medications quickly.  And unfortunately, psychiatric training now teaches residents to be good at prescribing medications, but not so good at taking care of someone. Like Dr. Peter Breggin says, the psychiatric field and the pharmaceutical industry are practically inseparable nowadays.    Parents understandably want relief and physicians feel the pull to offer it, which often entails a prescription.  Often, medications are given to address an urgent need while the other more insidious etiologies and issues are being investigated- “buying time” as it were while lab-work is pursued, for instance. But more often I see this quick-fix demand as a fault of an entitled society and a dysfunctional system, where the psychotropic prescription bandages the immediate behaviors back to “normal,” but does nothing to explore the underlying etiology.  The result is that the underlying dysfunction festers under the guise of symptom-management care. Symptoms are mollified, but deeper etiologies are rarely understood.

And prescription use is skyrocketing.

A look at the numbers is alarming.  It has been estimated that at any given time, mental health problems affect one in every five children.   For children in the US, psychiatric drug use increased 50% from 1996 to 2006, with spending on mental health increasing about 30% in that same time period (with the majority of the increase related to prescription drug costs). According to the US Agency for Healthcare Research and Quality, in 2006 more money was spent on treating mental disorders in children aged 0-17 than for any other childhood medical condition, totaling approximately $8.9 billion. There has been a 600% increase in antipsychotic prescriptions for children from 1993 to 2002; 11 million antidepressant prescriptions annually for children under 19 years old; a 49% increase in the use of behavioral medication for ADHD in children less than 5years of age from 2000 to 2003 (Medco Health Solutions 2004); from 1994 to 2009, prescriptions for amphetamines increased 120 fold, with over 2.5million youth receiving some type of ADHD medication.    Apart from the impact of what this means systemically for rising generations, these figures are really worth taking seriously given our national debate on debt and healthcare.

The numbers are staggering…and disturbing.

The reasons for this trend are myriad. Maybe we are recognizing illness better and moving towards quicker treatment and disease eradication, as is one of the arguments for the increasing incidence in Autism.   Or maybe we are over-pathologizing our everyday problems, where every temper tantrum is labeled bipolar.  Or maybe access to child and adolescent psychiatrists is scant, so medications are used emergently in lieu of ideal care by equally overburdened pediatricians. Or maybe we are under the influence of advertising and Big Pharma, ask your doctor about the benefits of Cialis in your life.  Or maybe we as a species are just getting sicker. Or maybe it’s a maelstrom of all of the above, created by an entitled society that demands freedom without the responsibility it entails.

“First Do No pHarm” is intended to look deeper into these trends, to look at these questions, and to explore alternatives to what we’re being prescribed and prescribing.  It is not a polemic against medications as its title might imply. Nor is it necessarily against the pharmaceutical & insurance industries, or even psychiatry for that matter.  It is intended to pose questions and alternatives to our current mode of being and to share information that I find interesting, essential, and hopeful as a psychiatrist, parent, and citizen-consumer.

I believe and hope that we are in the midst of a paradigm shift in our understanding of mental illness, and thus the care we subsequently can offer.   Most people and most bodies (brains included) have the ability to heal themselves if given the right environment to do so; we are highly intelligent and truly amazing biochemical machines.  What I hope to present here is more of an open-ended exploration of “the other,” what could be done instead of prescriptions, what could be tried instead, or at least thought about, first.