Cosmetic Psychiatry: Prescribing for Perfection
Assume for a minute that you do not have an underlying psychiatric or neurologic condition. You’re healthy. If you could take a pill that would significantly improve your memory, help you to concentrate through great distractions, keep you full of energy even though you’ve slept little, help you to be more social, or keep you from worrying much, would you take it?
That’s really the issue at stake with the concept of cosmetic psychiatry. Is it okay for psychiatry to evolve beyond simply treating disease and relieving suffering to the point where the goal is also enhancement of “normal” functioning?
Two recent studies in the Archives of General Psychiatry prompted my pondering of these issues.
In the December 2009 issue, there was a study that found that depressed patients who took paroxetine (Paxil) reported greater personality change than placebo patients, even after controlling for depression improvement. These patients experienced a reduction in neuroticism (a tendency to experience negative emotions and emotional instability) and an increase in extraversion (social extraversion, dominance, and a tendency to experience positive emotions).
I was not at all surprised by these results because I have seen them in my own patients time and time again from SSRI antidepressants. Although the subjects in the study were depressed, one does not necessarily need to be depressed to experience positive changes from SSRI’s.
The second study showed that stroke patients who received escitalopram (Lexapro), another SSRI, showed improvement in global cognitive functioning, specifically in verbal and visual memory functions. This effect was independent of its effect on depression.
These two studies are recent examples of SSRI’s treating symptoms beyond what they were intended to treat. I’ll say more about them in a minute.
In June 2004, the Psychiatric Times published an article specifically about cosmetic psychiatry. It is well worth reading. The below paragraph explains the difference between abusing drugs and using them for enhancement.
It is the use and not the abuse of psychotropic medication that forms the framework of cosmetic psychiatry. Cosmetic use is conceptualized as an adaptive, nonabusive approach to life. This is in contrast to the nonadaptive, abusing retreat of addiction. Cosmetic psychiatry can enhance but not distort memory and perception, increase performance but not create introversion, and establish conditions for an overall sense of enjoyment and fulfillment.
So, what’s the right answer? Is it okay for the field of psychiatry to move in this direction? Plastic surgeons perform elective procedures to enhance the already normal appearance of people all the time. Surgery is the most invasive intervention in the field of medicine, definitely with greater risks than many of the current medications that could be used to enhance functioning. Yet, there does not appear to a public outcry that it is happening.
However, I suspect that many people’s reactions will be different when it comes to psychiatry. Psychiatry is already a very stigmatized field. Some of the “treatments” and human rights violations from decades ago still haunt my profession. Will these be the reasons for the objections? I’m curious.
Personally, I’m pretty cautious about the idea of cosmetic psychiatry. However, I think that to make a blanket statement that it would be wrong under any circumstances would be a mistake. The issue is likely to evolve over time as new medications are developed.
The only way I would support the idea of cosmetic psychiatry would be if only the most benign medications were used, the potential benefits clearly outweighed the potential risks in each situation, and true medical necessity vs. “cosmetic” use was specified. Anyone receiving these medications for cosmetic purposes should pay out of pocket for both the medication and the medical visits. Insurance should not provide reimbursement for something not medically necessary.
The challenge would be that “medical necessity” is a very gray area. For example, prescribing to effect cognitive improvement after a stroke (the benefit shown in the second study above) would be a totally reasonable, medically-indicated use of escitalopram. However, I believe it would be more questionable to prescribe paroxetine to decrease neuroticism and increase extraversion (the benefits shown in the first study above). What about stimulants such as Ritalin to help college students study for exams? I’d say no. But, the problem is that there are endless such examples and many more shades of gray.
What do you think?
(If you want to see an interesting PowerPoint slide show about cosmetic psychiatry, click here.)
Mmmm, there’s a poser!
When I’m doing a meds round and six people are talking to me at once and all wanting my attention at the same time, and I am concerned I might give someone the wrong meds as I am so distracted, would I take one? Well may be, but then I already put named paper scraps in the pots to make sure that does not happen, so no.
When I’m writing the handover and searching my brain to remember if there is anything I have forgotton and then babble when I am giving the handover because I am so tired, would I take one? No. I’d just go home to bed.
But what if I did decide that cosmetic psychiatry was right for me? Would even the most benign little pill be worth the risk of adverse side effects? Would a single pill be enough to attain the desired effect, or would I have to take them long term? Would I cease to be happy being the real me – I am happy being me – or want to be the new improved version? If I ceased to be happy with the real me, I would have become addicted to the new me and therefore addicted to the meds. If I was an extrovert already – I am – would I become so extraverted that I became an annoyance to others? Would others like the new me? What if my new little pills that I had become addicted too, cease to be available due to what ever reason? Would I become depressed – a condition that did not exist prior to the new enhanced me? I will stop now!
I would not go down this road.
But if I was unfortunate to suffer a stroke, I would say escitalopram was appropriate and my right.