The way we practice now

According to current theory, people with ADHD have a relative deficiency of dopamine, an essential neurotransmitter in the brain.  Adequate levels of dopamine are necessary to induce incentive and motivation.  Stimulant medications boost dopamine levels and enhance the ability to stay focused on task.

But in our modern psychopharmacological approach to the treatment of ADHD we have all but forgotten the environment.  more»

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“Notes from a Healer” — Mindless Medicine

Many times good doctoring entails more than just prescribing another pill.

My latest installment of Notes from a HealerMindless Medicine — is now online, newly published in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine is an online clearinghouse for manuscripts dealing with the humanities and medicine. Interested readers can access a list of editorial board members and regular contributors here.

Addiction: Biochemical bondage or voluntary behavior?

“Addiction is a chronic and relapsing brain disease.”  Few would dispute this statement purported by the National Institute on Drug Addiction (NIDA).  Those of us who work in the disciplines of clinical medicine and research pharmacology have been inculcated with its corollary:  “once an addict, always an addict.”

Such claims conjure up the notion that those addicted to substances remain powerless over their pharmaceutical spells.  Substances like alcohol, nicotine, cocaine, opiates and their derivatives create a physical dependence in those addicted to them.  Denying the body access to such drugs triggers symptoms of physical withdrawal.  Those who succeed in extricating themselves from the regular use of such drugs remain constantly at risk for relapse.  Such facts are borne out by modern research and methods of treatment.

Or are they?

Now comes a work—Addiction: A Disorder of Choice—in which research psychologist Gene Heyman challenges the view that substance abuse is an irresistible act wholly beyond the control of the user.  Although Heyman does not deny that addiction is independent of the brain, he does argue that it is in part voluntary behavior.  He further maintains that “it is not possible to understand addiction without understanding how we make choices.”

Repeated use of drugs ultimately changes brain structure and function by altering biochemical pathways, reinforcing those that mediate the experience and memory of pleasure.  Such neuronal pathways persist, producing cravings even after the addict has stopped using.  If addiction itself is not a brain state, but rather a behavior, the question then arises:  do neurochemical changes in the brain prevent the user from exercising voluntary control over choice and actions?

Heyman argues that “drug-induced brain change is not sufficient evidence that addiction is an involuntary disease state.”  He points to a number of studies where, through the judicious use of contingencies, addicts demonstrated the ability to voluntarily change their behavior and stop using.

The more we learn about brain functioning from biochemical research, the more apt we are to regard behavior as something regulated by the action and balance of neurotransmitters in brain.  Ultimately, we might decide that all behavior is involuntary, that each one of us is an automaton, dependent upon the synaptic activity of the moment.  And yet—as any parent knows—behavior can be shaped by meting out consequences and contingencies.  Eventually, children learn to modify their own behavior through voluntary choice.

Heyman extends his argument to include other addictive behaviors such as compulsive gambling, shopping, and sex.  Each involves a craving, an intense impulse and—for Heyman—a voluntary choice.

These arguments bring to mind a passage from John Steinbeck’s epic novel East of Eden, in which he discusses sixteen verses from the book of Genesis about humankind’s ability to wrestle with the temptation of sin.  For Steinbeck, “these sixteen verses are a history of humankind in any age or culture or race.”  The crux of the premise centers around timshel, a Hebrew verb translated as “thou mayest.”

But the Hebrew word, the word timshel—‘Thou mayest’—that gives a choice. It might be the most important word in the world. That says the way is open. That throws it right back on a man. For if ‘Thou mayest’—it is also true that ‘Thou mayest not.’

Steinbeck goes on to develop this idea through character dialogue in the book:

‘Thou mayest’! Why, that makes a man great, that gives him stature with the gods, for in his weakness and his filth and his murder of his brother he has still the great choice. He can choose his course and fight it through and win.

Steinbeck concludes the passage with these words:

I feel that a man is a very important thing—maybe more important than a star. This is not theology. I have no bent toward gods. But I have a new love for that glittering instrument, the human soul. It is a lovely and unique thing in the universe. It is always attacked and never destroyed— because ‘Thou mayest.’

If Steinbeck and Heyman are correct, in the face of seemingly insurmountable odds, struggling addicts might be able to triumph over their addictions by an exercise of the will—one day at a time.

If they are wrong, ultimately we may be forced to confront our own pyschopharmacological demons in the form of serotonin, dopamine, norepinephrine and GABA.

The Child Psychiatrist

“Abuela, push me on the swing.”

“Not now, Alexi.  I’m not feeling well this morning.”

“Can you please take me out for a bicycle ride?”

“No, maybe later.”

“Abuela—please!”

“No.”

Six-year-old Alexi pouted as Maria brought her hand up to her forehead to shield her eyes. Suddenly Alexi’s face brightened.

“Abuela, come with me.”  She pulled Maria by the hand, leading her into the front parlor.

“Here, Abuela—sit down in the rocking chair.”

Maria sat down in the antique rocker with the caned seat.  It had been a gift from our former octogenarian neighbor years ago.

Alexi climbed onto Maria’s lap and put her arms around Maria’s neck.

“Now, Abuela, put your arms around me and rock back and forth.”

Maria put her arms around Alexi and began to move the ancient rocker back and forth as Alexi settled into her lap.  Neither one spoke for a few minutes.  Then Alexi broke the silence.

“Don’t you feel so much better now after rocking with me?

Maria nodded.

“It’s always good to have a little kid to make you feel better,” Alexi said.

Maria smiled.

“Now, Abuela, can we go outside and play?”

Those of us in medical practice sometimes forget that desirable behavior can be effectively shaped without the use of psychopharmacological substances.

Medicine and Madness

What heals the patient with mental illness: psychotherapy, the doctor-patient relationship, daily exposure to a therapeutic community, or psychotropic medication?

In his book The Soloist, LA Times columnist Steve Lopez explores these options in his efforts to help a homeless black schizophrenic musician, Nathaniel Ayers. Mr. Lopez quotes Dr. Mark Ragins on the treatment of mental illness as outlined in Ragins’ book A Road to Recovery: “Making a diagnosis isn’t as important as making a connection. We’re not even sure what labels like schizophrenia and bipolar disorder mean, nor do we have very strong evidence that medication is the best response.”

According to Dr. Ragins, the history of mental health treatment—diagnosis, prescription—has been a colossal failure. While there is no cure for mental illness, Ragins believes that patients can rebuild their lives in the setting of therapeutic communities—places where they can develop a sense of belonging and learn how to manage their disease.

Ragins’ approach is refuted by a psychiatrist from the Los Angeles County Mental Health Department, who plays down the notion that doctors should focus on patients’ lives rather than just treating their symptoms. “A ‘warm and fuzzy’ embrace won’t get the job done,” she argues. “Chronically mentally ill patients are sick, sometimes dangerously so. They need psychiatric counseling and medication, not sunshine and hugs.”

Traditional allopathic medicine relies on pharmaceuticals to treat illness and disease. The humane medicine movement seeks to create awareness in the power to heal through attentive listening, empathetic understanding and therapeutic touch. Many patients still look to their doctor to prescribe the appropriate drug for their illness. Where do patients place their faith: in the expertise of the physician or in the curative power of the drug?

Many psychiatrists now recognize that patients’ candid discussions of their experiences can help their recoveries. In a recent New York Times article, ‘Mad Pride’ Fights a Stigma, Dr. Robert W. Buchanan, the chief of the Outpatient Research Program at the Maryland Psychiatric Research Center, notes that it’s critical for patients to have open dialogue. “Problems are created when people don’t talk to each other,” he says.

In family-focused therapy, relatives are being enlisted to help manage the patient’s illness. “If you combine medication and family-focused therapy, you get quicker recoveries from episodes and longer intervals of wellness,” said David J. Miklowitz, a professor of psychology and psychiatry at the University of Colorado. “Relapses are less common, and functioning improves, including relationship and family functioning.”

Some people need medication to survive. But no two cases are alike; there is no right and wrong way to treat such patients, no universal therapeutic model.

Mr. Lopez concludes that in the treatment of the mentally ill “there are no magic pills, and thousands have gotten better only to chuck the meds and sink back into the grips of incurable disease.” In the end, Mr. Lopez learns to accept Mr. Ayers as he is, “to expect constant backsliding, to prepare for the possibility that he could be homeless again or worse, and to see hope in small steps.”

And finally, in striving to help another individual, Mr. Lopez learns a valuable lesson himself: “I’ve never had a friend who lives in so spiritual a realm as Mr. Ayers, and I know that through his courage and humility and faith in the power of art—through his very ability to find happiness and purpose—he has awakened something in me.…He has wiped away my professional malaise and shown me the dignity in being loyal to something you believe in, and it’s not a stretch to say that this man I hoped to save has done as much for me as I have for him.”

Office Psychotherapy

When he introduces himself, at first I don’t realize that he’s a doctor: he offers his first and last name only, without the title. Perhaps this is because, for the present, he regards me as next of kin—in the kinship of medicine—as evidenced by my bowtie and stethoscope draped around my neck. In any case, I offer him my hand and introduce myself in the same fashion—first name, last name; no title.

He has come to our office with his small entourage: two pharmaceutical representatives, both female, both strikingly glamorous. They are sponsoring the luncheon; he is the guest speaker. The doctor is chic himself—full head of thick wavy hair, parted in the middle, designer glasses, clean-shaven, wearing a pinstripe suit and dress shirt, open at the collar, no tie. The absence of the tie suggests a certain informality of youth and freedom. When he speaks, his accent betrays a southern origin.

He is, we learn, a psychiatrist. Currently he practices at a large mental health facility in Maryland. There are over seventy mental health providers in this agency: a fanfare of psychiatrists, psychologists, psychiatric social workers, family therapists, psychiatric nurses, as well as the usual gamut of support personnel needed to run a huge enterprise.

He tells us that he is also involved in psychopharmacologic research: he and his colleagues have published a number of studies in the medical literature, studies which lend credence to his professional standing.

We sit and listen to him talk, quietly munching our deli designer sandwiches and sipping bowls of hearty soup. The topic today is pharmacologic treatment of ADHD—specifically, the use of a newer non-stimulant medication. We learn that the doctor uses this medication routinely in all of his ADHD patients. In fact, it is the only FDA approved medication that achieves a steady state in the body to keep symptoms at bay twenty-four hours a day. What’s more, it’s safe: in his practice, he’s used much higher doses than recommended in the package insert with no toxic effects. Minor side effects such as drowsiness or abdominal discomfort can be lessened by dosing with dinner or in the evening hours. What’s the bottom line? Excellent drug: efficacious, easy to titrate, minimal adverse effects.

I ask about his clinical practice: what sort of patients does he see routinely? The gamut of child and adolescent psychiatric problems, he says: ADHD, oppositional defiant disorder, conduct disorder, bipolar disorder, panic disorder, anxiety and depression—in short everything except personality disorders: they don’t respond well to medication.

I inquire about his schedule: how many patients does he see a day? Forty to forty-five, he answers, matter-of-factly. I look surprised; my face has betrayed me. But, he’s quick to add, he’s got lots of support personnel available. If a patient needs counseling or talk therapy, there’s always a mental health provider on site to touch base with the family. He handles titrating the medications—after all, that’s his job; that’s what he was trained to do.

He encourages us to consider prescribing the drug: we won’t regret it, and our parents will thank us after we’ve helped their children get back on track. He winds up the session and slings his travel bag over his shoulder.

“Next stop, Springfield,” one of the glamorous pharmaceutical representatives says, glancing at her watch. “It’s just up the road. You’re scheduled for one o’clock.”

They disappear out the front door. We clean up the remnants of the lunch, and discover a box of designer cookies on the table: oatmeal raisin, white chocolate chip, chocolate chocolate chip, sugar cookies coated with vanilla icing.

I make my selection and savor the first bite, chewing thoughtfully. It leaves a slightly bitter taste on the back of my tongue as I swallow hard to force it down.

In the mood

Modern psychopharmacology has provided us a myriad of newer drugs for the treatment of mood disorders. Selective serotonin reuptake inhibitors have largely replaced older tricyclic antidepressants in the treatment of mild to moderate depression. The pharmaceutical industry encourages those on the front lines of primary care medicine to treat patients who meet the criteria for clinical depression for a minimum of four to six months in an effort to prevent relapse of the condition. Yet a fundamental question remains: do we need to prescribe medication routinely for every patient who meets the criteria for a diagnosis of depression?

Dr. Paul Keedwell, a clinician who specializes in mood disorders at the Institute of Psychiatry, King’s College London, suggests that in its milder forms, depression might actually serve to enhance an individual’s well-being. Depression may generate resilience, insight and creativity. Aristotle argued that depression allowed the sufferer to empathize more deeply with others. Henri Nouwen echoed such sentiments in his concept of the wounded healer: that person who, because he has walked a similar road, could more effectively support the sufferer in time of need.

In his essay In Praise of Melancholy, English professor Eric Wilson argues that sometimes feeling bad can do you some good. According to Wilson: “A person can only become a fully formed human being, as opposed to a mere mind, through suffering and sorrow.” Suffering prods us to consider more imaginative and creative ways of dealing with the world.

Many great artists have found inspiration through the depths of despair: witness the works of writers Sylvia Plath, Evelyn Waugh, Ernest Hemingway; artists Paul Gauguin, Vincent Van Gogh, Edgar Degas, Georgia O’Keeffe; musicians Elton John, Joni Mitchell, George Frideric Handel.

Perhaps the poet John Keats said it best when he wrote: “Do you not see how necessary a world of pains and troubles is to school an intelligence and make it a soul?”