Psychiatry, Disease Definitions, and the War on Drugs

The lines we’ve drawn to distinguish the sick from the well, and legitimate treatment from drug “abuse,” are blurring beyond discernment.  Earlier this month members of the American Psychiatric Association approved a new manual that re-defines many mental illnesses, prompting howls that the group has alchemized ordinary unpleasant behaviors and emotions into diseases.  Critics claim the newly-minted “disruptive mood dysregulation disorder” turns kids who throw tantrums into mental patients, while changes to the definition of depression transform sadness due to the death of a loved one into a symptom of a disordered mind.

While this angst is understandable, it’s surprising we continue to take these disease definitions so seriously.
Yes, you need a diagnosis to be entitled to certain benefits and accommodations – most notably having insurance pay for your medications.  But if you are suffering from emotional distress or your child has behavioral issues, it’s easy to obtain a diagnosis that justifies treatment.

There is no blood test for conditions like depression or ADHD.  Diagnoses depend primarily on doctors’ subjective assessments of patients’ self-reported symptoms.  The APA’s own research reveals that doctors faced with identical patients routinely reach opposite conclusions about the presence or absence of even the most common mental illnesses.

Moreover, as medicine has increasingly morphed into commerce, doctors’ aims have subtly expanded to encompass satisfying the desires of their “customers.”  When my wife sought a new family physician last year she first turned to Yelp, an online ratings service built on consumer input, only to find that many top-rated doctors had earned their high marks for their willingness to prescribe any drug patients wanted.

The declining importance of disease definitions will only accelerate with a new federal court ruling striking down a longstanding ban on marketing pharmaceuticals for unapproved uses.  Drawing on a recent expansion of corporate free speech rights, the Second Circuit Court of Appeals held that prohibiting so-called “off-label” promotion violated the First Amendment rights of pharmaceutical companies.  If that ruling stands, drug companies may no longer need to recast social problems as illnesses in order to market their wares.  Antidepressants can be marketed to shy people without having to persuade them they have social anxiety disorder.  Adderall can be pitched not just as a treatment for ADHD, but as a tool to help people study and work harder.

Even as healthy people increasingly use prescription drugs to boost moods and improve performance, sick people are turning to ostensibly “recreational” drugs to treat serious ailments.  MDMA, commonly known as the street drug Ecstasy, is showing great promise in clinical trials as a treatment for post-traumatic stress disorder.  Researchers at Johns Hopkins are successfully using psilocybin, a psychedelic compound found in certain mushrooms, to ease anxiety in terminal cancer patients.

Yet our policies continue to cling to outdated categories, with unjust and counterproductive consequences.  State-level experiments with marijuana policy highlight the arbitrariness of our existing approach.  As a result of state referenda approved last month, in Colorado and Washington it is legal (under state law) to smoke marijuana to promote relaxation.  Residents of 16 other states can use the drug in precisely the same way – some 55% of California medical marijuana patients say they use the drug to improve relaxation – but to avoid being criminals they must frame their use as a treatment for anxiety.

It has always been mystifying why we would require people for whom marijuana relieves pain or anxiety to turn instead to addictive narcotics like Oxycontin or antidepressants that carry black box warnings.  But the disparate treatment of marijuana by the states raises a more fundamental question: are we better off as a society requiring people to view themselves as mentally ill in order to obtain relief?

As both the definitions of mental illnesses and the available remedies have multiplied and mutated, the categories we have long relied on to distinguish therapy from abuse are fading into irrelevance.  It is not clear what will take their place.  Drawing arbitrary lines may be unavoidable when determining which interventions insurance must pay for or which challenges should be entitled to accommodations under laws like the Americans with Disabilities Act.

But when it comes to matters of criminal justice we should hold ourselves to a higher standard.  Faced with two people using drugs in the same way, it is unacceptable to send one to prison and cut the other an insurance check.  The idea that we can prevent people from using drugs to change how they think, feel, and behave has always been a pipedream.  It is long past time to focus on minimizing the potential for people to harm themselves in the process.

Matt Lamkin
Twitter: @lawbioethics