The medicalization of America: how it’s making most of us ‘sick’

The medicalization of America — the turning of relatively common variations in human behaviors and biological functions into medical conditions requiring treatment — is the focus of a terrific series of articles published jointly Sunday in the Milwaukee Journal Sentinel and MedPage Today.

As reporters John Fauber and Kristina Fiore point out, new and expanded medical definitions have turned a staggering number of people in recent years into patients who are told they need treatment, usually with prescription drugs.

Fauber and Fiore examined just eight of these new conditions: pre-diabetes, ‘low T,’ intermittent explosive disorder, binge-eating disorder, female sexual interest/arousal disorder, adult attention deficit hyperactivity disorder (ADHD), overactive bladder disorder and premenstrual dysphoric disorder.

They found that, according to current medical literature, those eight conditions alone affect more than 180 million Americans — or 77 percent of all adults in the United States.

“None of these conditions was considered part of the mainstream medicine just 20 years ago,” write Fauber and Fiore. “But thanks to new definitions or lowered thresholds, million more people — overnight — fit the criteria of having treatable disorders.”

A lucrative market

Many people have a huge incentive — much of it financial — for expanding the definition of disease to include millions of more people.

“For drug companies, bigger numbers mean larger markets and [they] can put more pressure on the U.S. Food and Drug Administration to approve new products,” Fauber and Fiore explain. “For advocacy groups and medical societies, many of which get drug company funding, having more people with a condition can make it seem more mainstream and lead to more financial support. And for university researchers, coming up with a big number can be good for your career.”

“The more of a splash they make, the more likely they are to get papers published, to get hired by universities or to get promoted — and the more likely they are to get research funding,” Massachusetts psychiatrist Daniel Carlat, author of “Unhinged: The Trouble With Psychiatry — A Doctor’s Revelations About a Profession in Crisis,” told the reporters.

For the people who suddenly find themselves diagnosed with one of these newly defined — and non-life-threatening — conditions, however, the benefits are anything but clear. Not only are the treatments for the conditions expensive, they often carry serious health risks.

A repeated pattern

Medicalization has a recognizable playbook, as Dr. Carl Elliott, a professor of bioethics at the University of Minnesota, explained to Fauber and Fiore.

“You destigmatize the condition,” he said. “Broaden it to include a much larger patient population, rebrand it or give it a name that is less embarrassing to people — people would rather have overactive bladder than be called incontinent.”

“Then you’re all set for selling your treatment.” 

Here, for example, is Fauber and Fiore’s summary of how “overactive bladder” came to be rebranded and expanded:

It was in the late 1990s that incontinence or “unstable bladder” became the nicer-sounding “overactive bladder.”

Two urologists thought the new name was “more intuitive” and sounded less like a psychiatric disorder. They convinced the International Continence Society to give it a new definition, and the two pushed related research that found the new condition affected 33 million people in the United States alone.

One of the two urologists, Alan Wein of the University of Pennsylvania, now acknowledges the estimates “overstate the market,” but noted many patients do have bladder issues that require treatment.

Kari Tikkinen, a urologist and epidemiologist at the University of Helsinki in Finland, researched overactive bladder and found the recent estimates of how many have it — 17% of adults — were vastly inflated. In his view, the real figure is less than half that.

While inflated numbers may lead some people to get earlier treatment, they also can cause healthy people to think they are sick, said Tikkinen. That can lead to added costs and the unnecessary use of drugs that subject patients to potential harms.

Another case in point: adult ADHD

In their series, Fauber and Fiore focus on several other successful efforts at medicalization. One of the most egregious (and most recent) of these efforts involves the now routine diagnosis of adults with ADHD.

As the reporters explain, ADHD was primarily diagnosed in children until 2006, when a major study declared that 4.4 percent of adults in America — as many as 10 million people in all — also had the condition.

Fauber and Fiore describe the “familiar pattern” that happened next:

More research papers — many of them based on research funded by drug companies — were published.

The 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, relaxed the definition for adult ADHD.

The previous definition, in effect since 1994, said adults needed to have at least six of a possible nine symptoms from either of two categories. The symptoms include the inability to focus on tasks, fidgeting, and interrupting others. The new definition reduced it to five of the nine.

It also increased the age at which some of those symptoms first must have been present — from before age 7 to before age 12. …

Finally, the cumulative result of these factors was as expected: Prescriptions spiked. …

And, since many of those drugs are amphetamines and stimulants that can lead to abuse, thousands more people began showing up in hospital emergency rooms.

People who abuse those drugs can very easily fake the symptoms of ADHD.

“A 2010 study found that 22% of adults tested for ADHD exaggerated their symptoms, exaggeration often made easier by the wide availability of online symptom check lists,” Fauber and Fiore report.

New evidence raises serious doubts

A recent long-term study that followed more than 1,000 children until age 38 has called into serious question, however, the entire hypothesis that ADHD starts in childhood and then, for some individuals, persists into adulthood. 

Write Fauber and Fiore: 

In that study Terrie Moffitt, PhD, a psychologist at Duke University, and her colleagues found that in childhood, 6% of those in the study had ADHD. At age 38, that number had dropped to 3%.

And the biggest surprise was the lack of evidence of significant overlap between the two groups. 

Only 5% of those with ADHD in childhood still met the criteria at age 38. And only 10% of those who met the definition at age 38 were among those with the condition in childhood.

That, in turn, led the researchers to speculate that some of the adult patients were substance abusers who had attention problems stemming from drugs and alcohol, and that others may have had a personality disorder and were trying to game the system to obtain stimulants to abuse. 

Moffitt noted that while childhood ADHD is considered a brain development condition, adult ADHD patients in her study scored normally on neuropsychological tests.

“It seems to be a different disorder,” Moffitt said.

FMI: There’s much more eye-opening information in Fauber and Fiore’s articles on how medicine in the 21st century has “lowered the bar” to redefine disease. The series can be read in full at both the Milwaukee Journal Sentinel and the MedPage Today websites.