On Antidepressants

Macbeth: Cure her of that.

Canst thou not minister to a mind diseased,

Pluck from the memory a rooted sorrow,

Raze out the written troubles of the brain,

And with some sweet oblivious antidote

Cleanse the stuff'd bosom of that perilous stuff

Which weighs upon the heart?

Doctor: Therein the patient

Must minister to himself.

Macbeth: Throw physic to the dogs, I'll have none of it.

The other day I was reading an account of Mozart's final hours, in which he lay wracked by fever and pain, still idiopathic to this day. When the doctor arrived, he prescribed cold compresses. If that good medical man had any notion of what he was dealing with, what might it have been like to attend to one of the greatest composers in the history of the world and to be able to do nothing better than cold compresses? (Of course, it is thought that his life may have been iatrogenically shortened by previous blood-letting as well).

I've been reading Thomas Hines's Architecture of the Sun, a history of modernism in southern California, in which various people moved to that region upon medical recommendations of a more salubrious climate. Those were the days, when a prescription for sunlight, dry air, and palm trees was respectfully viewed as deep medical wisdom! A doctor's word could relocate people across continents.

The history of medicine is a weird amalgam of ignorance and authority, incapacity and power. Even through the millenia in which the practical (positive) effects of medicine were minimal, doctors nonetheless occupied a crucial social locus of judgment and prestige.

Physicians now fight for space in a more crowded arena, but some of their outsized influence remains. For better or worse, a diagnosis from a psychiatrist often carries more weight than one from a therapist. When patients need temporary time off from work or apply for disability, the paperwork seeks the opinion of the physician, not the therapist, nurse practitioner, or physician's assistant. The physician still wields the gavel of the sick role most vigorously.

But if, as the commenter to the previous post suggested, the primary function of the doctor must be the relief of suffering, what happens when the doctor's tools are in fact too weak to accomplish this, or what is more complicated, what happens when the effect of those tools is owing to their wielders' social power rather than to any inherent properties (i.e. the placebo effect)?

Much has been heard of late about the dubious effects of antidepressant drugs, an issue that can only give any psychiatrist serious pause. This issue has been raised many places, and this post is not intended as a literature review, but Sharon Begley's Newsweek article may be as good a summary as any. If antidepressants are truly no better than placebo, then a scientific fraud on an unprecedented scale would have been perpetrated over the past half-century, and there would be something seriously rotten in the state of psychiatry.

I believe, of course, that antidepressants have real effects, otherwise I could not do my job in good faith. This belief could be deemed meaningless inasmuch as I have self-interested reasons of both professional standing and financial stability for holding it, and the human capacity for self-deception is unfortunately vast. But there are of course scientific reasons to doubt ambiguous drug trials, chief of which is the fact that many patients (or "patients") enrolled in drug studies are not representative of real clinical settings. Their disorders tend to be milder and more pure (i.e. uncomplicated by other diagnoses), and the very fact of their willingness to participate in a drug trial may heighten their response to placebo.

So, what do I believe about antidepressants based on 15 years of prescribing them to many hundreds if not a few thousand individuals in various settings? I believe that they are imperfect drugs that too often fail to work--my ECT experience alone would tell me that. I believe that antidepressants treat symptoms of still mysterious illnesses; they do not target the illnesses themselves. They are non-specific, affecting a broad spectrum of emotional response and anxiety level; in that sense they are more like what David Healy, in The Antidepressant Era, referred to as tonics than like magic bullets (think aspirin, not penicillin).

I believe that antidepressant effects are stronger, relative to placebo, the more severe and sustained depression or anxiety is. For mild and transient conditions they are often useless (thus the irony of the moral panic over Prozac-based emotional enhancement). I believe that people (prodded by drug advertising and cultural momentum) rely on them too much on average. Social and psychological interventions should be tried first.

But I refuse to believe, broadly and scientifically, that antidepressants are indistinguishable from placebos. For one thing, within the pharmacopeia there are a few drugs that I think of as internal placebos (buspirone or hydroxyzine, anyone?) having little effect beyond a hope and a prayer. But the mainstream antidepressants aren't like that, and while I know that the placebo effect is powerful and still not well understood, I have seen too many unimpressionable people with dramatic and sustained responses, and too many impressionable types who fail to improve, to believe that there is no physiological effect.

On what may seem like a trivial note, I haven't researched the literature, but many pet owners and veterinarians attest to the effects of Prozac, etc. on neurotic cats and dogs; can that merely be a mass phenomenon of placebo effect by proxy?

If Mama Ain't Happy...

What's the ugliest

Part of your body?

What's the ugliest

Part of your body?

Some say your nose

Some say your toes

But I think

It's your mind

Frank Zappa and the Mothers of Invention

"Since You Asked," Salon's advice column, features a strikingly detailed case of adult children trying to manage a parent's mental illness, in this instance severe anxiety and somatoform disorders superimposed upon baseline character pathology.

What is frustrating of course is the apparent lack of information and insight provided by psychiatry. The woman in question has no insurance, which in our benighted "health care system" renders her up a creek to begin with. To be sure, late-life anxiety and personality disorder are tough to treat--benzodiazepines can be risky, and rigid resistance to therapy is common. But one would have thought the family at least could have obtained a prognosis and suggestions for containment and harm-reduction, which psychiatry must be able to provide if nothing else.

Cary Tennis's "advice," such as it was, was unusually muted in this case: basically, deal with it (you will find the strength somehow) or don't deal with it (cut her off). Maybe he should have suggested that they plant themselves in a shrink's office and refuse to leave until they get an answer. As I've increasingly come to think recently, realistic prognostication is a lost art in psychiatry.

Much has been written about medicine's futile attempts to stave off inevitable death. Psychiatry is not directly involved in that fight, but it has its own counterpart, a perpetual stalling action in which medications and therapists are thrown at refractory symptoms willy-nilly in the notion that some day, somehow, either placebo effect or spontaneous remission will kick in. And perhaps they will, but patients and families should be told up front about the likelihood of that actually happening. Oops, honesty of that sort might disrupt the very placebo effect that one holds out hope for. So one can only steer between pessimism and disingenuousness.

Mad Scientists at Work

I have a new hero after reading a profile of neuroscientist and writer David Eagleman:

Eagleman rejects not only conventional religion but also the labels of agnostic and atheist. In their place, he has coined the term possibilian: a word to describe those who "celebrate the vastness of our ignorance, are unwilling to commit to any particular made-up story, and take pleasure in entertaining multiple hypotheses."

Sign me up--I want to be a possibilian.

The "guinea pig" complaint is far and away the most common one I hear about previous psychiatrists (and I'm sure it is said about me by those patients who move on to other prescribers). A new medication is tried every month, seemingly willy-nilly, without a sense of an overall framework or plan. A psychiatrist, plainly, is no auto mechanic. Psychotherapy, truth be told, really is a neverending experiment, but medication somehow is supposed to be different.

We know a vast amount about the effect of medications over large populations, but idiosyncratic variation in drug response remains too great to predict outcomes for individuals. In that sense medication reactions are almost like an extension of the assessment process. Treatment, diagnosis, and prognosis become one. Medication trials obviously don't give the same kind or precision of information that a brain MRI will give a neurologist, but they are very informative of a patient's dynamics and likely outcome.

The problem of prognosis is fundamental to psychiatry. Neurologists, even though they often can do relatively little about sometimes appalling diseases (MS, ALS, Huntington's Disease), nonetheless enjoy a greater stature than psychiatrists because, even if they can't do more, they know more. A patient would obviously prefer to get well, but if he can't get well, he wants to know what the future holds so that he can wrap his mind around it and plan accordingly.

There are of course crude measures of prognosis: general intelligence, education, financial and social support, and the presence or absence of past hospitalizations, suicide attempts, personality disorder, and substance abuse. But on a more subtle level, in psychiatry prognosis declares itself only over time, as the myriad variables involved in a mind interact with unique life circumstances. The physiological systems generating identity, behavior, and other aspects crucial to psychiatry are far more complex and unpredictable than those giving rise to, say, motor or sensory control.

The milder or more subtle a condition is, the harder prognosis can be to pin down. I can no more predict how a low-grade dysthymia will behave over decades than I can predict when a person might get married, or how much money they'll be making ten years from now. This isn't to say that I can't predict at all, but such prognostications are based as much on common sense (the past tends to predict the future, etc.) than on any grand professional expertise. Since I'm not allowed to keep a crystal ball in the office, I'm limited to indirect measures of understanding.

Maybe more psychiatrists should aspire to be possibilians, to "celebrate the vastness of our ignorance" rather than pretending to more knowledge than we actually have. Prescribing a medication isn't like performing an oil change--it is accompanying a patient in an experience of self-discovery. Physicians differ from drug dealers in that the substances we purvey, by social contract, must have minimal standards of safety, uniformity, and usefulness. In addition, we are expected to be wise and discerning students of human nature. Beyond that, things get interesting.

Talk About Cherry-Picking

This is it, a double-take headline on NPR that is the unholy spawn of social Internet and medical marketing pressures: speed-dating at the Doc Shop.

I have been mulling over the prospect of a new practice; this is exactly the start-up idea I was looking for.

Let us dispense with the longueurs of the 15-minute visit. Even allowing for the luxury of a 5-minute bathroom break, I can envision 11 accelerated diagnostic evaluations per hour. The Adderall scripts will by flying fast and furious.

(Note to DEA: this is a satirical post).

Vignette

A young guy with no psychiatric treatment history comes in for his second visit. After some initial pleasantries:

I: "How did the medication go?"

(Sheepish look). "Well, I got the prescription filled, but then I got scared and threw it away."

(Later in session, he): "You went to school for ten years to do this?"

"Yeah, it seemed like longer at the time."

(Later in session, he): "Is your job hard or easy?"

"Mumble, mumble, mumble."

Now I can't get it out of my head. Is it dishearteningly hard, or is it laughably easy? I discover that there is no objective way to gauge this. By how many years it takes to obtain society's assent to do it? By how one feels at the end of the day? By "outcome measures?"

What a comedian.

The Rest of the Story

"How sharper than the serpent's tooth it is to have a thankless child."

Lear


I haven't been inspired to write here the past couple of days, yet here I sit, typing. Why? Because writing is what I have to do; if it weren't here it would be somewhere else. The standard advice for writer's block, or even writer's procrastination, is to sit down, stare at the blank (screen), and write something, anything. As Lear also said, "Nothing will come of nothing." But out of something, something else may come. Granted, this write-at-all-costs mantra was pre-Internet; the adage was never to write something, anything for instantaneous, theoretically global release.

I've always been fascinated by the attractions and repulsions that operate between people--animal magnetism, as it were. Obviously a lot of what folks like me do professionally is to commiserate, if nothing else, with people for the slings and arrows of romantic entanglements. Those are interesting enough, but arguably parent-child relationships are more powerful in the end. Partners come and go, but parents, siblings and children are for life.

Except when they aren't. I'm always intrigued by family secrets of distancing and estrangement. Siblings who grow up sharing so many intense experiences during impressionable youth may turn out to live totally different lives, perhaps to have little to say to one another, perhaps to squabble bitterly over the inheritance or worse. Through what mysterious genetic and social unfoldings does the black sheep acquire his hue?

I've noted before that parenting gone bad seems to engender some of the worst suffering one sees. The divorced father who can't see his children. The dumbfounded mother who sees her boys turn into drug addicts and criminals. And then there is the puzzling torture of the child who won't communicate at all.

I see one every once in while, a middle-aged father or mother whose child is incommunicado. They may seem harmless enough--a woman whose chronic depression may have made her emotionally unavailable to her children, or a man whose alcoholism and workaholism may have left family scars. Their child (or sometimes all the children, or sometimes one child and not the others) not only won't maintain a relationship, but supposedly won't even grant a reason why. Calls and letters not answered, and no forwarding address. The silence is more exquisitely painful than any denunciation.

Was there some unspeakable atrocity of abuse? Most things in life may be atoned for if undertaken with sufficient sincerity, but perhaps not all. Or is this a case of an unforgiving child who has embraced the path of ruthlessness? How much "honor," in the Ten Commandments sense, is owed to the dishonorable mother or father? To the merely inadequate mother or father?

Family secrets. In encountering a person one confronts a subjective world unto itself, and yet there are parallel worlds giving onto a mutual universe. The "history" one obtains one is merely one volume of a potentially infinite library that is a family. The empty chairs in the office may speak alternative volumes. Their would-be occupants may sit in other, similar offices, next to other, similarly empty chairs.

Non-physician, Heal Thyself

I'm not sure that a word exists for the practice of obtaining prescription medications from friends, acquaintances, or (for whatever price the market will bear) from vending strangers. "Med-seeking" we designate the practice of sending health care providers to an early grave with endless and inappropriate pleas for pharmacological relief. "Self-medication" is the hypothesized use of alcohol, most classically, but also illicit drugs in an effort to treat some supposed mental disorder. "Substance abuse" is, well, substance abuse.

But the word I'm looking for involves co-opting the tools of doctors without having to resort to the doctors themselves in the same way that an autodidact bypasses educators or a vigilante bypasses law enforcement. It is surprisingly common for folks, lacking access to a doctor for reasons of money or transportation, to obtain meds from whatever source they can find. To be sure, these are often opioids or benzodiazepines, but by no means always. I saw a woman recently with bipolar disorder who had been obtaining Seroquel samples from her sister, who is a nurse. And if someone is going to run out of Effexor a week before he can get in with a doctor, who could blame him for scrounging up seven doses wherever he can? After all, it's not as if the medical system is flexible and easy to work with.

If someone has been prescribed Xanax for anxiety symptoms with positive results in the past, and finds himself between doctors for whatever logistical reasons, is it wrong for him to obtain Xanax in unconventional ways if he never exceeds a typically prescribed dose? The Drug Enforcement Agency would say yes, presumably, and certainly this isn't a practice one should condone, but does it constitute substance abuse? I don't think so, if he has a legitimate anxiety disorder and no substance abuse history. In this case it would be no different from someone using a friend's unused antibiotics for a (self-diagnosed) sinus infection. And consider that, because doctors are often understandably hypervigilant and restrictive as regards controlled substances, it may be hard even for patients who quite appropriately need and use them to gain access.

To be sure, medicine has a procedure for enabling this practice in cases where it's considered safe: it's called making a drug available over the counter. And doctors have a way of frowning on any circumvention of their alleged wisdom. Indeed, patients who engage in this practice (for which I can't think of a name) may simply have below average respect for authority in general (but perhaps above average resourcefulness). This practice has family resemblances both with people who decide on a medication for themselves based on television commercials and with physicians who liberally prescribe themselves medications (not recommended). All of these undertakings stem from the natural assumption that if you want something done right, you'd better do it yourself. "Self-doctoring" may be the term, but I wish there were something more felicitous...

Straight Shooter

Some clinical anecdotes are irresistible.

A 55-year-old gentleman with a vague history of schizophrenia was brought in by a community support worker for a new evaluation, apparently at the behest of a family member, although there was no report of specific symptoms or dangerous behavior. But he had recently moved back to the area, so maybe the family just assumed he ought to get an evaluation for regular treatment.

He presented as somewhat disheveled, with a glazed look in his eyes; he was calm and pleasant enough, albeit quite flat and concrete, answering questions minimally. He couldn't or wouldn't say much about his psychiatric history other than to acknowledge the diagnosis of schizophrenia, multiple previous hospitalizations, and the experience of monthly injections at some point in the past. "What brought you back here from Texas?" "Greyhound bus." For a fleeting moment I thought he was wryly joking (for which his manner otherwise certainly would not have prepared me), but no such luck. So I settled myself uncomfortably into the plane of the literal for the duration.

When I asked him how much alcohol he drank, though (I long ago stopped asking people whether they drink, and now go straight to how much), he answered, "As much as I can." For a second again I wondered about some sly humor on his part, but he was deadpan. Yet his response had the kind of upbeat, slightly dutiful tone one might use to answer a question like "Do you get regular exercise?" But he wouldn't quantify.

So I moved on to marijuana (for which I have also recently moved directly to asking how much)--the complacent yet somewhat eager reply was, "As often as I can get it." "How often is that?" He just shrugged. On to cocaine, for which I still ask whether rather than how much. "Crack," he assented, nodding with an attitude somewhere between satisfaction and gusto. "Do you think any of those drugs could be a problem?" Incomprehension. "Has anyone told you these substances could be bad for you?" "No, nobody ever told me that!" he countered, baffled yet dismissive.

The interview unwound from there. As we returned to his diagnosis, I learned that he had actually "gotten over" his schizophrenia. "Would you consider taking medication again?" "No." (There was more to it, but this was the gist).

In a world of duplicity and innuendo, particularly surrounding substance use and treatment compliance, this was actually refreshing. There was no need to dance around the facts, as it was abundantly clear that he had no use for me, and our relationship at this point could blissfully and neatly come to an end. No hard feelings.

The community support worker, driving him home with a couple of other patients from the same area, stopped at a store to pick up something. The fellow went in and emerged with a beer; upon being told that he couldn't bring the beer in the car, he proceeded to chug it in the parking lot.

One more thing: he does receive Social Security disability payments monthly. Tax dollars hard at work.

Look for Me on "60 Minutes"

Well, not exactly (and no thank you). But lacking both time and other pressing concerns today, I belatedly take note of a passing mention of the humble blog in Melissa Healy's health column in the Los Angeles Times last month.

The common mantra now is that if you have depression, seek treatment because it is a treatable illness. By all means seek treatment, but part of psychiatry's soft underbelly (well, okay, psychiatry is really pretty soft all over, a real pussycat) is the weakness of its antidepressant treatments.

Based on both my clinical experience and my understanding of the literature, I don't buy the argument that antidepressants are a vast fraud, no better than placebo. But they're certainly not as robust as many would like to believe.

Often in this blog I have been critical of psychiatry, and the profession has left a lot to be desired in terms of the results it delivers. And I know that the most puerile response to criticism of any field is to say, "Well, do you think you could do better?" As my recently profiled favorite Samuel Johnson put it, one needn't be skilled at making tables in order to offer an informed critique of a particular table.

However, when the antipsychiatry folks shake their heads in disgust when patients end up on multiple medications, often "off label" and carrying significant side effects, I can't help wondering what they would do if faced with the patients psychiatrists see. Tell them to eat healthy food, get fresh air and exercise, find God, get married, get divorced, get a therapist? What if you do all these things and a hundred more, and try all the FDA-indicated treatments for depression, and years go by, and nothing happens? Well, you get creative, in a sometimes desperate attempt to alleviate suffering. It is easy to disdain the endeavor in a blog, with no patient sitting across from you.

Clinic

1. I finally got around to seeing a few episodes of HBO's series In Treatment. I'll leave the expert analysis to folks at Shrink Rap and Jung at Heart; but what a lugubrious guy this therapist is (and I think I know whereof I speak)! The show contains a lot that is of serious interest, but the outlandishly ludicrous aspect of it is that nearly all of the guy's patients storm out at the end of the session (if not before), denouncing the process and/or his alleged ineptitude.

If that happens to a therapist on a frequent basis, it's a good sign that he or she has a really tough population, ought to consider career change, or is in fact a fictional character. In fact, I can envision a Kafkaesque cross between The Truman Show and In Treatment in which a therapist gradually comes to realize that he is actually starring in a television series. He ascends through a series of clinical supervisors in a vain attempt to break out of the fictional frame. Therapy as Plato's cave, on two levels. Probably wouldn't appeal to a mass audience.

2. I saw my first case of self-diagnosed swine flu yesterday. I'm sure that's happening millions of times over in doctor's offices all over the world, but at least this guy had the excuse of having schizophrenia.

3. I don't do prison work per se, but a number of folks follow up at the clinic after "discharge" from incarceration. One irony is that they often got more expensive meds in prison than they can afford after release. Also, I can imagine that even in a booming economy it's awfully tough for a felon to get a job; in the current climate it seems to be essentially impossible. That's the sort of thing that might drive a person to...crime.

4. For the pharmacologists...no matter how long you do this, you'll still encounter something new every now and then. A guy with (subjectively) terrible anxiety comes in and asks to stop his Klonopin in favor of a drug he had in the hospital that had miraculous effects on his nerves. It was Vistaril. My pleasure, at least until he comes back in, having realized he confused it with something else. It's nice to be able to give someone what they want for a change.

Where is Wisdom to be Found?

A commenter helpfully brought up the question of how to go about finding, one hopes, above average psychiatric care. I don't claim any special expertise here, but as usual I can be induced to give an opinion.

What would constitute above average? I envision a psychiatrist who has both a healthy respect for the claims of biology and an acceptance of the ambiguity and limitations of our understanding and our technology. You don't want someone who is continually touting the newest thing, because in contemporary psychiatry unfortunately, newer is not always better; but neither do you want someone who hasn't heard of the newest thing, because even if newer isn't necessarily better, it may at least be an alternative.

You want someone who is creative with meds and won't give up on them (or other biological treatments) too soon, but who isn't focused on them to the exclusion of all else. He should offer a differential diagnosis that is shorter than DSM-IV, but he should keep the options open. Human nature being what it is, I would have to say you'd be looking for someone with a marked resemblance to yours truly (humble too).

If you see an $80,000 vehicle parked outside the office, that is a bad sign, as is a waiting room festooned with drug company paraphernalia, because that means he isn't thoughtful about appearances if nothing else. If he seems rushed and doesn't make eye contact, you're probably not getting your money's worth. With all due respect to foreign medical graduates, if you can't make out his words easily or he can't make out yours, he should have chosen a specialty less dependent upon verbal exchange. If he guarantees recovery or even improvement, beware, but if he despairs of the efficacy of his own interventions, suggest a career change.

I wish there were a pat answer for locating this hypothetical sage. Grading doctors and medical facilities on treatment outcomes is the growing if controversial rage, but as always this would always have to be more imprecise in psychiatry (if we can't all agree on the scope of some diagnoses, how could we agree on treatment parameters for those diagnoses?).

Obviously picking someone out of the phone book is the worst option, although it may well be better than nothing. The Internet is somewhat better--there may be a website that reveals the doc's mindset in some way, or a Google search can often reveal a surprisingly detailed trail of even minor publications or conference appearances.

A recommendation from another doctor or therapist is better yet, although keep in mind that they are usually going on inferences based on a psychiatrist's reputation or how he interacts with (referring) colleagues, which may be very different from his bedside manner or clinical acumen. Best of all is word of mouth from folks who have been actual patients--they have the point of view most worth having. But even this isn't foolproof--is he well-liked by patients because he doles out Xanax like candy?

If I had nothing else to go on I would go with an academic center if one with a psychiatry department were less than perhaps an hour away. Even if you get a resident, which is likely, the (relative) enthusiasm, eagerness to please, and exposure to new information may more than compensate for lack of experience, although you would need to confirm that there is supervision by an attending psychiatrist. Academia has all kinds of drawbacks, but in a field as variable and nebulous as psychiatry a large institution usually offers a degree of quality control.

If I were screening a psychiatrist for, say, a family member with severe depression or bipolar disorder, I can think of some questions that might assess clinical flexibility and subtlety. What are side effects of SSRI's? (If sex isn't mentioned, it's already time to move on). What are side effects of mood stabilizers? (If weight gain isn't mentioned, move on). What is your opinion on lithium? Is there an off-label role for drugs like Neurontin and Topamax? Do you feel comfortable prescribing MAOI's and tricyclics? What is the role of ECT? How much do meds usually cost? Are you comfortable with prescribing stimulants or benzodiazepines (the proper answer, essentially, is "It depends").

These are the thoughts that come to mind.

On Med-Seeking

There cannot be a pinch in death

More sharp than this is.

Imogen (Cymbeline)

I was thinking yesterday about the benzodiazepines (Valium/diazepam, Klonopin/clonazepam, Ativan/lorazepam, Xanax/alprazolam), those somewhat disreputable but often unavoidable therapeutic reinforcements (sort of like a mercenary army, the Blackwater of anxiety treatments). Every doctor seems to have his/her unique philosophy about these drugs, ranging from benzos-as-Tylenol to benzos-as-Four-Horsemen-of-the-Apocalypse. Indeed, the sheer variety of benzo perspectives one encounters pretty much guarantees that ideology more than science or pragmatism is at work. And like much prescribing and diagnosing that goes on in psychiatry, benzos are both overdone and underdone depending on the situation.

My understanding of a substance use disorder is continued use of a substance despite ongoing detrimental effects, whether to health, finances, legal status, work, or relationships. Depending on severity, it may involve involuntary cravings for the substance, desperate attempts to obtain it, and the development of tolerance and potential withdrawal. As is the case for opioids and pain treatment and for stimulants and ADHD, though, the handling of benzos can involve some ambiguous situations.

The central conceptual problem is trying to distinguish recreational euphoria from real relief from ongoing distress, a relief that in itself can seem like a kind of euphoria. After all, a frequent complain among doctors about benzos involves those patients who come in specifically asking for them. To many clinicians this "med-seeking" behavior in itself reflects a likely abuse problem, and surely in some cases it does, but does it necessarily?

It is noteworthy that these three classes of drugs--opioids, stimulants, and benzos--are not only susceptible to abuse but are also among the most reliably effective treatments for pain, ADHD, and anxiety, respectively, especially but not only in the short term. This is no coincidence of course--they clearly have potent and pronounced effects on neurotransmitters that can, depending on the patient, induce therapeutic relief or iatrogenic problems. People in pain may "seek" Percocet, and people with ADHD who have benefited from Adderall in the past may "seek" it again.

To return to benzos, it is worth pointing out that the overall pharmacologic options for anxiety are quite limited. Sure, all the antidepressants, from MAOI's to SSRI's, have effects on anxiety, but they are neither as reliable nor as rapid as those of benzos, and antidepressant side effects are generally worse than benzo side effects (setting aside abuse liability). Beyond antidepressants, one has, for anxiety, such imperfect options as antihistamines, buspirone, atypical antipsychotics, and mood stabilizers, all of which may be plagued with weak efficacy or major side effects. And no, I'm not forgetting psychotherapy, but most of the patients I see have previously or currently tried that. (Primary care and ER docs prescribing benzos may be another matter).

So when someone comes in specifically asking for a benzo, it is at least possible that they do so because benzos have in fact been head-and-shoulders above other drugs in treating their symptoms. Why do patients not come in specifically asking for drugs like Prozac or lithium? (Well, occasionally they do, but not often). Because for depression or bipolar disorder Prozac and lithium are not as clearly superior to competing options.

Another thing doctors tend to hate is patients availing themselves of another person's medication, even if at reasonable doses (this is often from a close friend or family member and therefore more like "in the house" rather than "off the street"). This certainly has its hazards and I don't condone it, but in itself, in the absence of other red flags, could imply a person straightforwardly seeking relief rather than trying to get high. Maybe I'm being psychotically naive here, but I don't think so. Sometimes I think doctors object to such behaviors more because they tend to bypass medical decision-making than because they guarantee a drug abuse problem.

I certainly don't view benzos as panaceas and do not hand them out in a cavalier fashion. And like most psychiatrists I think, I view alprazolam as representing a significantly higher risk of addiction and potentially heinous withdrawal. But unlike some doctors apparently, I don't view patients seeking benzos as prima facie wrong. Innocent until proven guilty.

It occurs to me that just as the prescribing of opioids is somewhat concentrated in specialized pain clinics, which helps to focus attention on potential abuse problems (by random drug screens, the tracking of prescriptions, etc.), clinics devoted to the treatment of anxiety could help to defuse much of the, well, anxiety, related to benzos. Obviously some psychiatrists, particularly in academic settings, specialize in treating anxiety, but the practice is not as widespread as that of pain clinics. Maybe I'll start an anxiety clinic--in my next life.

Hard Labor

This is prompted by a post by one of my favorite interlocutors. A large part what is lovingly called "the art of medicine" is really just common sense, which has as little to do with art as with medicine (unless it can be said to be the art of life). Doctors are given surprising authority over what should be common-sensical matters, and a good is example is the dreaded "When should I go back to work?" question.

I don't recall a medical school course on determining when people can return to work, although that may have been more helpful (for those without common sense at least) than whatever impractical biochemistry we were memorizing at the time. I'm not talking about the toxic Permanent Disability matter, but the routine but frequent need for folks to have a doctor-sponsored mental health day (or week, or month).

Usually this comes up, of course, when someone is in crisis, and when a patient asks the return-to-work question, my unspoken mental response tends to be a shoulders-shrugging, slightly smart-alecky, "Beats me." That is, he knows the particular cognitive, interpersonal, or physical demands of his work, and the likelihood that he is up to them in his current state, far better than I do. But in reality, he has usually already decided how much time off would be helpful and appropriate, and he is seeking an officially medical imprimatur. The amusing thing is that employers would treat my handwritten note as some kind of solemn injunction. The enforced rest cure, as it were.

But at least I am there when common sense fails, as quality assurance I suppose. Usually the week or so that someone wants off is quite reasonable, but occasionally the inches threaten to extend to miles with respect to someone's hated job. Or more rarely, the workaholic or the dutiful will overlook the obvious need for a break. I am a kind of offsite referee for the peculiar dance of the workplace.

All this falls under the nebulous domain of clinical judgment, at least, when the magic wand and crystal ball are out of order. The wisdom thing. As the systemic and cultural authority of doctors wanes, hedged in by managed care, insufficiently awed patients, etc., one would be inhuman not to relish at least a few quaint areas in which we wield near-absolute power. Thou shalt not work...for three days, or the lightning bolts will fly.

How Much Time Do I Have?

But at my back I always hear

Time's winged chariot hurrying near;

And yonder all before us lie

Deserts of vast eternity.

Andrew Marvell

A couple of weeks ago I dragged myself to the dentist, to the same office I used to go to when I lived around here before, ten years ago. (This is not, granted, an auspicious beginning for a blog post, or for any writing except perhaps a letter to one's grandmother, but bear with me). Once there I was asked whether I had seen any other dentists in the decade-long interim. I thought they were joking; they weren't (and lest you suspect the obvious, they hadn't even looked at my teeth at that point). I assured them that I never go more than nine years between visits. But the fact that they had to ask that question is a good reminder of why, for me, dentistry was safely off the list of life possibilities from very early on. But that's rather uppity of me I know--like I'm too good to be gazing into other people's oral cavities?

Deciding the frequency of medication management visits is no exact science, obviously, so except with folks that I'm particularly concerned about and who need to return soon, I usually just throw out a number, and I guess my mind usually lands on one, three, or six months depending on the person. These are arbitrary, but just have a tidy sound to them. Occasionally I may split the difference and do two or four months, but never five. There is no clinical reason why someone couldn't come every five months, it just isn't a factor of twelve. In my view even the most stable medication patient ought to check in (in person) at least twice per year, but again, I can't say this is scientific, it just feels right to me.

Psychiatrists are well known to keep patients waiting much less than do other physicians, and presumably this is the legacy of the precisely regulated 50-minute visit. But even with medication visits, I can't imagine keeping folks waiting an hour as they undoubtedly do in other doctors' offices. To some degree this is common courtesy, but it is also the case that some might find the psychiatric visit to be more stressful than a routine appointment; in other words, there may be some folks one wouldn't want to be hanging out in the waiting room for an hour or two, for their own good and that of others as well.

Many psychiatrists schedule medication visits every fifteen minutes, but I haven't been able to bring myself to do that yet. In my opinion, unless there are a significant number of no-shows or cancellations, it is hard to manage meaningful visits, even with stable folks on medications only, on that kind of schedule. The single most common complaint I hear from patients about other psychiatrists (which have included both private and community types) is that they didn't take the time. That is, they had the prescription pad poised to write from the moment the patient stepped into the room, and the patient felt rushed and not remotely listened to. In a high-functioning population with some cancellations, scheduling three per hour may be reasonable, as I did in a student counseling center I worked at. (The most common complaint I hear about other psychotherapists is that they brought up their own problems and issues too often in session; who are these people?).

Of course, if there is anything that shouldn't be one size fits all, it is psychiatry. Some patients really do only need five to ten minutes, after which we find ourselves discussing weather or sports (and I don't keep them sitting there a half hour for that). But a good number of medication patients need a full thirty minutes, and if that's not factored into the schedule, one will either have to cut people off or get behind and keep people waiting. Medication management, though, is more nebulous in this regard than the classic "50-minute hour."

Not really ambitious this rainy Sunday--the drops fall and the minutes tick by...

Psycho-Logical

M. C. Escher: "Night and Day"

You start a conversation you can't even finish it

You're talking a lot, but you're not saying anything

When I have nothing to say, my lips are sealed

Say something once, why say it again?

Talking Heads

1. Where has Anonymous gone? For weeks, months maybe, a comment (acerbic, incendiary, ingenious as the case may be) for virtually every lowly post, but suddenly nothing, and with no explanation. Is this just a camping trip, off the grid? Should I be concerned? Was it something I wrote? Sure, there are lots of other bloggers--and commenters--in the Internet sea, but I just don't understand...

2. In the era of increasingly mechanized, rapid-fire medicine, no refrain is heard so often as the deep need of patients (that is, all of us, eventually) to have their stories listened to, at length if need be. I'm a big believer in this, as it is usually therapeutic--except when it isn't. Another artifact of our medical non-system is massive redundancy, as folks are shuffled between various providers across disciplines and up and down hierarchies.

Every now and then I have significant past records on a new patient before the first appointment. I like to get the story au naturel from the source, but I do always skim through any records I have beforehand in case any glaring discrepancies come up. Sometimes it happens that once a patient learns I have records, he becomes disinclined to go through a story that has obviously been rehashed many times. "Don't you have it there?" he says, pointing to the chart. (Where I work now he may be there under pressure, not entirely by choice).

Well, in a way I have the story, and in a way I don't at all. Obviously I have ways--not always effective--of trying to get someone talking. But just as one has a right to waive informed consent, one has a right not to cough up a life story upon request.

3. Many people seem fascinated by forensic matters, but I never have been, whether in life, popular culture, or psychiatry. Abstractly, the problem of evil is compelling, but in practical terms I find wrongdoing and mayhem to be merely sordid and sad. So the dimension of psychiatry that involves trying to figure out whether someone is lying or "gaming the system" is not my favorite.

Some clinicians are surprisingly jaded about disability status. Once someone has obtained disability status, they believe, they are beyond the pale, that is, consciously or unconsciously motivated not to get better, and condemned to a life of wanton passivity. I'm probably just naive, but I find it easier to unambiguously identify those who cannot work than those who definitely could and merely won't.

Disability payments are not large in the overall scheme of things (i.e. in middle class terms), and seemingly shouldn't offer so much temptation. But many of the people seeking it aren't in the game for middle class stakes anyway. No, their options are closer to minimum wage, which may not pay a great deal more than disability would. And it's odd how persistent unemployment starts to make people feel a lot more disabled, when logically of course they should feel merely unemployed. And a criminal history can make it a lot harder to find a job. As one repeat felon memorably told me the other day, "I need a bailout."

Of course it's good for one's self-respect and dignity to work, or even to keep trying to find something. It's also good for the waistline to exercise regularly and eat more vegetables. Wisdom cries out in the streets...

Freitag...Friday...Free Day

Glendower: I can call spirits from the vasty deep.

Hotspur: Why, so can I, or so can any man;

But will they come when you do call for them?

Henry IV

1. This isn't the first time I've lived in North Carolina, but I was surprised to learn the other day that a Eugenics Commission was established in the state in 1929 and not formally eliminated until 1977 (yikes). Under the auspices of the program, 7,600 men and women, most of them "feeble-minded" or mentally ill, were sterilized, if not forcibly, then under considerable pressure (e. g. either consent or your family will lose welfare benefits). A significant number of these were minors. The explicit intent, of course, was to "clean up the gene pool," and a number of other states apparently had similar projects, although North Carolina's lingered a few years longer than most. Currently the state legislature is debating compensation for past victims, although given economic conditions, it sounds unlikely.

This is appalling, of course, and is a good reminder that moral progress in society is possible. And yet...any psychiatrist can think of past patients, both men and women, who continued to produce offspring whom they were unable to take care of or who kept getting removed by social services. Since it's hard to remember to use birth control when you're high on drugs, one can't help but suggest to these people a more definite form of family planning (forcing it upon them is obviously another matter altogether). And while Oliver Wendell Holmes is forever notorious for his remark (vis a vis a sterilization case) that "Three generations of imbeciles is enough," we have all encountered families that seemed particularly unfortunate in their collective risk for mental disorder. But naturally we cannot become too zealous in our attempts at prevention.

2. Considering the way that television is so often spoken of as a stupefying scourge, particularly for children, the consternation over the impending switch from analog to digital signals (which may leave large numbers of people unable to afford service, at least for a time) is puzzling. Think of it: large swaths of the population unable to access this mindless, soul-destroying diversion! What's next, leaving asthmatics unable to afford cigarettes? Is television service some kind of right, an integral part of the pursuit of happiness?

3. How do you manage to see sure-fire no-shows in an outpatient clinic? You shuttle them directly from state hospital discharge to the clinic door, as we do occasionally here to try to foster compliance and prevent recidivism. The idea is, by orienting them to the clinic they would otherwise never get around to visiting, to say in effect, "If you keep coming here--and take your meds--you won't have to keep going there (to the 'big house')."

How do you know they'll no-show? A hint is when they say, "I told that doctor in the hospital that I would take the medication so that I could get out, but I'm not going to take it because I don't need medication." We appreciate your honesty. This from an older woman with bipolar disorder who kept dismissing her manic episode as "an incident" at Wal-Mart. I am continually amazed by how often "Wal-Mart" pops up in symptom histories.

4. A curiosity: a young woman with no other psychiatric symptomatology whose primary complaint sounded like hypnagogic hallucinations, which were already getting better on the Lunesta she had been taking for a few days. It's interesting at this kind of clinic to be able to say, rarely, "You can get that taken care of at your primary care clinic" (and to think: you are not one of ours).

5. I see a 20-something fellow who is accompanied by his mother. In gathering the history it emerges that he was diagnosed with ADHD as a child, and his mother said he was treated with Mellaril until he was 9. "Probably methylphenidate," I suggest. But no, she insists that it was Mellaril, for hyperactivity and learning problems, and she even recalls the dose, 75 mg. (He had no history of psychotic symptoms either then or since). Mellaril? I'll bet it did calm him down, and maybe his learning did improve, with respect to one lesson at least.

Clinical Notes

It's become just like a chemical stress

Traces the lines in my face for

Something more beautiful than is there

Rilo Kiley

1. Speaking of ambiguity in psychiatry, benzodiazepines are a great example. A certain and significant subset of patients crave them, and sometimes they seem to be more trouble--and harm--than they are worth. It might be such a relief to be a fundamentalist and determine never, ever to prescribe them; but there is a moral microcosm here about personal purity and meeting the world as it is. Not only do lots of patients come to a new psychiatrist already on benzodiazepines, but for every person who may abuse them there seems to be at least one who is an ideal candidate, and for whom no other treatment will do. So the peculiar dance, part waltz, part tug of war, goes on. Xanax is where I draw the line though; and yet...never say never.

2. While I don't know of a good colloquial or clinical term for it, I am convinced that there is a kind of psychological hypochondriasis, that is, overconcern for psychological rather than physical conditions, that is far harder to treat than either pure anxiety or classic hypochondriasis relating to physical symptoms. You can't really give yourself cancer by worrying yourself about the possibility, but can you worry yourself into having a riproaring depression or anxiety disorder by brooding on the potential of such maladies? Unfortunately, yes.

3. There was moral panic in the 1990's about Prozac and other newer antidepressants making people "happier than happy." The theoretical concerns persist, but by now I think most people realize that antidepressants aren't strong enough to afford much euphoria to the normal (they're only moderately good at treating the unambiguously depressed). However, the situation appears to be different with so-called "stimulants" like Ritalin and Adderall, classically used for ADHD.

As William Saletan at Slate notes, stimulants may be the new enhancement drug in baseball. Compared to a 3-4% prevalence in the general population, apparently upwards of 8% of pro baseball players are submitting medical justification (in the form of a diagnosis of adult ADHD) for taking stimulants. The problem is, unlike antidepressants, stimulants may well enhance useful qualities like energy and attention in normals, and as with depression, the boundaries of ADHD are quite fuzzy and subjective, vulnerable to being stretched all sorts of ways. However, one might object that ADHD folks might be expected to be overrepresented in sports settings, because the syndrome often inclines those who have it to pursue active lifestyles (when accountants start claiming adult ADHD in large numbers, we'll know something is fishy).

4. I have found humor in psychiatry to be a funny thing (so to speak)--okay that wasn't very funny. As one would expect from human nature, psychiatric humor does go on, and widely, but so far as patients are concerned it is behind the scenes, surreptitious. Because of the long and lamentable chronicle of the stigma and mishandling of the mentally ill, psychiatric humor is sort of like racial humor, practiced above board only if one is of an appropriate ethnicity and patienthood. That is how it should be--respect and professional ethics demand it. And yet...as compared to other professions, those in psychiatry (and I include here nurses, therapists, etc.) see more than their share of the absurd, which, human nature being what it is, provokes involuntary amusement. It is a stressful profession at times, and, well, we creatures need to find humor in situations, if we're not allowed to find it in people.

So I mention this vignette not for the sake of any unseemly humor, but only as a break from my endless harping on ambiguity in psychiatric diagnosis...

Well, I started to write a full vignette, but even with details removed, it ain't right, for this venue anyway. Suffice it to say though that if you have been psychiatrically hospitalized twenty times, if you store your feces in your freezer, if you bear said feces to church (freezer being full, presumably), and, having been hauled to the emergency room, become extremely agitated and transform your room there into a scene of scatalogical mayhem, then we can safely leave diagnostic subtlety behind and say, ladies and gentlemen, we have a diagnosis. I appreciate the symbolism and possible psychological meanings of what the fellow was doing, but he really, really, really needs to stay on some medication this time.

(Not) Just Another Day at the Office (continued)

How pregnant his replies are! A happiness
That often madness hits on, which reason and sanity
Could not so prosperously be delivered of.

Polonius


A young fellow comes in, for a routine check-in after hospital discharge. He has been diagnosed with schizophrenia, although he disputes that (surprise). But he protests that what he really needs is not "pills," but rather housing and a job. "All you all ever talk about is pills...always more pills...what am I supposed to leave my kids, a bunch of pills?"

Good question. Fortunately his community support worker is sitting in with us; hopefully she has all kinds of great ideas for him. His last job was $7 an hour at Biscuitville, and with gas prices being what they were then, what was the point, really? The Obama campaign/transition team keeps sending me emails--what are they going to do for him?

Another guy, middle-aged this time. It sounds like he was quite successful, with a high-paying sales job and a family until he developed a severe psychotic disorder several years ago. Since then it has been steeply downhill, with several hospitalizations, disability, and divorce.

I had first met him a few weeks ago, when his family brought him in in a floridly psychotic state. At that time he was disheveled, paranoid, and exhibited thought-blocking. This time it is after his discharge and I barely recognize him. To be sure, his appearance is subtly off: a few hairs out of place, and a jacket that is a bit too long and too bright. But he is making an effort, and arrives early for his appointment.

He has been put on prodigious amounts of haloperidol, both oral and by long-acting injection, but he tolerates it without complaint. His chief concern seems to be a compound of loneliness and futility. He is heartbroken over not having seen his kids for months, and his ex-wife seems to have been able to deny him access. He wants to look into working and being productive again, like he used to be. Yet he sheepishly allows glimpses of persisting delusional systems. I don't think he could or should hold a regular job at this point. He lives alone, but does attend a church, and has some support from his family of origin. He has lost almost everything.

Why?

Noises in the Attic

Alas, how is't with you,
That you do bend your eye on vacancy,
And with th'incorporeal air do hold discourse?


Gertrude

(Illustration by Adolf Wolfli, hospitalized for psychosis in Berne, Switzerland from 1895 until his death in 1930).

Auditory hallucinations are the darndest thing. We all have our moments in life obviously, and I think that my own experiences plus a willing imagination can provide at least a vague idea of what it might be like to undergo a good number of the clinical syndromes I see. Can I know exactly? Of course not, as some patients like to point out, but that is always the case between two people (can they know exactly what it is like to be me?). Like any decent doctor or therapist, I make the effort and continually check in with the person in question to see how my imagined approximation is holding up.


Voices are tough though, as I have never experienced anything like them. The ominous creak upstairs, the pillow in the dark mistaken for something else, yes, but voices are something else entirely. I doubt that dreams provide any semblance of waking hallucinations. I can only imagine that they are disturbing at the least and potentially terrifying. My lack of experience makes me all the more curious about what it might be like to have them, so I hope that imagination gives empathy a needed boost.


Voices are most commonly associated with schizophrenia, but they constitute psychotic symptoms that may occur in various other conditions: severe depression or mania, substance abuse or withdrawal, and various neurological disorders such as dementia and delirium. Visual hallucinations can occur along with voices, but the former are more commonly seen in "organic" conditions such as substance withdrawal and delirium. Atypical voices can occur with borderline personality disorder or post-traumatic stress disorder. Not long ago I saw someone with voices that, she volunteered, had names. This is unusual, and given her history of severe abuse, it may suggest dissociative identity disorder (the same as "multiple personality disorder").


If someone hears the voice of a loved one who has died, this is considered normal. Similarly, hearing the voice of God is normal if such is culturally appropriate for the person and not accompanied by psychopathology. It is also possible, although perhaps rare and certainly not well understood, for some people to have random and isolated auditory hallucinations without having a psychiatric or neurologic condition.


Like much in psychiatry, the heterogeneity of auditory hallucinations is impressive. Most commonly they are strange (i.e. not sounding like anyone known to the patient) and derogatory. That is, they utter insults, often using profanity. Somewhat less commonly, they issue commands, sometimes bizarre and sometimes threatening.


But auditory hallucinations can be quite subtle, and in those cases it is hard to know how aggressively to go after them (particularly when they aren't obviously distressing to the patient). Someone may hear faint voices but be unable to make out what they are saying (this is often described as hearing a barely audible conversation in an adjoining room). They may hear noises that don't seem "real" (i.e. generated by the physical environment) but that aren't voices. Some people hear music; this seems to occur with the elderly more often. Some of this may be more likely with the relative sensory deprivation of hearing loss.


When it comes to true schizophrenia, there is nothing quite like seeing someone in the grip of a first psychotic break, or in the months thereafter. There is a distinct air of dismay, bewilderment, and consternation. The patient appears at once puzzled, confused, and afraid. I am often surprised that patients and their families are not particularly focused on the diagnosis--it is as if they know already at some level. I give it to them anyway as gently as I can (or remind them as the case may be) and emphasize manageability of symptoms with treatment.


The psychotherapy of psychosis involves education and intentional self-distraction among other things. People in the grip of voices sometimes wander long distances away from home, as if they are being hounded. It takes them a while to learn and to believe that they don't have to listen to the voices, that the voices, despite their threats, are actually powerless to hurt them or anyone else. People who have lived with schizophrenia for years become relatively accustomed to voices, although they can obviously still be upset and agitated by an exacerbation.


While recent studies have suggested that older antipsychotic drugs (like haloperidol (Haldol)) are every bit as good as newer ones, in my experience the newer ones are better tolerated in a subjective sense. Patients are more willing to take them. The metabolic side effects (weight gain and diabetes) can be a major problem.


In the ten years since residency I have never accepted drug company gifts or support of any kind. So my drug preferences are based on what I read in the literature and my experience with patients. Risperidone (Risperdal) is my favorite antipsychotic to start with; it seems to balance solid effectiveness with good tolerability. I found out the other day that 30 doses of generic risperidone 3 mg was only $46; I was surprised, that almost approaches affordability.


Olanzapine (Zyprexa) has the worst metabolic side effects on average, but its efficacy is impressive; it is often a reasonable option for those having major insomnia and who are thin (to start with). Unfortunately it is exorbitantly pricy. Quetiapine (Seroquel) is well-tolerated, but as it too can cause weight gain (and is very expensive too), so is often prescribed too loosely for insomnia and anxiety (in the absence of psychosis). Aripiprazole (Abilify) is a decent alternative because it produces less drowsiness and weight gain, but not uncommonly it generates unpleasant akathisia (a restless feeling).


The other day at our small clinic 37 patients received their monthly or bimonthly antipsychotic injections (they are for people who cannot or will not keep up with taking pills daily, but these kinds of shots are voluntary). I heard that Risperdal Consta now comes with a smaller needle for deltoid rather than gluteal use; I suppose that is an improvement. I imagine it must hurt though.

Lugubrious Lucubrations

If you're down he'll pick you up, Doctor Robert

Take a drink from his special cup, Doctor Robert

Doctor Robert, he's a man you must believe,

Helping everyone in need

No one can succeed like Doctor Robert.

Lennon/McCartney

Psychiatry is mostly unlike the rest of medicine, for better and worse, but it seems to me it has some things in common with my (admittedly distant) understanding of what a pain specialist does. If any of the latter happen to read this, set me straight.


1. Mental disorders, like pain syndromes, are often correlated with objective factors, but they are nonetheless fundamentally subjective and therefore frequently misunderstood and vulnerable to stigma. Diagnosis is therefore ambiguous and liable to being contested.

2. Both mental disorders and pain syndromes may get better with the mere passage of time. Watchful waiting is always an option.

3. Conservative treatment methods (psychotherapy/physical therapy) should be considered first.

4. Both mental and pain disorders are at risk of settling into chronic pernicious syndromes (often in a mutually reinforcing way).

5. Medication treatments in both carry the risk of addiction, sometimes iatrogenic. This can create tension in the clinical relationship.

6. In both psychiatry and pain medicine, simple cases are rare because primary care physicians have already taken care of most of those.

7. Both mental and physical distress are sensitive to suggestion and placebo (or nocebo) effect, both cultural and medical.

8. The treatments are broad in their effects and not specifically pegged to diagnosis; therapy is therefore more empirical and pragmatic than theoretical.

9. The aim is not cure, but rather symptomatic management either indefinitely or until the episode gets better on its own.

10. Both physical pain and emotional distress, beyond a certain point, threaten to become all-encompassing and to monopolize consciousness.

11. Both physical and emotional pain are necessary and at times even advantageous, but one can have too much of a good thing.

12. People may be growing less stoic, more sensitive to both physical and emotional distress in contemporary culture. There is a straight line between aspirin and Prozac.