Back when Prozac (fluoxetine) and Zoloft (sertraline) were new, I remember the mental acrobatics doctors made to justify giving these drugs to anxious patients. The drugs were approved for treating depression, but we knew they often seemed to help anxiety. The reason, we were told, was that some anxious patients were actually depressed, deep down, and we had just failed to recognize their depression.
Now, with studies to support their use in anxiety, we are pressured to prescribe them, since they, unlike benzodiazepines, are said to “get to the root of the problem”. But do they get to the causes of either anxiety or depression?
Even before Prozac, my medical school courses in psychiatry, back in Sweden, taught the distinction between endogenous depression, treatable with the tricyclic antidepressants of that era, and exogenous depression, which only the Americans chose to treat with drugs. The Swedish opinion was that depression due to external factors should be treated by addressing those external forces or the patient’s cognitive-behavioral reaction to them.
Depression, along with other mood disorders, has earned the alternate name of “chemical imbalance”, even though we really don’t know all that much about the chemistry inside the blood-brain barrier. The new moniker does help justify choosing medication over exploring the psychological reasons behind the symptoms, though. Never mind that the efficacy of medication alone is only marginally better than placebo. And never mind that therapy along with medication has a much better success rate than medication alone. We truly are just treating symptoms empirically with these drugs. Worse still, our understanding of how our current medications work is very incomplete. For example, fluoxetine and sertraline are said to treat depression by inhibiting re-uptake of serotonin in synapses of the brain. Yet, in Europe there is a drug that instead enhances serotonin re-uptake, and it also helps depression, so two opposite drug mechanisms seem to bring about the same clinical result.
Psychiatrist Steven Reidbord blogs about how more and more diseases have been snatched away from the psychiatrists’ realm as science pinpoints their causes. He concludes that there will probably always be conditions with unknown or uncertain neurobiological mechanisms that only psychiatrists, with their tolerance for uncertainty, have the patience to treat.
Today, in primary care, urology and many other specialties, symptoms are what we treat all day long, it seems. From overactive bladder and erectile dysfunction to myofascial syndrome, restless legs, neurodermatitis and insomnia, we have the drugs but not quite the understanding of how and why they work. In many cases, several possible mechanisms seem to lie behind each symptom.
The old-fashioned notion of “syndrome” applies here; we recognize clinical constellations of symptoms, but we often don’t have a straightforward cause isolated. We have empirically established treatments that work at least some of the time, but we often don’t know why. In many cases, clinical syndromes are relegated to the sidelines, even when there are available treatments, unless those treatments are brand-name drugs. More than once, pharmaceutical companies have made obscure syndromes, such as Restless Leg Syndrome, famous in order to promote a new drug, even if the drug is not always effective, as it doesn’t quite seem to address the root cause of the disease.
This reminds me of the medical school professor, who during morning rounds on his top floor ward at Uppsala Academy Hospital dismissed many patient concerns with the words “I treat diseases, not ailments”.
Times sure have changed.
Today, ailments are honorable to treat. We talk about improving or enhancing quality of life. Ailments are also now big business. Myrbetriq, for overactive bladder, costs $250 per month; Viagra, for erectile dysfunction, $28 per pill; Lunesta, for insomnia, $280 per month, to name just a few examples.
In this era of genetic and neurobiological advances, we are sometimes naively optimistic about the depth of our understanding. We like to think that we have moved beyond treating symptoms, but even when we prescribe statin drugs or stent blocked coronary arteries, we are not even attempting to address the causes of coronary artery disease, for example.
So, maybe only a select few subspecialists among us can say that they only treat diseases and not ailments, or symptoms; most of us do a lot of it. For every new scientific breakthrough, there seems to be a handful of empirical discoveries of something that sometimes works, even though we don’t know why.
Dr Reidbord is not alone in living with the uncertainty of treating symptoms of unknown cause; welcome to the world of primary care.