“You wonder which is worse, the symptom or the cure”

In the musical Next to Normal by Tom Kitt and Brian Yorkey, the main character Diana undergoes various medications and electroconvulsive therapy (ECT) to manage her hallucinations and bipolar, resulting in severe memory loss. Throughout the second act, she struggles to gain back her memories, highlighted by the line, “You wonder which is worse, the symptom or the cure.” Though perhaps an extreme example, it still raises an interesting question: where does one draw the line between preventing the symptoms and protecting who we are?

To understand this question, we can look at drugs like selective serotonin reuptake inhibitors (SSRI), and how they are believed to work. The disease-centered model is a popular model, which states that medications such as SSRIs correct an abnormal brain state, and that any side effects that result from treatment are separate. SSRIs work by blocking neurotransmitters from being reabsorbed, leaving increased amounts of serotonin in the synaptic cleft for longer periods of time. This allows the serotonin to continuously stimulate postsynaptic receptors, correcting chemical imbalances that occur from depression. Though effective, it can take up to 6 weeks for the medication to work, and patients may experience enhanced symptoms during initial phases of treatment (Chu and Wadhwa 2023). One study even found a statistically significant gradual decline in patients’ MMSE cognitive scores over an 8-week period, and concluded that starting SSRIs can be associated with acute cognitive dysfunction or memory complications during the early phases of treatments (Sayyah et al. 2016).

Contrast the disease-centered model, researchers like Joanna Moncrieff and David Cohen propose a drug-centered model, which views drugs as psychoactive substances that create a deliberate, altered physical and mental state. From this model, the cognitive changes (e.g., numbness) are the mechanisms that suppress the symptoms of distress (Moncrieff and Cohen 2009). This raises an interesting ethical question: when a treatment alters your personality, are you being “cured”, or are you paying a heavy price to manage your symptoms?

This ethical question is further highlighted when we consider electroconvulsive therapy (ECT), a medical procedure where electric currents are safely delivered to the brain to induce a small, controlled seizure. It acts much faster than standard medications, often showing greater than a 50% reduction in depressive symptoms within a short 2-to-3-week period (Kritzer et al. 2023). However, there are ethical issues to consider with the use of ECT. Some argue that ECT causes amnesia, apathy, and memory loss in nearly everyone who receives it, and that true, uncoerced consent is difficult to obtain because patients are rarely fully warned about the possible side effects (Mosher and Cohen 2003).

When evaluating psychiatric interventions, there is a tension between beneficence (the medical duty to relieve suffering) and patient autonomy (preserving an individual’s identify) (Varkey 2021). While treatments can alleviate symptoms, their side effects force us to ask whether suppressing symptoms is truly a “cure” if the intervention alters a patient’s personality. Looking at SSRIs through a drug-centered model can help address this dilemma by empowering patients to weigh the real advantages and disadvantages of treatment, which supports true informed consent and patient autonomy. By stressing that psychiatric drugs are substances that alter your mental state, it allows people to judge for themselves whether they choose to take the drugs (Moncrieff and Cohen 2009). In the end, whether dealing with mild side effects from daily pills or major memory loss from ECT, patients must choose: is getting relief worth potentially losing a piece of who you are?

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References

Chu, Andrew, and Roopma Wadhwa. 2023. “Selective Serotonin Reuptake Inhibitors.” In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK554406/.

Kritzer, Michael D., Angel V. Peterchev, and Joan A. Camprodon. 2023. “Electroconvulsive Therapy: Mechanisms of Action, Clinical Considerations, and Future Directions.” Harvard Review of Psychiatry 31 (3): 101–13. https://doi.org/10.1097/HRP.0000000000000365.

Moncrieff, Joanna, and David Cohen. 2009. “How Do Psychiatric Drugs Work?” The BMJ 338 (May): b1963. https://doi.org/10.1136/bmj.b1963.

Mosher, Loren, and David Cohen. 2003. “The Ethics of Electroconvulsive Therapy.” AMA Journal of Ethics 5 (10): 463–66. https://doi.org/10.1001/virtualmentor.2003.5.10.oped1-0310.

Sayyah, Mehdi, Kaveh Eslami, Shabnam AlaiShehni, and Leila Kouti. 2016. “Cognitive Function before and during Treatment with Selective Serotonin Reuptake Inhibitors in Patients with Depression or Obsessive-Compulsive Disorder.” Psychiatry Journal 2016: 5480391. https://doi.org/10.1155/2016/5480391.

Varkey, Basil. 2021. “Principles of Clinical Ethics and Their Application to Practice.” Medical Principles and Practice 30 (1): 17–28. https://doi.org/10.1159/000509119.