depression

CHASING DEPRESSION

Editor’s Note: One of my favorite shows right now is CBS Sunday Morning with Jane Pauley. They do such a great job at presenting interesting topics in a meaningful way. When I saw the spot about the promising treatments for depression, I thought of dad (eshrink) and knew it would be a great topic for eshrink’s blog. This post is a wealth of information on depression and Eshrink FINALLY weighs in on the TV program that prompted me to have him write it (that’s a little sarcasm that you’ll get when you read his blog) That’s just how we roll 🙂 Here is link to the spot that aired. SAINT: Hope for new treatment of depression – CBS

CHASING DEPRESSION
My slave driving editor who sometimes masquerades as a loving daughter has directed me to write a critique of a Jane Pauley TV show that featured information about a newly discovered treatment for depression. Maggie’s interest comes naturally since she had worked in my office as a receptionist when she was in high school, and her interest was undoubtedly enhanced by the presence of depression in our own family. There is no doubt that what we call Clinical Depression is a very common disabling and often fatal disease. Unfortunately, the word depression is also used for less serious mood deviations which often leads to a lot of misunderstanding. It is estimated that over 1 million people worldwide commit suicide each year and no ethnic group or race is immune from its paralyzing grip. Nearly all these victims are suffering from depression.

In 2017 there were 9.6 million people receiving treatment for depression, never mind the millions who were not treated. According to data from the 2017 National Survey on Drug Use and Health, 17.3 million adults in the United States—equaling 7.1% of all adults in the country—had experienced a major depressive episode in the past year.

There is said to be an alarming increase in suicide rates in the United States over the past decade however; such stats must be viewed with caution for in the past, coroners, who in order to spare family members the stigma of mental illness, would often rule suicides as accidental or from natural causes. Unfortunately, the stigma persists although there has been considerable progress towards classifying depression, the major cause of suicide, as a medical illness.

DEPRESSION of the AGES

It seems as if depression has always been endemic in human populations. There are multiple Biblical references offering solace to the despondent, and fables from even older times suggestive of unwarranted sadness. Perhaps the high level of consciousness afforded us by our massively complex brains has in some way contributed to our vulnerability. Throughout history, there have been endless speculation and theories put forth as to the cause of depression including: moral failure, demon possession, witchcraft, sinfulness, masturbation, or sexual deviancy to name a few. Most of these theories blame the victim, which further contributes to the self-loathing that typically accompanies the disease. To this day there are those well-meaning souls who unwittingly aggravate the depression of the one they are trying to help. In my practice, I had some patients with a strong spiritual orientation who become depressed, sought help from their pastor who diagnosed the problem as lack of faith, and suggested they pray harder.

The COMPLEXITY of DEPRESSION

In medicine, as with most things, transparency minimizes speculation. There is little doubt in my mind that an understanding of the causes of mental illnesses would go a long way towards eliminating the stigma associated with psychiatric illnesses. There is also the maxim in medicine that prevention is preferable to treatment of a disease. It is my belief that since it comes in many different shapes and sizes, depression is not a single entity, but more likely a cluster of illnesses producing similar symptoms, much as we see the symptom of fever in many different types of infections. Depression also takes different forms as for example, some patients suffer from severe insomnia while others find escape from the horrible feelings of hopelessness by sleeping for days.

Although depression often occurs spontaneously, it can also be precipitated by extreme stress or loss. For example, grief presents with symptoms indistinguishable from depression. Seasonal affective disorder with its recurrent depressive episodes appears to be related to disturbance of circadian rhythms, and one could make a case for it having resulted from the migration of humans to temperate zones a few hundred thousand years ago. As a matter of fact, depression frequently accompanies a variety of mental health syndromes, not the least of which is bipolar illness in which a manic episode is frequently followed by extreme depression. There is even a separate category of bipolar illness where those afflicted only cycle to depression and don’t experience manic episodes.

A Little Shrink History

It has been my good fortune to have been involved in the shrink business during a time in which there has been more discoveries leading toward an unraveling of the mysteries of the mind than have happened since the beginning of time. For centuries a cure for what was called “the black dog” by the Roman poet Horace and later repeated by Churchill occupied the greatest minds to no avail. Hippocrates was the first to identify the brain as the major control center of the body. The pseudo-science of phrenology became popular in the 19th century, which was the idea that one could diagnose problems, estimate intelligence and diagnose personality types by measuring the size of the bumps on their skull. Although it was soon discredited, its proponent, Franz Gall, is credited for advancing the idea that there is localization of brain function. He identified 27 different areas of the skull which he said controlled different functions.

Franz Gall diagram that identified different areas of the skull that he said controlled different functions.

In the early 1900’s along comes a Viennese neurologist who would influence thinking about the entire field of psychiatry and psychology for a half century. Freud’s focus on sexuality, in a Victorian society in which even uttering the word sex itself was considered in bad taste, gained him much world-wide attention. He developed a form of treatment both lengthy and intensive which he called psychoanalysis. Even now that many of his theories have been discredited, many terms which he introduced have become part of our every-day lexicon.

The Pharma Era

Fast forward a half century and I was in medical school witnessing miraculous advances in medicine almost daily. Following Fleming’s accidental discovery of penicillin there had been a rush to develop antibiotics that might be effective in treating organisms refractory to penicillin. Among those was isoniazid which had proven to be effective in the treatment of tuberculosis. In those days total bed rest was required as essentially the only treatment for TB consequently; patients who were confined to continuously stay in bed for months at a time often became depressed. However, following the use of isoniazid, moods of patients in TB wards often brightened, they became more verbal, less angry, and even happy. This led to investigation of similar compounds and the first group of antidepressant compounds called Monamine oxidase inhibitors (MAOs) were developed. These drugs were effective for some, but not for all patients. They also required great care in their administration as they interacted with many other drugs and there were severe dietary restrictions.

Depression and Pharma

1956 was my junior year in medical school and it was a banner year for the pharmaceutical industry. It marked the development of broad-spectrum antibiotics, i.e., those effective against penicillin resistant organisms. Thorazine, the first drug to ever prove effective in the treatment of schizophrenia was introduced. Within a year more than 70% of patients in psychiatric hospitals in the US were discharged, and there would be no more barbaric lobotomies performed. A group of antidepressants called Tricyclics whose side effects were less onerous than with MAOs came on the market at the same time. The response to these antidepressants, even though understanding of their mode of action was largely theoretical, led to the development of what came to be called the catecholamine hypothesis of depression. It theorized that the symptoms of depression were due to defects in the transmission of chemicals called neurotransmitters which were necessary to transmit electrical impulses between nerve fibers.

No Silver Bullet

Despite all these treatment, relief from depression was still elusive for many patients. Electroencephalography had been around for nearly 20 years, and it had become more sophisticated and especially valuable in the treatment of seizure disorders. Before Freud, there was a guy named Bleuler who wrote a widely quoted book on schizophrenia. As a matter of fact, he is credited with coining the term. He noted that he had never seen schizophrenia and epilepsy coexist therefore concluded that seizures must protect against schizophrenia. With that in mind several people set out to induce seizures as a treatment for schizophrenia by giving drugs known to cause grand mal seizures. The problem was that response to the drugs was unpredictable and the mortality rate was too high even in a non-litigious time. They also noted that although seizures did not have any effect on schizophrenia except for those in a catatonic state, it did seem to be remarkably effective for those who were depressed.

In the 1930s Italians Cerletti and Bini found they could induce seizures by passing an electric current through the brain. This method allowed for better control, and proved to be remarkably effective in cases of severe depression. Electroconvulsive Therapy or ECT as it is called, was widely used throughout the world and I saw firsthand how effective it could be to treating depression that was resistant to drug therapy. It got a bad rap due to the type of complications that could accompany it, such as broken bones, and the movie ONE FLEW OVER THE CUCKOO’S NEST. Additionally, ECT was sometimes used in cases where it was not indicated, yet were we in the shoes of those guys would we not be willing to try it if it were our only tool? Recent developments of anesthetics and muscle relaxants have made it much safer and better tolerated, but it is still mostly reserved for antidepressant resistant cases, yet there are some cases of depression that don’t even respond to ECT, which has been designated the last line of defense.

My Experience with the NEXT SILVER BULLET to TREAT DEPRESSION

After years of research, primarily investigating the neurotransmitters, norepinephrine and dopamine, researchers had become interested in another neurotransmitter, serotonin, which eventually led to the breakthrough development of Prozac in 1987. I vividly recall the first person for whom I prescribed Prozac. He was a very depressed young man in his mid-20s who had been an outstanding athlete and valedictorian of his high school. Unfortunately, he had become severely depressed, and developed a disabling social phobia. He rarely left the home where he lived with his parents, except to keep his appointments, and requested to be allowed to come in via the back door of my office in order to avoid occupants of the waiting room. I had been seeing him for some time, but my efforts were to no avail. On this particular day, a drug rep had left a sample of this new drug called Prozac which had just been approved for general use, and I thought “What the hell, I ‘ll give it a shot!” Two weeks later, David (not his real name) bounced into the waiting room and with a broad smile announced to the receptionist that he had arrived. Indeed, he had. He was proud to inform me that he had just come from a theatre where he had enjoyed the first movie he had seen in several years. My first thought was, “Could I have misdiagnosed this problem, and this guy is actually bipolar?” but he continued to improve and said: “I have finally got my life back”. The last time I saw him he was a sophomore studying engineering at Ohio State University.

Needless to say, David sold me on Prozac. It proved to have a remarkably good side effect profile other than for occasional sexual dysfunction which most people thought was a small price to pay for relief from the horrors of clinical depression. There would follow, as always is the case, a number of other “me too” drugs all of which came under the heading of SSRI’s (selective serotonin reuptake inhibitors), and after prolonged usage would sometimes lose their effectiveness a phenomenon called Prozac poop out, but in my opinion they have remained heads above other treatments. Unfortunately, the SSRIs as with other antidepressants are only effective about 70% of the time, and psychiatrists are often forced to make use of the trial and error method of finding an effective medication.

Seeing is Believing

Other than the unraveling of the human genome, nothing has impressed me more that the development of scans. They always remind me of the STAR TREK physician Bones who could diagnose and simultaneously treat any problem by putting people in his scanner. I am in awe of those engineering types who figure out all this stuff. The Curie’s invention of the x-ray was monumental, but the enhancement of that technology with computers to produce a cross section view was over the top. It was called Computerized Axial Tomography (CAT or CT scan) and provided a much more detailed look at the brain. In addition to hundreds of other medical uses, it was a valuable tool for brain research and a straight forward way to eliminate brain tumors and other brain diseases which often mimic psychiatric syndromes, a problem that had bedeviled psychiatrists forever. It was not long (the late 70s) when along came the PET scan with which one could actually visualize brain function. Even more fascinating and incredulous to me was the MRI which use a powerful magnet to actually turn protons on end to produce an image from the energy given off when they return to their normal position. They produced amazingly detailed pictures especially useful to orthopedists.

MAGNETISM

There has long been interest dating back 200 years or so on the effects of magnetism on the human body. In 1989, after studies suggested that magnetic energy could be effective in the treatment of depression, the FDA approved TMS (trans-magnetic stimulation) as a treatment. It was a very benign procedure that involved placing a 2-pronged electrical coil which produced a weak magnetic field on the patient’s head. The procedure was simple, painless and without side effects, and could easily be performed in a doctor’s office. Analysis of effectiveness of treatments for depression are difficult due to the placebo effect, but double-blind studies (clinical trials in which some administrations are real, others shams, and neither the patient or the physician is aware of which treatment is real) demonstrated effectiveness in some patients, but not all. In general, responses were not seen as very robust, and it was used mostly as an adjunctive therapy along with antidepressants.

This paper is in no way meant to provide comprehensive review of past and presently available treatments of depression, but believe me they are numerous and sometimes bizarre. In the November 13, 2021 issue of PSYCHIATRIC NEWS, Charles Nemeroff MD, PH.D in his review of treatments for depression, notes there are currently 26 medications approved by the FDA for the treatment of depression and another 12 in the pipeline. There is one study published in the May 2020 American Journal of Psychiatry regarding the use of psychedelics like LSD and psilocybin in the treatment of depression. Who’d a thunk it? In addition to the many types of psychotherapy, there also are always a plethora of non-medical procedures touted to be effective. Lest I get carried away and in deference to my editor who is by now tearing out fists full of that beautiful red hair as she screams “When in the hell is he going to talk about the spot on the TV show?” I will proceed to offer my humble thoughts.

SAINT

After watching the Jane Pauley show about the Stanford Accelerated Intelligent Neuromodulation Therapy or SAINT (thank God for acronyms), I found the original publication that described their novel treatment of depression to be in the August 2020 issue of The American Journal of Psychiatry which I had discarded long ago. Since I am a lifetime member of the American Psychiatric association, I continue to be automatically subscribed, but I must confess that since my retirement eight years ago, I tend to scan rather than peruse journals in much detail. Frankly, because the rapid changes in the field with its increasingly complex technologies have left me often wondering what they are talking about. Nevertheless, the Stanford U website reported an astonishing 87% recovery rate in the treatment with this new procedure named SAINT. Even more impressive, was the fact that these patients had all failed on other conventional treatments. Dr. Nemeroff mentioned in his review that the effectiveness of SAINT had recently been confirmed by a double-blind study which lent even more credibility to the reports of its effectiveness.

SAINT: What it is

The procedure involved is a much more complex, powerful and targeted version of the TMS mentioned previously. The researchers (Dr. Cole et al) were able to direct a burst of very powerful magnetic energy to the dorso-lateral prefrontal cortex (you must look that up in an anatomy book if you plan to do this at home) of the brain for 5 minutes per hour for 10 hours daily times 5. They are convinced that their success is dependent on their ability to target that particular area of the brain which has long been suspected of playing a prominent role in mood regulation. The patients and their families who were interviewed on TV were absolutely euphoric in their endorsement of the treatments. They used the phrase “game changer” and one was convinced this procedure would change the world, and I guess it has changed her world. I agree that this treatment holds promise, but think changing the world may be a bit over the top.

CAUTION: With Experience Comes Pragmatic Skepticism

Members of my illustrious family have accused me of being pessimistic by nature, while I insist that I am simply a realist, and much too naïve to be a bona fide pessimist. In spite of this alleged cynicism, Maggie has asked me to share my opinion of this SAINT thing, and I do find it promising however; all those years practicing medicine have taught me that although all people are the same, they are also all different, or as Grandma used to say: “One size doesn’t fit everybody.” Time after time I have found the initial exhilaration associated with ground breaking discoveries in medicine are later tempered by experience. I do feel this may well be a large step towards conquering this dreadful disease.

Nothing that I have written here should be construed to mean that I believe pills or procedures alone are the answer to the problems of mankind. At best I feel that medications or other somatic treatments enhance the therapeutic benefit of human intervention. Pills are important, but so is the hand that dispenses them. I have been heartened by a trend towards more balance in the nature versus nurture debate which has persisted for generations, for in recent years neurochemistry has dominated the psychiatric literature. Those of you who have read some of my other blogs probably know that I have strong feelings about that subject. Again, one size doesn’t fit everybody, but the more tools (based on scientific research) that psychiatrists have to treat the black dog of depression, the better off the world will be. The brain is a wondrously complex organ and the acceleration of knowledge is promising indeed.

Rebuttal to NY Times Article “Medicating Women’s Feelings”

Note from Maggie, Dr. Smith’s daughter and proud editor of eshrinkblog.com

The minister (pastor, reverend, preacher…I never know the correct title) sent my dad an op-ed piece from the New York Times and asked him what he thought of it. To me, it sounds like they are both very well-read people and enjoy intellectual conversations about issues. Below is my dad’s response. For my part, I see why my dad is so baffled by Dr. Holland’s article. I think what she is saying is that the system is set up to reward male-dominated traits, and there is value in many of the traits females have as a part of their biology. But she doesn’t explain it very well. Instead, she seems to be saying, “Suck it up and appreciate your depressive state. These anti-depressants are just making you like a zombie.” As a person who suffered from post-partum depression after my second child, Prozac was a lifesaver…for me and my husband and children.

Here is the article:

Medicating Women’s Feelings

By JULIE HOLLANDFEB. 28, 2015

WOMEN are moody. By evolutionary design, we are hard-wired to be sensitive to our environments, empathic to our children’s needs and intuitive of our partners’ intentions. This is basic to our survival and that of our offspring. Some research suggests that women are often better at articulating their feelings than men because as the female brain develops, more capacity is reserved for language, memory, hearing and observing emotions in others.

These are observations rooted in biology, not intended to mesh with any kind of pro- or anti-feminist ideology. But they do have social implications. Women’s emotionality is a sign of health, not disease; it is a source of power. But we are under constant pressure to restrain our emotional lives. We have been taught to apologize for our tears, to suppress our anger and to fear being called hysterical.

The pharmaceutical industry plays on that fear, targeting women in a barrage of advertising on daytime talk shows and in magazines. More Americans are on psychiatric medications than ever before, and in my experience they are staying on them far longer than was ever intended. Sales of antidepressants and antianxiety meds have been booming in the past two decades, and they’ve recently been outpaced by an antipsychotic, Abilify, that is the No. 1 seller among all drugs in the United States, not just psychiatric ones.

As a psychiatrist practicing for 20 years, I must tell you, this is insane.

At least one in four women in America now takes a psychiatric medication, compared with one in seven men. Women are nearly twice as likely to receive a diagnosis of depression or anxiety disorder than men are. For many women, these drugs greatly improve their lives. But for others they aren’t necessary. The increase in prescriptions for psychiatric medications, often by doctors in other specialties, is creating a new normal, encouraging more women to seek chemical assistance. Whether a woman needs these drugs should be a medical decision, not a response to peer pressure and consumerism.

The new, medicated normal is at odds with women’s dynamic biology; brain and body chemicals are meant to be in flux. To simplify things, think of serotonin as the “it’s all good” brain chemical. Too high and you don’t care much about anything; too low and everything seems like a problem to be fixed.

In the days leading up to menstruation, when emotional sensitivity is heightened, women may feel less insulated, more irritable or dissatisfied. I tell my patients that the thoughts and feelings that come up during this phase are genuine, and perhaps it’s best to re-evaluate what they put up with the rest of the month, when their hormone and neurotransmitter levels are more likely programmed to prompt them to be accommodating to others’ demands and needs.

The most common antidepressants, which are also used to treat anxiety, are selective serotonin reuptake inhibitors (S.S.R.I.s) that enhance serotonin transmission. S.S.R.I.s keep things “all good.” But too good is no good. More serotonin might lengthen your short fuse and quell your fears, but it also helps to numb you, physically and emotionally. These medicines frequently leave women less interested in sex. S.S.R.I.s tend to blunt negative feelings more than they boost positive ones. On S.S.R.I.s, you probably won’t be skipping around with a grin; it’s just that you stay more rational and less emotional. Some people on S.S.R.I.s have also reported less of many other human traits: empathy, irritation, sadness, erotic dreaming, creativity, anger, expression of their feelings, mourning and worry.

Obviously, there are situations where psychiatric medications are called for. The problem is too many genuinely ill people remain untreated, mostly because of socioeconomic factors. People who don’t really need these drugs are trying to medicate a normal reaction to an unnatural set of stressors: lives without nearly enough sleep, sunshine, nutrients, movement and eye contact, which is crucial to us as social primates.

If the serotonin levels of women are constantly, artificially high, they are at risk of losing their emotional sensitivity with its natural fluctuations, and modeling a more masculine, static hormonal balance. This emotional blunting encourages women to take on behaviors that are typically approved by men: appearing to be invulnerable, for instance, a stance that might help women move up in male-dominated businesses. Primate studies show that giving an S.S.R.I. can augment social dominance behaviors, elevating an animal’s status in the hierarchy.

But at what cost? I had a patient who called me from her office in tears, saying she needed to increase her antidepressant dosage because she couldn’t be seen crying at work. After dissecting why she was upset — her boss had betrayed and humiliated her in front of her staff — we decided that what was needed was calm confrontation, not more medication.

Medical chart reviews consistently show that doctors are more likely to give women psychiatric medications than men, especially women between the ages of 35 and 64. For some women in that age group the symptoms of perimenopause can sound a lot like depression, and tears are common. Crying isn’t just about sadness. When we are scared, or frustrated, when we see injustice, when we are deeply touched by the poignancy of humanity, we cry. And some women cry more easily than others. It doesn’t mean we’re weak or out of control. At higher doses, S.S.R.I.s make it difficult to cry. They can also promote apathy and indifference. Change comes from the discomfort and awareness that something is wrong; we know what’s right only when we feel it. If medicated means complacent, it helps no one.

When we are overmedicated, our emotions become synthetic. For personal growth, for a satisfying marriage and for a more peaceful world, what we need is more empathy, compassion, receptivity, emotionality and vulnerability, not less.

We need to stop labeling our sadness and anxiety as uncomfortable symptoms, and to appreciate them as a healthy, adaptive part of our biology.

My dad’s response to the article above

Dear Dennis, March 9, 2015

Thank you for sharing the New York Times Op Ed. Although there are many points in which I agree, I do fear that the opinions expressed may have the power to cause as much harm as the side effects of the psychotropic medications which Dr. Holland feels are overused. My concern is that her essay may contribute to the stigma already attached to the treatment of mental illness or emotional problems in general. Although Dr. Holland does make some valid points, I believe that some of her analyses are inaccurate. She bases her expertise on having practiced psychiatry for 20 years. Lest you think it audacious of me to challenge her, I trumpet the fact that I had more than twice that many years as a psychiatrist and prior to that another 10 years practicing general medicine. In the latter capacity, I found myself frustrated by my helplessness to deal with the emotional suffering of many of my patients. With this in mind I returned for a residency in psychiatry.

The first paragraph of Dr. Hollands’s piece lists qualities which she presents as gender specific, with which I do agree in general. She then describes these qualities as a “source of power” and continues by asserting that women are “under constant pressure to restrain our emotional lives” while denying a pro-feminist ideology. I fancy myself as a firm advocate of equal rights for women having been well indoctrinated by three assertive daughters, and a wife who has extricated herself from the helpless, dependent role which she had been taught. As I have stated in a previous blog post, I believe that women will eventually achieve equality or even superiority. In general, I feel this would be a good thing, although I must confess I do occasionally have some nightmares of that Stepford Wives thing, for I realize that paybacks are hell.

In the next paragraph she bashes the drug companies for “playing on fear.” Those of you who have read my previous blogs would agree that I am no big fan of the pharmaceutical industry, and I believe that promotion of prescription drugs to the lay public is not helpful, but then neither is the endless promotion of alcohol on TV. I have long felt the cost of new medications outlandish, but that is another story. In their defense I must admit that the tools available for treating mental illness although not nearly perfect are amazing considering what was available to us 60 years ago—even 30 years ago. She uses the example of Abilify as the inappropriate use of a medication. She does not seem to consider that it may be used so much because it is effective. Although it was originally developed as an antipsychotic, it has been found to be efficacious when given in small doses to augment the effect of antidepressants.

She presents further evidence of a stoned female population by noting that 1 in 4 women are taking a psychiatric drug compared to 1 in 7 men. This would seem to indicate that men are under medicated and women are about right for the INH study shows a prevalence of mental illness of 26.3% of the adult population. The disparity may also have something to do with the fact that women are not burdened by the macho thing and the qualities in women, which the doctor extolled in her opening paragraph, allow them to be more likely to seek help. Could these same disparities in diagnoses between men and women also have to do with the sensitivity and other valued traits in women? It does not seem illogical that they might have an increased susceptibility to depression and anxiety disorders as is the case in many types of illness. After all “men are from Mars and women from Venus.”

Dr. Holland insists that women are designed to “be in flux” and such things as premenstrual syndrome with its despondency, irritability, and anger are simply part of the normal female physiology and apparently is something that shouldn’t be tampered with.

She should be reminded that biologically premenstrual syndrome (PMS) was not a problem for primitive women, because they avoided the problem by being constantly pregnant. Modern women have rejected that option, and menopausal symptoms likewise were rarely a problem since few lived to be as old as 40. When these facts are considered one could safely conclude that treatment of these problems is not in violation of natural law. On the contrary I have seen many women through the years who have been severely impaired and spend sometimes half of each month miserable. Then there is the guilt that follows when they later realize the effect their behavior has had on their family, friends and coworkers. I would dispute her statement that menopausal symptoms can ” sound a lot like depression”, and say it not only sounds like but is depression. If it quacks like a duck, etc.

Perhaps it is with her discussion about SSRI’s that I wonder if I really am on a different planet. I vividly recall the first time I prescribed Prozac, which was the first SSRI. The patient was a very unhappy young man who had suffered a social anxiety disorder with depression since the 6^th grade. He had lived in almost total isolation, had never dated, and worked in a warehouse on the night shift in order to have minimal contact with other people. After a few visits he appeared to be a bit more comfortable with me, but shuddered at the idea of branching out socially. After a couple of weeks there was a remarkable change. He had started out by making conversation with the check out girl at the grocery, and reported he was no longer avoiding acquaintances as he had in the past, but more importantly he arrived with a broad smile. He denied any depressive symptoms, and the changes in his persona were so remarkable that I wondered if he had been into something illicit. I was skeptical this might be a placebo effect, but the changes persisted and the last time I saw him he had quit his night job, and enrolled in a university to pursue an engineering degree.

At this point I was sold on Prozac, but my joy was short lived when I found that it did not always work as advertised. It did however offer many advantages over other antidepressants which were available at the time including fewer side effects , less sedation, and non lethality at even huge doses, an important feature when dealing with depression. There is a significant group who will experience some sexual dysfunction, but most of my patients say that is a price they are willing to pay. I do not recall noting the zombie like effects that she describes with SSRI’s. As a matter of fact, my patients usually are more animated and expressive. Dr. Holland notes that SSRI’s may dampen what she calls ”human traits” among which are irritation, sadness, anger, mourning and worry. I don’t know about her patients, but mine would not mind giving up those human traits.

She also lists as side effects that SSRI’s are apt to result in one becoming “more rational and less emotional.” It is difficult for me to understand how these traits could be labeled as negative effects; therefore undesirable. We are led to believe that emotional stability will make women more masculine with the capacity for leadership, which again we are to assume is a negative. Her response to patients who complain about the emotional instability associated with the premenstrual period could be likened to such macho statements as “suck it up, play through the pain, stop whining etc.” consequently I am confused as to exactly what behaviors she thinks are appropriate.

The most puzzling of all to me is the last statement in the article wherein she states “we need to stop labeling our sadness and anxiety as uncomfortable symptoms and to appreciate them as a healthy , adaptive part of our biology.” I see nothing healthy about depression and anxiety, but only pain. Nor do I see any virtue in needless suffering. As a physician, I have always seen as my goal the alleviation of suffering, and nowhere in life is the suffering more extreme than in those afflicted with mental disorders despite the cause.

Where’s Walter Cronkite When You Need Him? The media’s inability to multi-task (among other things)

The Curmudgeon’s Corner

The Media + Robin Williams
August 17, 2014

It would take longer than the time I have left on this earth to discuss all the complaints I have with our current news media; however last week’s performance exemplifies many of them. I spent much of my time this last week being dumbed down by CNN. You might ask ‘why didn’t you simply turn the channel?” and my answer is: if I had not watched it I wouldn’t be able to complain, besides where else is a news junkie to go? MSNBC and FOX news function as political propaganda machines rather than as news organizations. I had some hope for Aljazera USA, but was told by Time-Warner that I must buy a separate cable box in order to get it on the kitchen TV where I prefer to get my morning news. I suppose it is a coincidence that Time-Warner is the parent company of CNN.

Perhaps you have noticed that CNN only does one story per week; although that story is repeated continuously until something juicier comes along. Each retelling is presented with great fanfare as “breaking news”. Occasionally, they might break in to mention some trivial world events such as the numerous wars raging throughout the world, or the plight of the millions of refugees throughout the world facing starvation, genocide or slaughter. I sense they would prefer to focus on domestic stories for it must be cheaper to use reporters from affiliates than to hire independent foreign correspondents, which the closing of most of their news gathering facilities throughout the world necessitates.

The story to which I am referring mercifully ended in less than a week as it was recently replaced by the shooting in Missouri, which remains at the top of the charts. This morning there was breaking news that the Governor was planning to visit Ferguson again. How exciting! As you may have guessed the suicide of Robin Williams was the story of the previous week. I have always been a fan of Robin Williams and thought he and Johnathon Winters were the two funniest men in the world. My wife commented the other day that Robin had “kind eyes”, and watching the clips on TV, I had to agree. I was also impressed that his humor was not at the expense of others. There is no question that this man was a comedic genius in addition to being an exceptional actor.

Prior to my bitter old man days, I was a psychiatrist and as such have always had an interest in what makes people tick. I have found the genius thing to be especially interesting. For example, how is it that the brains of so called savants can perform unbelievable acts of genius when in all other areas they are so limited? In my younger days I had also done some research into attempting to learn more about suicidal behaviors. With these sorts of questions in mind, I found myself listening to a parade of so called experts discussing Robin’s life and tragic death. Physicians generally spend a lot of time attending lectures by various experts; consequently I have had a lot of experience in this area. I have even pretended to be an expert myself on occasion. Somewhere along the line some medical truth teller defined an expert as “someone more than fifty miles from home with slides.” I felt a CNN mental health expert could be characterized as “a smooth talker with an agent.”

With the exception of Dr. Oz (really smooth) who did give a short but accurate monologue about depression, I felt the experts sounded like amateurs. I feel sure that it would take any first year trainee in psychiatry about 15 minutes to diagnose Mr. Williams. His history of depression, and substance abuse, quick, nay lightning fast wit, periods of impaired judgment, racing thoughts, and family history were absolutely diagnostic of Bipolar I disorder. Bipolar disorder frequently gets bad press, and I felt this would be a wonderful opportunity to dispel some of the myths about the disease. Many historians now think that many of our most creative people have been afflicted in some form. Robin Williams certainly was in that group.

Arthur Miller, the playwright once said that he had not been able to write anything worthwhile since he started on lithium (a mood stabilizer) but he felt wonderful. This is the man who wrote Death of a Salesman in one day. Yes, bipolar patients can be incredibly productive until they run out of gas and fall into a pit of intolerable hopelessness, and despair. I don’t believe any of us who have not experienced that pain can truly understand suicide.

Robin Williams paid a big price for his genius, and I can’t help but wonder if in the past I may have stifled some potential genius’s creativity by treating his Bipolar disease. Yeah, unintended consequences can be a bitch, but I wager that Robin would have gladly traded fame and fortune for euthymia.