An Interview with Ronald Dworkin, MD, Ph.D. on Artificial Happiness (using antidepressants to mask ordinary unhappiness)
David Van Nuys, Ph.D. Updated: Sep 2nd 2008
In this Wise Counsel Podcast interview, Dr. Van Nuys interviews author and physician Ronald Dworkin, MD, Ph.D. about the ideas he expressed in his 2006 book Artificial Happiness: The Dark Side of the New Happy Class. Dr. Dworkin's argument, at least as articulated in this interview, can be easily boiled down to a single premise: Non specialist physicians (primary care doctors mostly) have entered into an unspoken agreement with patients to medicate ordinary unhappiness, an inevitable and existential aspect of life which is not a medical condition. In Dr. Dworkin's view, ordinary unhappiness is an important and helpful feedback mechanism serving to cause people to pay attention to problems they are experiencing in their environment or relationships which are not working. The use of medication to provide relief from the discomfort of unhappiness (or any other intervention which serves to reduce pain or distract people from non-illness forms of emotional pain) is not in the best long term interests of the patient, as it inhibits the patient from taking corrective actions to actually fix the problems they are experiencing.
Based on 2007 statistics, approximately 1 out of 4 Americans is currently being prescribed an antidepressant medication, but only 1 out of 5 of those people actually meet full criteria for Major Depression, an actual psychiatric illness. The rest of those medicated individuals are unhappy, but their unhappiness doesn't necessarily rise to the level of a true illness that requires intervention. Medication is useful and an important treatment for people who actually have a medical illness, Major Depression. However, with regard to the non-clinically significant depression-esque cases, it is Dr. Dworkin's opinion that the use of medication to improve people's happiness is bad for patients, as it masks patients' true problems and disincentives people from taking action to improve their actual circumstances.
According to Dr. Dworkin, this problem of inappropriate prescription of antidepressants to unhappy but not-actually-depressed people has occurred due to primary care doctors' desire to please patients and give them the relief they crave, and patient's desire to not feel pain. It is not due to pharmaceutical companies' marketing efforts, in his opinion, though those companies surely try very hard to influence doctor's and patient's opinions.
This unstated agreement to offer medication even when not entirely appropriate is, Dworkin argues, in large part driven by the way that doctors are trained to think about biological system in reductionist terms. Confusing association with causation, Dworkin argues that doctors have leaped to the idea that neurotransmitter problems cause depression (rather than simply co-occurring with it with both caused by some third factor, which is an equally plausible explanation). Based on this questionable association between neurotransmitters and depression, these doctors assume that they can remove unhappiness by adding medicine to "re-balance" neurotransmitter problems. Doctors also delude themselves by selectively interpreting findings from the new field of psychoneuroimmunology that show relationships between stress, depression and poor health, to mean that it is never healthy for someone to feel unhappy.
Dr. Dworkin doesn't address psychotherapy for depression in his book or in this interview, but he does suggest that it is a far superior response to ordinary unhappiness to talk about it with the idea of trying to understand the cause of that unhappiness better than it is to mask the unhappiness in any way.
Medication is not the only way that ordinary unhappiness can be masked. Dr. Dworkin is also down on the use of complementary and alternative medicine remedies to treat non-clinically relevant depression, and even down on the use of exercise for treating depression. To be clear, he is not against using treatments to combat actual Major Depression; but only questioning the wisdom of treating non-illness forms of unhappiness by any means that would cause someone to lose motivation to take actual action to root out the real causes of discomfort. As a case in point, he offers a brief case history. A young woman who was ambivalent and uncomfortable about a relationship she was in sought help from a primary care physician who offered her Prozac, which made her feel better. She did not leave the relationship until over a year later after she had stopped taking the medication and noted that her feelings of discomfort with the relationship had returned. Dr. Dworkin's argument is that if she had not used the medication to mask her discomfort in the first place, she would not have lost the year but rather could have moved on sooner.
Dr. Dworkin's bottom line is that in the majority of case of unhappiness (those who are not meeting full criteria for Major Depression) people are best off dealing with the issues that make them unhappy rather than looking for ways to reduce the pain these issues cause. His hope is that people and doctors will think twice when looking to address the common condition of unhappiness and not medicate unless medication is truly called for.
Ronald W. Dworkin, M.D., Ph.D. is author the 2006 book, Artificial Happiness: The Dark Side of the New Happy Class is available from Amazon.com . According to the book's cover, his essays on religion, medical science, and healthcare have appeared in The Weekly Standard, Commentary, Public Interest, and Policy Reviews. In 2000, Dr. Dworkin joined the udson Institute as a senior fellow while continuing to work part-time as an anesthesiologist. He lives in Baltimore, Maryland.
Advertising and drug companies - Megan - Nov 6th 2012
Dr. Dworkin, though correct about the historical incapacity of pharma companies to advertise directly to consumers via traditional advertisements, does not recognize other forms of advertising to the general public. There were and, as far as I know, still are no regulations on non-traditional forms of advertising including things like paying celebrities to mention drugs via media outlets, leveraging print and journal articles from magazines like Cosmopolitan and Time to mention specific drugs by offering incentives to the organizations including money, and sponsoring consumer advocacy groups for mental health drugs and mental health advocacy groups. There are other ways to reach the public which advertising firms utilize. Dr. Dworkin is right to speak of the influence of culture on the doctor patient relationship. With the added influence of DTC ads and growing consumer demand, physicians are under ever increasing pressure to prescribe drugs that their patients request. There are also ethical demands on a phsycian to help alleviate suffering and reduce the stigma and loss of productivity caused by the disabiling elements of both clinical depression and \\
Brillant - - Nov 21st 2008
Dr. Dworkin provides insightful commentary into today's movement toward medication which can be boilded down to one thought -- just because we can, does it mean we should. I thoroughly enjoyed reading his work, and hope to have much more from this insightful author. Bravo!!!!
Another avenue to explore - Mr. Lucky - Sep 27th 2008
I found Dr. Dworkin's interview insightful and would like to explore the possibility that pressures in society create the need for artificial happiness. Do we as a society striving for high achievment, productivity, status, wealth, and all things associated with the American dream, deny what essentially is human: feelings, the abilty to feel, the identification of those emotions in the pursuit? Dr. Dworkin states that the definition of happiness does not need to be spelled out. But as a culture, have people become so dehumanized and consquently, have we lost the ability to find real happiness? In a fast paced American lifestyle, anti-depressant drugs seem to be the quick-fix to some individuals' notion of unhappiness rather than taking the time to be introspective and addressing problems.Has mainstream America numbed itself down?
Hmmm... - - Sep 5th 2008
Dworkin believes psychiatrists, rather than primary care physicians, should administer antidepressants. Neither psychiatrists nor primary care docs perform laboratory tests which determine whether their patients indeed have a biologically based depression. Instead, patient interview-based criteria have been constructed for this purpose. Are such criteria prone to subjectivity, then, or are they absolutely objective? Does Dworkin know? He's an anesthesiologist, not a psychotherapist of any stripe. And he works for a right-wing think tank, though he claims political neutrality. Those of us who benefit from antidepressant therapy might wonder if his assertions aren't merely in lockstep with the ultraconservative cry for getting patients off all sorts of prescription meds for the sake of the health-care industry's (and in this country, it IS an industry) bottom line.
I see a disquieting angle here which undermines the credibility of his book's thesis. I doubt I'll even check it out from the library.
Editor's Note: Tests like the Dexamethasone Supression Test have been attempted in the past to try to demonstrate a biological marker for depression but the problem is that this tends to be unreliable - failing to identify some people who clearly meet criteria for Major Depression. There isn't (to my present knowledge) any medical test that will reliably show a physical marker for depression.