Is America Being Overmedicated? Suffering From Undertreatment

Tuesday, October 25, 2016 by Meg   •   Filed under General

 

In part one of this series, we saw that the pharmaceutical industry has evolved to influence modern care practices in ways that directly impact our health. In part two, we explored the ways that marketing can potentially trigger individuals to seek medications they may not benefit from

However, the issues of overdiagnosis and overmedication pale in comparison to undertreatment.

Undertreatment of Mental Health Issues

Nearly half of the population will have one episode of diagnosable mental illness in their lifetime1. Yet, only a fraction of those with mental health issues receive any type of assistance. Only ten percent of the population is on a psychotropic drug in any given year and far less are in therapy2

While those with severe, debilitating mental illnesses can often use drug therapy, even they are grossly underserved, because real research-supported approaches to treatment require more than a prescription. Medications, even well-prescribed, are not a substitute for therapeutic intervention. What this means is that even those who are receiving appropriate medications are usually being severely undertreated. 

Children, School Districts and Under (or no) Diagnosis

Undertreatment starts early for a plethora of reasons, not all of which are within the scope of this post. I am also quite certain that there are a number of parents (if they got this far) shaking their fists at me because of how hard they had to fight to actually get a diagnosis for their children. This is one area where there is a glaring discrepancy between what benefits the drug companies and what benefits the government on the whole. 

But why would lowering the threshold for diagnosis of conditions like ADHD work while other conditions are subject to changes in criteria that involve raising the threshold for diagnosis?  

The first issue is the ability to treat it. Though most fare better with therapy as well, ADHD specifically responds quickly to drug treatment. This makes the ability of the school systems to manage it quite easy without any additional accommodations.  Other issues are not quite so simple. 

Why would that matter? 

Well, because the school systems are required by federal law to provide accommodations for things like learning disabilities and autism, issues which are not easily resolved through drug treatment. Drug companies have no interest in altering those thresholds because they haven't found a magical pill that would change them. And without many treatments besides extra time and programs, schools already at their limit may benefit from ignoring those issues as opposed to trying to accommodate all those who are diagnosed, to the extent of not diagnosing them at all. 

As one example illustrated by Judith Warner in We’ve Got Issues, seventy percent of dyslexic children are in affluent areas2. Wealthy children are not actually dyslexic at higher rates, but they are diagnosed more because their parents have the means to get physicians and school administrators to assist them and pay attention. 

Another area where this is true is in autism, a class of conditions where push has led to actual changes in diagnostic criteria, leaving some children who would have been diagnosed prior to May of 2013 in a gray area where they are ineligible for services3. In these cases, treatment often rests on legally mandated programs for schools. With schools in no position to treat the influx of children with the diagnosis, there is federal pressure to alter the criteria and bump diagnostics up to more symptoms, not less as in the case of ADHD. This leaves parents to fight more and more difficult battles when their child suddenly doesn’t meet criteria for help. 

It’s not that schools are assholes (though any parent who has ever been to a stressful IEP meeting might disagree). It is more that they don’t have the resources to treat it and would lose even more getting sued for not providing the legally mandated services.If you can’t provide that treatment, you had better show that you don’t have dyslexic children or put up roadblocks to treatment and diagnosis, particularly since most parents don’t have the time, the money or the information to jump through those hoops and get their children the help they need.

It isn't just in the schools, though this is where some of the more striking examples occur. Even in adults, the middle class are treated more. The higher rates of medications and treatment in the middle class doesn’t mean they are sicker; it just means that they can actually do something about their suffering. Not only that, but most research indicates that depression and other conditions are actually more prevalent in impoverished populations, with financial strain being a strong risk factor for everything from anxiety to postpartum depression. So the most vulnerable populations tend to get far less than they need even with lower thresholds for treatment and the knowledge that conditions like depression lead to even more intense issues without assistance (more here).

While some will argue that the rise in mental illness rates is simply a matter of more drug company pandering (and there is some truth to that in terms of who fits into those boxes), the fact remains that the vast majority of those who should be receiving care are not. 

Lower Levels of Suffering and Personality Treatment: The Role of Stigma

There is also the matter of pathologizing personality traits that are not actually indicative of illness, but that become illness with the changing of definitions or less than ideal environments. Drugs such as those for ADHD and depression sometimes (though clearly not always) speak to a pre-approved baseline functioning in children and adults alike.

  • "They should be able to sit still for X amount of time." 
  • "He should smile more than X.” 
  • "He shouldn't feel X so much". 

The danger of a pre-approved, societally generalized baseline is the negation of viable differences that may not be inherently bad. The issues arise when people think that the traits that make up "them" are not good enough, which can lead to self-esteem shifts and possibly exacerbate issues in those who don’t fit these ideals. Of course, there are drug treatments for the alteration of personality, so this is of little consequence for those who flip those switches by promoting illness where it might not exist; if anything, it is of great benefit to their bottom line. 

It isn't that medication treatment is never warranted; it often is a critical part of healing. But at lower levels of illness we may be inflicting more harm on the self esteem of these children and adults alike through stigma than we are helping them through pharmaceuticals. 

Of course, the flip side of this argument is to destigmatize and foster acceptance of alternative personalities, which isn’t particularly likely based on our value system (discussed here)

The other issue is that some individuals suffer with certain personality traits while others thrive on the same traits. But that difference has the ability to alter our treatment for those who do suffer, because by seeing them as versions of normal, we inadvertently reduce the demand that therapy or services be provided or covered by insurance. Seeing these traits as normal also has the ability to encourage some not to seek help at all, or make others feel badly about themselves if they happen to feel “abnormal” or “wrong”. 

This is the reverse of the argument made here where I discussed the implications of pathologizing personality--because the flip side of that coin is that the ambiguous border of suffering can lead to fewer available services based on the tendency of insurance companies to be conservative at best when paying for treatable conditions. If one suffers with it and another does not, the tendency is to see it as something that is not necessary to pay for. It’s a dangerous game, a fine line between diagnosis to help provide necessary care for one who is suffering and pathologizing traits for one who isn’t. 

Regardless of whether it is a mismatch between personality and environment that is causing the issue, there is little doubt that the system is broken. Whenever you have powerful organizations with control over fundamental aspects of patient care, recognizing bias in treatment becomes of utmost importance in order to tease apart appropriate care from overmedication. 

No matter how it came about, people are on psychotropic medications because they are suffering, usually deeply. Therapy must be offered and enforced as a part of treatment in order to ensure that people are not being overmedicated while being undertreated. In addition, more initiatives must exist to assist those in at risk communities in order to address the very real issue of underdiagnosis, or no diagnosis at all. 

As time goes on it is likely that we will continue to see rises in mental health diagnoses, not because it is being overtreated, but because drug companies ensure that we are looking for it. One thing these companies have done is brought a number of these symptoms out into the open which may end up reducing stigma over time, leading to additional people who might seek help once there is less stigma to justify hiding it.

The issue may really be ensuring correct treatment, as opposed to focusing on overmedication, an issue which is dwarfed by the other issues at hand. My feeling is that we have occasional overmedication and occasional overdiagnosis in certain populations, undermedication and underdiagnosis in at-risk populations, and rampant undertreatment (with the most studied and effective forms of therapy) across the board. 

If we aim to truly assist, the focus must shift from “Are we drugging America?” to “Why do we actually think that these drugs will cure us?” 

I assure you, there is no magic pill.

Drugs used in conjunction with therapy are often very helpful in assisting those with more impaired functioning in their daily lives. But the costs and benefits of any drug—including whether it is being prescribed on label or off— should be discussed fully with a psychiatrist before embarking on that journey. 

Transparency can ensure that the drug choices you make have the best chance of assisting you, particularly when combined with talk therapy. You deserve to be treated appropriately. Don’t be afraid to demand more. 

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Related Posts: 

Citations
  1. http://www.ncbi.nlm.nih.gov/pubmed/15939837
  2. http://www.amazon.com/Weve-Got-Issues-Children-Medication/dp/1594487545
  3. http://autism.about.com/od/diagnosingautism/a/What-Are-The-New-Criteria-For-Diagnosing-Autism-Spectrum-Disorders.htm



Topic-Relevant Resources

We've Got Issues: Children and Parents in the Age of Medication
Judith Warner explores the misunderstood issue of overmedication in relation to children's mental health.

Overdiagnosed: Making People Sick in the Pursuit of Health
The history and evolution of drug company involvement in modern medicine, and the implications for current treatment.

Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer
Economic exploration of the American healthcare system, and why it may be making us sicker and poorer.



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