Cover

ARE YOU READY FOR YOUR MENTAL MAKEOVER?

Got a problem? We’ve got a pill. LIANNE GEORGE explores the realm of cosmetic neurology, and what we’re taking to tart up our brains.

June 20 2005
Cover

ARE YOU READY FOR YOUR MENTAL MAKEOVER?

Got a problem? We’ve got a pill. LIANNE GEORGE explores the realm of cosmetic neurology, and what we’re taking to tart up our brains.

June 20 2005

ARE YOU READY FOR YOUR MENTAL MAKEOVER?

Cover

Got a problem? We’ve got a pill. LIANNE GEORGE explores the realm of cosmetic neurology, and what we’re taking to tart up our brains.

IT’S A SUNNY DAY on Wisteria Lane, in the idyllic California suburb where the women of ABC’s Desperate Housewives pass their time switching lovers and maligning each other’s sweater sets. An unlikely drug deal is about to transpire. Lynette and her neighbour Jordana— both attractive blonds dressed like fugitives from a J.Crew catalogue shoot—are sitting on a park bench, watching over their children. In this episode, Lynette, scrambling to keep up with the neighbourhood supermoms, has become addicted to Ritalin, a stimulant used to treat her twins’ attention deficit disorder, but alas the prescription has run out. “Just three or four pills,” she pleads with Jordana, overwhelmed by the prospect of hosting another last-minute soirée for her husband’s demanding boss. “I’m really hitting a wall here.” Jordana, who’s got her own precious stash thanks to her daughter’s recent ADD diagnosis, is unmoved. No deal. “I won’t forget this, Jordana,” Lynette hisses. “Come Girl Scout cookie time, don’t bother bringing little Tina—because we won’t be home!”

Life, it seems, does sometimes imitate schlocky prime time soaps. Increasingly, North Americans, desperate and otherwise, are turning to prescription drugs—stimulants, antidepressants, tranquilizers and other “mind enhancers”—for quick fixes to everyday troubles. “It’s a real concern,” says Dr. Norman Hoffman, director of McGill Uni-

versity’s Mental Health Service. Every spring around exam time, he’s seeing more stressedout students frequenting the campus clinic, hoping for a dose of Ritalin (known as “Vitamin R”) to help keep them awake for allnight cramming sessions. “They come in saying, ‘All of my roommates are taking Ritalin, could I have a prescription just to help me study?’ And we say, ‘No you can’t.’ ” Still, students can easily find other ways to procure the dmg—perhaps from a local youth with ADD who’s looking to make a few bucks on the side.

It’s part of a larger social phenomenon that Dr. Anjan Chatterjee, a neurologist at the University of Pennsylvania, has dubbed “cosmetic neurology”—that is, the use of drugs among otherwise healthy people to manipulate mood, memory, concentration, libido, capacity to learn and general ability to cope. A person might take a daily selec-

As scientists learn more about the brain, he predicts market forces will continue to push drug companies to create more targeted and effective “lifestyle drugs” that allow us to nip and tuck our brains with fewer and fewer side effects. The public may come to view physicians as “gatekeepers in their own pursuit of happiness,” Chatterjee writes, a notion that’s creating an ethical quagmire for the medical community as it tries to figure out its role in the brave new world of neurochemistry. One plausible scenario, he suggests, is that neurologists will become “quality-of-life consultants,”

of neurochemical transmissions. And if we can learn to identify and isolate which interactions produce which emotional responses, we can use chemical concoctions to reduce them, enhance them or block them out altogether.

Already, tests of psychotropics on healthy subjects have produced startling results. Neurologists have learned, for example, that in small doses amphetamines used to treat stroke victims can improve their motor skills—a potential boon to would-be skiers, swimmers or pianists. The drug modafinil, a stimulant approved for narcolepsy, has

‘PROSPECTING FOR BETTER BRAINS MAY BE A NEW GOLD RUSH’ FOR DRUG COMPANIES

five serotonin reuptake inhibitor (SSRI) like Prozac to alleviate “down” days, for instance, or Paxil, another top-selling antidepressant, to combat social awkwardness. An architect might use Ritalin to boost his ability to memorize spatial layouts. And a classical musician might pop a beta blocker like propanol— a heart medication—to prevent stage fright from spoiling her performance. In our growing quest to perfect ourselves through science and technology, using drugs as tools for building a better brain is a logical progression. After all, cosmetic surgery has taken manipulation of the body about as far as it can go. The next phase in cosmetic enhancement? The mind-lift.

Last year, Canadians filled over 45 million prescriptions for psychotropic medications— a 40 per cent increase over 2000. Although exact statistics aren’t available, Hoffman estimates that 20 to 25 per cent of Canadians are on some kind of mind-enhancing medication. “Probably a fifth to a quarter of those should be,” he says. For drug companies, “prospecting for better brains may be the new gold rush,” Chatterjee wrote in a recent issue of Neurology, the journal of the American Academy of Neurology.

setting up what are essentially brain spas. “Following the model of financial consultants, we could offer a menu of options, with the likely outcomes and the incumbent risks stated in generalities.”

Though it may sound like a conceit ripped off from a 1950s sci-fi novel, the technology, experts say, is well within reach. “The last decade was the decade of the brain,” Chatterjee told Maclean’s. In seeking potential treatment options for sufferers of neurological diseases and disorders such as Alzheimer’s, spinal injuries and strokes, scientists have been able to glean essential new information about how different regions of the brain interact, store and retrieve information, encode memories and respond to stressful situations.

Traditionally, the medical community believed that the mind and the body existed separately, with the mind containing the essence of an individual and the body functioning as its physical shell. But in light of recent scientific developments, there’s been a massive shift toward a more “mechanical” understanding of the mind—the idea that people’s thoughts, memories, feelings and abilities can actually be reduced to a series been found to improve a person’s mental agility and ability to concentrate. It can reportedly keep a person awake and alert for almost 90 hours straight, without the jitteriness or distractedness that caffeine often produces. In 2002, a breakthrough Stanford University School of Medicine study found that pilots who were given a small dose of donepezil—a cholinesterase inhibitor approved for the treatment of Alzheimer’s— performed significantly better in Cessna 172 simulation tasks, particularly in emergency drills and landing sequences.

Currently, the efficacy and safety of such “smart” drugs, particularly in people without diagnosed mental disorders, are wildly debated. Still, the potential uses and demand for these pharmaceuticals is enormous. In part, experts say, this is because in North American culture, we’re increasingly looking to science and technology to solve the problems we don’t have the time or energy to solve ourselves—whether it be in the form of steroids for maximum physical strength or Viagra for a sexual kick-start. “Computers give us quicker access to news

and information,” says Gordon DuVal, a bioethicist at the University of Toronto. “There’s a sense that technologies that make other things better should make us so as well.”

At the same time, says Hoffman, mental health experts are seeing a trend toward the “medicalization” of normal life. There is an increasing tendency—and willingness—among people to recast undesirable emotional states (sadness, anxiousness, boredom, stress, plain old-fashioned unhappiness), as medical disorders: physiological roadblocks to maximum wellness and productivity. Medicalization, says Hoffman, not only provides people with a quick and easy explanation for their own emotional glitches, but it diminishes personal responsibility (you are victim rather than cause) while offering a built-in practical solution in the form of medication. Traditional, time-consuming forms of treatment like analysis and talk therapy fall to the wayside. Instead, we’re looking to cure emotional aches the way we would normally cure a toothache.

In part, some experts blame our growing readiness to pop a pill on the recent rash of “does this sound like you?” pharmaceutical advertising campaigns for mental health drugs, which the industry pours millions of dollars into each year. Although such direct-to-consumer advertising is illegal in Canada, we are nonetheless exposed to it via the media in the U.S., where it has been legalized. Critics of the pharmaceutical industry say these campaigns function as subtle mass diagnostic tools—attempts by companies to create large markets for their drugs by blurring the definition of “normal” and exaggerating the pervasiveness of the disorder in question. If they keep the questions general, and the diagnostic criteria broad (Are you fidgety? Do you get bored waiting in line? Do you feel a sense of hopelessness sometimes?), more people watching the ads will think, “that sounds like me,” and ask their doctors for a prescription.

A recent study in the Journal of the American Medical Association suggested that this kind of power-of-suggestion approach to mental illness translates into sales. Female actors were hired to feign various forms of depression and request drug prescriptions from physicians during unscheduled visits. When they made a general request for drugs, saying they had seen a TV segment on depression, they left the office with a prescription 76 per cent of the time. When they asked for Paxil by name, they got a prescription for that drug 53 per cent of the time. When they asked for no drugs at all, they still got a prescription for the pseudocondition 31 per cent of the time.

Over the last decade, there have been a slew of heavily marketed conditions—including general anxiety disorder, panic disorder, obsessive-compulsive disorder, social anxiety disorder and attention deficit disorder, to name a few—that were formerly considered rare but now explain away a broad set of symptoms. “Being a bit forgetful, not finishing things, being somewhat disgruntled, not doing as well in life as you think you should—all of these things are part of the normal human condition,” says Hoffman. “Maybe there’s an aspect of your personality that you need to try and work on, but not through diagnosis.”

Perhaps the best example of a marketinggenerated mental health epidemic is tied to the success of Paxil. In 1998, SmithKline Beecham, the maker of the pill, applied to the U.S. Food and Drug Administration to have Paxil approved as the first drug for treating “social anxiety disorder”—characterized by an intense fear of, usually, social and performance situations where embarrassment may occur. SmithKline Beecham, which in 2000 merged with Glaxo Wellcome to become GlaxoSmithKline, spent millions on promotion, with a slick campaign by New York-based public relations firm Cohn & Wolfe that featured the tag line, “Imagine being allergic to people.” According to the Diagnostic and Statistical Manual of Mental Disorders, social anxiety disorder seriously afflicts roughly two per cent of the population. The campaign, however, touted numbers as high as 13.3 per cent. By the end of 2000, Paxil’s sales had increased by 18 per cent, and by late 2001, the brand had supplanted Zoloft as the second-bestselling SSRI after the Eli Lilly blockbuster, Prozac.

and restlessness. But in the general population it’s easily misdiagnosed. Among the symptoms listed in ads for drugs like Strattera—the first to be approved for treating adult ADD in Canada and the U.S.—are things that everyone experiences to some degree: misplacing objects, feeling disorganized, procrastinating, and harbouring a sense of underachievement.

Dr. Edward Hallowell —author of Driven to Distraction: Recognizing and Coping With Attention Deficit Disorder From Childhood Through Adulthood— says that, although the disease is underdiagnosed among those who actually need medication, it’s increasingly overdiagnosed among those who don’t but believe they do. “ADD is such a seductive diagnosis,” he says. “You can think you have

IN 2004, CANADIANS FILLED 45 MILLION PRESCRIPTIONS FOR PSYCHOTROPIC MEDICATIONS

In an interview with Advertising Age, Paxil’s product director, the aptly named Barry Brand, said, “Every marketer’s dream is to find an unidentified or unknown market and develop it. That’s what we were able to do with social anxiety disorder.” Some have called it “the medicalization of shyness.” More recently, North Americans have been seeing adult-oriented ads for ADD, a disorder once thought to be unique to children. For as much as four per cent of the adult population, experts say, ADD is a very real problem, characterized by debilitating impulsivity, inability to concentrate,

it if you just have a cursory exposure to the symptoms. It can get overdiagnosed because people are running around overstimulated, overcommitted. That’s not a medical disorder, that’s simply an artifact of modern life.” Of course, people have sought external cures for internal woes since the beginning of time. “We use coffee to stay awake and keep us going,” says DuVal. “And we also use a glass of wine to relax and make us more sociable, enjoy an evening more. So I think we’re just looking for other ways to do that.” The real ethical problems arise, he says, when we begin to look to the medical profession

to develop and prescribe lifestyle drugs for particular purposes. And that begs the question: what is the purpose of medicine? To treat people with illnesses—or to enhance the lives of already healthy people?

Ironically, says Chatterjee, one of the reasons doctors are more willing to hand out psychotropics is that, within the medical community, the opposite of medicalization is happening. That is, rather than concentrating on the treatment of disease, doctors are placing more emphasis on improving the patient’s subjective quality of life. “Traditional Western medicine has really focused on mechanisms of disease and treadng disease,”he says, “but recently there has been more awareness that those kinds of treatments don’t necessarily correlate with people’s own perceptions of the quality of their lives.” So, for example, if a patient perceives himself to be depressed, the question becomes: who is the doctor to tell him he’s not?

If doctors are to become Chatterjee’s gatekeepers to happiness, it unleashes a flood of ethical questions. For example, there are medications, like the beta blocker propanol, that might dull the impact of negative mem-

ories. In cases where people are experiencing debilitating post-traumatic stress—as troops returning from war often do—most people would agree that doing something about it is a good thing. “But whose threshold do you have to meet to decide whether some pains need to be experienced and which don’t?” Chatterjee says. Should someone who has witnessed a violent incident have access to this medication? What about someone coping with the death of a loved one? Or going through a messy breakup? And when we begin meddling with people’s memories, how can we ensure they don’t forget too much—or remember things they’d rather forget?

With cosmetic surgery, we tinker with our external selves. But bioethicists say that messing with our minds is a far different proposition, because we bump up against a more fundamental notion of identity. When we change our brain chemistry, we have to wonder, at what point does a person stop being himself? “Who are we really?” asks DuVal. “We’re probably not our bodies, how fast we can run, how high we can jump. But when we’re talking about our minds—our personality, our memories, our emotions, our

cognition—it’s more tempting to feel that this is really getting at the essence of who we are. If we affect that in some unnatural way, some people think that may be really changing us in a way that is significant.”

Also, critics say, understanding ourselves as a set of neurological processes generally means undermining our own sense of responsibility and self-determination. “Some people think part of our notion of character is some integration of both our pleasurable and painful experiences, and if you blunt the painful experiences, you’re really distorting who we are,” DuVal says. “Should

‘IF PILLS TO MAKE PEOPLE SMARTER ARE EXPENSIVE, THEN THE RICH WILL GET THEM FIRST’

we be able to get smarter by taking a pill? If we’re going to get smarter, shouldn’t we do it through reading books or taking a course? Because the gain with no pain thing may end up being really corrosive to our self-discipline, our will, what makes us human.”

And if cosmetic neurology becomes the norm, will people—particularly those in competitive environments—feel pressured into taking medication just to keep up? Will pilots feel they need stimulants to perform at top capacity? Will aggressive parents put underachieving kids on Ritalin to help secure them a spot in the right school? If so, will this create a new social divide? “If pills to make people smarter or work harder are expensive, then rich people will get them first,” says DuVal. “Will that aggravate social circumstances? Will the rich get richer and the poor get poorer —or will a lot of people be able to use them and will that narrow the difference? Nobody knows which way it would go.”

Chatterjee takes a rather fatalistic view of the trend. The question, he says, is not

whether cosmetic neurology will become the norm, but how we should manage it when it does. It could very well turn out to be a good thing, he says. “If improving quality of life is an explicit goal for physicians, then why not consider biological interventions for the quality of individuals’ lives whether or not they have a disease?” But creating a cosmetic drug culture, say critics, could open up a Pandora’s box. “When you play with the neurochemicals, you’re going to get some results,” says Hoffman. “But we don’t know what effect it’ll have in the long run. Really we’re playing with our humanity.”