Beware a Brave New World: The Risks of Medicating Social Issues
Behavioral health is the least evidence-based area of health care today. The reality being there just isn’t a robust evidence base for much of what we deliver in behavioral health care, least of all for children and adolescents.
A case in point is an article published by The New York Times several weeks ago. The article cites statistics suggesting one in four women in America now takes a psychiatric medication, compared to one in seven men. The most common antidepressants prescribed in the US are selective serotonin reuptake inhibitors (SSRIs), which enhance serotonin transmission and thus modulate mood. Such medication is not without side effects, including feeling agitated and/or experiencing gastrointestinal discomfort.
While sadness and anxiety are undeniably common, it is a myth that one in four women today have an underlying mental illness warranting medication. Not only does it misrepresent a segment of the US population, bordering on gender bias, but it also distorts health care delivery. Driven by the marketing power of big pharma, this kind of propaganda is distracting scarce mental health resources, most often primary care doctors, from those who really need them to those who don’t. Psychopathology is distinct from the emotional rollercoaster of everyday life. The former warrants specialist health care expertise; the latter cannot be medicated away. Indeed, surviving the ups and downs of everyday life is more embedded in successful social relationships than in prescriptions from a doctor’s office.
Therein lies the problem. How can a health care system deliver on positive social interactions? As social scientists Nicholas Christakis and James Fowler have repeatedly demonstrated in their extensive research on contagion mechanisms, quantifying social networks and connections is set to be one of the next big public health challenges. Yet health care, as an industry, is not organized to capitalize on this opportunity. The end result? Many of the hardest cases (those with government-funded insurance, psychosis or drug addiction) may find it almost impossible to find the right help. Unwarranted variation in practice and prescribing results.
Whether experiencing a severe and enduring mental illness or an acute adjustment reaction – for all degrees of acuity –the benefits of a social intervention cannot be underestimated. Establishing social relationships may sound fuzzy, hard to qualify and certainly are harder to prescribe than popping a pill. However, increasing evidence from social neuroscience reveals that insufficient social relationships have the same impact on mortality as smoking. Lack of social interactions actually has a higher impact than obesity and physical inactivity on mortality.
This science is only exacerbated by the reality of the emotional landscape of today’s America. Over the last two decades, there has been a three-fold increase in the number of Americans who report not having a confidante, and the impact on health status is incontrovertible. As sociologist Robert Putnam pointed out in his seminal work, increasingly Americans are “Bowling Alone.” Empirical data also reveals the relevance of social relationships in improving compliance with medication regimens and reducing hospitalizations. Fundamentally, being part of a social network gives individuals meaningful roles that promote self-esteem and purpose in life. In short, the science is clear that loneliness is a risk factor for morbidity and mortality.
As such, prescribing antidepressants for the normal fluctuations of life is futile. In contrast, better understanding the science of social networks proffers the opportunity to enhance not only individuals’ quality of life but survival rates as well. Therefore, the challenge before the mental health care community is to figure out how to reorganize itself to incorporate the importance of social relationships into our treatment protocols. This is why Beacon is working with clients to embed self-management protocols, promote access to employee assistance programs and support primary care to do more than reach for the prescribing pad. Indeed, some of our most impressive outcomes have been achieved through a “Coach Approach” to peer work, using techniques such as motivational interviewing to enable individuals to explore and identify their own resources and solutions to behavioral health, substance misuse and physical health conditions.
Efforts to embed this thinking represent a step change from traditional siloed thought behind current service models of health care delivery. The goal is to become the land of the sighted where the one-eyed man is no longer king.
Holt-Lunstad, J. Smith, T.B. Layton, J.B. Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS Medicine. July 2010. Volume 7. Issue 7.
Luo, Y. Hawkley, L.C. Waite, L.J. Cacioppo, J.T. Loneliness, health and mortality in old age: A national longitudinal study. Social Science & Medicine 74 (2012) 907-914
Christakis, N.A. Fowler, J.H. 26 July 2007. “The Spread of Obesity in a Large Social Network Over 32 Years” New England Journal of Medicine 357 (4): 370–379