Doctor: Are You “Drugging” or “Medicating” Your Patients?

You have read the blogs and seen the placards a dozen times: doctors prescribe too many “drugs” for too many patients. Psychiatrists, in particular, are popular targets of politically motivated language that seeks to conflate the words “medication” and “drug”—thereby tapping into the public’s understandable fears concerning “drug abuse” and its need to carry out a “War on Drugs.” Misleading radio ads promise “drug-free” treatment of panic disorder (certainly possible, but not always achievable) and the Internet bristles with the phrase, “psychiatric drugging.” (My Google search pulled up 9310 results.) And, all too predictably, any physician who argues that psychotropic medication is often an effective and lifesaving intervention is hustled off to the perp line of “drug-company shills.”

All this will not surprise students of language, history, and philosophy. Those who control language are well positioned to control thought and behavior. If government officials can persuade the public that killing innocent civilians is merely “collateral damage,” they have gone a long way toward justifying the carpet-bombing of a village. If the forces of antipsychiatry—and they are alive and well—can persuade the public that psychiatry is “drugging” people, they have gone a long way toward marginalizing and discrediting the profession. To understand how powerful the words “drug” and “drugging” are, imagine the feckless campaign that would be waged if the perennial protesters in front of the American Psychiatric Association’s Annual Meeting carried signs that read, “Psychiatrists: Stop Medicating Your Patients!”

Philosophical problems begin when language goes on holiday.
—Ludwig Wittgenstein, Philosophical Investigations

Is this all merely a matter of “semantics” or—in the parlance of postmodernism—“competing narratives”? Is there any scientific reason to distinguish “drugs” from “medications”? And finally, what are our ethical obligations as healers when medication is administered, either voluntarily or involuntarily?

There is, of course, a qualified scientific case to be made against overuse of some psychotropic medications. In the first place, we have far too many medications that employ the same old mechanism of action, with only modest efficacy, and too many unacceptable adverse effects. The so-called atypical antipsychotics (AAPs) are good examples. With the exception of clozapine—and possibly risperidone(Drug information on risperidone) and olanzapine(Drug information on olanzapine), according to a meta-analysis—the AAPs are not substantially more effective than the first-generation neuroleptics.¹ Meta-analyses, of course, must be viewed cautiously, since the studies that compose them may be flawed or biased, and unpublished “negative” studies may be excluded, as my colleague S. Nassir Ghaemi, MD, has pointed out.² Thankfully, decreased rates of tardive dyskinesia with the AAPs are a bright spot in this otherwise dour assessment, and this is no trivial gain.

Nonetheless, the metabolic adverse effects of the AAPs (weight gain, lipid and glucose dysregulation, and so on) are substantial problems and call into question the goal of expanding the labeled “nonpsychotic” indications for these medications.³ We sorely need to escape from the “D₂–5-HT₂–me too” paradigm—antipsychotics that block mainly dopamine-2 and various serotonin receptors—and uncover more fundamental mechanisms of antipsychotic action. Critics of psychiatry are indeed justifiably skeptical regarding “Big Pharma’s” concerted efforts to expand the use of AAPs to the treatment of nonpsychotic conditions, for which effective and better-tolerated medications are already available. And yes—many of these same critics are quite properly alarmed at the decreasing use of psychotherapy in psychiatric practice.⁴