Updated: Aug 30
Editor’s Note: We’re pleased to kick off the month with the second in a series of posts by UCLA’s Brad Fidler, Director of the Kleinrock Internet History Center and a historian of anti-psychotic medication and its markets.
Gary Becker Wants You to Maximize Utility
Economists often expect us to be rational and self-maximizing when it comes to the financial choices we make as consumers: we are meant to wisely allocate our resources in order to secure the most utility for our dollar—and in the process to reward the most efficient companies. However, it turns out that we don’t always behave this way, and our economies are correspondingly less stable and prone to growth than was once imagined. Indeed, if we are truly self-interested, our interests are broad and contradictory, and each of us works from a laundry list of altruistic and other inexplicable motivations. The ideal of the rationally self-maximizing model of human behavior is called “homo economicus,” often derisively, by academics who believe it flies in the face of reality and decry the way it has been used to justify mainstream economic models that have led to forty years of slowing growth and stagnation.
Homo economicus is a useful concept for drug historians because, sometime during the heyday of the American post-war economic expansion, another rational consumer emerged: the health-maximizing consumer. (The homo salinas, perhaps?) It is worth rethinking the role that this ideal health maximizer plays in debates concerning the use and overuse of psychiatric medication.
The health maximizer is a model of the consumer whose motivation and behavior flow from concern for the risk-benefit ratios of the individual medications she takes. It’s a reasonable model, and also the place where controversy begins. Current rates of psychiatric medication use are defended most adamantly by adherents to the “biomedical model” who see mental illness chiefly as a neurological issue to be treated pharmacologically. Medication should be used, their thinking goes, so long as the drugs are more helpful in treating the illness than they are harmful in their side effects. When critics attack this explanation, they often do so by alleging (sometimes accurately) that pharmaceutical firms misrepresent the risk-benefit ratio of their products. This version of events assumes the ideal of the health-maximizing consumer, but argues that her ability to evaluate a drug’s harms and benefits is compromised by biased information. In this account, increased use of medication use has less to do with improving harm-benefit ratios than it does with false advertising and trickery. You would think more rational and self-aware consumers would notice.
Our reliance on the model of the rational health maximizer makes it difficult to break out of the harm-benefit debate sketched above. However, by moving beyond this simplified and abstract model, one alternative can be explored: how a medication’s therapeutic benefits and harms interact with the whole of an on-the-ground consumer’s existing coping strategies.
I want to use the examples of cycling, cigarettes, and Qnexa– the weight-loss drug I covered in my last post— to illustrate this point. A consumer’s bicycle commute to work simultaneously puts him at risk for severe injury at the hands of Los Angeles motorists, while keeping his blood pressure, weight, and stress in check. Like so many other therapeutic endeavors, cycling is at once good and bad for well-being.
Tastes Great, Smokes Mild, Seems Crazy!
Let’s say the consumer starts smoking cigarettes, a habit that, at first glance, has no health benefits, and many drawbacks. However, for some populations the trade-off makes sense, because nicotine seems to offset the cognitive deficits caused by serious mental illness and/or the antipsychotic medications used to treat it. Cigarettes are one of the most despised examples of a therapeutic strategy available, but there are still cohorts who use them and accept their side effects. For example, by some estimates, well over half of diagnosed cases of schizophrenia are smokers. Working from a different definition of health than we may be accustomed to, they also deploy a different constellation of therapeutic strategies. So let’s say our bike-riding Los Angeleno is smoking to blunt the effects of an antipsychotic medication.
Cycling helps him focus at work, which also reduces stress. Smoking, however, reduces lung capacity, which could lead him to reduce or stop his cycling, thus leading to weight gain and increased health risks. Qnexa can be used to help reduce weight and obesity-associated health risks, as well as body image concerns. However, it can also cause cognitive impairments that could, for example, reduce work productivity and increase stress (and, thus, harmful cortisol). If the antipsychotic drug that prompted the smoking was being taken for bipolar disorder, though, Qnexa could likely be replaced with off-label Topamax, its main ingredient, which is also popular as an off-label mood stabilizer. The substitution might allow the consumer to dial back the antipsychotic medication, which has a much larger side effect profile, including weight gain and metabolic disorders. It might also be a good time for him to cut back on smoking– assuming for the moment that he is in the first place, seriously interested in, and dedicated to, his physical health.
Even an extremely simplified scenario involving a commute, a bad habit, a psych med, and a weight loss pill can quickly generate an elaborate system from within which to evaluate a new drug. Understanding how a medication fits within an existing set of personal trade-offs may be a useful way to determine the way consumers evaluate drug effectiveness—more useful than a rhetorical contest over the severity of side effects. Here the social sciences have (another) valuable role to play in the clinical world: investigating consumer perceptions and experiences of the varieties of benefits and harms to their health as they bring psychiatric medication(s) into their worlds of coping strategies.