Commercialization vs. Medicalization

Suppose there was someone who's perfectly healthy, just stressed, or worried, or or unhappy.

And suppose that, for whatever reason, they go see their doctor about their problems, they get a diagnosis of depression, or social anxiety disorder, or something, and a prescription for Prozac.

What's wrong with this picture? Well, it's a clear case of medicalization: because I made it up to be a good example of medicalization. But what's wrong with medicalization? The medicines themselves? Many people think so, but if you ask me, they're the least troublesome part of the process.

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Drugs cost money, but not much: generic fluoxetine, i.e. non-brand-name Prozac, currently costs less than 10 cents per day. Drugs have side effects, but if our hypothetical person doesn't like the Prozac he or she's been prescribed, there's nothing stopping them from chucking it in the bin.

A diagnosis, on the other hand, is a lot harder to shake. In theory, one could get a second opinion from a different doctor and be declared perfectly healthy but in all my conversations with psychiatrists and patients I've never known of someone with a mental health diagnosis getting "undiagnosed" completely.

What's harmful about a mental health diagnosis? It changes the way you think about yourself, in many complicated ways. Just for one thing, it's likely to make you reconsider your past actions and ask if they were "really you", or whether they were caused by your illness.

Now, if you really are mentally ill, that is, if the diagnosis is accurate, this change will probably be a good thing; it might help you realize that with help, you can change, and avoid making the same mistakes you blame yourself for, for example. But if you're not ill, the same changes might be harmful.

A diagnosis invites you to think about problems through the lens of objective, impersonal analysis and treatment, what we might call the "clinical approach". The clinical approach is obviously the best one for most physical diseases. If you have cholera, you are ill, and you need to be diagnosed, and treated appropriately. Most people would agree that the clinical approach is also useful, albeit more problematic, in clear cut mental illnesses like schizophrenia, bipolar disorder, and (some cases of) depression.

But if your problem, or the root of your problems, is not that you're ill but that you're poor, or a victim of discrimination, or in the wrong job, or the wrong relationship, or you don't have either, etc. then a diagnosis is both futile, and quite possibly, actively harmful.

Futile because there's no disease to treat, and harmful because by situating that the origins of your problems are inside yourself (your neurochemistry, a "chemical imbalance"), it diverts attention from the real issues and the real solutions. Maybe you just need to change your situation, take a decision, get a new perspective, stop doing something.

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Is there an answer? Many people want us to stop taking so many antidepressants: reverse the trend of medicalization, by reducing the number of pills we take. But there may be another way: commercialization.

Suppose that you didn't need a prescription to get Prozac: you just bought SSRIs over the counter, like aspirin, whenever you felt like it. What would this mean? It might mean more people taking Prozac, although I'm not sure it would. But it would almost certainly change the way people think about antidepressants.

Commercializing SSRIs would, I think, mean that many SSRI users stopped seeing themselves as "psychiatric patients", or as the pills as cures for their "illnesses". Instead they'd see them more like aspirin, or coffee, or beer: something to help you "feel better", a nice thing to have in some circumstances, but not something that's going to solve all your problems. It would, in other words, prevent mentally healthy people from thinking of themselves as "mentally ill". With any luck, our hypothetical friend from the first paragraph would be one of them.

Of course, this would be no benefit if you think that the whole problem with Prozac is the actual drug, fluoxetine hydrochloride. But if, like me, you think fluoxetine hydrochloride is pretty benign compared to the idea of Prozac, it would be a good move. The good thing about commercialization is that it makes it easy to buy things without having to think about them.

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You can easily take this argument too far, and if you do, you'll eventually arrive approximately here. Don't. Serious clinical depression and anxiety disorders are real, and people who suffer from them often need "prescription-strength" drugs, and more importantly, professional help rather than being left to self-treat, because the ability to take care of yourself is, almost by definition, impaired in mental illness.

But these people might benefit from the commercialization of mood as well. They'd no longer be seen as qualitatively different from everyone else, weird and unusual. It's like how if someone's got severe pain, and needs prescription-strength painkillers, that's no big deal, because hey, we've all taken aspirin for headaches.

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Commercialization would be better than medicalization for other drugs too. Take flibanserin, the new drug for "Hypoactive Sexual Desire Disorder", a condition which, according to the drug company who make flibanserin, affects maybe 20% of women.

Whether flibanserin really boosts libido to any significant extent is unclear, but let's assume it does. Why not sell it over-the-counter? Give it a raunchy name, put it in a colorful box, and sell it in pharmacies next to the condoms. I can picture it now...

Now that would be pretty ridiculous. It would be a crass example of the commercialization of sexuality. But flibanserin already is - or at least, saying 20% of women ought to be taking it is. By selling it as a lifestyle product, instead of a medical treatment, its crassness would be obvious, and we'd just have lots of people taking flibanserin, instead of lots of people taking flibanserin and thinking of themselves as suffering from "Hypoactive Sexual Desire Disorder" i.e. a mental illness.

Unfortunately, I rather doubt that this is going to happen any time soon, although if you go to many "3rd world" countries, you'll find antidepressants, and indeed most other drugs, on the pharmacy shelves for anyone to buy without a prescription. To Westerners, this might seem primitive. I'm not so sure.