Friday, December 05, 2008

The Ethics of psychotropes consumption: An Overview

Psychotropes are taken by people in two different situations. On one hand, some psychiatric conditions clearly differ from usual life. The prevalence of schizophrenia is the same throughout the world and is readily identified through symptoms that are rarely seen in normal life. The treatment for this disorder produces relief only in the people diagnosed with this illness, and not in others. Neuroleptics for example are powerful psychotropes, but they cannot be used as enhancement and comfort drugs. On the other hand, some psychiatric disorders constitute the extreme of a continuum of behaviors that are seen in normal people. Who has never been depressed or anxious? Which child has never been inattentive? The medications used to treat these conditions are providing new opportunities for normal people to benefit from them. This adresses the problem of the limits between normality and disorder. Within this category, psychotropes can broadly be ranged into two groups depending on whether they are taken to treat mood or behavioral disorders, but their effects are very often observed on both with a primary effect lodged in one group and a secondary in another. Antidepressants act on mood but they create modifications in behavior including agitation and impulsiveness, especially during the initial phase of the intake. Psychostimulants like Ritalin, which is prescribed for Attention Deficit Hyperactivity Disorder (ADHD) or Attention deficit Disorder, can have effects on mood. The most often cited are apathy and emotional detachment. Recently, with the increase in consumption and the controversy surrounding the potential role some antidepressants may have in suicidal behavior in children and adolescents, a debate emerged in Psychiatry about the prescription of psychotropes, specifically antidepressants, for children and adolescents.

The most vocal critic of the over-prescritption and the over-consumption of psychotropes in Psychiatry is Dr. David Healy. In a November 15, 2005, in a portrait of him published in the Science section of the New York Times, Dr. Healy, a psychiatrist, is described as being ''internationally known as both a scholar and a pariah who established himself as a leading historian of modern psychiatry with the book, The Antidepressant Era." His cri d'alarme about the potential dangers of antidepressants earned him a strong animosity in the academic world. ''Because of his controversial views, Dr. Healy has lost at least one job opportunity, at the University of Toronto in 2001. In some circles, his name has become so radioactive that it shuts down discussion altogether." One of his colleagues said that "If you even raise the same issues he does, you're classified as being with David Healy and that makes people very reluctant to talk. He has become very isolated."

However extremes, clinical and academic anti-psychotropes positions never advocate the pure and simple interdiction of psychotropes. Critics of psychotropes consumption are only asking for more regulation from governments and more transparency from the pharmaceutical industry about the results of the drugs trials. But there seems to be a resistance to such an approach from the pharmaceutical industry, a resistance enhanced by an increase in demand for these drugs in our society. On one hand, psychotropes are among the best sellers, more regulation and more transparency mean less business. On the other hand, the pressures of everyday life in our society are pushing normal people, with no mood or behavioral problems, to seek comfort and performance enhancement with these drugs. In a November 16, 2005 New York Times article, Amy Harmon reports on the trivialization of psychotropes' consumption among college students in the US. Students take these drugs in order to calm their anxiety induced by college life and to enhance their performances before the exams. This more broader demand for psychotropes can backfire on the regulation of their consumption in a clinical setting and in pathological conditions by hindering the efforts to regulate their prescription.

The trend will probably persist and even increase. French sociologist Alain Ehrenberg contends that this is no different from taking prohibited drugs like ecstasy or marijuana and labels the attitude of governments toward prohibited drugs, as compared to psychotropes, as hypocritical. Ehrenberg analyses, in his book La fatigue d'ĂȘtre Soi, the need for psychotropes as enhancement and comfort drugs from a sociological point of view. For Ehrenberg, our entrepreneurial and modern western society (wild wild world) leaves the individual to construct his Self alone with his only internal resources, away from the help of social institutions. In France and in Europe, institutions were historically conceived to provide citizens with help and support to achieve a successful social and individual life, therefore participating actively in the construction of the Self.

Michael Gazzaniga, director of the center for Cognitive Neuroscience at Darthmouth College (NH) and author of The Ethical Brain (Dana Press, 2005) has another perspective on the means to achieve a successful life. He has no problem with the increase of the consumption of psychotropes for comfort and enhancement purposes. His perspective is a counterpoint to Ehrenberg's in the sense that, in the view he defends, drugs might replace institutions. From a social Darwinian perspective, Gazzaniga thinks that for those of us who have a less performing brain, it is only a matter of fairness to be able to compensate for this disadvantage with psychotropes.

Both views can be valid, one defends a social change in order to help the individual achieve a successful and happy life while the other defends a chemical change in the brain for those of us who are ill equipped, indvidually andsocially, to confront the challenges of life. Both views have also limitations. However, we have a real problem with Gazzaniga's view since Gazzaniga does not take his argument to its logical conclusion. One can argue that, according to the current consumption of psychotropes in our society, they seem to be pretty well available for everybody to use, and not only for the people who need them. College students buy them on the black market, like evry other drug. It is impossible then to view these drugs, as Gazzaniga argues, as factors for some kind of social egalitarianism giving everybody the chance to lead a successful and happy life. As our standards for success and happiness lie mainly in the imitation of others in a social context, considering drug intake as an option to compensate for some biological or social disadvantage can only worsen the situation because these drugs can also be taken by those who are not in need of them and who are already successful, in order to maintain their advantage on others in a social darwinian context. Contrary to Gazzaniga’s thinking, the consumption of psychotropes is thus not allowing those of us who have a less performing brain to compensate for a disadvantage. For as long as people who don't need the drugs can take them, the disadvantage will persist.

More than hundred years ago, instruction was not systematic and obligatory everywhere, classes were not crowded, knowledge required to achieve a diploma was not quantitatively loaded as today, women didn't use to work when having to care for their children at home and the standards of politeness and deference in school were tighter. Once these criteria changed, the new ones required different cognitive and behavioural abilities. By having different requirements with regard to the array of potential human abilities, society has progressively changed the human phenotype through socially constructed behavioural modifications. We do have a genetic endowment that can produce a vast range of phenotypes. By a constant exchange between each individual and different social environments, new phenotypes are progressively emerging. As a consequence, we are different from what our parents were and our children will be different from us. These trends in behavioural changes between generations have progressively tapped some cognitive functions that are extremely sensitive to various genetic and environmental influences. A sizeable fraction of the population has more difficulty to meet the expectations of society. On the other hand, today's society, due to current constraints, allows less variations to occur with regard to the social norms. Individuals who deviate from this wide normality become more easily excluded. This is probably the first reason for the increase in psychotrope use. As the risk for exclusion increases, psychotropes are being used either to decrease the feeling of isolation or rejection, or to improve the fitness within the social template.

It falls upon us, as a society, to judge if we are going to allow psychotropes to become an active factor in the construction of the social Self and, consequently, to participate in the elaboration of the social norms of tomorrow’s societies. Advantage in social status is a relative matter. If psychotropes are allowed for those with a disadvantage as a matter of fairness, it would not be fair then to refuse them to someone with a relative advantage compared to others but a relative disadvantage compared to different others, so he can reach a higher functioning stage and benefit from it in the competition. In a social darwinian perspective, competition and selection work throughout the range of behaviors, and not only between those who have an advantage and those who are disadvantaged. It is hypocritical to say that the over–consumption of medication is a kind of compensation for the disadvantaged members of our society. Theoretically and in current real situations, people who are taking psychotropes for enhancement are not disadvantaged per se, they are only relatively disadvantaged as compred to others. Moreover, as always, it is only the more advantaged people who are using better the ressources available to promote themselves socially. An unregulated use of psychotropes will not create social egalitarianism in chances to lead a successful and happy life, but will only render our social standards for success and happiness more out of reach of ordinary people. It will bring the distribution of our capacity closer to our genetic limits on the positive side of the distribution, and because the distribution of these critical capacities will become more and more asymmetrical, more and more people will end up in the negative side of this distribution. The approach is then to allow only those with a real cognitive or behavioral disorder, as assessed by professionals who will detect a real disadvantage, to have access to treatment with the objective of accessing a decent life. Because on the negative side of the distribution, psychotropes may change the life of those who are clearly in need of them and it would be unethical to refuse these people an access to psychotropes.

Following Ehrenberg’s critique of the consumption of psychotropes and conceiving a social solution to our discontent and mal-ĂȘtre is a valuable project but it needs the agreement of the majority on all levels of intranational social entities and international organisations and institutions concerned by the well being of their societies. Our recent twentieth century history shows that this is not an easy matter to achieve. Our cognitive and social realities are complex. They are intertwined in a web of biological factors, personal beliefs, social norms and local and global politics. None of the above positions, taken alone, can reasonably be considered as a solution to the problems of individual uneasiness with life. As social individuals and responsible citizens, we should probably work from both sides to alleviate the lives of the disadvantaged. Social interventions should be considered whenever possible. But everybody knows that social change, even wanted and planned, is slow in normal conditions. It takes sometimes more than one generation to harvest the fruits of a social reform and it requires great commitment from all levels of society. In the meantime, drugs should be considered, but only as a transient solution whose only purpose is to help disadvantaged people, who are below the equilibrium line, cope temporarily while developing new strategies in life and overcoming a difficult situation. During this time, the society and its institutions must do their part in developing a better environment for individuals.

As a society we face the same problem in the domain of physical health. To eradicate rachitism, we allowed the industry to add vitamin D in all kinds of food for everybody’s use. Are we going to follow the same path with some psychotropes for mental health? What kind of humanity are we willing to socially construct ? We are taller, healthier, smarter, etc…than our parents and grand parents. Pharmaceutical companies who are selling psychotropes have clearly interest in opening the market as widely as possible. In doing so, they do not behave differently from any other commercial entity. In a deregulated world, this may be the leading force of the make-up of our future. Therefore, we might be willing to gain some control on the world that we are building collectively by setting rules and ethical limits that will contribute to our cognitive and behavioral evolution. This is being implemented on the evolutionnary level by the way of interactions and transactions between our social norms and our biological heritage and by the way of biological mechanisms mediating behavior.

An inside/outside regulation of cognition and the Self addresses directly the problem of pathological norms in diagnostic and treatment in Psychiatry. Where are we to search for these norms? Inside or outside the individual? In the intimate or in the social domains? And when are we to label a state of mind or a behavior as abnormal? New research in neurocognitive development tells us that the inside/outside regulation takes place actually very early in development where it affects gene expression. The question is then much more complex and so are the answers.

Mood and behavior disorders can then be considered as being at the extremes of a range of self assigned and socially accepted norms and in continuity within this range. Psychotropes can be taken by individuals either because they need to attain an equilibrium point within this range or because they need to achieve a better well being. Because psychotropes have sometimes worrying secondary effects and because as a society and as individuals we need to feel in control of our destiny with our own individual and collective will, strict regulation is needed in this market. This regulation must include complete transparency from the pharmaceutical industry on their drug trials, a strict follow up by physicians, and a collective commitment to develop research for understanding better these disorders as well as creating alternative approaches for helping people to achieve a satisfactory equilibrium in the building of their intimate and social Self.

Dr. Philippe Robaey, child psychiatrist and psychophysiologist, contributed to this post by providing useful information about psychotropes consumption. However, the opinions expressed in this post are entirely mine.

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