Gatekeeper Drugs: Drugs that Require Gatekeepers
A friend of mine suffered from depression. Like so many depressed persons, he went to sleep very late — maybe 3 am. I told him that was a very bad sign, no one should go to sleep that late. He starting going to sleep earlier and waking up earlier and felt better. He wondered why none of the many psychologists and psychiatrists he’d seen about his problem had told him what I said. The first time he asked I think my answer was that I cared more than they did about the relation of depression and sleep.
Recently he asked again: Why didn’t they tell him something so simple and helpful? Maybe I learned something in the intervening years because my answer was different. I said all health care professionals — not just doctors, all therapists/healers, mainstream, alternative, Western, non-Western — have no interest in treatments that they are not needed to administer. If all you need to do is to get up earlier in the morning, you don’t need a psychiatrist. Therefore a psychiatrist won’t tell you to do that. The only advice they are likely to give is advice they are needed to administer.
I could give dozens of examples. Does the Chinese herbalist tell my friend with an infection to eat fermented foods to boost his immune system? No, because that wouldn’t involve the herbalist. Instead he prescribes herbs that probably do the same thing. Does a dermatologist tell a teenager that his acne is caused by diet? No, dermatologists make the absurd claim that diet isn’t involved. Because if it were you wouldn’t need them. You’d just figure out what foods are causing your acne, and avoid those foods. Why do medical schools fail to teach nutrition? Because you don’t need a doctor to eat better. Why is prevention almost completely ignored? Because prevention doesn’t require any gatekeepers.
The economic term is rent seeking: health care professionals act in ways that require you to pay them. The usual economic examples of rent-seeking cause a kind of overhead you have to pay but the rent-seeking engaged in by the entire health care industry shortens our lives. Simple cheap safe solutions are ignored in favor of expensive and dangerous ones that don’t work as well. Our entire health system centers on gatekeeper drugs: drugs that require gatekeepers. The usual name is prescription drugs; their danger is part of their appeal to the doctors that prescribe them. Because it makes the doctor necessary.
October 3rd, 2009 at 12:14 pm
I don’t agree with the use of the term rent-seeking. The psychiatrist that doesn’t recommend sleep to a depressed patient is acting in his own self interest. He doesn’t’ have an incentive to recommend a therapy that will solve the problem without repeat visit. He didn’t go to school for god knows how long to tell people to get better sleep. He went to school to make people better through the narrow lens of his specialty.
Now, something like the AMA controlling who gets to be a doctor, that is a form of rent seeking. They are the gatekeepers and the member doctors benefit from that constraint on who can practice medicine.
–Ed
October 3rd, 2009 at 3:30 pm
Seth, here’s a checklist of emotional needs that also might help your friend (or anyone who is depressed). It it useful for people with anxiety or depression (and probably other things):
http://anthny.com/2009/05/16/emotional-needs-fulfilled-contentment-fulfillment-well-being/
October 3rd, 2009 at 4:43 pm
EDM, I don’t follow your argument. Rent seeking is one way to act in one’s self interest. Here’s a definition:
Psychiatrists earn income by ignoring remedies that don’t involve them. I’m assuming that the therapeutic environment (what therapies are available and advertised and advised) and research environment (what research is done) are part of the economic environment. They affect what is and isn’t for sale.
October 3rd, 2009 at 9:46 pm
Seth,
I agree with your greater point. I only quibble with describing it as rent-seeking.
Rent-seeking happens by manipulating the political environment outside of normal market competition.
I think the distinction I am trying to make is that I believe rent-seeking is active. In this example it would be psychiatrists actively working to marginalize alternative remedies. I don’t think the passive, “not looking for” alternatives rises to rent-seeking…
–Ed
October 3rd, 2009 at 10:01 pm
EDM is right that we need a correct name for the practice that Seth is describing. “Rent-seeking” isn’t it; that’s already well defined. There might be a name already, but it doesn’t come readily to mind.
I recall a story about a free health clinic that moved to the same floor as a legal aid society. They ended up referring a big fraction of their patients to legal aid instead.
October 3rd, 2009 at 11:15 pm
It’s true that the “seeking” in rent-seeking implies activity; whereas the activity I’m talking about appears passive to onlookers. The discouragement of prevention research is subtle.
October 5th, 2009 at 4:46 pm
In the case of depression, there is a complication to your argument. Sleep problems are seen as a symptom of depression by conventional medical wisdom — just try googling “symptoms of depression”. It is unrealistic to expect the typical practitioner to offer treatments that run counter to the conventional wisdom.
I use your discovery about early-morning faces every day, and my doctors are amazed at my condition. But they have zero interest in acting as “research doctors” with respect to their other clients. Can you really blame them?
October 8th, 2009 at 6:28 pm
Wow, I couldn’t disagree more with the example. And the comment,
“The psychiatrist that doesn’t recommend sleep to a depressed patient is acting in his own self interest.”
Yikes. They want to keep their patients depressed?! Why do we have the medical profession in the first place? Do they give just partial chemotherapy to keep the cancer patient from going into remission, too?
Having participated in a number of fora for depression/mental illness and having both personal and anecdotal experience with depression, I can say that most mental health practitioners (psychiatrists and psychologists) are deeply concerned with making their patients well. And that includes inquiring about sleep issues, and educating on sleep hygiene, and (yes) prescribing sleep medications when needed. Some are faster to prescribe medication than others.
If your friend was making the unwise step of going to a general practitioner (GP) for depression treatment, then yes, I wouldn’t expect them to go through a complete lifestyle assessment.
But any mental health professional worth their degree will check crucial things like sleep, relationships, exercise, and alcohol use, both as symptoms and as lifestyle factors that should be addressed as part of treatment.
Frankly, demand for mental health services is robust and nobody is worried about “running out of patients”, so even if a psychiatrist didn’t have simple compassion, there’s no reason to drag out treatment.
I’m not saying anything about pharmaceutical-pushing/marketing, though; that’s a whole other can of worms.
October 11th, 2009 at 11:24 am
[...] Gatekeeper Drugs. How to Avoid Infection: Something I Didn’t Know. [...]
October 13th, 2009 at 1:55 pm
[...] A brief summary of my previous post is all I needed to do to cure/prevent a skin infection was buy more socks. Instead of buying 5 pairs every 6 months, buy 20 pairs every two years. That’s all. Costs nothing. No drugs. No special treatment of the socks. No special cycle on the washing machine. No following a hundred (or ten) instructions about how to avoid infection. Like my depressed friend, I had the reaction: Why didn’t my doctor tell me this? He didn’t tell me because he didn’t know, I realize. Why he didn’t know . . . is a harder question. [...]
October 15th, 2009 at 7:46 am
[...] A friend with bipolar disorder writes: When I wrote in your blog that I use your discovery daily, it means that every day I look in a mirror for an hour, starting at approximately 6:30 a.m. I have the mirror about 20 inches from my face because I have read that a mirror image is half the size of the object reflected. [Life-size faces appear to work best. Using a mirror means the face you see is perfectly life-size, allowing for distance. TV faces can be larger or smaller than life-size.] To keep from being bored while looking at my face in the mirror, I mostly listen to tapes of C-SPAN programs. Sometimes I listen to music. Once or twice a week I may just think, or plan my day. That does get boring after about 30 minutes. [...]