A putative speciality to optimise the subjective quality of life
Bruce G Charlton MD
Reader in Evolutionary Psychiatry
Department of Psychology
University of Newcastle upon Tyne
Editor-in-Chief, Medical Hypotheses
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The palliative perspectiveMainstream medicine is concerned with the diagnosis and management of disease. Control of symptoms is important, but subordinated to control of disease. However, when a disease is judged to be incurable or 'terminal' then it may be better to manage the patient palliatively. The difference is that palliative medicine uses the medical armamentarium to optimise quality of life rather than to maximise the chance of curing or preventing disease.
Here is an interesting analogy. Mainstream psychiatry aims to cure, control or prevent psychological disease. To this end psychiatry deploys an armamentarium of psychopharmacological agents (and also psychological therapies). But if life itself is regarded as a terminal disease, and one that is for some people characterised by chronic and severe psychological symptoms, then there is a role for a palliative speciality that deploys the psychiatric armamentarium to optimise the subjective quality of life. In short, a speciality which aims to make people feel better. Such a speciality could be named palliative psychopharmacology (PP).
The difference between palliative medicine and palliative psychopharmacology is that while the first is a thriving medical speciality, the second is just an idea. The purpose of this essay is to argue that PP, or its functional equivalent, ought to exist.
No, not psychiatryIt might be argued that the speciality of psychiatry already does the job of palliative psychopharmacology. However, mainstream psychiatry has several features which render it unsuited to practising a palliative function.
The most important reason is the public health role. Psychiatry is historically a speciality concerned with safety - the prime directive is protecting the public from mad people (with secondary functions of protecting mad people from the public and from themselves). Asylums functioned as places of separation - of the insane from their family and communities. Asylum may sometimes have been of therapeutic benefit, and may perhaps have made patients feel better, but even if asylums made patients behave and feel worse, the public health function still carried the day.
More recently, psychiatric drugs have been employed for a similar public health purpose. The difference is that psychopharmacology enabled psychiatric patients to live with their families or in the wider community without displaying excessively antisocial behaviours. Used for this purpose of behaviour-modification, psychiatric drugs may also improve quality of life as a pleasing by-product, but even if patients feel worse, the public health function still applies. The point is that the primary aim of treatment is to make patients ‘safe’, not to make them feel better.
Another example of the public health role of psychiatry is prevention of suicide. Keeping someone alive is not the same as making them feel better. In order to minimise the risk of suicide patients may need to be kept in hospital, observed, restricted, restrained, and medicated against their wishes with the goal of preventing them from harming themselves (for instance ‘chemical straitjacketing’ with high dose neuroleptics). It is obvious why suicide prevention is necessary and desirable. Equally, this priority has the potential severely to damage quality of life.
Optimal safety and well-being are not always compatible, nor are they always clearly differentiated within psychiatry. There is a tendency for the public health function to dominate since the sanctions for failure are stronger when public or patient safety is threatened. Violence by psychiatric patients is highly media-visible and for the past decade suicide rates have been monitored by the NHS for use as managerial performance targets.
A further reason why psychiatry is not well placed to pursue palliative aims is that the subject increasingly sees itself as applied neuroscience . Psychiatric practice (and pharmaceutical marketing) is dominated by the idea that the aim is treating specific brain diseases using specific drugs that are presumed to correct some putative neurotransmitter abnormalities . When disease control is the aim then the patient's well-being is naturally secondary to this objective. For instance, when an oncologist is trying to eradicate a lymphoma using chemotherapy and radiotherapy, it is accepted that the patient will feel much worse in the short term, in the hope that they will survive into the long term.
But when treating psychological symptoms, this can lead to paradox. Sometimes optimal disease control is also the best way to make patients feel better. But disease control may be also be achieved at the cost of side effects that make the patient feel even worse. For instance, the treatment of schizophrenia with neurolpetic drugs has often aimed to eradicate the diagnostic signs of hallucinations, delusions and thought disorder. In pursuit of this goal, neuroleptic dosages have been elevated to levels at which side effects such as sedation, lethargy, emotional blunting, impotence, Parkinsonianism, and agitation (akathisia) became so severe that the patient’s subjective quality of life was undoubtedly much worse than before treatment . Unsurprisingly, such patients required heavy persuasion or legal-coercion to take their prescribed drugs.
If, by contrast, subjective quality of life is regarded as having primary importance in some circumstances, there is need for a new psychological clinical speciality.
Making people feel betterGiven the limitations of the psychiatric perspective and the fact that many psychological problems are chronic, it seems legitimate to develop specialist expertise in using psychopharmacology to make patients feel better. But the idea of a speciality focused on enhancing subjective psychological states is one that is prone to raise suspicions among the medical profession. Perhaps from fear of creating addiction and dependence, doctors often display a reflex aversion to drugs that make patients feel better. Indeed, doctors seem more comfortable when persuading patients to take treatment that makes them feel worse. The general feeling is that ‘medicine is nasty’, and patients should need heavy encouragement to take what is good for them. If someone actually wants to take a drug, the suspicion is that they are probably abusing it.
But the experience of palliative medicine demonstrates that such attitudes have probably been responsible for needless suffering. Fear of addiction to opiates often led to preventable agony. It may be assumed that something similar will apply to the relief of other unpleasant psychological symptoms .
Palliation does not, of course, imply that people should be encouraged to ‘get high’ on drugs: there is a world of difference between crack cocaine and Prozac. Palliation is about removing painful or unpleasant symptoms, not about inducing euphoria. Drug misuse seeks chemical ecstasy, palliation aims to remove psychological obstacles to fulfilment. Palliative psychopharmacology would seek to make people feel better in the way that analgesics make people feel better . Nobody would call paracetamol a 'happy pill', but it is easier to enjoy life without a headache than with one. In this sense, paracetamol makes a vast contribution to human well-being, quality of life and happiness. The same applies to the treatment of psychological symptoms.
PP patientsA new speciality will arise only in response to demand, so we need to ask which groups of people might benefit from a palliative approach to using psychopharmacology. The answer, in a nutshell, is those patients in whom alleviation of unpleasant psychological symptoms is more important than control of disease or public safety.
Firstly, there are people with significant psychological symptoms such as depression, anxiety, panic, phobias or insomnia but who fall outside psychiatric diagnostic categories. The subjective ‘significance’ of psychological symptoms and the decision to explore pharmacological treatments are matters for individual judgement. Even ‘mildly’ ill patients may nonetheless experience significantly impaired quality of life, and may benefit from treatment . Such patients fall outside the current medical framework, and would typically be direct self-referrals.
Secondly, there are people who do fit within the prevailing psychiatric diagnostic categories but would prefer a quality of life-centred approach to their management. Psychiatric disease categories are expanding and multiplying all the time. There has been at least a 1000 fold increase in the number of people diagnosed as suffering from depression over the past forty years , and since 1980 there have been many newly recognised psychological disease categories such as panic disorder, social phobia and (most recently) female sexual dysfunction. Many people would fit one (or more) of these categories, but may nevertheless see themselves as suffering from unpleasant symptoms, rather than from formal ‘diseases’. For instance, the people who currently self-treat their own ‘depressive’ symptoms with St John’s Wort purchased from the pharmacist, rather than using a prescription of Prozac which comes only with the stigmatising diagnostic label of Major Depressive Disorder .
Thirdly, there are chronic psychiatric patients carrying diagnoses such as schizophrenia, but in whom the public health considerations (such as violence and suicide risk) are minimal. Such people may be faced with long-term psychopharmacological treatment, and may prefer their management to be based on a principle of optimising the patient’s subjective well-being, rather than have this potentially confused with the conflicting duty to maximise public safety.
A fourth group might include people who seek to explore a range of potentially beneficial pharmacological interventions to alleviate ‘lifestyle’ problems such as sexual dysfunction, cognitive impairments (eg. poor memory or concentration), or the psychological problems of old age . In other words, this is the point at which palliative psychopharmacology overlaps with pharmacological ‘enhancement’ technologies , including the ‘smart drugs’ . Given the under-developed state of knowledge in these areas, such management might be considered a form of expert-supervised self-experimentation.
The practice of palliative psychopharmacologyPalliative psychopharmacologists, if they existed, would be specialists whose focus was the palliation of psychological symptoms, principally by psychopharmacological means but also using whatever other methods may be effective - perhaps cognitive-behavioural therapy, for instance. PPs would develop expertise in detailed history taking concerning subjective states (phenomenology), and would be knowledgeable about drugs and their side effects. This combination would be expected to generate a new kind of understanding of a currently neglected area concerning the psychological effects of drugs - the question of ‘how drugs make you feel’ [6,7].
If the patients subjective well being were to become the focus of management, this would imply that the patient must have a decisive role - since each patient is the unchallenged expert in their own state of well-being. Again there is an analogy with palliative medicine, in which one of the breakthroughs in the treatment of pain has been patient-controlled analgesia. In the end, the patient must be the arbiter of success or failure of a management strategy. The role of the physician is to inform, advise, and guard against potential disaster (eg. drug contraindications, dangerous interactions, dependence and addiction).
When psychological palliation is the aim, it is likely that longer and more frequent consultations will be necessary than for psychiatry. It takes time to find the right drug for each person, even longer to find the minimum effective dose which offers the best balance of benefits to risk, and longer still to reach a judgement concerning the overall benefit versus harm . The ultimate decision to be made is whether life is better on the drug, or off it. Establishing this with confidence may require several ‘on-off’ trials, using placebo controls when necessary.
LogisticsWhether or not PP becomes a medical speciality depends on whether enough people want it to happen. But the logistics of getting a new medical speciality off the ground are complex. What seems to have happened in the past is that doctors with relevant training, experience and interest began to specialise in their practice, to advertise this specialisation (to colleagues, and the general public), and take referrals.
Once a critical mass of specialists has been attained, then such practitioners communicate and collaborate, have meetings, start journals, raise awareness, and set-up certificated training programs until eventually the process leads-up to formal ‘collegial’ recognition as a fully-fledged medical speciality. All this requires resources. In the case of PP supportive funding may come initially from patient fees, then charities and corporations, and eventually from the health service and health insurance payers.
Palliative psychopharmacology is an activity which is implicitly performed by many doctors already, especially in US private practice [9,10]. But specialisation has a considerable contribution to make. Specialist status would consolidate existing knowledge, contribute to scientific research and technical development, enable individuals to build-up and pass-on experience and expertise, stimulate broader education and serve as a focus for referral.
Currently, we have pharmacological experts to palliate death, but none to palliate life. It is time for that situation to change.
1. Ban TA. They used to call it psychiatry. In The Psychopharmacologists Volume 1. Edited by D Healy. Altman: London. 1996.
2. Healy D. The antidepressant era. Harvard University Press: Cambridge, MA, USA. 1997.
3. Healy D. The creation of psychopharmacology. Harvard University Press: Cambridge, MA, USA. 2002
4. Charlton BG. The potential for pharmacological treatment of unpleasant psychological symptoms to increase personal fulfillment in old age QJM. 2001; 94: 333-336
5. Charlton BG. Psychopharmacology and the human condition JRSM, 1998; 91: 599-601.
6. Charlton B. Psychiatry and the human condition. Radcliffe Medical Press. 2000
7. Pearce D. The responsible parent's guide to healthy mood-boosters for all the family. BLTC Good Drug Guide. www.biopsychiatry.com 30.01.2003.
8. CERI - The cognitive enhancement research institute. www.ceri.com. 30.01.2003.
9. Sobo S. Psychotherapy perspectives in medication management. Psychiatric Times. www.psychiatrictimes.com/p990423.html. 30.01.2003
10. Kramer P. Listening to Prozac. Fourth estate: London. 1994.
also by Bruce Charlton
The Malaise Theory of Depression
Public Health and Personal Freedom
Psychiatry and the Human Condition
Pharmacology and Personal Fulfillment
Awareness, Consciousness and Language
Self-management of Psychiatric Symptoms
Injustice, Inequality and Evolutionary Psychology