"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


Gerontologist. 2019;59(3):570-579. 

In This Article

Discussion and Implications

When antipsychotics were described as "the lesser of two evils," they were conceptualized as the less harmful or unpleasant of two bad choices or possibilities; as a mechanism for delivering care to helpless, vulnerable patients or to support carers who struggle to cope effectively with aggressive patients. The "other evil" in this sense was pitched as physical harm that patients would suffer as a result of their vulnerability, harm from a diminished quality of life, or from experiencing fear or agitation, as well as harm that carers would suffer as a result of not being able to cope with the disruption or unmanageability of an aggressive patient at home or within a formal care setting. When antipsychotics were described as "medicines not Smarties" they were conceptualized as prescribed too frequently or indiscriminately. They were depicted as having potent clinical and social adverse effects on patients, accompanied by a negative representation of health professionals who prescribe and use antipsychotic medications. The adverse effects were couched in term of potent medications which result in drowsiness, salivation, deskilling, dulling of interactions, and even loss of patients' personality, whereas the negative representation of health professionals who administer antipsychotics was conveyed in descriptions of unmotivated or overworked staff or those acting out of bad habit, or lacking knowledge.

One of the aims of critical discourse analysis is to shed light on representations circulating in everyday discourses. In this way, the current study is similar to that of Prosser (2010) whose examination of newspaper stories unearthed a dichotomous representation of "marvelous medicines" versus "dangerous drugs." The discourse resources described in the current study are not expected to be new because their validity relies on their use by other people in other contexts. For example, a qualitative study published a decade ago focusing on benzodiazepine prescribing (also contentious) describes this as doing something that is "the lesser evil"(Anthierens, Habraken, Petrovic, & Christiaens, 2007), whereas another on the same topic highlights the "medicines not Smarties" repertoire (Rogers et al., 2007). That the repertoires described in this study are in line with findings in other studies about the (over)prescribing of medicines acts to verify their soundness as common discourse resources. Another aim of critical discourse analysis, however, is to identify how discourse resources are used to construct and reconstruct social realities and the distribution of power. Therefore, another important point is howthese identified repertoires are used as discourse processes to depict decisions in relation to antipsychotic usage, that is, the way in which individuals or groups are characterized as benefiting from or sanctioning antipsychotic usage. This is completed here with reference to the existing critical literature on the meaning of medicines and dementia.

In their seminal paper examining medicines as metaphors and metonyms Van Der Geest & Whyte (1989) described medicines as being more than simply biochemically efficacious—it is not simply that medicines are powerful, they argue, but that people believe them to be powerful. Thus the key to their "charm" is their "concreteness"—that they have a concrete presence and are portable. This means that by virtue of containing the power of healing in them (versus e.g., psychotherapy where a psychologist needs to administer treatment), medicines become "democratic" such that "anyone who gains access to them can apply their power." Thus doctors have it in their gift to transfer the power of medicines through prescribing. In addition, Van Der Geest & Whyte (1989) argued that medicines can become vehicles of individualization, especially where a treatment can be carried out privately focusing on the individual body, and particularly "when sickness might reflect poorly on the patient or family." Whether dementia reflects poorly on the patient or their family is a cultural matter also worth considering.

The literature points to discourses that construct dementia as "the tragedy discourse" and the "living well discourse," with the criticism that such a consideration divides people with dementia into those living well or successfully with the condition and those no longer able to maintain society's notion of living well, thus living in the shadows (McParland et al., 2017). Zeilig (2014) examining dementia as a cultural metaphor argued that the framing of dementia operates on two levels; it is generalized as a vast, natural or monstrous force that we must fight, and also located as a very specific condition that affects individuals in extreme ways. In both cases, the effect, Zeilig argued, is to make us feel both terrified and powerless. Zeilig even argued that dementia can be considered a metonym, a figure of speech in which a word for a part of a subject is taken for the whole. In this case, she argued, the word dementia can be taken to mean a complex, unknowable world of doom, ageing, and a fate worse than death.

With this depiction of dementia in mind, consider now that Van Der Geest & Whyte (1989) argued that medicines have a metonymic association with medical doctors who prescribe them, with laboratories that produce them, with medical science that forms their ultimate ground. In this sense, it can be argued that antipsychotics embody the last remnant of medical comfort that can be imparted to shield the patient from the impending doom of dementia. Thus if doctors can be persuaded to transfer the power of antipsychotic medicines to carers then the powerless patient can be treated with due care and consideration, with antipsychotics portrayed as having a calming effect by allaying agitation, fearfulness, disorientation, and aggression. Thought of in this way, "the lesser of two evils" portrays antipsychotics as the less harmful or unpleasant of two bad choices or possibilities because they can empower carers to deliver compassionate care. Drawing on this repertoire therefore acts as a resource not only to defend the prescribing of antipsychotics but to uphold the prescribers' privilege to do so. The apparent contrast between guidelines, which advocate limiting the use of antipsychotic medication to severe circumstances, versus a belief that symptoms which result in patient suffering and distress necessitate pharmacological treatment, is also highlighted in a study of caregiver perspectives about the management of dementia (Kerns, Winter, Winter, Kerns, & Etz, 2017). The authors of that paper highlight that this preference is expressed despite clear enunciation of side-effects and the potential risk for harm from antipsychotics (Kerns et al., 2017), which is also reported elsewhere (Cornegé-Blokland, Kleijer, Hertogh, & Van Marum, 2012).

In "the lesser of two evils" repertoire the effectiveness of antipsychotic medication is similarly emphasized in preference to the portrayal of their side-effects (in contrast to "medicines not Smarties" where side-effects are a main focus). Etkin (1992) argued that because the interpretation of signs or symptoms of illness and medication effects is embedded in cultural meanings, there can be disagreement about what is primary and what is secondary to effective treatment such that a medicine's "side effect" might be embraced by another paradigm as a requisite part of a process in which therapy is under way. Take for example the portrayal of antipsychotics as "the lesser of two evils," where the effect of medication is to "improve quality of life" by dealing with someone who is "24 hr a day agitated and fearful." Here a calming effect of antipsychotics is taken to indicate their effectiveness. Yet this same effect is instead portrayed as a side-effect through the "medicines not Smarties" repertoire, where for example it is stated "I don't believe in my old people sitting in one big circle," "looking into each other's eyes and doing nothing." Although the calming effect of antipsychotics is represented as the very sign of the medication working as "the lesser of two evils," this effect of antipsychotics is rejected through the interpretative repertoire "medicines not Smarties" in preference for a more negative representation of their effects, of a sedentary and motionless existence. On the one hand, antipsychotics can act as the antidote to the impending demise of those with dementia and on the other these potent substances can intoxicate them. Drawing on the second repertoire acts to distance the speaker from others who overuse these medications and to enable the speaker to reject their own wilful involvement in overprescribing.

How people think and speak communicates and corroborates their understanding of social phenomena; it also has a role in constructing and verifying their version of reality, which in turn has the potential to impact on their own, and others' actions and behaviors (Burr, 2015). Thus one of the applications of critical discourse analysis is to enable the scrutiny of power and constructions of truths so that these can be used to rethink or reconfigure roles, relationships, or institutional practices. The current study highlights two dominant discourse resources which health professionals' draw upon to either sanction the prescribing of antipsychotics or to distance them from such prescribing. Regardless of what the speaker is doing with their speech, they reflect a shared understanding that antipsychotic prescribing is a choice that is taken. Identifying these interpretative repertoires can inform health professionals to their own and others' intentions when they contemplate prescribing decisions. When prescribers draw on "the lesser of two evils" paradigm to endorse the inappropriate prescribing of antipsychotics, implicit assumptions about these medications as being the less harmful of two bad choices need to be challenged. Future studies could focus on challenging the common repertoires that construct and validate inappropriate antipsychotic prescribing and use in dementia. Recall that interpretative repertoires examine the common-sense way in which people talk about the world, and are composed of the lexicon of common knowledge which people draw on to build explanations, descriptions, accounts and arguments. Therefore from a behavioral change perspective (Abraham & Michie, 2008) a future intervention would focus on changing normative beliefs about prescribing behavior and also the consequences of overprescribing to bring about a wholesale change in the cultural ideas, explanations and terms and metaphors which become available for people draw on.