Treating Dementia: Do We Have a Pill for It?

Walter A. Brown
Online article and related content current as of May 20, 2010. JAMA. 2010;303(19):1983-1984 (doi:10.1001/jama.2010.628) http://jama.ama-assn.org/cgi/content/full/303/19/1983

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BOOK AND MEDIA REVIEWS

to affect depression outcomes will delay recognition of this problem and divert existing resources from its solution.
Elaine W. Cotlove, MD Department of Psychiatry George Washington University (Emeritus) Washington, DC ewc.md@verizon.net
Financial Disclosures: None reported.

TREATING DEMENTIA: DO WE HAVE A PILL FOR IT?

Edited by Jesse F. Ballenger, Peter J. Whitehouse, Constantine Lyketsos, Peter V. Rabins, and Jason H. T. Karlawish 267 pp, $60 Baltimore, MD, Johns Hopkins University Press, 2009 ISBN-13: 978-0-8018-9365-0

THIS BOOK AROSE FROM A 2-DAY CONFERENCE HELD IN MARCH 2004 at Johns Hopkins entitled Drug Development for Alzheimer Disease: Historical and Clinical Perspectives. Although most of the chapter authors participated in the conference, to ensure a full range of opinion the editors asked several other experts who had not participated in the conference to contribute chapters. The result is an interdisciplinary analysis of the development of drugs for Alzheimer disease. Alongside and intertwined with the theme of drug development is thorough scrutiny of the concepts of Alzheimer disease and dementia from a wealth of viewpoints: anthropology, ethics, neurology, philosophy, sociology, psychiatry, and pathology. The book is meant to provide multiple perspectives and to illuminate the controversies surrounding dementia and its treatment. This it does. The perspectives offered are indeed diverse, and they are often incompatible. More than one chapter, for example, makes the case that Alzheimer disease is a social constructnot a disease but rather an accompaniment of normal aging; other chapters present the conventional (to health professionals) view that Alzheimer disease and other dementias are pathological entities and supply the genetic, pathological, and clinical evidence for that view. For the most part, the drugs used to treat Alzheimer disease take a beating. Older, widely used drugssome of which, like dihydroergotoxine (hydergine), are still in useare dismissed as essentially useless. As for the drugs currently prescribed for the cognitive symptoms of Alzheimer diseasethe cholinesterase inhibitors and memantinethe picture is not pretty. In his chapter on the history of dementia treatment, editor Jesse Ballenger meticulously tracks the flawed research behind the older vasodilators and metabolic enhancers and the newer cholinesterase inhibitors; in Science and Marketing: The Promotion of Donepezil in the Primary Research Litera2010 American Medical Association. All rights reserved.

ture, Gilstad and Finucane document the verbal sleight of hand used to make donepezil look better than it is; in Managing Dad, a memoir about her fathers dementia, Judith Levine describes how the benefits ascribed to antidementia drugs can draw attention away from psychosocial treatments that may offer more help. Levine recalls that on her fathers 86th birthday a social worker gave her father a squishy ball covered with multicolored patches. Tossing that ball back and forth seemed to do more for her fathers mood, agitation, and engagement than the donepezil and quetiapine fumarate he had taken for years. Still, alongside these negative views readers get Pharmacologic Treatment of Dementia: A Clinicians View, by Anderson. Based on clinical trial results as well as clinicians experience, Anderson believes that the antidementia drugs provide real, albeit limited, benefit. He presents several cases illustrating the substantial improvement that these drugs can bring. For example, when a severely impaired 72-year-old man with dementia was treated with a combination of rivastigmine and memantine he made such robust improvement in both cognition and behavior that he was discharged from the nursing home. Anderson concludes: For such a devastating illness, any treatment benefit, no matter how trivial or short acting, is a blessing for the patients and families who continue to suffer (p 114). In the preface, the editors express the hope that Treating Dementia will generate respectful consideration rather than arrogant dismissal of alternative views. It did this for me. I am a firm believer in the biomedical model of Alzheimer disease and have little doubt that a biological treatment directed at the underlying pathophysiology offers the best hope for a cure. I dismiss out of hand the postmodern approach to dementia that conceptualizes it not as a disease but rather as a social construct. Yet although Danny George and Peter Whitehouse, in their chapter challenging the concept of Alzheimer disease, take the social construct approach that makes no sense to methey argue that Alzheimer disease is a label arbitrarily applied to a position on the continuum of normal agingthey include in their chapter a discussion of the detrimental consequences of applying the Alzheimer label. That label, stigmatizing as it is, negatively shapes the expectations of patients, caregivers, and clinicians. The authors have convinced me that changing the labelor at least reconceptualizing itmay not, as they hope, allow persons with Alzheimer disease to be contributing members of society, but it certainly opens therapeutic options for such individuals. Whitehouse offers his patients a program of psychosocial interventions that includes volunteering as a mentor to children, learning new skills such as meditation, keeping socially engaged, and participating in structured conversations and writing exercises. Research has yet to document the
(Reprinted) JAMA, May 19, 2010Vol 303, No. 19 1983

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BOOK AND MEDIA REVIEWS

effectiveness of these interventions; however, as is often said about cholinesterase inhibitors, they couldnt hurt.
Walter A. Brown, MD Warren Alpert Medical School of Brown University Providence, Rhode Island Tufts University School of Medicine Boston, Massachusetts walter_brown@brown.edu
Financial Disclosures: None reported.

THE PROTEST PSYCHOSIS: HOW SCHIZOPHRENIA BECAME A BLACK DISEASE

By Jonathan M. Metzl 288 pp, $24.95 Boston, MA, Beacon Press, 2009 ISBN-13: 978-0-8070-8592-9

CITING DRAPETOMANIA, A MENTAL ILLNESS THAT CAUSED African American slaves to flee captivity, or the claim still popular at the turn of the 20th century that Negroes were psychologically unfit for freedom, psychiatrist Jonathan Metzl argues that race and insanity share a long and troubled past continuing well into the 20th century. In his most recent book, The Protest Psychosis: How Schizophrenia Became a Black Disease, Metzl adds more fuel to this troubled past by showing how schizophrenia was shaped as a black disease. To make his case, he uses US medical journals, newspapers, magazines, pharmaceutical advertisements, studies of popular opinion, music lyrics, oral histories, and films to examine how assumptions about race and schizophrenia in the United States changed dramatically during the civil rights era; the result is a fascinating, penetrating book by one of medicines most exceptional young scholars. While the book navigates the period from the 1920s to the present, it focuses primarily on social changes during the 1960s and 1970s. Before the civil rights movement, conventional US medical and popular opinion assumed that persons with schizophrenia were most often white, generally harmless, typically middle-class females whose behaviors were considered merely embarrassing and upsetting; it was also attributed to white intellectual geniuses. Indeed, Metzl maintains that from the 1920s to the 1950s psychiatric textbooks portrayed schizophrenia as a very broad, general condition marked by emotional disharmony that negatively affected the ability of white persons to think and feel. But beginning in the 1960s, a sudden change marked schizophrenia as an illness manifested not by docility, but by rage, now afflicting Negro men whose illness was characterized by volatility and aggression. Metzl shows readers how, in the worst cases, psychiatric authors conflated the schizophrenic symptoms of African American patients with the perceived schizophrenia of civil rights protest, particularly those organized by Black Power, Black Panthers, the Na1984 JAMA, May 19, 2010Vol 303, No. 19 (Reprinted)

tion of Islam, or other activist groups. In fact, the title of Metzls book is taken from a 1968 article in the Archives of General Psychiatry by a then-prominent psychiatrist and coauthor who described schizophrenia as a protest psychosis characterized by aggressive, hostile, and delusionally anti-white black men. This portrayal found its way into advertisements for antipsychotic medications such as haloperidoladvertisements that at the time showed angry black men with clenched fists, whose symptoms of social belligerence required chemical management. Thebookisdividedinto6parts,eachcontainingseveralchapters. The first part is a detailed description of Ionia State Hospital for the Criminally Insane in Ionia, Michigan, which between 1885 and 1976 . . . was home to one of the nations most notorious mental asylums. One of the few asylums with remaining records, Ionia offered fertile ground for Metzl to develop his case as he visited its archives over a period of 4 years. The next 4 parts of the book each bear the name of an Ionia patient hospitalized between 1941 and 1969, their stories reconstructed from close examination of their case files; from historical events, cultural assumptions, and medical knowledge of the time; and from oral histories of Ionia employees. One particularly fascinating discussion in this section focuses on the second edition (1968) of the Diagnostic and Statistical Manual of Mental Disorders, which Metzl suggests functioned as an implicitly racist text because it mirrored the social context of its origins in ways that enabled users to knowingly or unknowingly pathologize protest as mental illness. The final part of the book, aptly titled Remnants, offers Metzls observations on current thinking and research on schizophrenia, cultural competency efforts in medical training, and social institutions that continue to dominate, oppress, or exploit minority populations. As such, the author is careful not to cast this story and other phenomena related to race as the work of individual racist physicians, even though medical education hardly frees anyone from preexisting biases. Yet focusing on the individual [trainee/physician] obscures the impact of the structural, while putting undue pressure on even well-intentioned patients or doctors to solve problems in 10-minute office visits that have taken decades or even centuries to evolve. Folding together equal measures of historical analysis, psychiatry, social criticism, and impeccable research, The Protest Psychosis offers not only psychiatrists but anyone involved in health care new insight into the nature of disease, the ongoing flux of medical knowledge, the influence of culture and politics on medicine and science, and the unequal treatment still at play regarding race in the United States.
Delese Wear, PhD Behavioral and Community Health Sciences Northeastern Ohio Universities College of Medicine Rootstown dw@neoucom.edu
Financial Disclosures: None reported.

2010 American Medical Association. All rights reserved.

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