Sickening People

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.

Most people.

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.

30 thoughts on “Sickening People”

  1. In today’s medical practice, everyone wants a diagnosis. The insurance companies want a diagnosis for payment. The patient feel like they need a diagnosis to make the doctor’s visit worth the money. It is as if they are paying for a diagnosis and returning home without one is like not getting what you paid for. The medical industry is going a great service to all by giving a diagnosis to all normal conditions, abnormal conditions and anything in between!

  2. As someone who as a psychiatric social worker saw people only with severe mental illness, I can assure you that people with major depression really do need help. It is a completely debilitating illness which isn’t just sadness or boredom or apathy or angst. People with major depression need help so they can cope with life’s ups and downs — cry, pick up the pieces, whatever.
    It is very important not to get into a frame of mind of moralizing or saying more or less if you could do it anyone could. Anyone can’t. People with major depression kill themselves at worst, and frequently have problems which severely impair their functioning. Their perceptions of reality, including their place in it, are distorted, sometimes severely; they stop caring for themselves and sometimes those they care for as well. They may develop alcohol and drug problems. Their illness makes them unable to contribute to the world around them.

    Even people with less severe depression shouldn’t be dismissed. For instance, there was just an article today in the NY Times about reasons for truancy pointing out that it can be a sign of depression and anxiety in kids. In my experience, adults who are less severely depressed may still miss work, worry about missing work and miss more work and get themselves fired. Less severe depression can cause severe marital problems and severe problems between parents and kids.

    Please remember: depression is a disease which keeps people from handling adequately the normal sturm and drang of life. It is not because they are somehow wanting some kind of easy escape from it.

    If you have patients who complain of depression, you probably should refer them to a psychiatrist a counselor of some sort at a group practice with a member who can prescribe medications. Medicine is certainly not the only answer. Various forms of therapy have proven remarkably effective with depression and also can help when perhaps the dilemmas are situational and not clinical epression. What you shouldn’t do is assume that prescribing or not prescribing antidepressants is the end of your involvement.

    ADHD is not the same as depression in the problems people have because of it, although people with ADHD may also be depressed and vice versa.

  3. I am not referring to “major depression” in this case. I tried to make it clear that I was not dismissing the medical treatment of such. But the vast majority of antidepressants are not given by psychiatrists, but by primary care doctors. We give the medication for the majority of cases that are not to the level of “major.”
    All depression is not alike.

  4. Dr. Rob,
    Great topic. And you are on-target, as usual. The line that separates normal from disease is of course not a line, but a smear of gray, and it does appear to be on the move. I find it particularly true for my baby-boomers, who are frustrated with the natural consequences of aging.

    I had a patient a few weeks back complain of fatigue. She’s 40, has 3 kids, works full time. I took an extensive history, and by the time we were done I was able to say, “So, when you only get 6 hours of sleep per night, you’re exhausted, but those weeks that you are able to fit in 7+ hours of sleep you feel great?” and have her answer yes. And then she still wondered what tests I was going to run to figure out what was wrong.

    Some people expect an awful lot out of life and their bodies. It’s no wonder they are disappointed.

    Smak

  5. While I don’t think Dr. Rob could or would get away with it, there is much to be said for “just get over it.” You speak of people with major depression. That is not unlike someone with major heart disease or major cancer. We all have some weakness in our circulatory system and, I’m willing to bet, some initial stages of cancer in our bodies. The issue, as I see it, is that there is a point beyond which it is reasonable to treat the disease and there is a point where, if you have not yet reached it, all you have is a set of observable symptoms and nothing more. What I took from Dr. Rob’s post was that it takes more than the desire for a pill to be able to decide just where that point is. I take too many pills as it is for the very real diseases that I have. I do not need an enabler pushing more pills at me because I was a little disappointed in how last night’s game turned out.

  6. You are still a trouble-maker, only a smart one, with a keen sense of the obvious. Congratulations. And, no Jenny this time.
    In my middle school, punishment for behavior deemed pharmacologically actionable these days, entailed handwriting the Declaration of Independence. I knew this doc well and this therapy seemed to work, for me at least.

    JMM

  7. Dr. Rob, you just made me love you all over again with this post… OK, seriously, I can completely relate to that tendency in our culture to stick diagnostic labels on darn nearly everyone, at times overzealously. And I can also vouch for your theory that rough seas make for good sailors, because I was the one with all sorts of issues who fell through the gaping chasms in the educational system before finally being diagnosed with both a quirky sort of LD and eventually ADHD (inattentive type; I never caught their attention by bouncing off the walls or causing mayhem) when I tried to survive college at my true potential. I had several people say, “Most of those in your situation would have given up any hope of a college degree and/or gainful employment years ago.” People want the quick fix for everything, and sometimes there just ISN’T one (or else if there is, it’s not appropriate to a given situation or individual). A good physician recognizes that and uses it to educate his (or her) patients. As one who shied away from any sort of pharmacological help because I was of the mind that you can’t fix everything by trying to medicate it away, I was clearly able to distinguish between run-of-the-mill doldrums or excessive worrying vs. the kind of depression or anxiety that really needs prescription help. Sometimes a “diagnosis” in this sense can be more of a burden than a useful tool. There is tremendous value in enabling people to make that distinction instead of just throwing drugs at every problem that comes along, and yet also knowing when the meds will have the potential to be useful.
    And as one who was never “normal” in any sense of the word, I can also say confidently that sometimes our expectations (or lack thereof) can be the source of most of our agonizing and griping and general discontent. At least I realize there is no medication or surgery that can fix my scrambled brain and all that goes with it, but I had a heck of a time changing my once lofty expectations of myself to a more reasonable, sane level. I always said “normal depends on who’s looking”, and how boring the world would be if we all fit that arbitrary standard!

  8. I agree with what you say, I have Fibromyalgia and RSD and I live in pain all the time and take medications when I need them, not daily. But the teacher that I once was would like to correct your spelling. You were in the principal’s office, not the principle’s!

  9. Your suggestion that people who have depression, and other emotional disorders, should be referred to a psychiatrist is so correct. I have suffered from depression my entire life and only psychiatrists have had the knowledge it takes to prescribe the correct medications and deal with side effects from those that don’t work. I know general practitioners do most of the prescribing of these drugs now but that does not make it right. We all have different brain chemistry and someone who knows well the different ways that brains work has the best training for treating psychological disorders. I wouldn’t recommend that psychiatrists do appendectomies, for instance, even though they are M.D.s. I don”t recommend that general practitioners try to do the complicated medications that some psychiatric patients need, although I know that a good conversation with a good doctor of any type can often cure what ails us.

  10. People with major depression – clinical depression that is causing major problems – should see psych. People who FEEL depressed, don’t necessarily have clinical depression. People who are going through hard times and are struggling with depression also probably don’t need psych. The truth is, psych sees about 5% of people complaining of depression. If we sent all to psych, there would be no room for people with significant clinical depression. Plus, the majority of folks won’t set foot in a psychiatrist’s office but will talk with their primary care doctor. Let’s not equivocate on the word “depression.” As Geezer said, all depression is not the same.

  11. I had the misfortune to come of age during the period when the FDA decided it was perfectly legal for psych hospitals to advertise on TV. Their ads basically boiled down to “Do you have a sullen teenager? Send them to our hospital and we’ll fix them right up!” My parents, who paid more attention to themselves and to the television than they did to their children, thought this was a wonderful idea. I ended up in special education for two years because that’s what the shrink my parents forced me to see recommended. And now, 25 years later, the new “fashionable” psychiatric term for your garden variety rebellious teenager is “Oppositional Defiant Disorder”. Disorder? Really? What does “normal” even mean anymore, if we’re going to medicalize every fork in the road of life?

  12. I have a REAL problem with Doctors who chuck the Somatoform diagnosis’s around.It so often means the Doctor has no answers and so you must be Somatoform.Without anything to base that diagnosis on.This is something that makes me really angry!! Too many Doctors are using this as a cop out without consideration of the consequences the diagnosis has on a persons life.It may well have its legitimacy in some cases but I have known way too many people who have been given this diagnosis to get them fitted nicely into a Doctors damn box!!
    Too there are those who are being fed tablets and told this will help you to deal with life!! Well NO it won’t it might help the chemical balance but if someone is having problems then it would be wiser to prescribe a therapist or counsellor to help with coping skills and make people think there is a tablet to solve every problem!
    I am having cognitive problems right now and know I haven’t said all I could say or nearly anything I want to say on this subject.
    Again Dr.Rob you make me happy because you THINK about things and try a little to turn the boxes inside out!!

  13. See, this is the problem. Medication is not a replacement for learning coping strategies. Medication doesn’t eliminate the symptoms, especially in ADHD. What it does is assist in making them manageable so that you can learn to cope without drowning. And, speaking of psychs, you should see one and get tested before diagnosing yourself :p As it happens, many very intelligent people learn to cope in spite of their cognitive disabilities. But no one would ever suggest that a person with an ambulatory disability should just learn to cope through the struggle. Why are mental disabilities viewed differently?

  14. Again I must correct my typing error I meant to say “help with coping skills and NOT make people think there is a tablet to solve every problem!

  15. It is not a “disability” for me. I have been diagnosed “officially” and psych agreed that I am in the right circumstances. The presence of a diagnosis should not be confused with a “mental disability.” You are showing exactly the confusion I wrote this post to address – that the presence of a diagnosis does not mean it needs to be treated. You treat only things that cause problems, and ones in which the treatment creates less problems than the diagnosis itself. I have learned to cope, and that learning was enhanced by my non-medication. It was sink or swim, so I had to learn to swim. Would I have done better if I had worn a life-preserver?
    Let me state for the nth time, I DO treat people for ADD and depression. Those who would sink without medication are treated as appropriate. But learning to swim takes some risk of sinking (with supervision, of course). Look at the examples in the post: bad behavior, bad grades, getting angry at work…all are life-skills people need to learn. We protect ourselves and our children from work at times. There is a huge grey area here that I am talking about, not the obvious cases where treatment is needed.

  16. I just wrote about something similar yesterday, how really hard things make a person stronger and that is kind of what life is all about. I agree that I am who I am because of my rough times that at the time I would have wished away. For myself, I wouldn’t ask for help unless I really needed it so I appreciate your willingness to give help despite your uncertainty about where we should be drawing the line.

  17. Normal is just a cycle on the washing machine. You’re right, everyone has pain. The real issue here is how debilitating illness is in the quality of a patient’s life. . . and what interventions have been used to offset/bypass/reduce illness. I always think that medication shouldn’t be a first-step treatment.
    My daughter has ADHD and being a psychologist, I opted for teaching her skill-sets instead of medication. She’s done well and, like you, is finding what best suits her temperament and interests.

    Dr. Rob, you impress as being a very thoughful line drawer. That’s the best kind to be!

  18. Great post! Sounds like “The Road Less Traveled” by M. Scott Peck. Most people try to avoid pain and can’t delay pleasure, but those that can learn to be disciplined, accept that some suffering is part of life, and work to overcome obstacles are healthier individuals.

  19. Well I know that. I did move on to less severe examples. I think that it is unfortunate but true that people lack the kinds of social supports that might help them understand and handle difficult situations they never faced before and thus never learned to handle. Suggesting counseling for such people is really not a bad idea. I just had a discussion with a Mexican friend about the difference between living among and not among members of extended families. She said the danger in the former is that you don’t get the chance to really strike out on your own so much and I said the danger of not having lots of support is that you can drown. We did agree that some kind of mix was probably best. However, in the US there are plenty of people who have really no resources. While I recommend counseling, I’m all too aware that counseling can be awful, too.

  20. I’m currently in graduate school, for the second time. I’m published. I’m shockingly effective. I’m also cripplingly disabled because I’m not able to live up to my potential. It just so happens that my disability makes me “average.” I can get by without my medication (and unfortunately for me have been doing so for about a year). I can excel with it. But even taking the medication doesn’t make life easy. It certainly doesn’t protect me from work. It didn’t magically make me a star pupil in grade school. It didn’t make me not weird in high school. It didn’t hand me a 4.0 on a silver platter (I’ve never had one). But even if it did, why shouldn’t we with mental disabilities be protected from the extraordinary, abnormal level of coping required for our abnormal problems? I have a minor astigmatism and very slight presbyopia. I could learn to cope without glasses. But no one would ever expect me to.Medication, and any treatment, requires an analysis of the benefits and the risks. In your case, perhaps the benefits aren’t attractive enough. But your feelings about your own success should not color how you treat your patients.

    My comment is honestly less about whether you appropriately prescribe medication and more about the idea that people have to be “disabled enough” to deserve assistance that pervades our culture. It’s pernicious and it shouldn’t be perpetuated by those who should know better. Because of these attitudes, people with simple ADHD end up with chronic depression because they have to fight to breathe, even if you don’t think they are fighting that hard.

  21. Look how the disease hypercholesterolemia has been re-redefined over the past 20 yrs. The lower limit of normal is steadily sinking. Soon, the entire country will have the disease and will march, or be led, to their physiciancs to undergo ‘statinization’.

  22. I’m seventeen, and have chronic pain condition. Its not normal, I have had doctors tell me to suck it up, some try to medicate the hell out of me, and some who actually know where the ‘line’ is. Everyday I look at around at all of the other university students, listen to their trivial problems and I just want to run away. I know life isn’t fair, but it is also not fair that I struggle everyday to so the simplest things because of pain. I have missed out on so much of high school, and now I am just watching that happen again in university. Life gives you pain to make you stronger, but too much makes you weaker.

  23. I really enjoyed this post, Dr. Rob. It reminds me of a wicked question we’ve been milling about here: “How do you get people to want rail lines and runways when all they see are Ferraris being driven in the system?” (i.e. how do you get people to want better, higher capacitive preventive health and wellness when all they see is high tech curative medicine and pharmacology?)

  24. People do want a pill to fix everything. Anythng like eating a heatlhier diet, or getting some exercise outdoors is too much effort. But its been so easy to get into the drug cocoon where you can feel all warm and fuzzy, and not responsible.
    But to be fair, how can this be avoided when you are constantly bombarded with advertisements, and doctors get paid for prescribing certain drugs? And for an overworked doctor, its so easy to just prescribe something rather than argue with them.

    I’ve had doctors on both ends of the spectrum. One that would prescribe anything you asked for, and one that wouldn’t even prescribe aspirin unless you were dying. I’m grateful for the one that made me take care of myself.

  25. It’s funny. I have some reasonably serious chronic conditions, meaning that my day-to-day life is often painful and my sleep stinks, and I go to the doctor’s maybe once every three years aside from my annual appointment.
    I’ve apparently had plantar fasciitis for 16 years and didn’t realize it until it worsened to the point that I could no longer ignore it and it suddenly occurred to me that it’s not normal to not be able to stand without pain and that having to sit down every 10 minutes to get up the mental fortitude to face the pain would generally be considered a problem. The fact is that I’m in pain so often from my treatment-is-worse-than-the-pain condition that I have become habituated to it–the plantar fasciitis was, until recently, the LEAST of my concerns. I just don’t usually go to doctors for anything because they can so rarely offer solutions. The plantar fasciitis is the only foot concern I’m going to get treatment for (on Tuesday!)–mainly in the hope of coming away with air casts and a rec. for that rigidity of orthotic I should get. But I have a nasty bunion and Morton’s neuroma in both feet, too, that have no non-surgical treatments that doctors can prescribe, so I’ve never seen a doctor for them. (I actually diagnosed my father’s Morton’s neuroma first, after a sport LPN diagnosed my problem. Idiot GP agreed with this after first claiming he had no idea what it could be and sent him to a specialist who confirmed it. It bothered him enough that he had surgery. I can avoid pain from mine with good shoes.)

    I have exercise-induced anaphylaxis, misdiagnosed by my first allergist as asthma and caught by my second. (Given my history, the second is more unusual than the first.) That’s easiest to manage with OTC antihistamines, avoiding aspirin before exercise, and self-monitoring. So doctors are pretty useless for treating that.

    *I’m* the one who figured out what the ugly familial pain syndrome I inherited was, though a whole lot of surfing of medical journals looking at a very short list of its distinguishing features (dominant inheritance pattern, varying penetrance, must be metabolic but improved with exercise, non-degenerative, worsened with tiredness and cold). There’s only one possibility–and yet 99% of doctors can’t even recognize it when named. Unsurprisingly, there are no treatments that aren’t worse than the pain and disease.

    I came down with some insane condition that landed me with literally months of low grade fevers and malaise that culminated in six weeks of misery, the first of which I spent 21 hours asleep out of every day, coupled with intense pain, waking dream hallucinations, difficulty understanding and producing speech, and prosopagnosia so profound that I could no longer recognize my boyfriend and family’s faces (it actually took years for this ability to slowly come back). Doctor’s response? “Wow. You’re obviously quite sick, but your fever isn’t all that high. I have no idea what you have. Want an antidepressant, just in case?” At that point, I’d have tried anything, so I took it for about a week until I realized that I was getting a severe sense of alienation from my body, coupled with the strangest loathing for it that I’d ever had, and my sleep and pain were no better. When I was sleeping “only” 16 hours a day a month later and the fever went away, I felt like I was getting my life back. It was six months before a trip to the grocery store didn’t exhaust me for the rest of the day, though.

    Doctors are good for sewing up split lips, repairing injuries, antibiotics when antibiotics are warranted, surgery when required, and cancer treatments–stuff that’s either very major and obvious or obvious and easy to fix. When I realized my DH had appendicitis, I drove him to the hospital right away. Doctors are good at appys. They’re not good for much else. And I say this as a person with a surgeon, four nurses, an OT, and a PT in my small family.

    I’m constantly baffled by people who go to the doctor’s office for flus and colds. At least there, the doctor has a high probability of figuring out what’s wrong, as opposed to illnesses with a modicum of subtlety, but what do they expect? That he’ll kiss it and make it better? Is it really worth the trip to the doctor’s office to get told to take a Tylenol and stay in bed? I don’t understand. If you’re sick enough t stay at home, surely you’re too sick to drive into the doctor’s office!

  26. Rob,
    Thanks for the good post. I wish there were many more primary care doctors who thought about and worried about these issues as much as you do. It is absolutely amazing to me, now that I am doing basically an emergency room based practice of psychiatry, how many people want me to come up with, in the space of a 15-30 minute interview, some treatable diagnosis that can be fixed with medications. The vast majority of kids and families I see are having trouble communicating, sending each other suicide notes by text message and feeling that there are no rules worth following (kids) or there are no rules that can be adequately enforced (parents). Like you, I have seen the wonders of what medications, judiciously used after a proper diagnosis, can do. I use them when needed and indicated. However, most doctors who have paid any attention at all to their own practices know that much of what they do is listen, understand, educate and support. Patients often need that from us, and it does not come in a pill.
    Thanks again for the post. I enjoy your work.

    Greg

  27. I think i have to agree with your point about people being “too lazy” for long-term treatments. When looking into possible treatments for my Morton’s Nueroma – most people automatically talk about surgery being the magic bullet. Now i think the reason is that people don’t want to take the time and effort to retraint their feet or change their behaviour. They would rather just get put under ansthetic and get back with their busy lives. It’s sad that this is the way the world is going…

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