Medicalize Me: Experts Look At Perceptions Of Illness

Do prescription drug ads make people think they're sick when they're not, or create "disease" out of thin air? Does the "empowered patient" movement mean that doctors have lost some of their professional clout when it comes to making diagnoses and prescribing treatment?

These questions and more are the focus of a set of probing essays in a special section of the Feb. 24 issue of the journal The Lancet, all addressing the topic of "medicalization" and what it means in modern society.

The essays, which grew out of an international workshop, zero in on the fact that even the word "medicalization" has a different meaning today than 30 years ago.

"When the term first came into use in the 1970s, it was used critically to mean the 'evil' actions of doctors who turned deviation from the norm into disease, and imposed medical authority on aspects of everyday life such as birth, aging or dying," says Jonathan Metzl, M.D., Ph.D., a University of Michigan Medical School psychiatrist and U-M women's studies researcher who co-organized the workshop and wrote or co-wrote two of the six Lancet articles. "But today, it's used more in connection with the actions of pharmaceutical companies, and we need to understand its effects better."

The six essays focus on the intersections between medicine and society, including the role of the physician and the patient, and of the values, wants and needs that each doctor or patient brings to each interaction.

Metzl co-authored the introduction with Rebecca M. Herzig, Ph.D., a professor in Women and Gender Studies at Bates College in Maine who worked with him to organize the workshop. They report that a Google search for the term "medicalization" (and its British spelling, "medicalisation") yields more than 358,000 hits most of which have to do with the drug industry's role in changing societal perceptions of disease, "normalcy" and wellness.

But the authors also warn against painting this phenomenon with an entirely negative brush. "The same drugs that treat deviances from social norms also help many people live their lives," they write. While the old definition of "medicalization" painted patients as the victims, the new model gives them the opportunity to be advocates and choosy consumers if they and their doctors discuss openly their beliefs about what they think the drug from the television advertisement will do for them.

Metzl examines the impact of direct-to-consumer drug advertising even further, in an essay on what Europeans can learn from Americans' ten-year experience with the ads if Britain and European countries decided to allow them too.

"Is it the case that our notions of illness are created by the pharmaceutical industry's advertising, or is it also the case that drug companies are reflecting societal expectations?," Metzl asks. "Culture plays a large role in this process, and the drug companies aren't just inventing this from scratch. They're playing to a market that's used to asking for things from their doctors, and it's raising very interesting questions of interpersonal dynamics."

Metzl and other writers of essays in the special section look to history to shed light on the current situation. Metzl is the author of a 2003 book "Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs," which examined how depression and anxiety medications were represented in advertising aimed at physicians, and in the entertainment media, in the latter half of the 20th century.

Today's ads amplify people's cultural expectations, or even change them, he says in the new essay for instance, erectile dysfunction drug ads that are featured prominently at sporting events as well as on TV play to men's perceptions of what it is to be a normal, healthy man. The same goes for antidepressant ads showing women who are able to fulfill their roles and duties as mothers.

What people do in response to these ads is another aspect to the medicalization issue, Metzl says. Studies have shown that patients who go to their doctors and ask for a medicine they saw in an advertisement are likely to get it which, of course, is part of the reason the blitz of ads has escalated every year since the U.S. Food & Drug Administration relaxed the rules for them in 1997.

But this has led to a kind of tension in the interaction between doctors and patients that is new, Metzl notes, as physicians try to decide whether to say yes or no to each request. The fact that physicians themselves are exposed to the same ads, and are part of the same society as their patients, further complicates the issue.

The answer for U.S. doctors, and for the British and European doctors who may soon find themselves in the same position as their American counterparts, may be to bring the social issues directly into their conversations with patients, Metzl explains. "If a problem is being medicalized, we need to look at what else we can do as physicians besides blaming drug companies, and talk to patients about what else they need to be aware of and what may be driving their response to an ad," he says. "Doctors and patients shouldn't mindless follow the suggestions of drug ads, but they should talk about the options and the expectations that they have, and how realistic those expectations may be and then decide whether the medicine is right."

In addition to Metzl and Hertzig, the essay section features writings by Nancy Tomes, of the history department at the State University of New York at Stony Brook, writing on patient empowerment and the dilemmas of today's medicalization; Nikolas Rose of the London School of Economics, who looks at the history and future of medicalization; Troy Duster of New York University, who examines the medicalization of race including medicines that are being aimed at members of certain ethnic groups; and Cindy Patton of Simon Fraser University in Vancouver, who looks at the specific issue of medicalization in the treatment of HIV/AIDS.

The workshop that led to the writing and publication of the essays was funded by grants from the University of Michigan, the Charles Engelhard Foundation, and Bates College.

Lancet, Vol. 368, Feb. 24, 2007

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