This is an opinion piece from the first author of this article: http://www.ncbi.nlm.nih.gov/pubmed/21474251 Medicalisation: not necessarily a dirty word By Simon Arnett Advances in biomedical research, market forces and profit seeking by pharmaceutical manufacturers has given rise to the phenomenon of medicalisation the development and encroachment of medical interventions into aspect of life that were previously thought of as unavoidable aspects of a personal life history. Most commonly the term is used in the context of medical therapies for conditions that while not life-threatening, are argued have the potential to reduce the quality of life of affected persons. For example, where previously a child may have historically been considered to be simply badly behaved, such behavioural patterns may be medicalised to represent a developmental disorder such as attention deficit hyperactivity disorder that can be remedied with a drug regime. The modern pharmacological treatment of depression and mood disorders, once considered the sole province of psychologists, is also the result of the process of medicalisation. Fatigue due to disrupted sleeping patterns is increasingly seen as something that can be managed with drugs such as modafinil rather than a regular sleeping pattern and sleep hygiene. And of course, there is what could be considered as the most lucrative triumph of medicalisation: sildenafil and the management of erectile dysfunction. However, in recent years the term medicalisation has attracted a significant negative connotation. Critics use the term to refer to the aggressive marketing of expensive drugs and medical procedures for trivial complaints, which come at the expense of research and provision of treatment for more significant disease conditions with substantial associated morbidity and mortality. And such fears are wellgrounded; expenditure on trivial health complaints as a result of medicalisation is costing billions of dollars of both private and taxpayer funds annually. This trend is only likely to continue, given the extremely profitable nature of this market and the relentless demand for cures for maladies no longer considered an unavoidable a part of life. There is also the potential for a cost to patient welfare beyond a financial one. A potent example of the potential pitfalls of medicalisation is the treatment of tall stature in women; as a result of patient demands, some in the medical community regard it as a condition that needs to be treated in puberty with exogenous oestrogen to induce early growth plate fusion. This is done with scant regard for the possible side effects of treatment such as development of ovaian cysts, hypertriglyceridaemia and increased risk of clotting disorders. Thankfully this practice has waned in popularity but there are others like it. As a result, the long term wellbeing of a patient is placed at risk for the sake of treatment of a pleiomorphism that is only regarded as a condition because of the whims of arbitrary societal fashions. Despite these costs, the benefits of medicalisation should not be ignored. Expansion of research into areas previously considered as a natural facet of the human condition or complaints which western biomedicine simply had no solution for represents real hope for an improvement in the quality of life for patients afflicted with these conditions, as well as substantial benefits to society as a whole. For instance, the reality of chronic fatigue syndrome, has been debated inside and outside of the medical community for a many years. Despite chronic fatigue syndrome being identified in the medical literature in the late 1980s, some medical practitioners still harbour scepticism as to whether CFS represents an organic disease state pathophysiology, as opposed to a somatisation of psychological disturbance, despite patient accounts about the very real lived experience of the condition. However, recent research findings are at last providing a cohesive disease model explaining affective disorders as a qualifiable disease state precipitated by an acute inflammatory infectious episode. There is also an emerging body of evidence identifying a long-term increase in reactive oxygen species production in CFS patients compared to controls, which may be an important mechanistic underpinning of the disease process. With a plausible disease mechanism in place, it may finally be possible for researchers and clinicians to begin the systematic design of efficacious therapeutic interventions for a previously intractable disease condition. This progress also represents a vitally important vindication for patients afflicted with affective disorders, validating patient experiences in the eyes of western biomedicine. If this research is borne out, it may not be long before a chronic fatigue syndrome patient consults a primary care health professional, and instead of being met with an exasperated shrug or well-meaning but ineffectual encouragement, are instead offered a course of treatment that reliably improves patient outcomes and quality of life. Therefore, CFS may represent an emerging triumph of medicalisation, bringing CFS into the fold of diseases that can be effectively managed with biomedical interventions. Medicalisation can also be a progressive force within established medical fields. As mentioned previously, medicalisation of depression lead to modern treatment regimes encompassing use of SSRIs and pharmacotherapy. This medicalisation has advanced in recent years to include the depression that accompanies chronic disease. While it is intuitive that chronic disease would carry a substantial risk of depression owing to the psychological burden imposed by lifestyle restrictions and organic pain, it is increasingly apparent the chronic disease (especially those with an inflammatory component to their pathophysiology) is of itself an independent risk factor for the development of depression. There is a substantial body of evidence that indicates that inflammatory mediators such as TNF have a direct neuromodulatory effect, and part of this effect is the ability to drive development of clinical depression. It has been demonstrated that there is a direct correlation between cerebrospinal fluid concentrations of inflammatory mediators and severity of depression, and there have been suggestions that part of the clinical efficacy of SSRIs is attributable to an anti-inflammatory property of these drugs on microglia, a major source of inflammatory mediators within the brain. Again, as with CFS, medicalisation of what was previously a psychosocial field has produced benefits for patients. A more thorough understanding of the pathophysiology of a disease processes, in this case the close functional interplay between the neurological and nervous systems, will provide a theoretical framework that will direct the development of more efficacious therapeutic interventions that will improve the quality of life for patients. So what impact should medicalisation have on the practice of individual medical providers? Furthermore, what is our role in the progression of medicalisation? Primary care providers are placed in a unique position of being a common initial point of contact for patients who are seeking advice following learning about medicalisation advances through traditional and electronic media. As a result general practitioners are arguably the most heavily affected by medicalisation than other specialties. It is this authors opinion that it is up to individual practitioners to direct the implementation of medicalisation by understanding what the latest and greatest advances offered by medicalisation actually represent, and judging if they are offer a real benefit for patients as opposed to frivolous and expensive, but often wellmarketed, money sinks. This is no easy task, as such judgements require a comprehensive understanding of the relevant field and in some cases an appreciation of the primary literature, a substantial ask of notoriously time poor and over-stretched primary care providers. We bear the burden of being wary of medicalisation of diseases whose impact on patients may be trivial and could be managed through careful counselling or provision of some perspective, such as the example of treatment of tall stature, or where the ends achieved at substantial expense are better achieved with sustainable lifestyle modification, such as the medicalisation of some cases of obesity as metabolic syndrome. Nevertheless, it falls to us to be aware of advances brought through medicalisation that offer tangible and substantial benefits for the quality of life of our patients. Dismissing medicalisation as a whole puts our patients at risk of missing out on interventions that may offer very real and substantial benefits for patient quality of life. Simon Arnett is a Year 2 student at the ANU Medical School Source: http://www.ama-act.com.au/files/CanDocSept10 (1).pdf Note, I had to strip the formatting when I cut and pasted the text, I may edit the formatting more later.