Prescription Solutions for Personal Problems
She's been off the medication for a couple of years now.In October 1984, at the age of 16, Ellen (not her real name) tried to kill herself. After a week in a psych ward, she was sent back to school with a prescription for a tricyclic antidepressant, Tofranil. Within two months, she was hospitalized again, for two weeks.The years that followed were a steady climb out of a nightmare in which she described feeling "like someone had put me in a field, and there was nothing for miles and miles, nothing I could see, nothing I could latch onto." On a regimen of Tofranil and extensive psychotherapy, she says, she was able to isolate the causes of her feelings and learn to deal with them. "In the beginning, when I would start to have a lot of negative feelings, he [her psychiatrist] suggested doing things like thought stopping' -- putting a big stop sign in my head if I was starting to get into a negative feedback cycle, to help me get things in perspective," she recalls. "The goal of therapy...was to help me get to a level where I could solve my own problems."As time went on, the frequency of Ellen's therapy appointments and the dose of her medication were gradually reduced until she no longer depended on either. Although she still has bad days, she believes she has been cured of her severe depression -- "in the sense that I can recognize when I'm feeling really down...enough to recognize that I don't feel that way every day, and I know that when I need help I can turn to help."But when Ellen talks about turning to help, she's talking about talking -- to friends, relatives or counselors -- not the Tofranil. Although she maintains that it was initially necessary to open her up to the therapy ("Once it starts," she says of the medication, "it's like night and day") and although she was reluctant to stop taking it completely (she spent a couple of years at the minimum dose, worried that her depression would return), she doesn't believe that it's what she really needs."The medication will lift your mood, but ultimately it will not help you if you don't manage what's causing you to feel that way in the first place," she says. "Just taking a pill isn't going to solve your problems."America, however, isn't acting like it really believes that. The last couple of decades have seen explosive growth in psychiatric diagnoses of emotional and behavior disorders and corresponding growth in the prescription of medications to treat them. And "treat" is the operative word, rather than "cure," as many of those disorders are being viewed as problems that will never really go away but must be controlled -- indefinitely -- with medication, without much attention to or understanding of the reasons why people are feeling or behaving the way they do.What is known -- but is not widely publicized -- is that psychoactive drugs are no angels of mercy. The long-term impacts of many popular pharmaceuticals are at best uncertain and at worst unexamined. They have unpleasant and sometimes dangerous side effects. They have been known to react badly with other drugs. They generally treat symptoms rather than causes. Getting off them can be a bitch. So can staying on them.And they are actively, heavily promoted by a multibillion-dollar industry with a strong interest in seeing people's problems defined as diseases that their products can control -- if people keep using them.Depending on whom you ask, the number of boys between the ages of 6 and 14 who have been diagnosed with either attention deficit disorder or attention deficit hyperactivity disorder and are taking Ritalin to treat it is somewhere between 2 and 12 percent. Many people say that ADD and ADHD are being underdiagnosed.ADD and ADHD are generally described as disorders in which children (overwhelmingly boys) are restless, impulsive, disruptive at school and unable to restrain themselves or maintain focus. But the exact descriptions depend not only on whom you ask but on when: the definitions in the Diagnostic and Statistical Manual, the official compendium of mental illness, have been changed many, many times. And the definitions keep getting broader."This ADD used to be called minimal brain damage,' " says David Keirsey, a California psychologist and psychotherapist. "Then minimal cerebral dysrhythmia.' Then dyslexia. They had a dozen names for the same thing....It's the same old thing, always aiming at the same idea: There's something wrong with the brain."Sometimes something actually is wrong with the brain -- in cases of fetal alcohol syndrome, for instance, or of birth defects. But ADD and ADHD are distinct from those in one important respect: They can't be traced back to a specific physical condition. In other words, no one knows with any certainty what causes them. And if you can't find a cause, Keirsey asks, how can you call it a disease?"People act crazy to defend themselves," he says. "Calling it a disorder says there's something wrong with the body. The medics are still looking for the physical cause of unacceptable behavior. They still believe that so-called schizophrenia is a physical disorder, that there's something wrong with the brain. They've never said what's wrong with the brain."Nevertheless, ADD and ADHD are a big deal. A number of high-profile medical schools have established centers to study the disorders, to assess people who might suffer from them and to train patients and relatives (usually parents) in dealing with them. A national group, Children and Adults With Attention Deficit Disorder -- better known by its contrived acronym, ChADD -- exists to provide support and information services to people diagnosed with ADD or ADHD and their families. And, of course, there's Ritalin, a drug so popular that a couple of years ago manufacturer CIBA-Geigy had to ask the Drug Enforcement Agency to increase its production limits because there wasn't enough to go around.Why did CIBA-Geigy have to ask permission? Because the DEA classes Ritalin as a Schedule II controlled substance. Ritalin is an amphetamine, and there have been widespread reports of kids, mostly high schoolers, crushing the pills and snorting them like cocaine to get high.Why would you give a stimulant to a hyperactive kid? "Stimulants in low to moderate doses do increase those areas of the brain involved in inhibition, self-control and attention," explains Dr. Michael Gordon, professor of psychiatry at the State University of New York Health Sciences Center in Syracuse and director of the center's ADHD program. "That's why they can be popular among people who need to keep alert, especially over long periods of time....What people are more familiar with are uses of stimulants at high doses, like speed, but that's not what happens."But Keirsey argues that kids' apparent settling down in the classroom is more a side effect than a beneficial outcome. "Their sleep is restless, and it's not very good sleep," he says. "If you were to drink 30 cups of coffee and try to sleep, you're gonna be very tired in the morning. And these kids report being tired all the time. So naturally, when they're in school, they're not active anymore. They're bombed out. The deprivation of sleep makes them seem calmer, but it deprives them of their energy."Moreover, while there's substantial evidence showing that kids on Ritalin sit still more and get better grades in the short term, there's none showing that they achieve more or behave better in the long term. And the surge in Ritalin usage -- a 489 percent increase from 1990 to 1995 -- compared with the less drastic rise in the number of children taking it suggests that people aren't getting off the drug but rather are continuing to take it through adolescence and adulthood. That in turn suggests that not a lot is being done to help wean people off the drug, the way Ellen was eventually able to give up Tofranil."Generally, the emphasis is on treating [ADHD] as a chronic condition," acknowledges Gordon, "but the fact that a disorder is chronic doesn't mean that it's always interfering in somebody's ability to function at the same level. In other words, depending on the demands on an individual at any stage, their ADHD symptoms can be very much interfering or not interfering much at all. You have to keep in mind that ADHD is essentially a trait gone awry."Keirsey agrees with that last assertion, but he takes issue with the assumption that there's a disorder behind it. He maintains that ADD and ADHD are simply manifestations of an impulsive personality -- which he refers to as an "artisan" or "tactical" type, one that needs constant activity and feedback -- in kids who haven't learned to deal with situations in any way other than what comes most naturally. He even hesitates to label that lack of social development immaturity. "To say that the so-called ADD kids are immature is a mistake," he says. "It's just that they aren't maturing in the direction that the elders want."Part of the problem, Keirsey believes, are educators who feel threatened and want to secure children's obedience however they can. "Schools got into the habit of saying, Well, if a kid doesn't do what I want him to do, there's something wrong with the kid, he needs special education,' which is a bunch of malarkey," he says. " If a kid doesn't fit the curriculum, change the kid, not the curriculum, or put him in another place -- or drug him.'...The tragedy is, it is unnecessary to do this! There are other ways of helping these children adapt to their school environment that are very simple. But very few people try them."When adapting the curriculum fails to bring a child back into the fold, Keirsey strongly advocates what he calls "the principle of logical consequences," which applies a strict cause-and-effect treatment for disruptive behavior: If the kid acts up, remove the kid, without question or comment. Then let him come back the next day."It's very simple," he says. "These kids want to be where the action is, and if you take away the privilege that they have, the privilege of going to school and having classmates and a teacher and lessons, well, then they very quickly decide they want to be in school. It's no fun at home when all the kids are at school. They learn to control themselves."In 20 years working for public schools, he says, he never worked with a child for whom that approach didn't work.But some cases resist simple solutions. Michael, a pediatrician, tried a lot of them with his son, Casey (not their real names), who was diagnosed with ADD in pre-kindergarten and started on Ritalin at age 5. (The Physician's Desk Reference, a guide to prescription drugs, warns, "Ritalin should not be used in children under 6 years, since safety and efficacy in this age group have not been established"; Michael admits that he and his wife had some concern about the drug but decided it was a chance worth taking.) Casey seemed easily distracted and had difficulty connecting with other children, often acting as if he were "in his own little world." According to Michael, his teacher was the first to suggest that Casey might have ADD, followed by some neighbor parents.Casey was evaluated by a physician, identified as a specialist in attention and learning problems, who diagnosed "overfocused attention deficit disorder with features of nonverbal learning disability" and prescribed Ritalin. But in the two years Casey was on the drug, his parents found him "hard to reach," and one of the drug's side effects -- heightened anxiety -- became pronounced, worsening his attention problems. After changing pediatricians and child psychologists several times and going through a variety of different drugs -- including Dexedrine ("disastrous," Michael says), Vistaril and Tofranil, none of which helped -- they finally settled on Paxil, an antidepressant closely related to Prozac, and a nonspecific diagnosis that includes features of obsessive-compulsive disorder...but not ADD. Casey's problem was not that he couldn't concentrate but that he concentrated too hard, on the wrong things.All during his treatment, Casey has been seen by child psychologists. But his receptiveness to therapy has risen and fallen. Emotionally, he's catching up with kids his age, but the acting-out behavior has continued. His intelligence is both a help and a hindrance; he's very rational and verbal, but he has trouble with abstract concepts and communication with kids who aren't as smart, and he tends to get deeply preoccupied with personal interests such as Nintendo."I've heard it said over and over, when you look at behavior of kids, the range of accepted or normal' behaviors in school and society has become so narrow that more and more kids fall outside that norm," Michael says. "Our son is a little bit more complicated, and it's really hard to know what the right thing is for him. You just want him to be happy with himself and fit in as best he can."Notable in Casey's instance is that his disruptive behavior began shortly after his parents adopted another child; Casey, too, is adopted, and his adoptive parents know little about his birth parents' medical backgrounds. Ellen's depression as a teenager also was precipitated in large part by stresses at home: her father was laid off, her mother went to work reluctantly, money was very tight, and she was discouraged from participating in extracurricular activities because her parents thought it was wrong to ask others for favors, such as carpooling. She was intensely shy. And she believes her lack of coping mechanisms stemmed from being taught that she shouldn't bother other people with her problems."Virtually all forms of human unhappiness and conflict have been redefined as medical problems, suitable for treatment with drugs," claims Bethesda, Md., psychiatrist Dr. Peter Breggin, who has come under fire for his harsh criticism of the psychiatric profession and the pharmaceutical industry. "The question isn't whether they're serious....The real problem is that serious problems are being called psychiatric. A woman becomes depressed because her husband's job takes him away six months at a time and it re-stimulates in her when her father left the family when she was a child, and she gets very sad and depressed and confused about this, and she goes to her HMO, and they don't even refer her to therapy -- they put her on Prozac. Instead of resolving her issues, she's told she has a biochemical imbalance and gets a drug."Breggin says that not only industry pressure but government pressure leads to therapy's being dismissed as a desirable form of treatment. Medicare, for instance, pays a psychiatrist $56.80 for a 20-minute session and $88.30 for a 45- or 50-minute session; a psychiatrist can thereby make nearly twice as much by scheduling three 20-minute sessions in an hour. "It's clear that the government program is pushing the drugs, because you can't do therapy in 20 minutes," he says. "You can only do medication follow-up."Yet according to a study by David Antonuccio and William Danton of the University of Nevada School of Medicine and Garland DeNelsky of the Cleveland Clinic Foundation, research into depression treatment has shown conclusively that "the vast majority of depressions are not attributable to identifiable medical causes"; that behavior therapy is significantly superior to drug treatment, offering a higher rate of success and a lower rate of relapse; and that combining drugs with psychotherapy does not achieve results significantly superior to psychotherapy alone."These antidepressants aren't as effective as people might think," says Antonuccio, also a clinical psychologist at the Reno Veterans Affairs Medical Center. "Out of 100 people, about 29 will respond to the antidepressant medication -- that is, get better -- whereas with psychotherapy it's about 47 out of 100....We reviewed every study we could find in the literature. We concluded that psychotherapy should be the treatment of first choice, because a lot of people respond, more than to drugs. And you don't have some of the medical risks that you do with medication."Nevertheless, according to their study, "drugs are the most commonly delivered treatment for depression in the United States." And Antonuccio observes a strange circular logic: When patients on medication experience relapses that cause them to stop taking their drugs, the medical conclusion is that they need to get back on the drugs, to prevent the relapses that the drugs didn't prevent before.Cognitive-behavioral therapy, a method cited in the study as being highly successful, aims at helping patients see their problems from new perspectives, observe their own mental activities and responses, calm themselves with pleasant activities and improve their social skills. Social skills, in fact, are very strongly linked with depression and other behavioral disorders, in both directions: not only can poor social skills precipitate a disorder and improved social skills help one emerge from it, but the disorders themselves cause further breakdowns in the ability to deal with others. In short, behavior therapy deals with the person, not the body. "You can give a hungry man food, or you can teach him how to fish," Antonuccio says. "Cognitive-behavioral therapy is basically teaching someone how to fish."And yet, says David Oaks of the Support Coalition, a patients' rights umbrella organization, even behavior therapy has demonstrable physical effects. "They did brain scans of obsessive-compulsive people, and by God, they found an area of the brain that was more active, and they found a drug that calmed down that area of the brain," he recalls. "But psychotherapy did that too."So why isn't behavior therapy the treatment of first choice?In part, because people have bought into the pharmaceutical industry's massive promotional effort: "We talk about psychiatrists, but statistically general practitioners are the most frequent prescribers of any of these drugs, and it's becoming pretty casual," says Oaks. "A lot of people are asking for them."In part, because pills are quick and easy, while psychotherapy is time-consuming and difficult. "I am of the opinion that all medicine is a crutch," says Dr. Scott Nekrosius, a Dayton, Ohio, psychiatrist who works with children and adults. "If you fall down and break your leg, what do you do? I go to the doctor and get a cast.' How do you walk to work? I get a crutch.' How long do you use a crutch? Till my leg heals.' " When medication is prescribed without accompanying therapy, he says, the underlying causes are never addressed; the patient can get around, but the spirit isn't healed.In part, because of managed care and the medical profession's unwillingness to stand up to it. "Managed care would like to see everything acute, reversible and short-term, and it's not," Nekrosius says. Also, he notes, HMOs contract with businesses, not with patients; they get paid up front but must pay out money themselves when members require treatment. Thus, brief medication checks are preferred over long, costly therapy sessions without immediate, measurable results. "You've got to realize that if I get paid when you don't get help, I'll make sure you don't get a lot of help," he says. "They don't suffer the consequences of bad management."Meanwhile, complains Oaks, patients, who must consent to any form of treatment, are not being informed of the risks of the drugs they're being given or the availability of alternatives, including behavior therapy. Oaks also contends that the managed-care structure encourages doctors to leap to premature diagnoses without adequate testing and to overlook long-term solutions in favor of maintenance strategies -- that is, keeping people on symptom-treating drugs indefinitely, regardless of demonstrated tolerance effects."With some people, with some drugs, you put them on for a long period of time, you can create the opposite of the intended effect," he notes. "Neuroleptics suppress the dopamine receptors; they are known to sprout, to fight back. You withdraw that person [from the drug], and now the brain changes are unmasked for the first time....It's drug-induced, manufactured madness."Earlier neuroleptics, Oaks says, produced a constant twitching in the face and hands, sometimes escalating to severe spasms; drug companies promoted the next generation of drugs by saying they were less likely to cause the spasms, because they focused on more sensitive brain receptors. "So the new drugs may cause an even worse rebound effect," he says. "They have a new diet pill that just came out that's a serotonin stimulant, similar to Prozac. The FDA at first didn't approve it because animal studies showed that the serotonin pumps shut down." The result of that, according to Oaks, would be a condition similar to speed burnout: a sluggish personality that occasionally lashes out with fierce aggression.The heavy-handed behavior of the "health-industrial complex" -- Oaks' term -- is nothing new, maintains Breggin, who says psychiatrists have always pushed the limits of what kind of treatment they can give the uninformed and the unwilling. But what about people who believe they can't live normal lives without the aid of medication? Depressives stress that their condition isn't something one can just snap out of, yet Ellen points to an acquaintance on antidepressants who, she says, "had problems, but all she really needed to do was get away from her mother." And while many claim that drugs such as Prozac have no effect on non-depressed people, Breggin says that's bunk -- the drugs blunt the range of emotions, he says, making depressives think they're feeling good by making their "lows" less low. (Many self-proclaimed "Prozac survivors" complain of feeling "zombie-like" on the drug.)In sum, what many people are trying to treat is not illness but life itself. "Any child who's going to grow up to be an interesting adult shows manifestations of multiple things that a psychiatrist could diagnose," says Breggin, "and any adult who seriously cares about life has been seriously depressed, and it's ridiculous to get psychiatrists in there saying who should be treated and who shouldn't for these things that occur in the lives of everybody who leads a full life. You can't read an autobiography about anybody who hasn't experienced a period of severe hardship."