December 28, 2006

Mood Enhancement



Amphetamines, barbiturates, benzodiazepines, and other ‘mother’s little helpers’ have long been used to improve the moods of healthy people. However, the high potential for addiction and tolerance with these drugs dissuades most people from using them (Farah & Wolpe, 2004). Classic antidepressants, while presenting no such risks, have unpleasant side effects that limit their appeal only to those suffering from clinical depression.

Since the introduction of Prozac (fluoxetine) in the late eighties of the last century, a number of so-called selective serotonin reuptake inhibitors (SSRIs) – the ‘new antidepressants’- have been developed and introduced. Originally developed for the treatment of major depression and other emotional problems so disabling as to indicate the presence of mental illness, such mood-enhancers presently are also, and increasingly, prescribed for people whose problems are not so severe and whose neurochemistry may not be abnormal (President’s Council on Bioethics, 2003). The SSRIs have relatively narrower neurochemical effects and consequently fewer side effects then classical antidepressants.

Most people using SSRIs meet DSM IV criteria for some psychiatric disorder, although not necessarily major depression: dysthymia (a mild depression), social phobia (an extreme form of shyness and self-consciousness), premenstrual dysphoric disorder (a recurrent negative mood associated with PMS) and various eating disorders respond well to SSRIs (Farah & Wolpe, 2004). And, as said, some people using SSRIs have no recognised illness and feel, in Peter Kramer’s words, ‘better than well’ when taking an antidepressant (Kramer, 1993). People who use Prozac and the other SSRIs say that they feel energized, more alert, better able to cope with the world, and better able to understand themselves and their problems (Elliott, 1999).

Neurologically, SSRIs alter the brain’s handling of serotonin. Like other neurotransmitters, serotonin is released from one neuron to bind with and activate another. The brain recycles serotonin after each release, gathering it up again by means of a ‘reuptake system’. SSRIs inhibit the serotonin reuptake system, thus increasing the concentration of serotonin available to the receiving neurons – hence the name ‘serotonin reuptake inhibitor’. When given to patients diagnosed with mood disorders, SSRIs brighten or stabilize moods in most of them, presumably as a result of the increased availability of serotonin in certain crucial places in the brain. Scientists do not yet know how inhibiting the reuptake of serotonin alters the mental state. What serotonin does, how it functions, and even whether it is a serotonin problem that causes depression in the first place, remain largely unknown (President’s Council on Bioethics, 2003).

Beyond psychopharmaceuticals
Using ‘cosmetic psychopharmaceuticals’ like SSRIs is one way to promote mood enhancement (Elliott, 1999). Technical advances in non-pharmaceutical methods for altering brain function are also creating potential enhancement tools (Farah & Wolpe, 2004). Transcranial magnetic stimulation (TMS) and, more rarely, vagus nerve stimulation and deep-brain stimulation have already been used to improve mental function or mood in patients with medically intractable neuropsychiatric illnesses (Berghmans & De Wert, 2004). Research on the effects of non-pharmaceutical methods on brain function in normal individuals has been limited to the relatively less invasive TMS (Farah & Wolpe, 2004).

It is, however, to be expected that in the near future the combination of data from advanced biochips and brain imaging will accelerate the development of neurotechnology (Lynch, 2004). Growing knowledge in the neurosciences, enhanced by exponential advances in neurotechnologies (forms of technology that make it possible to monitor and manipulate the brain’s electrochemistry) are rapidly moving brain research and clinical applications beyond the scope of purely medical use (Sententia, 2004). So-called neuroceuticals, used for therapy and enhancement, and used to improve different aspects of mental health, will become possible. Unlike today’s psychopharmaceuticals, neuroceuticals are neuromodulators that have high efficacy and negligible side effects. By being able to target multiple subreceptors in `specific neural circuits neuroceuticals will create the possibility for dynamic intracellular regulation of an individual’s neurochemistry (Lynch, 2004).

The enhancement of mood raises the following ethical questions

At first glance, enhancement of mood does not seem to be a morally objectionable goal. What can be wrong with striving after the promotion and pursuit of happiness, if the means used do not involve risks or harms?The proliferation of mood-enhancers, particularly outside the domain of recognised mental disorders such as clinical depression, however, raises a number of moral issues. Three sets of concerns seem particularly salient.

The first set of concerns relates to issues of safety; the second is related to less easy to articulate concerns resulting from the many ways in which neuroscience-based enhancement intersects with our understanding of what it means to be a person, to be healthy and whole, to do meaningful work, and to value human life in its imperfection (Farah & Wolpe, 2004). These concerns are related to our self-understanding.A third set of concerns relates to issues of justice, fairness and equity.

1. Safety
Safety is a concern with all medications and procedures. In comparison with other enhancement procedures such as cosmetic surgery or growth hormone treatment, neuroscience-based mood enhancement involves intervening in a far more complex system. So far, medications such as SSRIs have good safety records, and their long-term effects may even be positive. Nevertheless, drug safety testing does not routinely address long-term use, and relatively little evidence is available on long-term use by healthy subjects (Farah & Wolpe, 2004). Recent concerns about SSRIs are about the possible risk of suicide connected to their use, particularly in children and adolescents (Wong et al., 2004), but also in adult patients (Healy & Whitaker, 2003). It thus remains an open empirical question whether the net effects of these or other yet-to-be developed drugs and other non-pharmaceutical interventions will be positive or negative.

2. Self-understanding
Using mood-enhancers for non-medical reasons may alter our self-understanding as individuals and as society as a whole. This self-understanding relates to issues of personal identity and personality, authenticity, emotional estrangement, and to mechanisms of medicalization and ‘democratization’ of mood, emotions and temperament.

Identity and personality
If a person undergoes a striking transformation on medication but feels more ‘like himself’, is this then a metamorphosis to a new, ‘better self’, or the restoration of a ‘true self’ that has been masked by pathology? (Elliott, 2003) The use of SSRIs raises questions about personal identity and personality change. Kramer, the author of Listening to Prozac, found that some of his patients who were shy and withdrawn, or who were rather compulsive, or who had poor self-esteem or were just chronically sad, when put on Prozac underwent a kind of personality transformation. The controlling, compulsive types became laid-back and easy-going; shy people became more self-confident and assertive (Elliott, 1998).Philosophical questions concerning the relationship between mental disorder and personal identity are little researched. Even less reflected upon is the relationship between pharmacological mood changes and personal identity and personality. Obviously, in this regard empirical questions (for instance the self-evaluation of people taking mood-enhancing drugs) have relevance for philosophical analysis.

Related to concerns over identity and personality is the issue of authenticity or the ‘authentic self’. The ideal of authenticity says that if a person is not living a life as him- or herself, than he or she has missed out on what life has to offer (Elliott, 2003). This does not imply that an authentic life is a happier life; an authentic life is considered to be a higher life, because it is a life in which a person knows who he or she is and lives out his/her sense if his- or herself. Authenticity presupposes self-discovery and self-understanding (leaving aside the philosophical question whether there is a ‘core’ or ‘authentic self’, or whether it is more adequate to talk about ‘multiple selves’). The already mentioned transformations which may result from mood-enhancers may be seen as chemical makeovers (suggesting inauthenticity), or, alternatively, as chemical self-discoveries, which contribute to a sense of authenticity.A serious concern with regard to mood enhancers is connected to personal truthfulness and genuinity. Using artificial means to change psyches and mental states involves a kind of ‘taking over’: the experiences of the person can be considered neither true, nor truly his (President’s Council on Bioethics, 2003). In human affairs people care about the difference between ‘the real’ and ‘the merely appearing’.

Emotional estrangement
A worry is that using artificial means to change mental states may prevent the individual from being genuine and true. A central concern with mood-enhancing drugs is that they will estrange people emotionally from life as it really is, preventing them from responding to events and experiences, whether good or bad, in a fitting way. A danger may be that mood-enhancers will keep people ‘bright’ or impassive in the face of things that ought to trouble, sadden, outrage or inspire them.

Medicalization and ‘democratization’
The use of mood enhancers outside the domain of ‘classical’ mental disorders such as depression raises concerns about the medicalization of ‘normal’ behaviour (President’s Council of Bioethics, 2003). Hand in hand with the medicalization of mood changes and feelings of unhappiness goes a ‘democratization’ of depression and depressive or low mood (Pieters, te Hennepe & de Lange, 2002). Both trends have implications for the self-understanding of individual persons, but above that for society as a whole.The Diagnostic and Statistic Manual of Psychiatric Disorders (DSM-IV) of the American Psychiatric Association is the golden standard for the diagnosis of mental disorders in many western countries. This implies that DSM serves as guiding principle in distinguishing between normality and illness, between depression and mere sadness. From a historical perspective, the different versions of DSM go hand in hand with a proliferation of a growing number of diagnostic categories (Pieters, te Hennepe & de Lange, 2002).The democratization of psychic pain and suffering involves the de-tabooization of mental distress (depressive mood, fear).

From a historical perspective, mental distress was associated with feelings of guilt and shame, and stigma was connected to its expression. Nowadays, clinical depression as well as less severe forms of low mood and psychic distress are normalized in the sense that professionals and mass media make an effort to characterize them as ‘normal’ states-of-affairs for which the individual has no moral responsibility. By describing depressive mood as a form of illness (comparable to somatic illnesses), feelings of guilt and shame are to be prevented. It is to be expected that this form of ‘democratization’ of depression will have repercussions for the individual and societal perception and valuation of mood-enhancing interventions, as it will lower the threshold for such interventions and stimulate social acceptance of their use.Underneath the use of psychopharmaceuticals to address different kinds of human misery lies a particular, mechanistic view about psychological and emotional states (Freedman, 1998). It is connected to biological reductionism. Thanks to the efficacy of mood brightening agents, and of psychotropic drugs more generally, there may well be a temptation to redefine and to treat what are currently considered normal emotions, moods, and temperaments on the model of mental illness, and mental illness as a matter purely of bodily (and ultimately of molecular) character and causation (President’s Council on Bioethics, 2003).

This view may endanger our dignity as responsible persons who owe it to ourselves to struggle toward insight through dialogue, and may alter the assignment of moral responsibility for any improper behaviour, not only in criminal matters, but in all interpesonal relations.

3. Justice and fairness:
competitive advantageThe nontherapeutic use of mood-enhancing drugs or other interventions also raises questions of unfair advantage and suggests that when one person is perceived as having such an advantage, others will be compelled to use it (Blank, 1999). To the extent that mood enhancers actually confer a competitive advantage, their use by some people will result in pressure on nonusers to become users, or else to accept what amounts to a handicap in the social competition (Whitehouse et al., 1997). Self-medication may become the social norm, and may create new anxieties about mental health, creating new problems in the realm of social justice.

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