"The Lesser of two Evils" Versus "Medicines not Smarties": Constructing Antipsychotics in Dementia

Dilbagh Gill, MPharm; Saleh Almutairi, PhD, MSc, BSc; Parastou Donyai, PhD, BPharm, BSc

Disclosures

Gerontologist. 2019;59(3):570-579. 

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Two distinct interpretative repertoires were identified. In one, antipsychotic medications were typically portrayed as "the lesser of two evils" whereas in the other as powerful "medicines not Smarties." Each of these representations is part of a different kind of resource drawn upon to talk about antipsychotics. In the first, antipsychotics were conceptualized as an aid to patients and their carers; as devices that enable the delivery of care. In the second, antipsychotics were portrayed as substances that are used far too casually and frequently with little regard for their adverse effects or reference to usage guidelines. Both repertoires are described here.

Antipsychotics as "The Lesser of two Evils"

There is a proverb "Of two evils choose the less," attributed to Aristotle (Speake, 2015), which is the basis of a commonly-used English idiom "the lesser of two evils" (Ayto, 2009). The meaning conveyed is that the less harmful or unpleasant of two bad choices or possibilities should be chosen.

One of the ways in which language was used to construct antipsychotic medication as "the lesser of two evils" was in reference to the state of patients with dementia, with two contrasting representations of the patient as a vulnerable individual and the patient as a threat. These representations were deployed during the interviews to build up arguments to support the choice to use antipsychotics in order to treat patients (and to counter alternative choices). With the first, the patient was portrayed as vulnerable, for example, when their safety was shown to be compromised because they "leave things on the stove" (Supplementary Material, extract 1). The use of these specific words describes an individual struggling to cope with everyday life which makes them a danger to him/herself. The description infers that antipsychotics prevent accidents and harm that can arise as a result of the patient's actions. In the context of "the lesser of two evils" antipsychotics are presented as a more desirable choice than the status quo which is leaving the patient vulnerable to unsafe acts. The "evil" of the patient coming to harm as a result of their own behavior is pitched against any presumed "evil" that might arise from using antipsychotics.

The interpretative repertoire "the lesser of two evils," however, also pitches the use of antipsychotics against arguably less obviously-harmful situations. For example, the medication helps "improve quality of life" for the patient who experiences "24 hr a day agitated and fearful" due to the progressive nature of their illness (Supplementary Material, extract 2). Here the harm associated with the vulnerable patient's diminished quality of life or being constantly agitated and fearful is presented as more harmful than harm which might arise from using antipsychotics.

In contrast to being vulnerable, patients were also portrayed as individuals who pose a threat to those around them, something which needs managing because again the status quo is a less desirable choice to antipsychotic usage. Here antipsychotic medications were characterized as a tool for managing uncontrollable and disruptive patients who are "hitting other patients or the staff," "trying to break down the window" or have "ripped a radiator of the wall" (Supplementary Material, extract 3). In this regard, antipsychotics are portrayed as helpful to the carer at home or within a care-home when faced with an even more harmful option of not being able to deal with an aggressive patient. Consequently, those caring for the patient with dementia, as well as health professionals helping these carers (through prescribing antipsychotics), were another group of people referred to as part of the construction of antipsychotic medications as "the lesser of two evils."

The interviewees paraphrased quotes to illustrate the families' willingness to accept risks associated with antipsychotic medication usage for the benefit of being able to cope with the patient at home—thus presenting the decision to use antipsychotic medication as their (the families') choice. For example, in reference to reducing the dose of an antipsychotic, one family member is quoted as saying "please don't touch anything" as "I wouldn't be able to cope, she'd have to go into a home" (Supplementary Material, extract 4) which conveys the dichotomized choice; being unable to cope with the patient versus maintaining the dose of an antipsychotic medication and any associated adverse consequences. These particular representations portray the relatives and carers (not the health professionals) as being in charge of decisions to start or continue antipsychotics, with health professionals merely helping carers to cope.

For example, where a nurse states "the doctor said, well we have to respect the fact that he's doing a very, very hard job keeping her at home" (Supplementary Material, extract 4), it suggests that the decision to use antipsychotic medications comes primarily from, and is allowed to come from, the carer. In another extract, the nurse participant describes a scenario where if a patient "wasn't on these" medications, "her husband wouldn't be able to manage her at home" and thus "she would have to go into residential care" (Supplementary Material, extract 5). The patient removed from their loved ones is then described as becoming distressed, disorientated and "quite aggressive." This culminates in the speaker concluding that these drugs are sometimes "the lesser of two evils" by helping the patient to remain with their families and stopping a downward spiral of distress and aggression which might otherwise ensue. Thus prescribing an antipsychotic is portrayed as helping to deliver care by helping both the patient and their carer avoid alternative consequences.

From a critical discourse analytic perspective, when participants employed "the lesser of two evils" repertoire, they were not merely expressing their attitude but actively constructing people and situations and mobilizing these in a way that legitimizes the prescribing of antipsychotics. They did this by presenting the use of antipsychotics as a choice between potential harm that might arise from medication versus leaving things as they are, for example, not dealing with a vulnerable patient whose behavior puts their life at risk or whose diminished quality of life warrants action. Or not dealing with the patient who poses a threat to others, and whose behavior justifies the prescribing of an antipsychotic, which is presented as a choice made primarily by carers with the support of the health professionals. The use of this interpretative repertoire is encapsulated here:

""I do find enormous pressure from the homes to prescribe antipsychotic. And even individuals, obviously married couples when one of the partners has dementia say, for example, there's two elderly people and there's a man with dementia and he's still strongly aggressive, he's being cared for by his wife and it's just on a one to one basis it's very difficult to get his, to get the wife to manage the behaviours so you do have to sometimes have to prescribe antipsychotics to get that happy, to get that balance right." (CPN, Interview 12)"

Antipsychotics as Powerful "Medicines not Smarties"

The Oxford Dictionary of Word Origins refers to "Smarties" as follows.

""The sugar-coated chocolate sweets called Smarties were launched in 1937. Because of their similar appearance to pills, doctors are sometimes accused of handing out drugs 'like Smarties'." (Cresswell, 2009)"

Smarties are a brand of sugar-coated, inexpensive sweet/candy popular in many countries. The sweets are small meaning a hexagonal tube contains about 48 of them. The reference to drugs being handed out "like Smarties" reflects the commonly-held belief that Smarties are shared out, no doubt owing to their inexpensive nature and pack size, while also drawing on their similarity to "pills". But unlike sweets, drugs produce pharmacological effects including unwanted adverse effects which restrict their use, or "ought to" restrict their use. The meaning conveyed when it is stated that drugs are handed out "like Smarties" is that drugs are being prescribed commonly or indiscriminately.

The way in which language was used to construct antipsychotic medication as powerful "medicines not Smarties" was in reference to their potent clinical and social adverse effects on patients and also via a negative representation of health professionals who prescribe and use these medications. For example, one CHM expressed that the patient taking antipsychotics becomes "extremely sleepy," is at a greater "risk of falling" and begins to "feel really sick" (Supplementary Material, extract 6). To portray their opposition to the use of antipsychotics, they employed a rhetorical question "There's not an awful lot of plusses are there?" In the context of "medicines not Smarties" here antipsychotics are portrayed as medicines with a range of adverse effects which limits their use.

Another CHM stated "I do not like antipsychotic drugs for people with dementia' as these "are not getting the best out of them" (Supplementary Material, extract 7). They expressed that these drugs "deskill them, in all their long life skills," reflecting a view of the adverse social effects of antipsychotics (Supplementary Material, extract 8). The participant used powerful imagery to construct their disapproval exemplified by "I don't believe in my old people sitting in one big circle," "looking into each other's eyes and doing nothing" (Supplementary Material, extract 9). Within the "medicines not Smarties" repertoire, these representations act as arguments for why these medications should not be prescribed commonly or indiscriminately. The representation of antipsychotics as potentially harmful is also supported by a GP's choice of words that antipsychotics "dampen their natural reflexes" and "calms them too much" and consequently "you lose a little bit of the person's personality" which can therefore "take away" from the patient (Supplementary Material, extract 10).

The adverse effects of antipsychotic medication were also juxtaposed against non-pharmacological activities that might "enhance" the patient's state. A CHM chose to speak in the first person, a tool to portray the patient's perspective "When my wellbeing is adequately taken care of, my behaviour will not be a destructive one" (Supplementary Material, extract 11). Particularly, some GPs and nurses suggested that those using medication as a first resort may be less pro-active and prefer "somebody to start on an antipsychotic" rather than exploring other methods of managing behavioral symptoms in patients. Thus another way in which language was used to construct antipsychotic medication as powerful "medicines not Smarties" was in reference to health professionals who decide to prescribe and use these medications—in effect, the people who do the "handing out" of medicines "like Smarties."

A nurse stated "I know the realities," "staff are lowly paid, poorly motivated" and "are very overworked" (Supplementary Material, extract 12) suggesting there may not be a desire to explore alternative solutions for the patient. Noticeably, this speaker alleges care home staff want "to increase medication all the time" to "make their life easier." Another nurse referred to "these are powerful drugs" which should not be handed out "too readily like Smarties" (Supplementary Material, extract 13) signifying an unwarranted relaxed attitude toward the prescribing and use of antipsychotics by others. Such portrayals were consistent amongst GPs, one of whom said "reaching for a prescription pad and pen is very easy to do" and not "much thought has gone into" initiating antipsychotics (Supplementary Material, extract 14). GPs expressed prescribing of antipsychotics "should always be justified" with one acknowledging their own role: "it's still used as the easy option" as "it's something as doctors, we do, we just prescribe a medicine" (Supplementary Material, extract 15), suggesting that bad habit also plays a role.

The other way in which participants used language was to portray their own role in the (over)prescribing and use of antipsychotic medications, which involved the dismissal of guidelines. This is exemplified by one GP who, in a colloquial manner, states "I tend to throw them out and hope I get the gist of it" (Supplementary Material, extract 16), whereas another clearly states "I've not read any guidelines" moving on to say that most of the prescribing is based on "what the consultants" say (Supplementary Material, extract 17). Here, if the speaker implicates themselves as someone who prescribes antipsychotics "like Smarties," then they do so unwittingly because they have not read the guidelines relating to antipsychotic use or are following consultant advice.

From a critical discourse analytic perspective, when the participants employed the "medicines not Smarties" repertoire, they were actively constructing people and circumstances and mobilizing these constructions in a way that questions the legitimacy of antipsychotic prescribing. This repertoire portrays antipsychotics as potent substances with a multitude of clinical and social adverse effects, which indicates that their use ought to be limited. Antipsychotics were portrayed as being used too frequently either for the convenience of those who provide care for patients with dementia, where it is easy to prescribe out of bad habit, or because prescribers have not read or understood the guidelines associated with antipsychotic prescribing in dementia or are following consultant advice.

The two interpretative repertoires identified here, antipsychotics as "the lesser of two evils" and "medicines not Smarties" appear to be inconsistent, yet they were drawn upon by the same individuals in different sections of an interview and used as social resources. Interpretative repertoires enable people to "justify particular versions of events, to excuse or validate their own behaviour, to fend off criticism or otherwise allow them to maintain a credible stance in an interaction" (Burr, 2015). The first repertoire is a resource that can be drawn upon to defend the prescribing of antipsychotics because it depicts the benefits of medication and its utility in helping people to care for patients with dementia. The second repertoire is a resource that can be used to put distance between the speaker and the decision to knowingly sanction the overprescribing of antipsychotics, since it depicts medication as potent substances used too readily by others for convenience or from ignorance. Table 1 shows the participants' propensity to draw on one or the other repertoire during the discussions. Thus for example, three CHMs structured their discussions mainly around the "the lesser of two evils" repertoire whereas two CHMs around "medicines not Smarties."

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