THE PHILADELPHIA INQUIRER
March 24, 2001, Saturday

Rush to medicate mental illness raises concerns
By Shankar Vedantam

BODY: In the movie version of madness, ""Psycho" and ""Hannibal" reign
supreme. The terror of Norman Bates and Hannibal Lecter lies in their
mysterious strangeness and their abrupt lunges into violence.

But in real life, most mentally ill people act ... like you.

Federal mental-health experts say that more than one in five Americans
are afflicted with a diagnosable mental illness every year -- although
few are the psychotic type that seems to interest moviegoers.

Add drug addicts to that number, and nearly a third of the country is
said to suffer from "a mental or addictive disorder" each year.

In the last few decades, more and more of them have begun to seek
psychiatric care -- and medications.

Sales of medications for psychiatric conditions dwarf the gross
national products of most small countries. Last year, Americans and
their insurers paid more than $8 billion for antidepressants, $3.9
billion for antipsychotics, and more than $1 billion for antianxiety
medications. Doctors wrote more than 125 million prescriptions for
mental disorders -- up from 73 million in 1995.

What lies behind these enormous numbers? And is all that medication
necessary?

Leading psychiatrists say that a growing understanding of mental
illness has allowed doctors to spot disease where none could
previously be diagnosed. What was once thought to be senility can now
be determined to be Alzheimer's disease. What was once painful shyness
is now considered a treatable social-anxiety disorder.

Pharmaceutical companies say that powerful drugs have offered people a
way out of depression, anxiety and psychosis. As a result, they say,
more students graduate from high school, more adults keep their jobs,
more families stay together.

Patient-advocacy groups say that broader public understanding of
mental illness has led to less stigma, which in turn has increased the
number of people willing to ask for help.

Critics of the rush to medicate include some psychiatrists and
psychologists who feel that insight-oriented talk therapies are being
given short shrift. They say that managed care, which places limits on
therapy sessions, has induced doctors to prescribe more medicine.

Some see the growing number of prescriptions as a conspiracy between
therapists and pharmaceutical companies to recruit more patients.

There are also many doctors and public advocates who fear that
Americans are turning to pharmaceuticals as a form of cosmetic surgery
of the mind: Can't sleep? Take a pill. Feel groggy? Take a pill.
Restless? Take a pill. Anxious?  Worried? Sad? Excitable?  Forgetful?
Angry? .. You get the idea.

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"We're into a drug culture," said Aaron Beck, a professor at the
University of Pennsylvania in Philadelphia and founder of cognitive

behavioral therapy, a respected form of talk psychotherapy.

"We have illegal drugs and prescription drugs. The whole society turns
to drugs as the quick fix," Beck said. "A lot of people who are mildly
depressed think the way to get better is to take something in the vein
rather than to work something out to get better."

At the heart of the controversy lies the difficulty in diagnosing many
mental illnesses.

Unlike most diseases, there are no simple lab tests to prove that a
patient has a mental illness.

Although many respected scientists have suggested that mental
illnesses are indeed brain disorders, psychiatrists cannot look at a
picture of a patient's brain and diagnose depression, mental
retardation or severe anxiety.

Diagnosis is largely based on an evaluation that involves a doctor's
estimate of the intensity of a patient's symptoms. When does sadness
become depression? When does inattention become attention-deficit
disorder?

The difficulty of diagnosis is compounded because many doctors being
called upon to prescribe these drugs are not psychiatrists but general
physicians.

"How does the symptom in terms of intensity rise to the point where
you consider it an illness?" asked Herbert Pardes, past president of
the American Psychiatric Association and a former director of the
National Institute of Mental Health. "Everybody experiences some
anxiety and depression. When it crosses the line into disorder is an
important question."

With increased public knowledge about drugs such as Prozac, Paxil and
Ritalin, patients are willing to "shop" until they find a doctor who
will give them the prescription they believe they need.

"I would be concerned if people were treating the relatively expected
ups and downs that everybody has with medications," said Pardes, who
is president of New York Presbyterian Hospital. "I think that is
happening."

In part, the very efficacy of the drugs in altering the mood states of
people -- both healthy and sick -- can lead to their overuse.

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"We have got drugs that seem to be helpful with certain conditions but
now we have a reflexive, thoughtless formula," said Paul McHugh,
chairman of the psychiatry department at the Johns Hopkins University
School of Medicine in Baltimore. "If you are depressed, bring out the
Prozac. If the observers think you have ADHD (attention deficit
hyperactivity disorder), pass the Ritalin."

Gary Tollefson, a vice president of Indianapolis-based Eli Lilly &
Co., which makes the antidepressant drug Prozac, agreed that
medications are not always necessary.

"There are probably examples of individuals or groups who are
under-treated and there are equally groups for whom medications should
not be necessary," he said. "So you paradoxically get both over- and
under-prescribing."

"It is a concern of the company and the medical profession in
general," he said of those who seek medication to alleviate normal
fluctuations in behavior. "These medications have been approved by the
FDA based on trials for specific disorders. Often they have not been
demonstrated among individuals who want lifestyle enrichments or
enhancement."


Some critics like New York psychiatrist Thomas Szasz, author of ""The
Myth of Mental Illness," have long said that mental illnesses exist
only because psychiatrists say so. They point out that virtually none
of the major disorders being treated have biological markers. Thus,
they contend, diagnoses are based on the subjective opinions of
patients and doctors.

Psychiatrists diagnose patients based on their symptoms according to
criteria in the American Psychiatric Association's Diagnostic and
Statistical Manual -- the DSM-IV. In recent years, the number of
disorders in the book has expanded.

"A lot of people will say psychiatry is out to pathologize everybody,
and they (point to) the increase in the number of diseases described
in the DSM-IV," said John Blamthin, a spokesman for the association.
But if large populations are studied over time, he said, "the total
number of people estimated to have a mental illness has remained the
same."

"People talk about road rage as if it is a diagnosis, and it isn't,"
he said. "People think all you have to do is add the word 'symptom' or
'disorder' to something and it is in the DSM, and it isn't."