Medicating Mood & Stress: Clinical Bioethics and Public Health Ethics Conflict

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In COVID-19, public health ethics and clinical ethics converged. The effort to reconcile competing ethical priorities should go further, especially in the case of refusals of antidepressants and antianxiety medications for children and adolescents. Generally, in the example of how clinical and public health bioethics clash, the doctor treats the patient but does so ignoring big picture data on overuse of pharmaceuticals. When people seeking care bring up largescale public health or consumer data, should the physician who does not subscribe to beliefs in disease creep and asserts the person needs the medicine consider the public health data on widespread use of medication? What is the clinical role of societal data?

Many doctors rely on pharmaceuticals for symptoms that once were simply feelings and emotions. Yet they do so with ample clinical data, clinical trials, and with expertise. Those patients wishing to refuse may feel unable to persuade the doctor to acknowledge the data on widespread overuse in the clinical setting.

Public health ethics call for kids playing outside.
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The medical data demonstrates some level of efficacy (medicine may be especially crucial in a mental health emergency or a severe or chronic case). But the data, especially on mild to moderate mental health issues, to me, suggests overuse. What is overuse? Overuse could be an amount of use beyond that needed for medical treatment, that is an amount subjectively declared too much based on what is defined as “needed”. (Here overuse does not mean personal use of a prescribed medicine with symptoms of overuse.) Overuse implies a set of norms (e.g., a cultural or personal non-medicalization preference that creates an obligation to save medicine for a last resort) and a set of assumptions (e.g., that some amount of use based on raw data or sales of pharmaceuticals is unnecessary). Those asserting the numbers reflect appropriate use similarly rely on norms, a near-absolute professional obligation to use medicine as a first- or second-line option, assumptions about the benefits and goals, and a willingness to tolerate side effects. I suspect that many prescribing clinicians are unlikely to consider their own prescribing habits contributing to “overuse” but other scientists, public health professionals, epidemiologists, and health data social scientists note the circumstance of overuse.

The public health infrastructure and socioeconomic or political conditions may make it easier to access medication than to achieve those social or public goods that determine mental health. That is, demand (or arguably need) increased due to poor policy. Pharmaceutical advertising may also impact the demand for medicines, contributing to use. While certainly the failure to address those goods that support mental health contributes, Marcia Angell’s assertion that the epidemic in mental health is partially due to broadening diagnostic criteria and aggressively treating mild and moderate conditions is likely accurate. The nonmedical factors increasing use would be best addressed by policy and situational changes.

While rightly, the person seeking or refusing care, making decisions according to their values, is the focus of the appointment with the physician, the ethical issue of whether the largescale data should impact the prescribing habits should be addressed. By the numbers, public health information, epidemiology, or consumer data validates a public health concern that pharmaceuticals are overused. The clinical care, overdiagnosis, and prescribing habits do not align with an arguably robust public interest in reducing the use of antidepressants and antianxiety medications. The availability of such medicines to those who want them, also a societal issue, is secondary to the issue of the difficulty people avoiding the medicines face. Going against doctor’s recommendations is not easy.

Public health ethics call for outdoor activities and groups interaction.
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**NOTE: the following paragraph mentions suicide rates. If experiencing a need for help, contact / 800-273-8255.

Antidepressant use is way up yet not tied to a decrease in suicide rates or to a decrease in disability claims due to depression. Antidepressants “do not always have a beneficial effect on the risk of suicidal behavior.” The continued debate over their effectiveness varies geographically. In the US, they are well accepted in the medical community, so much so that opting out of them for a teenager is difficult and even can be medical neglect. Yet Marcia Angell questioned the overuse of many drugs for anxiety, depression, and an array of mental illnesses years ago, citing disease creep. The expanded definitions of mental illness (arguably 46 percent of Americans encounter one in their lifetime), new phobias, and a blurring of the lines and definitions evidence disease creep. Not long ago, nervousness was an everyday feeling. Now, psychology aims to define feelings as different from emotion—feelings “are what arise as the brain interprets emotions”.

I assert that neurological advances and a better understanding of the physical and biological mechanisms of emotion have created a movement to treat unwanted emotions or emotions that may get in the way of accomplishing a task. The new developments may have influenced prescribing habits for mild or moderate symptoms, alleviating the need to address mental health prevention through broad policy. To a degree, psychiatry is a short-term band-aid; but when seen as curative or the best approach, medicine could be hampering the development of policies that promote access to the social determinants of mental health.

There is an inherent financial conflict of interest that contributes to the long average lengths of pharmaceutical use (or even of therapy). Lisa Cosgrove, et al. argue “It is not surprising that proponents of the movement—who are mainly psychiatrists and psychologists—strongly advocate for scaling up diagnosis and pharmacological and psychotherapy interventions. Certainly, many youth in the U.S. and internationally are underserved and in need of treatment. However, the fact that the pharmaceutical industry and the mental health professions are obvious beneficiaries of scaling up efforts warrants more serious attention.”

Public health ethics call for approaches to loneliness.
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It may be worth stepping back and allowing more societal input into why we view some emotions as “bad”, whether resilience is lost when people choose pharmaceuticals over coping mechanisms, and whether the approval of drugs to treat mild to moderate cases of depression and anxiety in adolescents or children should be withdrawn. From 2000-2016 there was a steady increase in the suicide rate in the US. From 1999 to 2014, antidepressant use soared, a trend that is continuing. I anecdotally observe pushback among friends who are mothers: many do not want to label a little nervousness “anxiety” or seek medical treatment for emotions, moods, and feelings. Yet pediatricians seem to see it differently and prefer to engage in emotion as a medical endeavor early on even when the experiences are mild.

Research on older adults demonstrates increased resilience. While age and experience likely contribute, I wonder whether being raised without access to drugs for emotions allowed some people to outgrow their anxieties, mild depression, or even irrational fears without intervention. The same generation certainly may have been hurt by policies surrounding the more seriously mentally ill, who were often institutionalized. Like many adults, I attribute my resilience to experiences building resilience growing up. I wonder whether societal conditions like helicopter parenting and pharmaceutical approaches to anxiety could lead to a less resilient generation of adults in time.

We need a holistic examination of whether we as a country (or a world as the problem is somewhat global but more severe in the US) benefit from or are hurt by more drugs in the mental health arena. Everyone acknowledges the medicine might help. But having everyone live within tight emotional parameters could be harmful, a notion that supports acceptance of neurodiversity in other arenas like autism. And people deserve physician support for the many nonmedicalized ways to accomplish the same goals.

Public health ethics call for fresh, healthy foods.
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Exercise and healthy eating habits contribute to overall mental health, something I recommended as a nutrition counselor. Nutrition is often overlooked by doctors facing mild and moderate cases of depression and anxiety. The Ultramind Solution has many medical non-pharmaceutical options. Lifestyle changes also have power to decrease anxiety and depression. The use of social media may hurt self-esteem and exacerbates all different societal pressures to live up to varying aspirations whether fitness, body image, popularity, or even college choice. The pressure to be the smartest, fastest, and prettiest contributes to anxiety. Those contributions are not in the medical realm. In the case of refusals of pharmaceuticals for mental health, reconciling the public health bioethics with the clinical bioethics would lead to a more cohesive approach and foster public trust and trust in the doctor-patient relationship. The public should not rely on pharmaceuticals at the expense of promoting solutions to societal problems that hurt mental health.

Feature Photo by Sharon McCutcheon on Unsplash

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