When Did Anything Abnormal Become a Treatable Disease? Entry 6 – 2008

When I was a child, my family often told a funny story about my grandfather. In the 1920s he was screened by an eye doctor and found to have better than 20:10 vision. Instead of celebrating, the doctor prescribed glasses to “correct” his vision to a normal 20:20 level, which would be “easier on his eyes.” Apparently, it was believed that seeing too well might he harmful in the long run. As the story goes, he got the glasses, but chose not to wear them. We all laughed at how unsophisticated medicine was in the “old days” when doctors didn’t know better. Certainly, with all the technology and medical advancements of today, we wouldn’t treat something just because it wasn’t normal, would we?

A disease classification for everyday life.

Oddly enough, last month psychologists published a study regarding a condition called Limerence (1). They suggest that this mental disorder will become an accepted diagnosis in the near future, with associated medical treatments. The symptoms of the disorder include euphoria, mania, and obsessive-compulsive, single-minded thoughts. When and how does it afflict people? When they fall in love. Giving a new meaning to love-sick and crazy-in-love, these researchers believe that in some cases the condition requires treatment because it becomes a disorder.

The psychologists intentionally differentiate Limerence from other personality disorders and mental conditions, hoping that by 2012 (the next release of official diagnostic categories), the next iteration of diagnostic labels will award it the attention it deserves. In the spirit of prevention and cure, perhaps there will be an immunization for spring fever, or a surgical repair for broken hearts. OK. Joking aside, one has to wonder how our society has become so willing to label every aspect of life a medical disorder in need of a cure. What happened to supporting people as they go through life experiences?

In his book, The Last Well Person, Dr. Nortin Hadler gives worrisome statistics about how we have so expanded our all-encompassing definition of illness that it is becoming almost impossible to be considered healthy (2). More and more ordinary human events are declared to be “recognized” disorders. One only has to watch the latest advertisements to hear about symptoms that are now official-sounding, treatable diseases, including hot-flashes from menopause, trouble sleeping and dry-eyes (a tear-duct disorder).

Criteria for classifying known diseases keep getting pushed to earlier and lower levels. Treatment guidelines for high blood pressure, diabetes, and high cholesterol now reach down to classify “pre-” conditions and borderline levels. One diagnosis, Metabolic Syndrome, is, ironically, a classification applied to people who cannot yet be diagnosed. This syndrome is classified when a person has pre-diabetes, and elevated, but not-high-enough-cholesterol and is overweight, but perhaps not obese. Metabolic Syndrome is one of the latest, popular risk targets for health vendors, because it predicts future costs and illness. Good information about risk? Yes. A reason for yet another diagnosis? We’re not so sure.

Do not underestimate the power of a disease label. It can provide permission for treatment (insurance often requires the label to approve the treatment), it can disqualify you from a job (such as being a pilot or a truck driver), and it can provide eligibility for services or money. Labels open some doors and close others. The label itself has many consequences, and embodies incentives for both the patient who receives it and the provider who applies it.

Because screening often seems harmless and well-intended, the public is slow to object to efforts to cast a wider net and find risk sooner. Rarely do we consider the downside to getting a new label. But more often than not, a Metabolic Syndrome label does little to raise awareness and self-care in patients, and instead encourages more and earlier medical treatments. Seldom do we stop to ask if more treatment is universally a good thing, or at least meets a reasonable level of cost benefit.

How abnormal is abnormal enough to warrant treatment?
Besides applying new labels, we have also continued to broaden existing labels beyond effective levels of treatment. One example of expanding treatment is evident in the widespread use of statins, a medication that helps prevent heart attacks and strokes. Several recent articles have recommended expanding use to people with lower levels of cardiovascular risk (3). And the arguments seem convincing. Essentially, medical experts want to expand statin treatment to all people with a 1.5-in-10 chance of heart disease in 10 years instead of just treating those with a 3-in-10 chance in 10 years. More is better, right?

But do we really save more lives simply by intervening with earlier medical treatment? Not necessarily. A 2006 modeling study projected results from seven different guidelines regarding statin treatments (4). As shown, the most efficient guideline (used in New Zealand , shown in red) treated about 13% of the population and saved one life for every 108 people treated. The least efficient guideline (an optional one used in the U.S., shown in turquoise) recommended treating 24.5% of the population and saved the same number of lives while treating twice as many; one life for every 198 people treated! Perhaps we can be smarter about identifying the right people instead of simply expanding treatments to more people who may or may not benefit.

All of this comes at a cost. While many insist cost should not matter in making health decisions, resources are finite. Cost-effectiveness reviewers looking at statins note that if we treat people at a 30% risk of heart disease, the cost is “bearable.” If we drop the requirement to 15% risk, the cost is “huge,” and could add the equivalent of $140[i] for every U.S. adult—to treat a 1.5-in-10 possibility of one disease in the next 10 years (5). This doubles the expenditure, for a minimal benefit.

Expanding treatments also comes with potential health risks. While statins are generally considered quite safe, we all know that no treatment is free of side effects (6), and there is concern about whether we have enough information to predict long-term effects of statin use (7). Specifically, there are reports of side-effects at higher dosages (8).

And, as is so often the case in medicine, we avoid the most obvious solution: that most of us could lower our risk with simple improvements in our health habits, like exercise, eating right and not smoking.

Why this matters
The way our system works makes it natural for this expansion to happen. Pharmaceutical companies have a natural incentive to sell more medications to more people. Providers in a fee-for-service arrangement have an incentive to see patients more often, with more serious disease. (Services for a more severe disease usually correspond with a higher reimbursement fee than services for a minor symptom.) Patients naturally want an easy way of minimizing risk, but because they often do not pay the full price for medications, there is less economic incentive to ask questions about how valuable a new drug really is, or what their lower-cost alternatives might be.

All combined? A recipe for more official diseases, more treatment, more healthcare consumption, and more cost to each one of us, without a measurable improvement in health for anyone. Pretty soon, being normal might become so rare (and abnormal!) it will get its own classification.

Now, please excuse me while I go get some glasses—I think my eyes hurt from seeing too clearly.

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1. Jayson, S. "'Limerence' Makes the Heart Grow Far Too Fonder." USA Today, 6 February 2008.
2. Hadler, Nortin M. The Last Well Person : How to Stay Well Despite the Health-Care System. Montreal; Ithaca: McGill-Queen’s University Press, 2004.
3. Komaroff, A. L. "The Expanding Role of Statins." Journal Watch Psychiatry (2004).
4. Manuel, D. G., K. Kwong, P. Tanuseputro, J. Lim, C. A. Mustard, G. M. Anderson, S. Ardal, D. A. Alter, and A. Laupacis. "Effectiveness and Efficiency of Different Guidelines on Statin Treatment for Preventing Deaths From Coronary Heart Disease: Modelling Study." BMJ 332, no. 7555 (2006): 1419.
5. "Health Economics of Statin." Bandolier.Ogbru, O. Marks J.
6. Statins." MedicineNet.com (2007).
7. Carey, J. "In the Real World, a Slew of Side Effects From Statins."2008. (accessed March 10, 2008).
8. DN Kiortsis, TD Filippatos, DP Mikhailidis et al. Statin-associated adverse effects beyond muscle and liver toxicity Atherosclerosis. 2007 Nov;195(1):7-16.
   

Footnote:
[i] This figure was calculated by converting the British pounds into equivalent dollars, using a conversion of 1:2. The authors estimated £70,000 for 1,000 patients in a practice. For 100,000,000 adults, the total cost is $7B to expand treatment from 30% risk to 15% risk.