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.)

Imagine that as a child you thought you had been born in the body of the wrong gender. If you were biologically male, in your mind you really thought of yourself as female. Likewise, if you were born in a girl’s body, you thought that you were actually a boy.

Yes, you were probably more interested in children’s role-playing games more often associated with the opposite gender as well, but the issue went much deeper than that. It was your core identity that was at stake. You knew that you were the other sex, at least in all ways except for the reproductive organs of your body.

You felt this way during childhood, but nobody seemed to understand or accept this about you.  But you were dressed in the clothing of your biological gender and expected to participate in the activities stereotypically associated with it as well. Imagine that as your body matured in adolescence, you hated your penis if you had one, or likewise, you wanted to hide your developing breasts. You simply felt that you were trapped in the wrong body.

This experience is the gist of what transsexual or transgender persons face every day.

To some who have never met a transgender person, the concept itself may seem bizarre. I can assure you, though, that transgender people are not freaks; they are human beings who were born with a challenge that no person would choose to have.

Both in the community and in prisons, I have worked with several transgender patients over the years. They have taught me more about the challenges that they face every day than any book ever could have. Their life challenges, though, are magnified several-fold in jails and prisons.

The terms transgender and transsexual have approximately the same definitions, but transsexual is a medical term. However, please note that there is a great deal of debate and controversy about terminology that will be beyond the scope of this article. A brief overview can be found here.

Transgender does not imply anything about sexual orientation; it is all about gender identity.

Unfortunately, society can be a cruel place for anyone perceived as “different” from the norm. This issue could not be truer than in a prison environment.

Prisons in general are very black and white places. There are rules and regulations to handle different situations, and shades of gray tend to create confusion.

Men go to men’s prisons, and women go to women’s prisons. So, where do transgender people go?

Well, it depends. As far as I can tell, in most systems, those with a penis (present from birth or surgically constructed) go to men’s prisons. Those with a vagina go to women’s prisons. Sounds simple, right?

Not at all. First, assuming that the transgender person has not been taking hormones and has not had sex reassignment surgery (sex-change operation), he or she will likely have to psychologically endure being housed in an institution for those that the person perceives as being of the opposite sex.

What if a person with male genitalia who believes himself/herself to be female has started taking female hormones before the incarceration and has fully-developed breasts? Then, the person would likely end up in a men’s prison. That’s right, a penis and breasts, in jail with a bunch of men.

It is pretty easy to see how there are various possibilities that present challenges since transgender people do not easily fit into male and female categories.

Once incarcerated, regardless of the gender of their inmate peers, there are other challenges.

How can they avoid discrimination? My guess is that most security personnel in most institutions are not well-versed in working with transgender inmates. People often fear what they don’t understand, and there is a significant risk of these prisoners not being treated fairly. Likewise, I believe it’s rather obvious how transgender inmates potentially face significant harassment, intimidation, and violence from other inmates.

What about hormone treatment in prisons? Should inmates who are already receiving it on the outside be prescribed these medications in prison, too? What about sex reassignment surgery? Should taxpayers bear the burden of this for long-term prisoners? Some have argued that they should.

How should one address a transgender person: “he” or “she”? I’d suggesting asking them how they wish to be addressed. However, I will say that every transgender patient I’ve ever worked with wanted to be addressed as the sex they felt they really were, not as the gender into which they were born. This presents an interesting dilemma in a correctional environment because referring to any inmate as “she” in a men’s prison or vice versa elicits shocked and confused reactions from prison staff.

My purpose of this post is to raise awareness about challenges faced by transgender inmates, an issue that I rarely hear discussed and about which there is much ignorance. Transgender people deserve to be treated with dignity and respect just like anyone else. They deserve not to be discriminated against, and they deserve to be safely housed if incarcerated. However, there are many details involved in their custody and health care that will never be simple to solve.

To read a very recent NY Times article about transgender people and name changes, click here.

What are your thoughts about or experiences with this topics? Please share your comments.

The Archives of  General Psychiatry published an article this month entitled, “Metabolic Testing Rates in 3 State Medicaid Programs After FDA Warnings and ADA/APA Recommendations for Second-Generation Antipsychotic Drugs.”

The retrospective analysis examines how frequently the recommended metabolic testing for second generation antipsychotic drugs (SGA’s) was performed in Medicaid patients in 3 different states. The conclusion was that the monitoring was not being done nearly as frequently as recommended. Less than one-third of patients treated with these medications, which can cause metabolic syndrome,  undergo serum glucose or lipid monitoring.

Obviously this is not good news. In recent years, we’ve learned that the risks associated with SGA’s is higher than originally thought. My intent in this post, though, is not to focus on this study itself as much as to examine an ethical dilemma related to it that I have never heard discussed.

What I’ve been wondering: Is it ever appropriate to prescribe SGA’s to severely mentally ill patients who have no financial means to obtain the necessary blood monitoring tests? I’ll explain.

A few years ago I provided psychiatric services to patients at several different public community mental health centers in several different counties of my state. These patients all had Medicaid or no insurance. Indigence was ubiquitous. If the medications I prescribed to a particular patient were not covered by Medicaid, then I would typically provide the patient with free drug samples from our sample closet (medications procured from the pharmaceutical reps).

Not uncommonly I would treat patients with serious mental illnesses such as schizophrenia, schizoaffective disorder, bipolar disorder, and major depression. I often used SGA’s, and I when I did so it was frequently to treat psychosis in such patients. This was during the time just before the SGA monitoring recommendations were published. Since many of these patients had no insurance coverage or money to pay for laboratory monitoring, I simply didn’t do it. I easily justified this practice to myself because they were seriously impaired by mental illness, I had a treatment that usually helped them to function better, and the risks of the medications were thought to be less than we realize they are today.

I did not have the opportunity to provide services in that setting after the SGA monitoring guidelines were released. The risk/benefit analysis has shifted, but the SGA’s are still life-saving medications for the seriously mentally ill. Since then I’ve often wondered what the right thing to do is for those patients today, those with psychosis whose lives are in shambles without medications yet who do not have the means to obtain the appropriate blood tests.

The purists will insist that the medications should never be prescribed unless the appropriate monitoring can be done, but those of us on the front lines of medicine understand that clinical practice is never that simple.

In some patients, using the older first-generation antipsychotics dodges the metabolic monitoring issue, but then the risk is of tardive dyskinesia, not necessarily a great trade-off, particularly in persons likely to need life-long pharmacotherapy. Also, some patients will not have the means to pay for the older antipsychotics, and it will be more likely that the SGA’s will be readily available to them via samples or indigent medication programs.

In indigent, seriously mentally ill patients who clearly have the decision-making capacity to make good informed decisions (admittedly not always the case in this population), would it be sufficient to do thorough informed consent about the potential side effects and recommendations for blood monitoring, weigh and measure the patient often (this is part of the monitoring anyway and is free), teach them to look for symptoms of diabetes, and then document all of this thoroughly?

I think that in select cases the most ethical answer will be to do just that. However, this approach should be the exception and not the norm.

I don’t have the answer here. This is a real dilemma. What are your thoughts?

Photo Credit: Sectionz via Flickr