May 4, 2006
by Ronald W. Dworkin
Doctors now view everyday unhappiness and clinical depression as lying on a continuum, with biochemistry accounting for the whole range of human moods, from pathological to normal variants. Whether a patient suffers from clinical depression or just everyday unhappiness is immaterial because neurotransmitter imbalance is thought to be the cause of both. In both conditions, antidepressants are the treatment of choice.
Statistics affirm the new attitudes. In the United States, doctors treat both major and minor depression with medication at roughly the same rate, even as the symptoms of minor depression merge into everyday unhappiness. In one study, for example, doctors medicated 77 percent of their patients with major depression, yet practically the same proportion (68 percent) of patients suffering from minor depression received the same treatment.
The new thinking causes doctors to dismiss as irrelevant whether a patient's unhappiness precedes or follows the onset of disease. Take irritable bowel syndrome as an example. Some studies show that 20 percent of the American people fit the criteria for IBS. Obviously not all of these people are going to doctors, complaining of symptoms, and demanding treatment. Why do some people put up with their symptoms while others seek medical help?
In my experience, unhappiness exacerbates physical symptoms, or at least makes people acutely aware of them. Unhappiness is often the major factor in determining whether people will put up with irritating but fairly harmless symptoms or, instead, go to doctors.
I see this phenomenon play out in my own anesthesia practice. Several years ago, I treated a man for hip fracture pain with narcotics. During the day, the man rarely complained of pain, but at night his narcotic needs soared. Eventually I discovered the reason: The man's irritating son visited every night around dinnertime. My patient felt stress during these visits, which aggravated his pain and led to a transitory spike in his drug needs.
Viewing unhappiness as a biochemical problem, many doctors forget the role that unhappiness plays in channeling nagging symptoms into a focused complaint and, beyond that, into a "disease." Medical diseases are not always cut-and-dried affairs. On the contrary, they include physical symptoms that merge with the everyday experience of millions of healthy people. When unhappiness becomes a problem of neurotransmitters, doctors treat it as a separate disease, disconnected from physical symptoms, even though it is sometimes the decisive factor bringing patients to their offices.
Perhaps the most curious thing about the new physician attitudes is the branch of medicine that has embraced them. For the last 40 years, critics of the medical approach to unhappiness have focused their attacks on psychiatry. Yet the movement to treat unhappiness with drugs originated in primary care, which remains the force behind the movement to this day. It was primary-care doctors who overprescribed Valium in the late 1960s; it is primary-care doctors who overprescribe drugs like Prozac and Zoloft today.
From 1988 to 1998, the prescription rate for psychotropic drugs tripled in the United States, with antidepressants accounting for most of the increase. Primary-care doctors wrote 75 percent of the new antidepressant prescriptions during this period. According to IMS Health, a health-care consulting firm, from 1998 to the present, the prescription rate for antidepressants doubled again - with primary-care doctors writing the majority of these prescriptions.
Antidepressants solve an age-old problem. In the past, happiness was scarce, vulnerable to life's trials, and sometimes gained only at the expense of others. Antidepressants, on the other hand, make happiness available to everyone, even when life is hard, and for as long as people want it.
These drugs are vital in the treatment of clinical depression, but in using them to treat everyday unhappiness, doctors are changing the psychological dynamic in millions of Americans. Instead of finding happiness through a better life, many people now handle the due stress of life with medication. To the extent that they do, they are simply following the doctors' lead.
This article appeared in The Philadelphia Enquirer on May 2, 2006.
Ronald W. Dworkin is a practicing physician and a Senior Fellow at Hudson Institute.