Thursday, September 30, 2010

Rerun: Thomas Kuhn, Paradigms, and Psychiatry

This from late January. Enjoy ...

Haters of the word, paradigm, have Thomas Kuhn to blame. His seminal 1962 publication, The Structure of Scientific Revolutions, is a regular on all manner of Top 100 lists for books that rocked the world. In my line of work, you can’t browse a website for five seconds before being paradigmed to death.

My latest close encounter was an online book by Todd Finnerty PsyD on the fine points of Depressive Personality Disorder (see recent blog post). Dr Finnerty thoughtfully summarized Kuhn’s main points, which, together with Wikipedia and other sources, spares me from having reread Kuhn (which I did read way back in college).

Here’s the basics:

Forget about the quest for knowledge being an objective inquiry governed by scientists rationally sifting through the facts. That may be their intention, but in reality they are operating within their own particular conceptual frameworks (paradigms) that govern how they think. Thus, if you are living in an era where the ruling paradigm features the earth at the center of the universe, then your typical 15th century Polish heliocentric firebrand named Copernicus is going to come across as a raving lunatic (okay, make that solartic).

Ironically, says Kuhn, the 15th century scientific community, such as it was, was perfectly correct in rejecting Copernicus, as Ptolemy’s model of the universe still proved a superior predictor of observable planetary motion. Only later, with Galileo and others building on Copernicus, did Ptolemy (pictured here) and his world come crashing down.

During a period of normal scientific development, researchers are working off a shared set of general beliefs, which frees them up for working on specific problems. Anomalous findings either get dismissed or folded into the paradigm. But anomalies have a way of accumulating like unwanted snow. The old guard has a legitimate role as keepers of the paradigm, but history is not on their side.

According to Kuhn, the old and new paradigms are so different that they are “incommensurable.” In essence, there is no common ground by which a scientist working within a new paradigm can prove her point based on the assumptions of the old.

For an example of worlds in collision: At the 2004 American Psychiatric Association Annual Meeting, I heard Jack Barchas MD of Cornell University and a pioneer in the field of how biochemistry and behavior interact, recount how as a young investigator an early mentor challenged one of his ideas on these grounds: “How is this justified in the writings of Freud?”

Not surprisingly, Freud soon became to psychiatry what Ptolemy became to astronomy. But was Freud getting a raw deal? At the following year’s APA, I heard Nobel Laureate Eric Kandel MD state:

“A major need of psychiatry in the future is to put the psychotherapeutic arm of psychiatry on the same solid biological footing as the pharmacological aspect of psychiatry."

Dr Kandel was very much moved by Kay Jamison who said if it wasn’t for lithium she would be dead, but that it was really psychotherapy that gave her a coherent view of her life, that allowed her to tie the various strings of her life together.

"We’re in a fantastic phase of psychiatric thought," Dr Kandel concluded. The biology of the mind is the central scientific challenge of the twenty-first century. Molecular genetics and molecular biology, he said, have given us insights that would have been inconceivable 20 or 30 years ago. These advances will revolutionize psychiatry, but hardly eliminate it. Instead, psychiatry will synthesize with molecular biology into what he describes as "the new science of the mind."

Paradigms, paradigms, paradigms.

Wednesday, September 29, 2010

Staying Well - Part II

Yesterday's post focused on a very unusual 2005 study by Sarah Russell, in which she actually asked 100 "successful" bipolar patients what worked for them. The patients' keys to managing their illness are the type of things we advise each other in support groups and other venues all the time, such as maintaining a strict sleep schedule, being microscopically attuned to mood and energy levels, managing stress, taking strategic down times, and so on.

The one knock on Russell's study was that her inclusion criteria relied solely on the patient's own self-reporting of their wellness. Researchers tend to be sticklers for quantifiable data, and a very recent study published in Clinical Psychology and Psychotherapy (abstract here) addressed that concern.

The researchers found 33 Canadians with bipolar who qualified as "high functioning" according to a number of rating scales, then interviewed the patients individually or in focus groups. The authors of the study openly acknowledged Dr Russell's work, which they cited as the only previous qualitative study that has examined stay well strategies by those with bipolar. (Pause for a brief second to consider the implications of that statement.)

To no one's surprise, the patients in the study identified very similar stay well strategies to those in Dr Russell's study, which the authors broke down into six key areas, namely:
  1. Sleep, rest, diet and exercise
  2. Ongoing monitoring
  3. Reflective and meditative practices;
  4. Understanding bipolar and educating others
  5. Connecting with others
  6. Enacting a plan.
To go into more detail:

Sleep, rest, diet and exercise

According to one patient in the study: "I make sure that I get to bed by 10:30–11:00 every night. And a routine is really important." The researchers also identified "waking rest" such as lying down or watching TV, which "enabled people to meet social and work responsibilities."

Sleep and rest are tied into diet and exercise, as all have to do with maintaining a sense of mental alertness. One patient reported that she avoids heavy foods when she's down; another that "being active really works for me." As the authors observed: "These strategies are inexpensive, within one’s control and reflect common sense."

Ongoing monitoring

According to the authors: "Participants described the importance of learning to pay close attention to their moods and involvement in activities, in order to judge when to make changes." Thus, "individuals would spread tasks out over the week, cancel social engagements if necessary and maintain some unscheduled time."

As one patient described it:

To me it’s an ongoing basis where it’s like a ship that’s always righting itself, you know. Or when you’re driving, you’re sort of correcting as you’re trying to drive in a straight line. So those were the things that I see, and then I make minor adjustments and hopefully I don’t have to make major adjustments because I’ve been always making these corrections.

Reflective and meditative practices

These ranged from yoga to praying to journaling. One patient's Tai Chi practice, combined  with self-monitoring strategies fostered a "zone of stability" that allowed her to manage her illness well, despite experiencing symptoms.

Understanding bipolar and educating others

The successful patients in the study engaged in a variety of practices, from reading to attending support groups to charting their cycles to learning new skills from practical talking therapies such as CBT. In addition, the patients shared what they learned with family and friends, which in turn enabled them to become more supportive. As one patient explained:

I think my husband is really important because he will notice a depressive episode coming on before I will and he can tell by my body language. He says I walk differently. I carry myself differently and there is a look in my forehead and my eyebrows. He picks it out before I do. . . . He makes me aware of it and [then] I will just become more diligent about exercise, eating right, more sleep, and trying to . . . I guess, reassign priorities.

Connecting with others

Successful patients reached out in various ways, from contacting friends to finding formal support venues to volunteering to seeking professional help. As the authors explained, these activities are not unique to people with bipolar; rather the difference is the impact that these social interactions had on maintaining wellness especially during times of stress.

Enacting a plan

The patients in the study acknowledged the likelihood of things going wrong, and accordingly they had various arrangements in place, ranging from WRAP plans to informal understandings with friends and family.

Final word

The authors expressed the hope that once clinicians became aware of these stay well skills, they could tailor their therapies accordingly. But the successful patients in both Dr Russell's study and this one did not wait for their clinicians to become enlightened. Yes, they did learn from their clinicians. But, more important, they figured things out themselves.

Trust me, "Knowledge is Necessity" is not just a title to a blog; it's a way of life.

Tuesday, September 28, 2010

Staying Well

Today, I came across an abstract of a very recent study that solicited wellness tips from high functioning bipolar patients. This is only the second study I am aware of where researchers actually felt they could learn a thing or two from us rather than regard us as mere guinea pigs. I will comment on the study in a future blog piece. In the meantime, here's an article I did five years ago for mcmanweb of the first study ...

A study in the March 2005 Australian and New Zealand Journal of Psychiatry (abstract here) by Sarah Russell PhD of the Melbourne-based Research Matters of Psychiatry is so unusual that it merits a full article to itself.

Dr Russell recruited 100 bipolar patients who had stayed well for the past two years or longer. Staying well to some patients meant being symptom-free and behaving normally. For others, it meant a sense of control over their illness. The sample included 63 women and 37 men. Ages ranged from 18 to 83 years, with most over age 30. Seventy-six percent of the participants were in paid employment, 38 percent were parents.

Dr Russell asked these patients what they did to stay well. (In more than nine years of researching and writing about my illness, this is the only study I have come across that solicited the wisdom and experience of patients.)

The patients informed Dr Russell that they were extremely mindful of their diagnosis and “how they were responding to their mental, emotional, social, and physical environment.” Rather than simply taking their meds and forgetting about their illness (an impression created by their doctors), patients would “move swiftly to intercept a mood swing.” Moving swiftly often meant a decent night’s sleep and other strategic stop and smell the roses moments.

The study patients were adept at identifying their mood triggers, which needed to be picked up much earlier, they reported, than what their doctors recommended. By the time the sex, productivity, and spending of hypomania started to roll around, they said, it was already way too late. Instead, they were microscopically attuned to subtle changes in sleep, mood, thoughts, and energy levels.

Most participants were fanatic about maintaining their sleep. When disruptions to their routines did happen, they did not hesitate to take a sleep medication. In addition, participants did what they could to minimize stress in their lives. Smart lifestyle choices (diet, exercise, etc) were a must, and this included drastic career changes if push came to shove. Self-education was vital, and support also mattered, but more in a social and community sense rather than seeking out fellow patients.

The patients in the study tended to shop around until they found a psychiatrist who suited them.

Eighty-five percent were on meds. Adjusting doses was par for the course, but meds changes were seen as minor compared to the life and lifestyle changes the participants were willing to make. Many combined meds with complementary treatments that included cognitive therapy, nutritional supplements, naturopathy, psychotherapy, Chinese medicine, massage, tai chi, meditation, and yoga (often over the objections of their psychiatrists). Ten participants stayed well on talking therapy without meds.

Dr Russell was particularly impressed by the “stay well plans” of the patients, which ranged from verbal understandings with family members and others to informal written documents. It wasn’t that the patients were obsessed with their illness. Rather, “when participants were feeling well, the illness was in the back of their minds. It did not play a large role in their lives, but they knew it was there. On the other hand, when participants encountered triggers and felt 'early warning signals', it was necessary to become more vigilant.”

Dr Russell's Book

Dr Russell expanded her study article into a 140-page book, A Lifelong Journey: Staying Well with Manic Depression/Bipolar Disorder. The book features the 100 patients in her survey in their own voices.

Says Jodie, 29, who has been episode-free for three years: "Changes I have made to stay well include moving from a ‘party house’ in the city (which I thrived on) to living by myself … close to the ocean. I left a highly paid, stressful, and social job as an events manager in the city. I am now a full-time student … I also gave up smoking marijuana and moved away from people who were not good for me."

In addition, Jodie learned to take her pills without resentment, has limited her social activities and involvement in various projects, and established a regular sleep schedule and other routines. Especially important, Jodie has developed "the capacity and insight to see episodes coming on." For example, when she finds herself talking very quickly and craving excitement, she implements her "action plan."

Dr Russell was particularly impressed with the "stay well" plans of the people she interviewed. Susie, for instance, knows her main triggers are family stress and caffeine. When she finds herself buying more than one lotto ticket, visiting adult bookshops, and writing late at night, she goes to battle stations. This includes limiting her coffee, restricting her access to cash, turning off her computer after 6 PM, and not going to night clubs on her own.

Recognizing early warning signs is crucial. Ellen finds diagnostic language obscure and unhelpful. Referring to the standard mania checklist of grandiosity and increased energy and the like, she reports: "I would be pretty far gone if I had all those symptoms. To manage this illness, I need to intervene a long time before I start making grandiose plans and taking myself on a major shopping spree."

Ellen relies on her friends to act as the canary in the coal mine. "I no longer confide in my family who have no insight into bipolar," she says. "The people who monitor my moods are the people who understand my illness. I trust my friends completely."

Alan takes charge of his illness by staying informed. The nurses in the hospital, he reports, "kept pushing the medical line – ‘take your tablets and you will be fine.’ They seemed to think the only treatment for manic depression was medication. If only it was that easy!"

Dissatisfied with the simplistic quality of the standard literature for patients, Alan began researching medical journals with a critical eye. "Some of the research methods are questionable," he reports. Nevertheless, "once I knew what was wrong with me, I could deal with it. I have not looked back since."

One Patient’s Wisdom

"Let me give you a few tips of how I stay well with bipolar after 10 years ‘in the game,’" Damien told Dr Russell. On one hand, Damien acknowledges his need to be informed and vigilant. On the other, "I must loosen the tag on my forehead that says ‘bipolar’ and just get on with it … It’s an essential Zen paradox; take it seriously and not seriously at the same time."

Meditation and massage are two staples for Damien. Exercise, he says, gets the serotonin levels right and helps him "feel in my body." Laughter is also good medicine. Through his illness, he has achieved greater spiritual understanding and awareness.

Damien is microscopically attuned to early shifts toward depression or mania. Herbal tea, he says, usually "does the trick" for heading off a potential manic attack, but he has Zyprexa handy – as a standby med with the permission of his psychiatrist - just in case. He has used the Zyprexa twice in the past year. He maintains "humdrum" sleep and work schedules and relies on friends for support. He is not afraid to hit the mattress and "batten down the hatches" till a foul mood passes. "I have a fridge magnet," he concludes, "that says ‘Next Mood Swing in Six Minutes.’ Unfortunately, my low moods can last a bit longer than that."

Staying Well

The patients in Dr Russell’s book were successful in finding and applying what worked for them. Dr Russell spotted common themes, including:
  • Acceptance – This is the first step to taking control to one’s life.
  • Knowledge – "With time and experience, people can develop the wisdom to manage their illness and stay well."
  • Sleep – "A crucial ingredient to staying well."
  • Stress – "It is not always possible to avoid stress. It is possible, however, to develop strategies to minimize the impact of stress."
  • Lifestyle – Diet, exercise, sleep, etc.
  • Awareness and insight of triggers and mood states - This includes fatigue, jet lag, hormonal fluctuations, stress, lack of sleep.
  • Interventions – such as canceling social engagements and getting a few good sleeps.
  • Medication – "The right medication at the right dose."
  • Support – "Outside insight" is often welcomed.
  • Professional support – "It is worth shopping around for the most suitable healthcare professionals."

Sunday, September 26, 2010

Myth-busting the Kennedy-Nixon Debates

Ten days ago, I ran a blog post on the 1960 Kennedy-Nixon Presidential campaign. The focus of the piece was how we make choices - including those that decide the fate of the world - based on emotion rather than reason. My piece made a brief reference to the three television debates, which Nixon won on radio but lost to the more telegenic Kennedy on TV.

Today marks the 50th anniversary of the first JFK-Nixon debate, with no shortage of media attention, including a NY Times op-ed piece by Ted Sorensen, a top JFK aide who helped prep his boss for the debates. The popular myth has it that the debates were a triumph of style over substance. That may have been the case, but as Sorensen notes:

In fact, there was far more substance and nuance in that first debate than in what now passes for political debate in our increasingly commercialized, sound-bite Twitter-fied culture, in which extremist rhetoric requires presidents to respond to outrageous claims.

Indeed, that is the case. In researching my previous blog post, I reviewed a number of clips from the three debates on YouTube. I was tremendously impressed at the quality of the debate, way higher than what passes for political discourse in this day and age. The two may have projected entirely different TV personae, but what they both showed in common was an extraordinary level of deep thinking.  Clearly, these were two forceful intellectuals with a thorough grasp of the issues, each one making a strong case that they were the right man to lead the US and the free world through a time of global and domestic uncertainty.

Why would this have mattered to an American public 50 years ago? The knock on Kennedy prior to the debate was that he was a lightweight, way too young to be taken seriously, with little experience compared to Nixon. Even though both were around the same age (the two served as junior Navy officers in World War II and entered Congress the same year), Nixon was perceived as Kennedy's elder.

What surprised me in reviewing these clips was Kennedy's gravitas, not his sex appeal. If anything, by today's standards, JFK could be considered a nerdy wonk. Yes, he looked better on camera than Nixon, but what the American public really saw was a serious Presidential candidate who deserved to be on the same stage as the better-known Nixon. An undecided voter could now vote for JFK with a clear conscience.

To drive the point home: Kennedy "won" these encounters by debating the favored Nixon to a draw, by convincingly displaying that he deserved to be taken as seriously as his rival. This is what would have mattered most to voters, not his pretty boy charm. Yes, the Kennedy charisma would have entered into it, but these were the days before movie stars ran for high office.

Does this mean that voters back then cast their votes according to considered reason rather than emotion? No way. Major and minor decisions 50 years later are still made by the brain's primitive limbic system. The more highly evolved cortical areas merely rationalize how the non-thinking pleasure and fear centers react. But the thinking part of the brain still needs something to work with. Voters may have "liked" Kennedy more and "hated" Nixon with even greater intensity, but most of them were still ready to vote for Nixon till Kennedy gave them a valid reason to "think" otherwise.

Then they became "comfortable" with their choice. So the progression works something like this: A "like" or a "hate" or both from the limbic system, then over to the cortical areas to justify the decision, then back to the limbic system for that comforting glow.

Sorensen also noted that on the key issues, the two candidates did not vastly differ. Intriguingly, "while Kennedy would probably find a home in today’s Democratic Party, it is unlikely that Nixon would receive a warm welcome among the Tea Party."

My guess is the reason Republicans have failed to rehabilitate Nixon has less to  do with Watergate than with the fact that he was far more liberal as a President (1969-1974) than Clinton. Nixon had no place for fringe conservatives, who have long ago taken over the Republican party. Of all things, Nixon could be called "the last liberal President," less liberal than his predecessor LBJ, but willing to serve a broadly progressive agenda for the common good.

Crazy, huh?

Saturday, September 25, 2010

When Medicine Got It Wrong

On Saturday morning, I attended a NAMI San Diego screening of Katie Cadigan's gut-wrenching documentary, "When Medicine Got It Wrong."

Boy, did they ever. Back in the bad old days (actually, we are still deep in the bad old days), psychiatry blamed schizophrenia on bad parenting, a view that persisted well into the 1980s. The villain of the piece was the "schizophrenogenic" mother, one who committed the crime (in apparent complicity with the disinterested father) of being overprotective toward her child.

Practically on a whim, kids could be legally separated from their parents and locked away for the rest of their lives. By some logic way too crazy to comprehend, it was considered far more therapeutic to consign these kids to the hell holes of state institutions than keep them with their families.

Parents were treated with outright hostility by those who should have known better. One parent in Cadigan's film recalls being told by a hospital staffer that she was the reason her kid was in there. Another parent recalls a psychiatrist telling her kid, in her presence, that it was okay to express his hostility to his mother. If psychiatrists could not find anything wrong with the parents, by God, they were going to find something wrong with them, anyway.

One parent only half-jokingly remarked that "One Flew Over the Cuckoo's Nest" got it all wrong. There was only one Nurse Ratched in Cuckoo's Nest. In real mental hospitals, there were many Nurse Ratcheds.

During the 70s, parents started to get together and compare notes. Then they began organizing. They got in the face of mental health boards and politicians. They were told to behave. They did not. They refused to take no for an answer. This was the beginning of NAMI. Literally, NAMI started out as a kitchen table enterprise. Kitchen tables in California, kitchen tables in Maryland, kitchen tables in Wisconsin ...

Then the people from these kitchen tables banded together and went national. Slowly, the parents began making headway. They found allies among the few enlightened psychiatrists of the day. They helped close down the institutions, they promoted brain science and biological psychiatry, they fought for humane treatment and services for their kids. They moved mountains.

Alas, the law of unintended consequences proved a far more formidable obstacle. Their kids were released into the streets, with no services. The jails and prisons became overcrowded with the mentally ill. And biological psychiatry has yet to deliver on its bright promise.

There has been a generational transition. The film shows a sister as the caregiver for her brother. She has taken over the responsibilities from her deceased mother. The mothers and fathers in the film - unsung heroes, founders of NAMI - are getting on in years. Their kids - well into middle age - are still struggling. We see the early home movies and photos - young kids, laughing, clear eyes, their lives ahead of them. We see present day clips - grizzled adults, thousand-yard stare in their eyes, but with a small flame flickering.

The torch has been passed. A new generation of NAMI advocates are fighting the fight. That generation, in turn, will make way for a newer generation, who in turn will make way for yet a newer generation. No matter how successful we may be in getting people to listen, there will always be a fight. No matter how much progress we may make, we will always be in the bad old days.

Just one person in need is one person too many. We have a long long way to go. Just so long as we have people willing to fight ...

On Friday, Oct 8, at its Inspirational Awards Dinner, NAMI San Diego will be honoring Katie Cadigan as its Inspirational Person of the Year. You are cordially invited to attend. For further info, please check out the dinner page on the NAMI San Diego website.

Friday, September 24, 2010

TR and John Muir - Two Visionaries Who Saved America's Treasures

I wrote this for mcmanweb back in 2002. Enjoy ...

"We do not intend our natural resources to be exploited by the few against the interests of the many."

Believe it or not, a Republican President said that, Theodore Roosevelt. TR was not your average President. According to Kay Jamison, who needs no introduction, speaking to the 2002 Depression and Related Affective Disorders (DRADA) Conference, Teddy Roosevelt was "hypomanic on a mild day." He suffered from depression, and mental illness ran in the family, including a brother who had to be institutionalized and a son who committed suicide. He wrote 40 books, and read a book a day, even as President.

The context of Dr Jamison’s talk was exuberance, which was the title of her next book in progress (since published in 2004). We have "given sorrow many words," says Dr Jamison, "but passion for life few." Exuberance, she says, "takes us many places," with "delight its own reward, adventure its own pleasure." But exuberance and joy are also fragile, "bubbles burst, cartwheels abort," all part of the yin and yang of emotion, as "joy with no counterweight has no weight at all."

TR came into the world in 1858 "a full-blown exuberant." According to a Harvard classmate, "he zoomed, he boomed, he bolted wildly." A journalist said that after you went home from a meeting with the President you had to "wring the personality out of your clothes."

In 1903, TR teamed up with fellow exuberant, John Muir, for an extended hiking trip in Yosemite. Nature was Muir’s deliverance from his strict Scottish immigrant upbringing. Someone described his writings as the "journal of a soul on fire." He literally spoke in tongues to wildflowers, and his constant stream of letters to lawmakers ultimately attracted the attention of the twenty-sixth President of the US.

"Any fool could destroy trees," Muir wrote. "They can’t run away." Muir saw God’s immanence everywhere in nature, particularly in the mighty sequoias. "Unfortunately, "God cannot save trees from fools," he observed. "Only the government can do that."

TR was a committed conservationist long before he met John Muir, but after the Yosemite trip he marshaled his exuberance with new urgency. When TR assumed office in 1901, half of the nation’s timberlands had been cut down, the buffalo and other species faced extinction, and special interests were teaming up to lay waste to huge tracts of pristine wilderness. Thanks to TR, five national parks were created, along with 150 national forests, 51 bird refuges, four national game preserves, 18 national monuments (including the Grand Canyon which later became a national park), 24 reclamation projects, and the National Forest Service. Significantly, TR extended the concept of democracy to include future citizens, arguing that it was undemocratic to exploit the nation’s resources for present profit. "The greatest good for the greatest number," he wrote, "applies to the number within the womb of time."

In 1912, a would-be assassin shot TR in the chest. Faced with the prospect of premature death, he remarked, "No man has had a happier life than I have led; a happier life in every way." The deaths of his first wife and mother on the same day followed by a grieving period that lasted two years seemingly belies that statement, but personal realization has long been recognized as the reconciliation of opposites, and the same applies to John Muir, as well, who wrote he only went out for a walk but stayed out till sunset, for "going out was coming in."

Thursday, September 23, 2010

Fred Gage, NAMI San Diego Researcher of the Year

Tuesday afternoon, I drove down to the Salk Institute for Biological Studies, set above the cliffs of Torrey Pines in San Diego, overlooking the Pacific. My mission was to get a minute of Fred Gage PhD on film.

In 1998, Dr Gage's lab turned neuroscience upside down by discovering that human beings are capable of growing new nerve cells throughout life, a process called neurogenesis. Following from this, Dr Gage found that environmental stimulation and exercise can promote brain cell growth.

Dr Gage's work has literally changed how all of us think about the brain and mental illness and recovery. Soon after, for instance, Ron Duman at Yale found that antidepressants can promote brain cell growth and Husseini Manji, then at the NIMH, found that lithium can act as brain fertilizer.

Together, these and other findings caused researchers and clinicians to rethink mood disorders. Dead or atrophied brain cells, for instance, may compromise entire neural networks. Neurons cannot efficiently communicate with other neurons. Thinking and feeling and perceptions become distorted, resulting in all manner of personal catastrophes.

Looking deeper inside the neuron, we find that various complex bio-chemical processes responsible for the cell's maintenance may be on the fritz. Of special interest are signal transduction pathways, which interact with incoming and outgoing signals from neurotransmitters.

Thus, if a key signal transduction pathway is down inside the neuron, the cell may lack the means to communicate with other cells. The cell may literally shrivel up and drop off the grid. We know that stress can be particularly toxic to nerve cells. Over-excited neurons literally buckle under the load.

But, thanks to Dr Gage, we know the process can be reversed. Physical exercise can regenerate brain cells, as can living in enriched environments. As can certain medications. In other words, we are not stuck with the brains we are born with. Neither are we hard-wired for life.

Neurogenesis takes place in the hippocampus, which is involved in both emotion and memory. Hippocampal neurons are also intimately wired into other areas of the brain. Dr Gage and his team found that not only do new brain cells grow here, but that these new cells can join neural networks.

Dr Gage's work may explain why it takes antidepressants at least several weeks to produce results. In theory, an SSRI should work almost immediately. But if these meds are involved with the complexities of brain cell growth and restoring neural networks, then obviously we are talking about long lead times.

This has led researchers such as Dr Manji to focus on new meds development that can more precisely target pathways inside the neuron (rather than neurotransmitters outside the neuron) and thus significantly reduce lead times. In the meantime, Dr Gage's work has encouraged patients to take a more active part in their own recovery by doing what we know is good for us, namely: be mindful of stress, make sure we are actively interacting with the world around us, and exercise.

I walk across the Salk Institute campus to a large building and find my way to Dr Gage's lab. Dr Gage greets me and leads me to his small office. He has a much larger office upstairs, but here is where he actually works. He apologizes for his casual attire and ducks in a back room to change into an emergency white shirt.

On a white board behind his desk is a very complex diagram of blobs and squiggles, apparently representing something going on inside the neuron. I spot three letters - Wnt - and joke to Dr Gage that I think I actually know what something on his rendering means: Wnt (pronounced wint) signaling pathway.

My knowledge of brain science is largely derived from hearing brain scientists such Dr Gage (I heard him three years ago at a conference) dumb down their presentations for psychiatrists. That way I can almost understand the broad outlines of what is going on. Trying to make sense of brain scientists talk to brain scientists is Mission Impossible.

Dr Gage is curious about where I fit into the picture, and when I tell him how I'm coping with my illness with very little use of meds, with no hesitation he replies, "good." A psychiatrist would have hesitated. I tell him that moving to southern California nearly four years ago did wonders for me.

Enriched environment, exercise - where have I heard that?

Dr Gage will be in London during our Awards Dinner and will be honored in absentia. I'm here to get a minute of him on film, for showing at the dinner. Dr Gage has received no end of high honors from the research community. He was also recognized by Time Magazine as one of the 100 most influential people of 2000. But he is also very clearly flattered that people like us are paying attention, and this comes across loud and clear with the camera rolling.

We finish shooting, then he escorts me outside, where we stroll across the campus engaging in small talk. I ask him if being at the Salk Institute means he doesn't have to worry about where his funding is going to come from, but that is not the case. Like researchers everywhere, he is responsible for raising literally every penny, including his own salary. He says this helps keep him on his toes and keeps his lab lean and mean (he has some 45 researchers under him), but then he adds he's looking at things from the glass half full.

Thus, in my view, the vital importance of bringing our world and Dr Gage's world together. Enlightened research can only flourish with an enlightened public. We shake hands. It's time for him to return to his world, and me to mine. But I cherish those precious moments when our worlds connect, and I'm looking forward to those attending our dinner getting a little taste of it.

Tuesday, September 21, 2010

John Bell, NAMI San Diego Young Advocate of the Year

I serve on the board of NAMI San Diego. At our annual Inspirational Awards Dinner on Oct 8, we will be honoring John Bell as Young Advocate of the Year.

On April 17, concurrent with the NAMI San Diego Walk here, John organized some 100 fellow soldiers in his platoon in a 5K run in full body armor. "The US Army has taught me not all wounds are visible," says John, who has experienced PTSD. "As tough as a U.S. service member may be, many still suffer the effects of having endured life in a combat zone."

One in six veterans of Iraq and Afghanistan is affected by PTSD, depression, or anxiety. Only half seek help.

You gotta watch this video ...

Monday, September 20, 2010

Putting Your Best Foot Forward

The gorillas are my favorite animals at the San Diego Zoo. We may have moved away from counting our toes, but I know people who would greatly benefit from evolving toward the humanity of these wonderful creatures.

Also, check out this footage I shot at the same location two years ago ...

Thursday, September 16, 2010

A Lesson in History: The 1960 Presidential Campaign

I recall my father sitting me down and offering this sage advice: "Son," he said, "there is no excuse for dancing like a white man."

Actually, he said no such thing. Rather, he counseled, "Son, there is no excuse for thinking like a Republican."

Okay, he never said that either, but I do recollect my father dragging me out on a bitter cold autumn night in New England fifty years ago. I was 10 going on 11, and an historic Presidential campaign was underway.

JFK was due to address an evening rally in nearby Waterbury, Connecticut. He should have arrived hours before, but no one was leaving. I was standing in the drizzling freezing cold with my father and thousands of others. People were warming their hands around improvised fires they had lit in steel trash drums.

I don't remember much about Kennedy that night, but I vividly recall that crowd. I recall my father, I recall the emotion. History was being made. Theodore White, in his book "The Making of the President," recounted that memorable night and how Kennedy was astounded by the turn-out and the enthusiasm. That reception, others have commented, animated the exhausted candidate, gave him a second wind, imbued him with the strength to squeak out a win in what was then the closest election in history.

Had my father and others voted according to reason rather than emotion, Nixon would have easily won the election. Nixon, after all, had more experience by far, having served as Vice-President under Eisenhower, a true moderate Republican who presided over a decade of unprecedented prosperity.

A continuation of the Eisenhower years under Nixon would have been the sensible choice, but many voters harbored a visceral hatred of the Republican candidate. Part of this had to do with Nixon's early rise to fame. Conservatives saw him as a principled man standing up to home-grown communism. Liberals saw him as a rat bag red-baiter out to ruin innocent people for his own personal gain.

Part of this also had to do with Nixon's unfortunate "Tricky Dicky" image, which JFK exploited to the max. (Would you buy a used car from this man?) By contrast, JFK literally invented charisma. All politicians who came after are mere pale imitations. In their first debate (see the above YouTube clip), most of those who heard the proceedings on radio thought that Nixon had won, but JFK emerged a clear winner to the TV audience.

During the campaign, JFK resorted to a scare tactic involving a fictitious "missile gap" with the Soviet Union. Nixon could not respond without disclosing classified information. There was also the complicating variable of JFK's religion, then a contentious issue. Make no mistake about it, in our Irish-Catholic household it wouldn't have mattered if Kennedy were Forrest Gump - he had the McManamy vote securely locked away.

Conversely, all hell could have frozen over before many Protestants would have voted for a Catholic. Then there was the "solid south," in those days staunchly Democrat, still irrationally nursing a grudge against the party of Lincoln.

Nixon and Kennedy entered Congress the same year, 1946. They became good friends, Kennedy a conservative Democrat, Nixon a moderate and almost liberal Republican. Both were thoughtful men, with sharp intellects. Both were keen students of history. On paper, very little separated the two. On all the intangibles - the things that reason cannot explain - it was an entirely different story.

In the final analysis, the right man won for the wrong reasons. Such is the capricious nature of democracy. Jefferson and our Founding Fathers naively assumed that a well-informed public, making reasoned choices, could be trusted with their own government. According to a recent Pew Research Poll, 34 percent of conservative Republicans think Obama is Muslim.

This time around, capricious democracy - fueled on cynically fanned emotions - is leading us to an inexorably wrong result. God help us all.

Wednesday, September 15, 2010

Hamlet's Madness

Yesterday, I wrote on the madness of Lear. This inspired me to dig out two pieces on Hamlet I did for HealthCentral back in early 2007. Following is a reworked version:

I have of late - but wherefore I know not - lost all my mirth, forgone all custom of exercises; and indeed it goes so heavily with my disposition that this goodly frame, the earth seems to me a sterile promontory …

The speaker is Hamlet, of course, and he is either severely depressed or doing a damn good job faking it:

What a piece of work is man!
How noble in reason!
how infinite in faculties!
in form and moving, how express and admirable!
in action how like an angel!
in apprehension, how like a god!
the beauty of the world!
the paragon of animals!
And yet, to me,
what is this quintessence of dust?

Somehow, our hero has to get over his grief and harness his anger long enough to elicit the facts, figure out who his enemies are, then lie low and bide his time for the right opportunity to strike, assuming he can summon up the nerve to act against his true nature. 

Shakespeare wastes no time in introducing his madness theme. In the first scene of the first act, sentinels Barnardo and Marcello assume their night watch with extreme caution. Their conversation reveals that they have had two close encounters with a ghost. Are they hallucinating? Hamlet’s buddy Horatio definitely thinks so, but then …

Enter the Ghost in complete armour, holding a truncheon, with his beaver up.

Suddenly, Horatio is a believer. But Marcello needs confirmation that he is not losing his marbles. “How now,” he implores Horatio. “Is not this something more than fantasy? What think you on’t?”

This is Horatio’s cue to deliver his own prognosis: “This bodes some strange eruption to our state.”

Hamlet has yet to make his entrance, and already mad is the new normal.

Now we learn that no sooner have they buried Hamlet’s father than his uncle (Claudius) has married his mother (Gertrude) and assumed the throne. Perfect sociopaths that the new love couple are, neither parent can fathom why Hamlet is so upset.

“How is it that the clouds still hang on you?” enquires Claudius, apparently noticing that his newly adopted son is not exactly acting like the life of the party.

Gertrude gets straight to the point: “Good Hamlet, cast thy nightly colour off.”

In other words, snap out of it, get over it. What’s the big deal? So what that your mother is shtupping the guy who murdered your father?

Clearly Hamlet is becoming unhinged, but if his new father and all his retainers think he’s crazy (as in resolving to exact his revenge on them) then it's curtains for Hamlet. (Actually it turned out to be curtains for Polonius – yuk-yuk.)

We are talking about a normal reaction to a crazy situation, especially in a culture that gave birth to the terms anger and berserk, not to mention the name of the weapon of choice, the knife. This is what everyone around him is expecting, for Hamlet to act as they would, were they in his shoes. The catch is that they are bound to display their understanding in a preemptory outpouring of unsheathed steel.

One slight misstep for Hamlet, then, one indiscreet glance the wrong way, one blown syllable in one soliloquy, and cue up the grave diggers for the first act.

So - was Hamlet mad or was he just faking it? That is the question. Scholars pose this as an either-or “to be or not to be” riddle when reality (keeping in mind our hero is fictional) suggests a far more nuanced “to be AND not to be.”

Hamlet clearly knows he cannot hide his perfectly logical and dangerous madness. No, his survival depends on showing the Danish court a different kind of crazy, a harmless crazy, a crazy so crazy that even fair Ophelia is confused.

At one point in the play, Ophelia advises her father Polonius of Hamlet's interest in her:

He hath, my lord, of late made many tenders
Of his affection to me.

But later on, our title character abuses the object of his affections:

Get thee to a nunnery: why wouldst thou be a
breeder of sinners?

Ophelia has bought in to Hamlet's madness:

O, what a noble mind is here o'erthrown!

And so has Claudius, who has overheard everything:

Madness in great ones must not unwatch'd go.

Hamlet has bought himself time. He is mad, faking mad, going mad. Then there is the not-so-small matter of his force nine depression, introduced at the beginning of the play. As we know, any decent red-blooded male of Viking descent would have been hell-bent on revenge. But no, Hamlet can barely summon up the motivation to get out of bed, and Prozac is eight hundred or so years from being invented.

Someone needs to pull our melancholy Dane out of it. Enter Horatio and Marcellus and Barnardo with a very strange sighting to report, an apparition armed and with his beaver up – Hamlet’s father!

The life and death battle of wits is on.

Tuesday, September 14, 2010

The Madness of Lear

On Saturday I attended a superb production of King Lear at the Old Globe in San Diego's Balboa Park. Sample this luscious insult:

What dost thou know me for?

A knave; a rascal; an eater of broken meats; a base, proud, shallow, beggarly, three-suited,
hundred-pound, filthy, worsted-stocking knave; a
lily-livered, action-taking knave, a whoreson,
glass-gazing, super-serviceable finical rogue;
one-trunk-inheriting slave; one that wouldst be a
bawd, in way of good service, and art nothing but
the composition of a knave, beggar, coward, pandar,
and the son and heir of a mongrel bitch: one whom I
will beat into clamorous whining, if thou deniest
the least syllable of thy addition.

Lear's madness is already the topic of conversation in the first scene of Act I, when our main character retires as king in all but title, leaving him to the tender mercies of his two scheming eldest daughters, Regan and Goneril. Lear compounds his bad judgment by impulsively disowning his youngest and most beloved daughter, Cordelia. When his faithful retainer Kent objects  - "When Lear is mad. What wilt thou do, old man?" - Lear, in a rage, banishes him.

In private, Regan and Goneril take note of their father's mental instability, knowing full well they may be his next target, and the scheming begins in earnest.

Later on, the houseguest from Hell (Lear) meets the hostess from Hell (Goneril). In a rage, Lear takes leave, cursing his daughter thusly:

Dry up in her the organs of increase;
And from her derogate body never spring
A babe to honour her!

Meanwhile, his fool counsels:

thou hadst little wit in thy bald crown,
when thou gavest thy golden one away.

Lear, in a moment of clarity, realizes he has wronged his youngest daughter. "O, let me not be mad, not mad, sweet heaven," he pleads. "Keep me in temper: I would not be mad!"

But Regan turns him out (in the company of his fool) into the stormy night, a broken man, raging into the fury:

Your horrible pleasure: here I stand, your slave,
A poor, infirm, weak, and despised old man

Out on the heath, Lear encounters Edgar, a victim of a frame-up and fugitive from his father's wrath, disguised as a mad man. A surreal dialogue ensues, with Lear referring to the fake madman as "philosopher" and "learned Theban," a conversation that continues indoors, with the fool fitting right in. In an aside, Edgar empathizes with Lear, confessing:

My tears begin to take his part so much,
They'll mar my counterfeiting.

Soon after, in an ironic twist of fate, our storm-drenched band encounters Edgar's father and dupe in the frame-up, Gloucester, who has recently had his eyes plucked out and consequently fails to recognize his wronged son. He takes a liking to the youth, and engages him as his guide. In a commentary on the sad state of affairs in the world, he utters: 

'Tis the times' plague, when madmen lead the blind.

The action picks up further afield in Dover, with Lear thoroughly mad and disheveled. Cordelia and her army manage to get to her father before the armies of her scheming sisters. A doctor advises Cordelia, watching over her sleeping father:

Our foster-nurse of nature is repose.

On awakening, a more settled Lear reconciles with his daughter. The doctor advises:

Be comforted, good madam: the great rage,
You see, is kill'd in him: and yet it is danger
To make him even o'er the time he has lost.
Desire him to go in; trouble him no more
Till further settling.

The good old fashioned rest cure, based on the ancient principle that much of mental illness is stress-based. A number of years ago, I came across an article in the very first issue of the American Journal of Psychiatry (then the American Journal of Insanity) from 1844 that noted with approval:

Now we confess, almost with shame, that although near two centuries and a half have passed since Shakespeare thus wrote; we have very little to add to his method of treating the insane. To produce sleep and to quiet the mind by medical and moral treatment, to avoid all unkindness, and when patients begin to convalesce, to guard, as he directs, against everything likely to disturb their minds and to cause a relapse is now considered the best and nearly the only essential treatment.

Alas, tragedy is about to unfold. We were watching the production under a night sky, with the ghostly eucalyptus trees as a backdrop. Lear appeared as if from the trees, carrying his beloved dead daughter. The only sound that could be heard was the sickening thud in our hearts.

No one does literature better than Shakespeare. Ditto for psychology.

Monday, September 13, 2010

My America

Yesterday, a friend took me to a service at the First Unitarian Universalist Church of San Diego. I scanned the printed program. "Recitation from the Holy Koran," I read. Interesting. In walked the minister of the church, Rev Arvid Straube, with Imam Taha Hassane of the San Diego Islamic Center and his two young daughters.

A number of members of the church welcomed the Imam and his daughters. The Imam and the minister went to their places, the daughters sat directly in front of me.

The Imam explained that the Koran is the Word of Allah, and should be recited in one's most beautiful voice. He sounded forth a wonderful aural caligraphy, of all things not unlike that of a Jewish cantor reading from the Torah. Same God, same children of Abraham.

The Imam was moved by the warm welcome he received. He noted that a number of individuals from this church had attended his mosque the day before. His daughters, in the meantime, were taking this all in. They looked this way and that way. The oldest one had a camera. She lined up her shots and began clicking.

I could say a million words. Instead, I will conclude with the complete text of the letter that George Washington, early in his Presidency, sent to the Touro Synagogue in Newport, RI:  


While I received with much satisfaction your address replete with expressions of esteem; I rejoice in the opportunity of assuring you that I shall always retain grateful remembrance of the cordial welcome I experienced on my visit to Newport from all classes of citizens.

The reflection on the days of difficulty and danger which are past is rendered the more sweet from a consciousness that they are succeeded by days of uncommon prosperity and security.

If we have wisdom to make the best use of the advantages with which we are now favored, we cannot fail, under the just administration of a good government, to become a great and happy people.

The citizens of the United States of America have a right to applaud themselves for having given to mankind examples of an enlarged and liberal policy: a policy worthy of imitation. All possess alike liberty of conscience and immunities of citizenship.

It is now no more that toleration is spoken of as if it were the indulgence of one class of people that another enjoyed the exercise of their inherent natural rights, for, happily, the Government of the United States, which gives to bigotry no sanction, to persecution no assistance, requires only that they who live under its protection should demean themselves as good citizens in giving it on all occasions their effectual support.

It would be inconsistent with the frankness of my character not to avow that I am pleased with your favorable opinion of my administration and fervent wishes for my felicity.

May the children of the stock of Abraham who dwell in this land continue to merit and enjoy the good will of the other inhabitants; while every one shall sit in safety under his own vine and fig tree and there shall be none to make him afraid.

May the father of all mercies scatter light, and not darkness, upon our paths, and make us all in our several vocations useful here, and in His own due time and way everlastingly happy.

G. Washington

Wednesday, September 8, 2010

Is Happiness Possible?

Over on HealthCentral's BipolarConnect, I recently wrapped up a major series on Happiness. Four of my pieces dealt with the positive psychology of Martin Seligman of the University of Pennsylvania. Addressing the American Psychological Society in 1998, Dr Seligman challenged his colleagues to focus on the things that go right in human nature rather than what goes wrong.

In his 2002 book, "Authentic Happiness," Dr Seligman notes that despite our vastly improved standard of living, depression in the US has increased ten-fold since 1960. Part of the cause, he suggests, may be that our society is good at building shortcuts to pleasure.

Pleasure (which is fleeting), maintains Dr Seligman, is not the same as gratification (which is long-lasting). Typically, gratification involves effort. Settling back in the warmth of our homes with the TV clicker may seem like a rational choice. But the exhausted mountain-climber freezing on an exposed ridge doesn't want to be anywhere else.

Likewise, popping something in the microwave may be quick and easy, but making a meal from scratch is going to be a lot more satisfying (as is inviting people over).

A critical key to making the effort is "flow" - literally when time stops and you find yourself doing exactly what you want to be doing, totally immersed, and never wanting it to end. Of all things, flow involves the absence of emotion.

A study that compared "high-flow" teens (who had hobbies and did their homework) to "low-flow" teens (who hung out in malls) found the high flow kids did better on all measures of psychological well-being but one. The exception? The high-flow kids thought their low-flow peers were having more fun.

But tasks are not necessarily fun, per se. Typically, they involve challenge and hard work. Instant and ephemeral pleasure, such as watching sitcoms, is a sure flow-kill. Better, says, Dr Seligman, to pursue a life of meaning - to connect to something greater than yourself.

Dr Seligman also discusses optimism, which is not to be confused with our popular notion of "positive thinking" (which may involve viewing events in ways that fly in the face of unpleasant reality). Naturally, optimists and pessimists think a lot differently. For instance, optimists tend to internally credit themselves for good things happening and write off their inevitable setbacks as bad luck. Pessimists are just the opposite: If something happened to go right, they were just lucky that day. If something went wrong, it was obviously due to a major fundamental character defect.

Not surprisingly, optimists fare better in all endeavors save law. Lawyers are paid to spot negatives that no one else sees - only pessimists need apply. But lawyers have the highest depression rates of any profession or vocation, as well. (Perhaps they are envious of those wild and wacky undertakers.)

Dr Seligman lays considerable emphasis on strengths and virtues. These are embedded in the old-fashioned concept of "character." With his colleagues, Dr Seligman explored 200 works of literature that dealt with virtue including: Aristotle, Plato, Aquinas, Augustine, the Old Testament and the Talmud, Confucius, Buddha, Lao-Tze, Bushido, The Koran, Ben Franklin, and the Upanishads. Out of this emerged six universal virtues:
  • Wisdom and knowledge
  • Courage
  • Love and humanity
  • Justice
  • Temperance
  • Spirituality and transcendence
From there, Seligman et al identified 24 character strengths, such as curiosity and love of learning to augment wisdom and knowledge. Dr Seligman believes that everyone has 
several signature strengths, which they can deploy in their daily lives to their advantage. (You can test yourself for your signature strengths by going to Dr Seligman's Authentic Happiness site.)

My guess is that we tend to elude happiness far more than happiness eludes us. Heaven knows, I'm an expert at that, but thankfully I appear to be losing my edge.

My HealthCentral Happiness Posts

Happiness: Life's Greatest Challenge

Happiness: The Compassion Challenge

Happiness: Is Managing Our Misery the Key?

The Happiness Challenge: Keeping it Small

Happiness - Making the Effort is Always Worth It

My Practical (and Gratifying) Experience with Happiness

Happiness, Mental Wellness and Positive Psychology

Learning Optimism

More on Happiness: Using the Flow

Happiness: Capitalizing on Our Strengths and Virtues

Tuesday, September 7, 2010

Two Suicide Prevention Videos

This week is National Suicide Prevention Week. I produced both these videos more than two years ago. The first, "Brilliant Lives Cut Short," I did with the iMovie program that came with my new iMac. Please forgive the rookie mistakes. The second, "The Road to Nowhere," shows more sophistication, but it was my first or second outdoor shoot and it shows.

On top of that, this was the pre-HD era on YouTube. Despite all that, the message comes in loud and clear.

Saturday, September 4, 2010

Systems in Collapse

Instead of conceptualizing the brain as some sort of uniform chemical soup that could use a bit more serotonin or dopamine, we need to see the brain as a highly intricate ecosystem that requires sophisticated nurture and cultivation.

In a guest blog here last year, Cristina Romero had this to report from a talk by Kay Jamison of Johns Hopkins:

The brain is like a pond. It’s like an ecosystem. You want to get the ideal ecosystem and then you don’t want to disturb it very much. ... You want to really create a stable environment.

The brain, like an ecosystem, is highly complex, non-linear, and self-organizing. Both brain scientists and environmentalists describe this self-organizing principle as "homeostasis," where the system maintains its own equilibrium at a particular "set point."

We see this in the cycle of the seasons. But what if a drought or global warming intervenes? That's where "allostasis" kicks in. The system engages in compensatory wobbles to restore its sense of balance, either back to its original set point, or to a new one. That could be going on right now with Mother Earth.

Over the last two decades, southern California has gotten drier. The drought-weakened oaks in San Diego's eastern back country, my home until very recently, have been sitting ducks for certain species of beetles, who lay eggs in the bark crevices. The larvae then bore under the bark, and literally drain the life out of the tree. By the time you see dying leaves, it is too late to save the tree. Literally, a walk in the back country here is a walk along arboreal death row.

It doesn't stop there. The dead and dying trees serve as kindling for wild fires, which the seasonal Santa Ana winds fan like a bellows. In 2004, a once-in-a-century fire raged through the back country and other areas of San Diego, scorching more than a quarter million acres and killing 15 people. In 2007, another once-in-a-century fire struck.

Cycle of nature or planet in crisis? Who knows? The earth will heal one way or the other. It's just that it may no longer look the same or have people in attendance to witness the change. San Diego's Museum of Natural History has a fossilized mastodon skeleton on display, together with a mural depicting the beasts frolicking in the local swamps.
Then global warming happened. The swamps became desert. The earth eventually adjusted - found a new set point - but it was a new world order that did not include the mastodon. (Thanks for the memories.)

Then there is allostatic overload, a state of total collapse. As it happened, late last year I was hiking along the arboreal death rows of San Diego's back county - enjoying the sun, sucking in the type of air that city people would happily pay a dollar a bottle for - as I contemplated a person close to me in a psych ward back east. Back in the old days, they simply would have referred to his condition as a nervous break-down. They got that right. His brain was indeed broken. But which part of the brain was broken? That’s what I wanted to know.

Ha! If only life were so simple. In a review article in Psychiatry, Dhwani Shah MD of the University of Pennsylvania et al point out that “psychiatric syndromes cannot be localized in a single, so-called ‘abnormal’ brain region.” Rather, “mood and anxiety disorders involve immensely complex interconnected systems or networks of organization within the brain.”
Repeat: The brain is an ecosystem, the brain is an ecosystem, the brain is an ecosystem ...

The causes of depression and other mental illnesses are complex and only partly understood. Nevertheless, a picture is beginning to emerge of interconnecting brain systems in allostatic overload on the brink of collapse.

Tell me about it ...

Thursday, September 2, 2010

Kitty Dukakis on ECT

Following is an edited excerpt from a much longer piece on ECT, from mcmanweb:

In 2006, Kitty Dukakis (with journalist Larry Tye) published "Shock: The Healing Power of Electroconvulsive Therapy." Ms Dukakis is the wife of 1988 Democratic Presidential candidate Michael Dukakis. From the time she was old enough to worry about her body image, diet pills were a constant in her life. Ms Dukakis describes her quarter-century love affair with amphetamines as an addiction, though these pills almost certainly did more for her depression than the antidepressants she later took (readers, please don’t get any ideas).

The cure turned out to be worse than her addiction. Once she was off the pills, her depression manifested in full measure, together with a new dependency on the bottle. A steady round of rehabs followed, plus failed trials on antidepressants and mood stabilizers. In a state of emotional unraveling and desperate for a solution, in 2001 Ms Dukakis turned to ECT.

The very fact that Ms Dukakis had the option to choose electroconvulsive therapy is something of a miracle. As she and Larry Tye describe in their book, had events played out according to expectations, the plug would have been pulled from ECT years before.

Ironically, ECT's worst enemy has been the psychiatric profession. The over-use of the treatment during the forties and fifties and sixties, often against the patient’s will, under primitive conditions, and on populations upon whom the procedure conferred no benefit, gave rise to strong opposition. Part of the backlash came from the new antipsychiatry movement which got its start from patients who had been abused by ECT and inhumane institution-based practices. The movement found ready allies in other sixties-era groups pressing for political and social reform.

At around the same time, new psychiatric meds, with marketing campaigns heavily bankrolled by the drug industry, promised a new day. The death knell was the release of the 1975 movie, "One Flew Over the Cuckoo’s Nest," that portrayed head nurse Ratchett as Torquemada and ECT as a torture rack with voltage.

According to the authors of "Shock," Max Fink MD of New York State University, Stonybrook, helped save ECT from extinction. Essentially, he led with the facts – that for depression the response rates were exceptionally high (even in treatment-resistant populations) and offered immediate relief. For most depressed patients, the treatment worked better than antidepressants, and without their troubling side effects. The treatment also worked for mania and for depressive symptoms in schizophrenia.

But there was still the persistent problem of memory loss to contend with. Psychiatry did not help its own cause by repeatedly down-playing and even denying this disturbing invasion to the brain’s hard drive. Ludicrously, psychiatrists picked fights with patients who uncooperatively reported they could no longer remember their own kids’ birthdays. Clinical evidence, anecdotal or otherwise, was difficult to come by, as few clinicians even bothered to follow up on their patients.

Ironically, the authors report, during ECT’s golden era, its champions cited memory loss as an advantage of the treatment. (Economists would call this creative destruction.)

If Dr Fink saved ECT, it was Harold Sackeim who restored its credibility. To the horror of Dr Fink and others, Dr Sackeim freely acknowledged the memory loss. What the old guard saw as giving aid and comfort to the enemy, Dr Sackeim saw as a chance to improve upon technology and technique. Thanks in large part to his efforts, a more sophisticated generation of machines has been introduced and "unilateral" placement (to only one side of the brain) is replacing bilateral placement (though there still may be scope for the latter).

The authors cite Dr Sackeim for the observation that new generation ECT can target specific regions of the brain, thus reducing side effects and memory loss. By contrast, clinicians lack control for how meds are diffused throughout the brain.

During the early nineties, the media began observing that ECT was making a quiet comeback. Lately, the psychiatric profession has been more vocal in advocating ECT as an early treatment option, a development that may frighten some people otherwise prepared to accept the procedure as a last ditch or desperation measure.

The debate is by no means settled, and moderates tend to get assailed on all fronts by psychiatry and antipsychiatry zealots alike, who unfortunately tend to dominate the discussion (such as it is). As Kitty Dukakis and Larry Tye freely acknowledge, memory loss is still a legitimate concern and needs to be weighed against the promised benefits of treatment. Indeed, Ms Dukakis confesses to not being able to remember important events in her life and to having difficulty recalling names and other details. But she also writes, in relation to her first treatment:

Next thing I know I am waking up. I am back on the upper floor of Massachusetts General Hospital, in the unit where I slept last night … I am not sure I got the treatment. One clue is a slight headache … Another is the goo on my hair, where they must have attached the electrodes. There is one more sign that I did have my first session of seizure therapy: I feel good – I feel alive.

Yes, Ms Dukakis acknowledges, "I still can’t remember Paris," and that ECT may not be for everyone, but, "as my counselor Corky says, the choice is simple: Would I rather be depressed or be forgetful?"

Wednesday, September 1, 2010

Is Republicanism the New Stupid?

"Republicanism isn't a party. It's a diagnosis." A friend of mine happened to relate that to me in a conversation about a year ago, and I have no reason to dispute it. In fact, we actually have the brain science to lend credence to his statement. The same findings also indict Democrats, though I would contend there are mitigating circumstances. It breaks down like this:

It appears that nearly all of us are wired to register moral outrage, but we have very different on and off buttons. The same event can turn us all into avenging angels of God, but for entirely different reasons. A conservative, for instance, might want to kick a beggar. A liberal would kick the person who kicked the beggar.

Yes, environmental factors loom large, but a 2005 NY Times article brought attention to a Virginia Commonwealth University survey of a large sample of identical and fraternal twins on such divisive issues as taxes, labor unions, and x-rated movies. It turned out the identical twin pairs showed much greater concordance on political and social issues than did their more fractious (and apparently less) fraternal counterparts.

We have decades of research to back the proposition that our genetic makeup contributes mightily to our gut-level reactions to all manner of things that go off in the world around us. That same body of research also indicates that our pretenses at reasoned discourse are little more than elaborate justifications for our thoughtless emotional reactions.

In his excellent book, "How We Decide," science writer Jonah Lehrer cites an analysis that found that only 16 percent of voters with "strong party allegiances" during the 1976 US Presidential campaign were persuaded to vote for the other party. In a more recent study, political partisans had their brains scanned as they were read out the on-the-record inconsistencies of George W Bush and John Kerry. Predictably, the prefrontal cortices - the seat of reason - were recruited, which should have been a good sign.

For instance, if exposed to the fact that while on the same day George Bush promised "to provide the best care for all veterans" his administration cut medical benefits to 164,000 veterans, you might expect a Republican to seriously question his or her cherished beliefs. Or at least register some level of primal disgust.

Instead, the Republicans (and Democrats, too, when exposed to stupid Kerry tricks) felt a rush of pleasurable emotion. What seemed to be happening was that the thinking regions of the brain were activated - not to dispassionately weigh the facts and formulate some kind of rational response - but to fabricate a favorable interpretation of the facts, no matter how unpleasant those facts happened to be.

Thus, when the thinking brain had successfully arrived at "mission accomplished" - that is, a palpably absurd conclusion - the lower regions of the brain slobbered like a dog gorging on red meat.

As Lehrer contends, these and many more studies force us to rethink the long-held notion that reason, judiciously applied, overcomes ignorance and blind instinct. Adolph Hitler proved us all wrong on that count.

Now I know why I regard engaging in any kind of dialogue with a Republican as a total waste of time. I came to this unfortunate conclusion back in the nineties, but it wasn't always this way. Before that, I actually cultivated conservative friends. I also worked in a field (financial journalism) which involved total immersion in conservative opinion.

These individuals had a strong influence in my moderating many of my core beliefs and turning me around completely on my more flaky ones. Likewise, I like to think that I exercised a similarly beneficial influence. But in today's highly divisive political climate - the worst in my estimation since the Vietnam era - that simply is not possible. Heaven help if I were to point out to a Republican that Clinton actually turned federal deficits into federal surpluses.

I'm sure Republicans can make similar complaints, but how can I take them seriously when they cite Sarah Palin or Glenn Beck with approval? Hopefully, we can eventually restore reason to the dialogue. In the meantime - forgive me for my attitude - I have to go along with my friend: Republicanism is a diagnosis.

More to come ...