What’s With These Names in Mental Health Care?

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PSYCHIATRIC VIEWS ON THE NEWS

Recently, there were two reports about concerns over changes in terminology in our field.^1,2 Though the reports covered different areas, it seems there may be a deeper issue here.

I know how important a name is. All parents do. My given first name, abbreviated professionally with “H.” is Hillard-my father’s choice. But my mother and I never really liked it. It seemed ripe for teasing, so I always used my middle name, Steven, though as I aged I came to embrace the Hillard in me.

Not long ago, I had a debate with two of my youngest grandchildren about the word “crazy.” They had come to like using it in everyday speech. I tried to explain that “crazy” was a detrimental, stigmatizing term for those with mental illness. Such terms and names can have powerful effects on psychology and attitudes.

Names and terminology do change in psychiatry. Take manic-depressive disorder morphing into bipolar disorder in DSM. Personally, I still think that manic-depression is more descriptive and understood by the public, so I often use that terminology when I discuss bipolar publicly.

Medication names have always been confusing, though important. We have always had generic names. However, these are unwieldy and not well recalled by patients. Brand names are carefully chosen by Pharmaceutical companies-sometimes in consultation with experts who specialize in the business of “name chosing.”

Pharma wants their product names to convey a positive, if subliminal, message. Take Prozac. The name implies that the medication will proactively zap away your depressed mood. What does the generic name, fluoxetine, convey? Not much. One of my favorites is Abilify . . . not too much different than ability. Certainly, we want patients who take it to recover their ability, but sometimes medication is not essential to that recovery.

An international group of psychopharmacologists now feels that the nomenclature for classifying psychiatric medication is outdated. They cite (for example) patient concerns about being prescribed a so-called antidepressant for an anxiety disorder. We clinicians know that such medications can help both depressive and anxiety symptoms.

It is hoped that the new nomenclature might reduce stigma by referring to the drug’s biologic mechanism. For example, instead of referring to clomipramine as an “antidepressant,” it would be described as a “serotonin reuptake inhibitor.” Or, the “antipsychotic” perphenazine might be renamed a “D2 receptor antagonist.” This change would be more akin to how medications are being described in the rest of medicine.

A headline in the Boston Globe is titled “Language of addiction itself can hurt.”² Advocates for addiction recovery feel that many words, such as “addict,” “abuse,” “dependence,” “junkie, and “dirty” urine are stigmatizing. Those concerned refer back to other stigmatizing terms in medicine and psychiatry, such as “cripple,” “retards,” and “insane asylum” that have generally disappeared from public discourse. Will people come for treatment if they feel stigmatized, or will they instead wind up in prison for the criminalization of drug problems?

One of the challenges in addressing psychiatric terminology is that no agency or organization is responsible for determining such nomenclature. That leaves it open to professional and public discussion, including the recent tendency for being PC. There must be a better approach.

In some articles for Psychiatric Times, Ronald Pies, MD has argued against the simplistic use of “chemical imbalance” to explain how antidepressants work. Yet, new proposals by the psychopharmacologists seem to connect to that perspective.

Given that there is still much to learn about the underlying mechanisms of psychotropic drugs, I tended to respond to what my patients wanted to know about the drugs I was prescribing. I said things like, “this medication often helps depression like yours.” I used the name that appeared on the bottle of the medication.

In the realm of substance use and its potential problems, those terms do seem stigmatizing to me. Wouldn’t “overuse” be more acceptable than abuse, for instance?

And I would prefer that psychiatrists not be referred to as “shrinks.” At best, we help expand the minds of patients, not shrink them-despite the concern of anti-psychiatrists that psychiatric medication shrinks the brain.

But I would like to hear from you. What names and terminology would you like to change, to what, and why?

References:

1. Moran M. Psychopharmacologists seek new nomenclature for psychiatric drugs. Psychiatric News. January 22, 2016. http://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.PP1a1. Accessed February 8, 2016.
2. Freyer F. Language of addiction itself can hurt, advocates say. Boston Globe. February 4, 2016. https://www.bostonglobe.com/metro/2016/02/03/finding-right-words-for-addiction/EdNzUNS10KQDinOEk3lQpN/story.html. Accessed February 8, 2016.