Inkwell: Authors and Artists

    
Gary, I happened upon an article today about Personality types and
depression.  It seems to muddy the distinctions even further.  

> The temperament harm avoidance (HA) has consistently demonstrated an
association with major depressive disorder (MDD), serotonin
functioning and reduction in depression symptoms in response to
antidepressant medications targeting the serotonin system.  ...

> HA mediated the response to antidepressant treatment, such that any
treatment effect of clomipramine occurred through HA reduction.  ...

http://www.medicalnewstoday.com/articles/181733.php 

Changing temperament?  Is personal identity the next frontier for mind
drugs -- "gimme a prescription for a new personality?"

Or is that already part of what treating depression is about.  
  

    
>Or is that already part of what treating depression is about.  



That's an interesting way to pose the question. The quick answer is
that this is not supposed to be what treating depression is about
because depression is an illness that, at least theoretically, can
strike anyone regardless of their personality type, just as diabetes
is. (I use that comparison because it is the one that the depression
industry uses; they'd be smarter to compare depression to heart
disease, as that does have robust correlations with personality
factors.) But studies, most of them recent, have shown that it is
possible that the personality changes wrought by the drugs are prior to
the changes in depressive symptoms, and maybe even cause them. The
most impressive of these was in the Archives of General Psychiatry at
the end of last year, and it purported to show that the personality
changes actually caused the remission in depression, perhaps because
people, once changed, liked themselves better.

Personally, I'm skeptical of this work, much as it corresponds with
what I believe, which is that depression, in many cases, and certainly
in the less severe cases, is the expression of something essential (if
not happy) about the person who is depressed. "Personality" itself is a
highly problematic construct, and the dimensions along which it is
measured tend to be oversimplified, reductionistic categories tailor
made for the measurements. Nonetheless, I think this line of research
is valuable, if only as a counterweight to the conventional wisdom
about depression as a disease.

An interesting implication here is that it reverses the main and side
effects of the drugs. Peter Kramer. in Listening to Prozac, wrote about
the personality changes in SSRI takers  as if they were accidental
outcomes of treating their depressions. But it's opssible that he had
it backwards.
  

    
>Changing temperament?  Is personal identity the next frontier for
mind drugs -- "gimme a prescription for a new personality?"

Well, of course, we already have drugs explicitly for that
purpose--psychedelics, entheogens, etc. That's why you're unlikely to
see the drug companies pushing to evaluate the personality-changing
dimensions of antidepressants. It would blur the line that they ahve
painstakingly painted between "medicine" for "illness" and "drugs" for
"enhancement."
  

    
Gary, I'd like to take this opportunity to thank you so very much for
joining us in Inkwell.vue.  We will be turning our focus to a new book
today, but you are all welcome to stay here as long as you like.
  

    
Been a really great discussion. I'm glad you wrote that book.
  

    
Thanks. This was lots of good,challenging fun.
  

    
One of the most valuable classes I didn't take in medical school was a
history of medicine course at Berkeley, and the discussions about
well-accepted and frequently diagnosed diseases that went in and out of
favor, really gave some good perspective on what we think we know vs
what we really know.  

It's good to reexamine the roots of our current understanding again.
  

    
I'd reexamine the roots of my current understanding, but my
neurasthenia is acting up again. ;-)
  

    
>One of the most valuable classes I didn't take in medical school >was
a history of medicine course at Berkeley, and the discussions >about
well-accepted and frequently diagnosed diseases that went in >and out
of favor, really gave some good perspective on what we >think we know
vs what we really know.  

For many docs, the specialization in science starts so early
(sophomore year, maybe even freshman) that they don't get much exposure
to history, let alone history of science, and only minimal coursework
in literature. So they are not well-equipped to understand the context
of their knowledge. And while much of science does seem to operate
outside of history, on a sort of gradual climb through ignorance and
error to the pinnacles of knowledge, in fact that history is really
important to understanding what a doctor is doing. 

Especially what a psychiatrist is doing. Freud wrote an essay called
The Question of Lay Analysis, in which he outlined why he was so
vehemently opposed to the New YOrk Psychoanalytic Society's decision in
1926 to limit the practice of psychoanalysis to physicians. Medical
training, Freud wrote, was exactly the wrong kind of education for
being a psychotherapist. Without that grounding in history and
literature, and the accompanying view that the life of the mind
demanded its own kind of science, doctors would be prone to seeing our
suffering as a disease and to seek cures. Freud lost that battle.

And Psychologists suffer a similar version of this problem--their
education is constrained by needing to get into ph.d. programs, which
are in agggregate harder to get into than m.d. programs, and as a
result tend also to miss out on the liberal arts. 

If nothing else, that kind of education can help to instill a kind of
modesty, a sense of how much we just don't know and of how contingent
the knowledge that we have is, that is a good counterbalance to the
certainties and pieities of medicine.
  

    
I was easily able to fit that course into my curriculum as a pre-med
student, and so were a lot of my fellows.
  

    
And many doctors start out as liberal arts students, changing in
midstream, or even doing the science in a post-baccalaureate program.
But it's pretty much left up to the student, unlike, say, organic
chemistry, which is a requirement. I think this is changing at some
medical schools, which are also trying to teach doctors about the
intricacies and importance of patient communication. But at least when
it comes to psychiatric training, I think a good grounding in history,
religion, literature, etc., ought to be mandatory.
  

    
As an idle data point, my partner checked himself into the psych ward
of the hospital we use about a fortnight ago. The doctors prescribed
him Prozac immediately; the first appointment with the therapist is
mid-to-late April. I am exceedingly unthrilled by this. Unsurprised,
mind you, particularly after reading your book, but unthrilled.
  

    
Take two Prozac and call me in a month? That's pretty bad, even by
current standards. I do hope they suggested you and he keep a close eye
on his level of agitation, impulsiveness, and suicidal thoughts as he
embarks on Prozac, and call in if you have any concerns. The first days
are often the hardest days. 
  

    
Ha. They said nothing to either of us. I've been carefully reading all
the documentation, going online to look at other effects (I refuse to
call them "side-effects") and interactions with his other meds, and
<scraps> and I have been talking about this daily. Thus far, he seems
to be handling it well.
  

    
Congrats on the Harper's cover story, Gary.
  

    
Thanks.
  

    
I've been in therapy 30 years. Giving someone Prozac, and then shoving
them out the door is wrong. The person made need drugs and talking
therapy. Prozac is a generic short half life drug. I'd look for a
person  who deals in both meds and talking. I know what I'm talking
about been through it many times due to moving from state to state.
  

    
I feel that most psych drugs today are like painting over rusty metal
or rotting wood - covers up the problem, makes it look functional, but
unless you deal with the problem, it will continue to rot away until
not even the most powerful drugs/strongest paints will help.
  

    
Sometimes you have to put put in braces and scaffolding before you can
fix the building.
  

    
That's very true.  And there are therapy methods to do that.  But,
just drug-and-go is only covering up the problem, not fixing it, or
preparing to fix it.

Had a girlfriend once, she started having panic attacks, went on Xanax
and Prozac, changed her personality, killed her sex drive, and she was
still having debilitating panic attacks four years later,
before...well, I broke contacts with her 3 years after we broke up,
though we'd been friends for those 3 years.

Me, had a robbery a hair over 4 years ago that triggered debilitating
panic attacks.  Got therapy, didn't take any drug courses, dealt with
it, and while I still have an occasional panic attack, haven't had a
debilitating one in years.

Where she painted it over, I immediately got to work on the
scaffolding and braces.  Still could throw on some paint, but it's good
enough now, why bother?
  

    
Painting over is a real problem if we are to live authentic lives, I
agree.  A percentage of people, though, have genuine chemical
imbalances in their brains that cannot be fully changed by therapy and
action.  Sometimes brain chemistry needs to be augmented on a long term
basis.
  

    
I recently had the mother of a patient get really angry with me that I
would not give her a new prescription to continue a psychiatric med a
psychiatrist started her on *without* arranging any ongoing
followup/counseling with any sort of mental health practitioner.

Always have to wonder if the family misunderstood, hard to believe a
psychiatrist would start it without even the *intention* of followup,
but still, all too common that patients get the drugs without
counseling, even kids.  Yikes.  
  

    
Around here (Eastern CT) that's pretty much par for the course. The
only followup is the one to the psychiatrist to make sure the drugs are
working. Fewer and fewer psychiatrists place much stock in therapy,
except for the assembly line CBT version, and often that's just lip
service.
  

    <scribbled by castle Tue 12 Oct 10 23:35>
  

    
Oh, a permanent imbalance is a whole 'nother critter...but anything
that can be dealt with by therapy instead of meds, I'll take the
therapy, hard and fast, rather than drug myself into someone else.