Abstract
Psychiatric medication, or psychotropics, are increasingly prescribed for people of all ages by both psychiatry and primary care doctors for a multitude of mental health and/or behavioral disorders, creating a sharp rise in polypharmacy (i.e., multiple medications). This paper explores the clinical reality of modern psychotropy at the level of the prescribing doctor and clinical exchanges with patients. Part I, Geographies of High Prescribing, documents the types of factors (pharmaceutical-promotional, historical, cultural, etc.) that can shape specific psychotropic landscapes. Ethnographic attention is focused on high prescribing in Japan in the 1990s and more recently in the Upper Peninsula of Michigan, in the US. These examples help to identify factors that have converged over time to produce specific kinds of branded psychotropic profiles in specific locales. Part II, Pharmaceutical Detox, explores a new kind of clinical work being carried out by pharmaceutically conscious doctors, which reduces the number of medications being prescribed to patients while re-diagnosing their mental illnesses. A high-prescribing psychiatrist in southeast Wisconsin is highlighted to illustrate a kind of med-checking taking place at the level of individual patients. These various examples and cases call for a renewed emphasis by anthropology to critically examine the “total efficacies” of modern pharmaceuticals and to continue to disaggregate mental illness categories in the Boasian tradition. This type of detox will require a holistic approach, incorporating emergent fields such as neuroanthropology and other kinds of creative collaborations.
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Notes
As reported by the New York Times through data provided by IMS Health (International Marketing Systems) and compiled by PsychCentral, http://psychcentral.com/lib/2010/top-25-psychiatric-prescriptions-for-2009/, accessed July 2, 2013.
Lexapro, or escitalopram, is the patented racemic isomer, of Celexa, which is a mixture of both R and S citalopram isomers (McConathy and Owens 2003, p. 72). Celexa was introduced and marketed first in the US and then Forest Pharmaceuticals, the manufacturer, transitioned to Lexapro, which has had a longer patent life on the US market.
IMS Health data form 2011 also supports this claim and was compiled by the Web Site, Psych Central, which began in 1995 as a way to index online support groups (psychcentral.com/lib/top-25-psychiatric-medication-prescriptions-for-2011/oo12586, accessed February 6, 2014).
http://medical-dictionary.thefreedictionary.com/polypharmacy, accessed February 6, 2014.
The informants discussed and quoted in this paper have given written and/or verbal consent to participate in this study, which was approved by the Internal Review Board of the University of Wisconsin-Whitewater (#O11203096Q). All the names of individuals and recognizable sites/places have been altered to preserve the anonymity of participants; quotations are used for pseudonyms, native terms, direct quotes, and remembered phrases.
I have engaged in direct observations and interviews, off and on, with key informants over the long-term (i.e., Dr. Wilby—20 years; Dr. Vindrik and Straminski 9 years). I have observed Dr. Wilby’s clinical practice in two different settings—private practice and public practice. I have recorded fieldnotes in written form, audio file, and scratch notes; and include 100+ h of clinical observations and detailed interview transcripts. Part of this research was also supported through a Research Growth and Initiative Grant (Project: A Clinical Ethnography of Mental Health Services in Wisconsin, 2009/10) through the University of Wisconsin System; co-recipients of this RGI grant were Kalman Applbaum (see Note 23), and Paul Brodwin, Anthropologists, UW-Milwaukee.
Some countries, such as India and Mexico do not require a doctor’s prescription for patients to obtain medication from a pharmacy or clinic. Many medications can be obtained “over-the-counter.” In the United States, Canada, many countries in Western Europe and Japan a prescription is required, and thus the marketing efforts of Big Pharma are focused intensely on the prescriber. For an interesting discussion and mapping of countries and prescriptions in the context of oral contraceptives see www.motherjones.com/kevin-drum/2012/03/lots-contries-doknt-require-prescriptions-oral-contraceptives, accessed February 6, 2014.
The recent work of Carl Elliot regarding psychiatric clinical trials and corruption is a case in point. As an investigational bioethicist, he has not been afraid to call out by name in print the very doctors who have been involved in psychiatric clinical trials at teaching centers. He has highlighted how the structure(s) of the trials, incentivization of clinicians, and the involvement of third-party, for-profit companies have corrupted the very nature of humane care of the mentally ill. This nexus of for-profit interests has led to severe patient side effects and subsequent death (see http://www.motherjones.com/environment/2010/09/dan-markingson-drug-trial-astrazeneca, accessed February 14, 2014.). The level of transparency his work has created has come at personal and professional cost (see http://www.reportingonhealth.org/blogs/qa-dr-carl-elliott-part-2-finding-fault-his-own-university-after-patients-death, accessed February 14, 2014). Ethnographic work requires anonymity of all informants and “outing” specific unethical or criminal activity by informants would present unique challenges. However, my recent expert legal work and the ethnographic work of other anthropologists (e.g. Applbaum 2010) have shown one way to get at naming “the truth” of pharmaceutical practices (and involved clinicians) is to access the public record of court transcripts and/or detailed, depositions of stake holders while under oath.
I worked for a multi-national pharmaceutical company as a drug rep from 1989 to 1998 and promoted a blockbuster SSRI antidepressant from 1992 to 1998, see Oldani 2004 for auto-ethnographic assessments of this time period; see also ex-reps who reflected on their work in Fugh-Berman and Ahari (2007) and Reidy (2005), pp. 8–57.
Groopman has reported on this in the New Yorker (“What’s Normal?”), specifically as it relates to the growth of Bipolar II diagnoses in children. He shows how one book in particular, the Palolos’s “The Bipolar Child: The Definitive and Reassuring Guide to Childhood’s Most Misunderstood Disorder,” gave parents the right verbiage to speak to clinicians in a way that fuels the diagnostic process for their children (http://www.newyorker.com/reporting/2007/04/09/070409fa_fact_groopman, accessed July 3, 2013.
I have seen numbers in this range both as a drug rep and as an expert consultant on court cases related to pharmaceutical promotion of products off label.
There is an infamous case covered by the Canadian Broadcast Company of a single doctor on Prince Edward Island that prescribed SSRIs to over 5,000 of his patients and eventually had his license suspended. The doctor felt he was doing good clinical work considering the shortage of primary care doctors on the Island (see “Little Helpers, CBC Broadcasting, Fifth Estate)
For work examining pharmaceuticalization (or drugs first treatment practices) in the area of asthma see Whitmarsh (2008); for HIV/AIDS see Biehl (2007); see also van der Geest et al. (1996) and Oldani (2004), Note 9. Similar to the ways medicalization has been studied and articulated by social scientists, pharmaceuticalization has become an extension of “medicalization,” or medicalized practices, that tend to recast social, familial, and cultural-based problems as pathological, in need of control, and treated through the biological efficacy of prescription drugs (see Suissa 2009, pp. 45–46 for a review of literature).
In 2009 and 2010, Abilify and Seroquel (quetiapine fumarate) accounted for roughly $10 billion dollars in sales in the US (see Note 1).
In 2009 for example, National Public Radio reported on Baraga County having the highest unemployment rate in the US, http://www.npr.org/2009/09/27/113251646/u-p-county-tops-state-unemployment-rate, accessed July 2, 2013. The UP’s unemployment rate remains above the national average, in December of 2012 the rate was 9.4 %, with a county-range of 7.3–18.3 % (Baraga), http://michigan.gov/budget, Accessed July 2, 2013—Civilian Labor Force Estimates, December 2012.
See the entire issue of PLoS Medicine, April 11, 2006, “Disease Mongering Collection,” http://www.ploscollections.org/article/browse/issue/info%3Adoi%2F10.1371%2Fissue.pcol.v07.i02, accessed July 12, 2013.
According to my doctor informants, the chair of the psychiatry department had created an integrative psychiatric culture by stressing both psychopharmacology (i.e., hiring psychopharmacologists, who brought their funding with them and could teach the state of the art of modern psychotropy) and setting up an insurance reimbursement scheme that paid for 100 % of psychotherapy and psychoanalysis for all medical staff, residents, and medical students. The result was several generations of psychiatrists and other specialties that understood, both through practice and personal experience, the benefits of integrating both approaches. I also verified through personal conversations with the former chair of the department of psychiatry, that this indeed was his overall goal.
Potential high prescribers are always targeted by pharmaceutical sales persons. They have the data to see how many branded and generic psychotropics a prescriber writes over a given time period. The overall “universe” of prescribing is a key assessment a rep makes through this data. A physician, like Dr. Wilby, may currently have a very low “quintile” rating of say 3 out of 10 for their product, but the data shows she can be potentially be moved into a quintile of 10 over time. That is the goal today of Pharma sales reps, to move those potential high prescribers into high branded product quintiles of 8 and above.
The non-addictive chemical properties of quanfacine also help to explain why a second-line ADHD medication could so easily become a first-line agent through the activities of a local drug rep (i.e., low risk to prescribing the medication for a “sales friend” (Oldani 2012b)).
During October of 2011, I was told by multiple staff members at the clinic, including the director that Seroquel was the “new favorite” of middle-class, white suburban children and young adults. Its mildly sedating, but according to their experience, users were “hitting” multiple dosages (by crushing and sniffing or by injecting) to get a real “downer effect” (see Sansone and Sansone 2010 on Seroquel’s emerging illicit reputation.)
Interestingly, Dr. Wilby described these parents as “the same parents who would actually call the authorities to have their child arrested for abnormal behavior usually related to drug addiction and criminal activity.”
There are no official public records, but supportive staff at the county jail that dispense medications and administer the budget have told Dr. Wilby she saved them around $75,000 in 2012.
The worried well in this clinical context are not part of the classic definition of patients having only “emotional problems,” that do not require medical management. Rather, I believe Dr. Wilby sees the worried well as mentally ill and needing less medication.
There is not enough space here to fully discuss the pharmaceutical management of these patients. However, clinical ethnographic work I have conducted with Kal Applbaum (2009 to present) has initially indicated that the future of branded psychotropy may center around IV and intra-muscular (IM) forms of psychiatric medication. Schizophrenics at Wilby’s clinic will be prescribed one of three intramuscular formulations on the market: either CONSTA (IM risperidone), IM Abilify, or Invega Sustaina. In particular, Invega Sustaina seems to be a very promising form of antipsychotic medication—100 % compliance, if you get the patient to clinic. One IM injection is good for one month. At Dr. Wilby’s clinic, there is one nurse practitioner dedicated to administering Invega Sustaina—she says it’s “a miracle drug,” because, there is “no negotiation.” If the patients have family support and are compliant (they want to get better, they want to decrease the voices or visual hallucinations) they are prescribed oral, atypical antipsychotics and return to see her on a routine basis, often with parents if they are young adults, and they receive a tremendous amount of social support. The drug talk revolves around whether or not the atypical antipsychotics, are even working at reducing hallucinations. There is quite a bit of polypharmacy with other psychotropics: dosage titration (up and down) adding and discontinuing meds. All of this drug talk and polypharmacy is an effort to try and restore daily functioning, allowing the patient to resume a kind of normality. Dr. Wilby: “so they might be able to live on their own some day, to understand money, to perhaps cook a meal.” These cases are heartbreaking because a large percentage of the patients are never fully restored, many patients remain noncompliant, and their life revolves around polypharmacy.
See American College of Physicians’ ACPINTERNIST newsletter compiling IMS National Audit Plus database, http://www.acpinternist.org/archives/2009/11/national-trends.htm, accessed July 9, 2013.
I did not have direct access to patient numbers or medical records. Based on interviews with clinic staff and Dr. Wilby as well as taking into account Dr. Crenna’s two plus decade involvement in treating mental illness at the primary care level, the numbers are probably much higher—mostly likely, into the thousands of patients.
Allen Frances was Chair of the DSM-IV Task Force and offers a trenchant critique of DSM V throughout this volume.
I have pending IRB approval to begin tracking patients outside Dr. Wilby’s clinic, including working with the aforementioned Diane, and also with a group of patients that are being sent to Wilby’s clinic (from other counties) through clever bureaucratic maneuvering for detox—especially patients in the in the criminal justice system on addictive psychotropics. Additionally, I am part of a case study project in southeastern Wisconsin, where I will specifically work with a mentally ill client, who is also on probation and being monitored through a public defender office pilot program. This client-patient, a forty-six year old white male, is currently being prescribed Ambian (Zolpidem) for sleep, generic Xanax (alprazolam) for anxiety, Luvox (fluvoxamine) for OCD, Lamictal (Lamotrigine) for bi-polar disorder, lithium, intermittently for manic episodes, and oxycodone for pain management. His primary care doctor and psychiatrists have been described as “defensive” when the issue of his polypharmacy and drug side effects have been raised.
These processes were elaborated on by Arthur Kleinman, within the context of using medical anthropology and medical humanities to confront the inadequacies of modern healthcare systems, during a symposia at the University of Wisconsin-Milwaukee on December 10, 2005 (see http://somatosphere.net/2010/12/arthur-kleinman-on-caregiving.html, for a full review, access February 1, 2014. See also Kleinman 2009 and 2008).
Increasingly, we will not need to be prescribed pharmaceuticals to feel their nature/culture effects. We now swallow small amounts of psycho-pharmaceuticals through our urban water supplies. And recent research has shown if you adjust the concentration of fluoxetine (i.e., Prozac) in the water you can “turn on and off” the mating signals (i.e., the sexuality effect) of other species, such as freshwater fish (Crago et al. 2011)—a researcher in this field described to me that we need to understand “serotonin pathways as evolutionarily deep” and occurring across species.
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Acknowledgments
I owe a debt of gratitude to all the ethnographic participants who made this work possible. I would like to thank the Center for 21st Century Studies at the University of Wisconsin-Milwaukee for an intellectual home to complete this project during 2013–2014 year; in particular, I would like to thank Richard Grusin, Director of C21 and Emily Cark, as well as my fellow Fellows for robust exchanges and critique. I want to thank Kal Applbaum and Paul Brodwin at UW-Milwaukee for their ongoing collaborations and intellectual exchanges. Versions of this paper were presented at the American Anthropological Association Meeting (2012); the UW-Whitewater Brown Bag Sociology Series (spring 2013) and UW-Milwaukee, Anthropology Colloquium series (fall, 2013), and I would like to thank Tazin Karim, Akiko Yoshida, and Ben Campbell and Kal Applbaum, respectively, for their invitations and assistance. I want to also thank the two anonymous CMP reviewers for extensive input and critique as well as Brandy Schillace at CMP for her editorial guidance.
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The content and analysis were derived from my own original research and writing (with some ethnographic work completed in conjunction with Kalman Applbuam/UW-Milwaukee, see footnote 23). This publication has not been previously submitted for peer review.
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Oldani, M. Deep Pharma: Psychiatry, Anthropology, and Pharmaceutical Detox. Cult Med Psychiatry 38, 255–278 (2014). https://doi.org/10.1007/s11013-014-9369-8
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DOI: https://doi.org/10.1007/s11013-014-9369-8