Blurring the Boundaries Between Health and Illness

"The desire to take medicine," wrote Dr. William Osler, "is perhaps the greatest feature which distinguishes man from animals." This desire, however, is neither innate nor stable over time. At present, it is actively promoted by direct-to-consumer advertising on TV and pop-up ads on the Internet as well as by industry-funded disease-awareness campaigns. New diseases may result from new pathogenic agents, of course. But they are most often the result of three deliberate processes: the medicalization of aspects of everyday life (e.g., menopause), the portrayal of mild problems as serious illnesses, and the framing of risk factors (high cholesterol, obesity, osteoporosis) as diseases. The recent issue of PLoS Medicine cited elsewhere illustrates how these processes have affected the diagnosis and treatment of a number of relatively new disease entities, three of which are described here.

ADHD

The line between quirky behavior and disease is often fuzzy. Behavioral conditions are therefore particularly susceptible to being labeled as diseases. Attention Deficit Hyperactive Disorder (ADHD) is one that has evolved from largely unrecognized to increasingly prevalent in a relatively short period of time, a trend accompanied by aggressive advertising and pharmaceutical interventions. In the process, the drug industry has cultivated new allies within the education establishment.

Christine B. Phillips, Senior Lecturer in Social Foundations of Medicine at the Australian National University Medical School in Acton, Australia, looks at the role of teachers in the growth of ADHD and the resulting use of psychostimulants to treat the condition. While there has been much debate and controversy concerning the veracity of ADHD as a disease entity and the personal cost-benefit ratio of treatment with psychostimulants, there is not doubt that this type of intervention has increased in popularity. Prescription of the drug methylphenidate (Ritalin, Methylin) increased 2.5 times in the United States and fivefold in Canada between 1990 and 1995.

Because ADHD affects educational performance, teachers have become active participants in detecting the condition and referring potential patients for treatment. As Phillips indicates, "with ADHD, the teacher’s work extends beyond simply ensuring the disorder is understood by parents. Instead, the teacher participates in the diagnosis, and may broker different forms of treatment, or rejection of treatment." In this role, teachers may administer specialized assessment instruments, and even supervise the administration of psychostimulant medication during the school day. Not surprisingly, this new role for teachers has provided the pharmaceutical companies with an entry into the schools. Working with patient advocates, these companies have sponsored educational programs for teachers, and supported online science materials. The incursion of the drug industry into schools has in effect made teachers franchisees in the medical marketplace. "While there is an argument for providing unbiased education to teachers about a high-profile condition," writes Phillips, "education provided by pharmaceutical companies is self-serving in that it often provides education which references their own products, and channels the reader toward medical therapy."

Bipolar disorder

A similar attempt at expanding the market for drugs has occurred with respect to bipolar disorder, as David Healy has indicated in his article "The Latest Mania: Sellling Bipolar Disorder" in the issue of PLoS Medicine. Patients have been enlisted in an effort at self-diagnosis that can either alert them that they may be suffering from manic-depressing illness or alarm them about mood shifts that serve to label normal variations in behavior as illness. Broadening the criteria used to diagnose bipolar disorder has expanded the ‘need’ for medication and extended the use of antipsychotics from the treatment of acute manic states to prophylaxis against bipolar disorders. As initial estimates of the prevalence of the disease have been revised upward, academic interest in the condition has grown, thereby fueling the "bipolar market" with all its attendant activities: the creation of new journals and scholarly societies, and the holding of annual conferences on the topic.

At present, however, there is very limited evidence to support any claims for the prophylactic drug treatment to prevent the emergence of manic-depressive illness. Related to this, there are several disturbing trends in the diagnosis and treatment of the condition. In the United States there has been a surge in the diagnosis of bipolar disorder among children, some as young as 2, and pediatric bipolar disorder is being treated by drugs such as Zyprexa and Risperdal. While the disorder has not been recognized outside the US, it is only a matter of time before both the label and its treatment transcend national boundaries.

Restless Legs Syndrome

The most recent entrant into the diagnostic lexicon is "restless legs syndrome." This disease is defined by four criteria: an urge to move the legs, onset or worsening of symptoms when at rest, relief by movement, and symptoms that can occur primarily at rest and can interfere with sleep or rest. While some people may experience symptoms that are severe enough to be disabling, many who are labeled as "sick" may suffer more from the label than from the restlessness.

In a case study on restless legs and how the media makes people sick, Steven Woloshin and Lisa M. Schwartz from the Center for the Evaluative Clinical Sciences at Dartmouth Medical School examined news coverage of the new disease and its progression from unrecognized condition to the centerpiece of a multimillion dollar international campaign to bring it to the consciousness of both doctors and consumers. Originally approved for Parkinson’s disease, the drug ropinirole (Requip) was touted by GlaxoSmithKline as effective for treating restless legs. After examining the media coverage of the condition, the authors found that many articles tended to exaggerate the prevalence of the disease; encouraged self-diagnosis and linked the condition to other problems such as insomnia, daytime fatigue, ADHD in children, and depression; suggested the possibility of treatment ("ask your doctor…"); and omitted or minimized adverse effects. Woloshin and Schwartz therefore conclude that, in publicizing restless legs syndrome, "the media seemed to have been coopted into the disease-mongering process."

These case studies, while discrete vignettes of particular conditions and specific drugs, highlight the dangers of indiscriminate labeling, inflating the benefits of treatment, and enlisting advocates with a vested interest in the disease entity. They also illustrate the wisdom encapsulated in another of Dr. Osler’s aphorisms: "One of the first duties of the physician," he counseled his students, "is to educate the masses not to take medicine."