About pills

David Karp (“Matter over Mind,” Summer 2006) states that rote prescription of psychotropic medications, often by primary care medical providers, is neither helpful nor therapeutic. Most mental health professionals would agree. Before we chastise primary care providers too much, though, it’s worth pointing out that they do their best under the burdens of a health care system that is itself in need of a cure. For all their good intentions, harried practitioners will find it a challenge to locate a therapist who has an open appointment and is able to accept a patient’s particular insurance.

The problem, says Karp, “is the sense [among patients] that prescribed drugs can erode personal authenticity and tamp down feelings that reflect one’s true self.” My own experience with several thousand patients suggests that although some patients feel this way, many do not. Professor Karp also says that we are creating a “nation of victims.” What I missed in his article is mention of the large numbers of people who would say that psychotropic medication has “saved their lives.” I hear this regularly from patients—”I was reluctant at first, but seeing how much better I feel, I wish I had started taking this a long time ago.” Psychiatric research makes clear that the most rapid and effective path to therapeutic success is the combination of psychotherapy (talk therapy) and medication. It is not one or the other, it is both.

Consider depression, for example. In quoting the Yale sociologist Allan Horwitz, Professor Karp suggests that joining a gym, going to confession, or returning to school can be as effective as medication in treating the disorder. There are no studies that make this comparison scientifically. Such behavioral suggestions often come from family and friends. When these nonmedical activities prove successful, people usually don’t come to my office. More often, however, a depressed individual cannot follow loved ones’ recommendations because of lack of energy or motivation, excessive sleepiness, or fear of failure. Psychotherapy, which is portrayed as promoting self-reliance, works best when a patient can focus on what the therapist says and has the energy to pursue behavioral assignments between sessions. While not necessary for everyone, medication can assist in these processes.

Professor Karp draws the comparison between mental illness, for which there may be no diagnostic test that “demonstrates the [brain’s] dysfunction,” and diabetes, for which treatment (insulin replacement) follows only on “definitive” testing. Com­parison with a headache would be more apt. Often we cannot determine the specific biological basis for a headache, and there is no laboratory test to document its existence. Should we then keep the aspirin in the cabinet and suggest that the patient take personal responsibility for the societal factors that may be partially at the root of the headache? In Karp’s view, if in doubt, it is better to withhold such treatment “for the good of a healthier society.”

Certainly, the influence of pharmaceutical companies on medical practice is stronger than is ideal. There are many patients who come to me saying, “I need help, this isn’t me,” and then directly seek a “pill for their ill.” In some circumstances I agree and prescribe, and in others I don’t. When I write a prescription, am I reinforcing the pharmaceutical companies’ advertising message? Probably. Does the professor have a better solution for the patient sitting in front of me?

Practitioners of mental health and medicine dance with the devil every day, but dance we must, since pharmaceutical companies are the only source of new medications. A competent physician considers medications carefully, looking for flaws in the manufacturer’s research and for weak conclusions. Pharmaceutical companies may market their messages, but that does not mean most prescribers accept them or utilize the products as suggested.

Christopher M. Doran, MD, ’68
Denver, Colorado

The writer is associate clinical professor of psychiatry at the University of Colorado Health Sciences Center.

David Karp’s brilliant, compassionate, and politically incorrect essay on the very nature of biology and psychiatric illness has caused me to rip the article out and copy it several times over for colleagues, friends, and many of the patients whom I serve. The general public and many health care providers have been hijacked by Pharma and the slave drivers of managed care companies who sit back in their swell offices garnering perks and inflated salaries while we frontline workers scramble to meet the needs of our patients in a 15-minute visit. Is it any wonder when someone speaks of pain that we offer a pill? Professor Karp’s is one of the best articles that I have seen in BCM. I am off to buy the book.

Brianne R. Fitzgerald ’71
Boston, Massachusetts

The writer is a project specialist with the New England AIDS Education and Training Center.

Professor Karp has written an incisive critique of contemporary psychiatric practice, particularly of the intertwined interests—”unholy alliance”—of the pharmaceutical industry and organized psychiatry.

One point not addressed, however, is the prominent role played by the managed health care industry in successfully promoting a largely “medication management approach” via financial disincentives and other barriers (including inordinate paperwork requirements) imposed on mental health professionals. These practices discourage the use of psychosocial interventions as complementary to or, in many cases, viable alternatives to medication treatment.

Jerrold Pollak Ph.D. ’77
Portsmouth, New Hampshire

The writer is a psychologist at the Seacoast Mental Health Center.

As someone who works in pharmaceutical market research, I feel the need to point out that my industry is facing significant challenges not only from consumer groups that expose conflicts of interest so well, but also from a source you may not expect: physicians. The American Medical Association now sponsors the Prescribing Data Restriction Program, whereby physicians may elect to have data on their prescription activity restricted from pharmaceutical sales reps. Traditionally, reps have been the driving force behind sales for Pharma companies. Without data on the physicians they are meant to target, their job is significantly harder, and the returns for the company potentially smaller. The message is clear to me: Physicians are willing to give up the lavish meals, consulting gigs, and even samples in order to take back control.

To Professor Karp I ask: How does the medicalization of our daily lives, the propensity of Americans to pop a pill at the sign of any sadness or anxiousness, change when physicians remove themselves from the equation?

Aimee Marlow Delorey, Ph.D.’02
Burlington, Massachusetts

Thank you, David Karp, for an insightful piece. As a parish priest, I am keenly aware of how people are made to feel truly inadequate when facing normal life transitions arising from loss, conflict, or growth. The propensity to “routinely medicate for life troubles” is disquieting. Society needs the courage to set boundaries and the capacity to help its members deal with ambiguity, respond to injustice, and cope when the cultural norms of continuous happiness and instant satisfaction are unmet.

Rev. Thomas J. Powers
Lynnfield, Massachusetts

We in the psychotherapy profession focus primarily on individuals, while sociologists focus on society. True change is not external, but internal—what the Greeks called “metanoia,” a change of heart.

Harry Moo Young ’67
Brockton, Massachusetts

The writer is a psychotherapist, life coach, and mediator.

BC’s Graduate School of Social Work taught us to identify the strengths and weaknesses that each individual brings to therapy and then to consider these factors within the context of that person’s environment on the way to formulating diagnosis and intervention. There is perhaps a small cohort of patients for whom medication therapy must be implemented prior

to starting a course of psychotherapy. For the greater part, the interventions are done in tandem when necessary. Chemical treatments are best considered as adjunct therapies, employed to treat certain target symptoms within the individual’s larger psychosocial circumstance.

Edward R. Dalton, MA’83
Framingham, Massachusetts

The writer is a clinical social worker.

I agree with David Karp that too many doctors prescribe medication to eradicate or change people’s appropriate negative emotions and problematic behaviors, instead of suggesting they learn coping skills (in therapy) to tolerate, accept, and manage those feelings or behaviors.

Although some medications can effectively eliminate the neurovegetative systems of depression, anxiety, and other mental illnesses, all fail to teach people the necessary mood management skills and stress reduction tools that can effectively improve quality of life long after the medication wears off.

Julie M. Pearson, MA’92
North Kingstown, Rhode Island

The writer is a psychotherapist at the Rhode Island Center for Cognitive Behavioral Therapy.

I must submit my deepest disagreement with Professor Karp’s premise. I fear that his personal experience has tainted his view of an entire field of medicine.

Most physicians enter medicine to help people, alleviate pain, and aid in the discovery of new therapies. While controversial for some, psychiatry is in line with the other medical fields in the recognition of real symptoms—symptoms that for years went whispered about and were kept private by too many families. There are clearly psychiatric diseases that were ignored and untreated. Anyone who has been afflicted with one, or knows someone who has been, can recognize the need for treatment.

As with cancer and hypertension, there are now new therapies and new profitable drug companies. And as with orthopedic surgery, we know that supplemental treatments—physical therapy in the case of orthopedics; group therapy and exercise in the case of mental health—are extraordinarily helpful. However, to ignore proven pharmacologic treatment is, frankly, malpractice and maleficence. Psychiatric medications have saved the lives of thousands of people and will continue to do so. Perhaps we can all do a little more to recognize the contributions of all therapies.

Paulette Tucciarone, MD, ’98
San Diego, California

David Karp responds:

While the article that appeared in BCM reflects my concerns about the dramatic increase in the use of medications to treat an expanding array of troublesome moods and behaviors, I am not anti-pills. Since an excerpt cannot convey the full complexity of an author’s position, I invite readers to consider all the stories in Is It Me or My Meds?. The book necessarily includes accounts of the extraordinary–indeed, life-saving–success people have had with antidepressant medications. And I quite agree with those readers who suggest that it would be a form of medical malpractice to withhold psychiatric medications from individuals dealing with major depression and other life-threatening mental illnesses. My quarrel is with the blurring of the line between normal and pathological pain, the relative inattention to the cultural sources of human distress, and the impulse to hand out powerful medications as a first response.

I am pleased that there are physicians like Dr. Doran who won’t prescribe a pill to every patient who requests one. And it’s a welcome change that physicians are increasingly giving up perks for greater independence from drug company representatives. At this point, though, I wonder if we will ever see a general return to a more balanced approach to helping people in debilitating pain, with appropriate value ascribed to both medication and therapy. The imperatives of capitalism and the triumph of biological explanations of mental illness make significant changes from our current path unlikely.

When a social direction seems to have irreversible momentum, sociologists such as myself would be derelict if we failed to analyze its influence. Without critical dialogue, the prospects for maximizing our individual and collective well-being become more remote.

Commencement addressed

I read “A Civil Discourse” by David Reich (Summer 2006) with interest and nostalgia. My commencement speaker was Vice President Bush in 1982. As the date of graduation approached, much ink was spilled in the Heights over his appearance. A certain segment of the student population and some professors protested that he should not be the speaker, for most of the same reasons given against Secretary of State Condoleezza Rice. There was a rally held on campus, and plans were made to wear protest messages and turn away from the vice president. Sound familiar?

At the graduation, a rainy day, the vice president made a fine speech and the protesters were barely noticed. Most students were there to celebrate their accomplishments and were not interested in the so-called controversy. It sounds as if the same attitude prevailed last May.

In my opinion, graduation celebrates the time spent in improving one’s mind. It is not an occasion for a small segment of the student population (and a larger segment of the professors) to try to impose their worldview. I congratulate the class of 2006 for their accomplishments and wish them the best in their future careers.

Paul R. Donahoe ’82
Braintree, Massachusetts

I am appalled and shamed that the present administration at Boston College has demeaned the reputation of the University by bestowing an honorary degree on Condoleezza Rice, who supports fully the evil and very unethical war in Iraq.

Robert Burns ’57
Rockport, Massachusetts

I was very disappointed to hear that Secretary of State Rice was presented with an honorary degree. It’s difficult to understand how the Jesuit values espoused by Boston College were applied. Rice was shoe shopping while thousands of American citizens in New Orleans were abandoned by our government in the immediate aftermath of Hurricane Katrina. That hardly shows compassion. She was a key player sounding the drum beat that rushed this country into war with Iraq based on a bunch of lies and without a plan for the peace. That hardly shows a sense of justice.

The process by which honorees are chosen should be reexamined.

Paul Cantello ’92
Hawthorne, New Jersey

The discourse may have been civil, but honoring the secretary of state on Commencement Day was dismaying. I will not make my annual contribution to BC in 2007.

Richard J. Dionne ’62
Canton, Michigan

More vets, more views

BCM should be commended for “From BC to Vietnam,” the effort to identify Boston College alumni who served in the Vietnam War. The website now lists 23 graduates as “killed in action.” Our president, board of trustees, alumni, faculty, and students should consider whether this list is enough.

Boston College surely can provide a memorial tablet bearing the names of every graduate killed in action, not only in Vietnam but in all of America’s wars before and since that most painful time. Such a memorial would neither glorify war nor ratify past policies. It would acknowledge the brave sacrifices of our own who fell in the prime of life in response to duty, and serve as a reminder to future students of the terrible cost of war always borne by the young.

Joseph P. McEttrick ’67, JD’71
Milton, Massachusetts

I note from the letters in the Summer 2006 issue that graduates continue to surface asking that their names be added to the list of those with Vietnam service. Accordingly, I ask that my name be added to that list.

Given how the University sent the ROTC Program off-campus during the Vietnam War and how the country treated those of us who served during that time, it is refreshing to see this effort to record our service. Thank you.

Col. William. F. Kelly ’60, U.S. Army (Ret.)
Kilmarnock, Virginia

I served in Vietnam as a chaplain with the Marine Corps up along the DMZ from late April 1968 to May 1969 and am a disabled veteran of the conflict. Out of that experience, and years of pondering the war’s waste and worth, a novel emerged, Purple Sun, published in 2003. It is a war story that is not about war but about the sin and sacredness found in the depth of the human spirit.

Lawrence McAuliffe ’53
Boston, Massachusetts

Please add to your list of Vietnam veterans the following members of the class of 1963: Eric Farrell, USMC A-4 Pilot; Robert Smith, USMC Artillery Officer; Thomas Tierney, USMC UH-34 Pilot.

Perhaps we should pay as much attention to keeping up with these matters as we do to egregiously insulting our secretary of state on the occasion of our commencement exercises.

Thomas K. Tierney ’63
Jacksonville, Florida

I think you may find several BC Law School graduates who, like me, were drafted in 1968 between our first and second year when the 2S deferment ended for graduate students. After serving in Vietnam, I returned to what seemed to me a somewhat different BC Law School—many more women, a new dean, new faculty, different grading system.

Robert D. Fleischner, JD’73
Northampton, Massachusetts

First ladies

Re “Staggered Start” (Summer 2006), the time line of women’s firsts at Boston College: Why was there no mention of the School of Nursing’s administration, faculty, and students? Women have made up the majority of all three, and they were on campus during the latter part of the period covered.

Diana Newman ’63
Plymouth, Massachusetts

I would like to add to the “firsts.” I also graduated from the School of Management with an MBA in 1972 (Clare Schoenfeld is mentioned as the first woman in 1972). In 1973, I was the first woman member of the accounting faculty, and in 1982, I became the first woman president of the MBA Alumni Association.

These were important milestones in my life, and my superior education at Boston College led to a successful professional career.

Nancy H. Drago ’61, MBA’72
Canton, Massachusetts

Editor’s note: Thanks to Ms. Newman and Ms. Drago for their insights. In addition, the following error has come to our attention. The time line mistakenly reported that BC’s School of Education introduced the first women undergraduates “to study alongside men on campus” in 1956. The School of Education, and, of course, its women students, started on the Chestnut Hill Campus in 1952. That first class containing women graduated in 1956. The School of Nursing opened in 1947, on Newbury Street, in Boston’s Back Bay. From the start, its students were allowed to take science classes (and no others) on the Heights.

Fiction factor

I was very surprised to find a short story in Boston College Magazine (“The Marriage Privilege,” by Chuck Hogan, Summer 2006). Well-conceived and well-written—I liked it very much, particularly the ending.

Ed McMorrow MA’87
Beverly, Massachusetts

Church and state

As a citizen of “old Europe,” I read your article on Catholics in politics and government (“Faith, Hope, and Politics,” by Michael Molyneaux, Spring 2006) with great interest. I was looking for answers as to how U.S. Catholics leaders today respond to the major issues of the world. As I now understand it, the ultimate challenges for American Catholic leaders are issues like abortion and homosexuality. Although I recognize the complexity of these moral themes, I was deeply disappointed.

When I studied at the Graduate School of Management in the early 1980s, the United States was the moral leader of the world. It set the moral standards, initiated dialogue, reduced tensions; it was open, listening, tolerant, problem-solving. From this side of the ocean, we now see a United States that is almost the opposite. We see violations of international law, environmental egoism, disrespect for human life and for other cultures, wars with little cause, and the absence of political initiative.

Let me put it this way: The perception the world has about the moral leadership of the United States is substantially misaligned with the perception the United States has about its moral leadership. Given the huge consequences of this misalignment, is not this the ultimate challenge for Catholic politicians?

Bart Welten MA’85
Heerlen, The Netherlands

Paula Gavin’s letter (“Public and Catholic,” Summer 2006) maintains that “we live with an extremist notion of the separation of church and state, as if faith were a threat to democracy.” Well, actually, sometimes it is.

Since Gavin mentions homosexuality, I think it’s fair for me to point out that I don’t have the same civil rights that many others have because my life partner is female. My access to life, liberty, and the pursuit of happiness is stunted in a number of ways, from the fear of being gaybashed to the fact that I am denied benefits because I can’t marry my beloved legally. The Catholic Church has been a key player in socially devaluing my sexuality and standing against my access to equal rights. While not all Catholics (or Christians or Jews or Muslims) support prejudice and discrimination on the basis of sexuality, many do, and their faith is, unfortunately, a literal threat to me.

I wish it were otherwise. I’m a person of faith, and I believe that religion has the power to play a profoundly constructive role in our society. But until it consistently does so, I will have to support the “extremist” notion of the separation of church and state.

Amanda Udis-Kessler, Ph.D.’02
Colorado Springs, Colorado

Editor’s Note: In the Summer 2006 issue, the chart comparing Boston College data from 1996 and 2006 (“Ten Years in Review“) should have been credited to the Office of Public Affairs.

BCM welcomes letters from readers. Letters may be edited for length and clarity, and must be signed to be published. Our fax number is (617) 552–2441; our e-mail address is bcm@bc.edu.