Legal marijuana, antidepressants, and the danger of not listening

 A popular blog post Why I Tried to Kill Myself at Penn is making its way around the college-age crowd. The author calls attention a high-stress a culture that does not value listening.

During my sophomore year at Penn, I tried to kill myself by swallowing a bottle of Wellbutrin. I spent 4 days in the hospital.
Penn’s response? – Sending some administrator to see me in the hospital (HUP). The first and only thing that she said was, “Are we going to make this an annual pattern?” because I had been hospitalized the year before. I said “No” and she gave me her business card.
After suicides, everyone laments, “Why didn’t they talk?” Often, we did. People just didn’t want to listen, because in the moment it was easier for everyone if you put on a smile and pretended to be okay.

A parent recently described calling the emergency student support services when she was worried about her son's emotional state during his first semester at college. After a five minute conversation, she was told by the person who responded to her call, " We can make an appointment with the psychiatrist to see if he needs medication."

I thought about these two stories when a study, a survey of 1,829 people being prescribed antidepressants, was released showing a much higher than expected rate of serious psychological side effects:

Over half of people aged 18 to 25 in the study reported suicidal feelings and in the total sample there were large percentages of people suffering from 'sexual difficulties' (62%) and 'feeling emotionally numb' (60%). Percentages for other effects included: 'feeling not like myself' (52%), 'reduction in positive feelings' (42%), 'caring less about others' (39%) and 'withdrawal effects' (55%). However, 82% reported that the drugs had helped alleviate their depression. 

Professor Read concluded: "While the biological side-effects of antidepressants, such as weight gain and nausea, are well documented, psychological and interpersonal issues have been largely ignored or denied. They appear to be alarmingly common."

Psychiatric medication side effects are a double-edged sword. The first, that receives the most, though as indicated by this study insufficient, attention is from the medication itself. But the second, and equally if not more serious, is the way prescribing of psychiatric medication becomes a replacement for listening.

What makes us human is our ability to empathize. Drawing from both Buddhism and psychoanalysis, the "presence of mind" of another person is responsible for therapeutic healing. "Being with," "bearing witness," are other phrases that describe this phenomenon. When we jump to a pill we run the risk of skipping this step. If the medication itself also has psychological side effects, it is not surprising that, in combination with feeling alone and unrecognized, a person might attempt suicide.

Psychiatric medication may be necessary when an individual is unable to function without it. Ideally such a determination is made in the setting of both psychotherapy and other self-regulating activities such as yoga or meditation. But that is not the way these medications are used. Because they can be so effective at eliminating distress in the short term, our fast-paced, quick-fix culture makes them very appealing, almost irresistible.

I decided to include the topic of legalization of marijuana in this post as a kind of cautionary tale. In California cannabis is commonly prescribed to treat anxiety. Psychiatric diagnoses and drug prescribing are often based on symptoms alone, as is well captured in this amusing though disturbing anecdote from a Psychology Today post by psychologist Jonathan Shendler:

During my first week as a psychiatry department faculty member, a fourth-year psychiatry resident—I will call her Gabrielle—staffed a case with me. She gave me some demographic information about her patient (38, White, female) and then proceeded to list the medications she was prescribing. The rest of our conversation went something like this:“What are we treating her for?” "Anxiety." "How do we understand her anxiety?"Gabrielle cocked her head to the side with a blank, non-comprehending look, as though I had spoken a foreign language. I rephrased the question.“What do you think is making your patient anxious?”She cocked her head to the other side. I rephrased again.“What is causing her anxiety?"
Gabrielle thought for a moment and then brightened. “She has Generalized Anxiety Disorder.”“Generalized anxiety disorder is not the cause of her anxiety,” I said. “That is the term we use to describe her anxiety. I am asking you to think about what is making your patient anxious.”She cocked her head again.“What is going on psychologically?”“Psychologically?”
“Yes, psychologically.”There was a pause while Gabrielle processed the question. Finally she said, “I don’t think it’s psychological, I think it’s biological.”

As we are on the cusp of general legalization of marijuana (that I do not oppose) it becomes imperative that psychiatric medications not replace listening. It is essential that we protect time and space for being present, for curiosity, for empathy. Otherwise we are simply offering another way, and one that is not without side effects itself, to devalue the role of human relationships in healing.

Epigenetics, Psychoanalysis, and Listening to Parents

Psychoanalysts for over a hundred of years have recognized the significance of early relationships in health and development. Now the exploding science of early childhood offers evidence that early parental care regulates physiology, influences development of the stress response, and even affects the expression of genes and structure and function of the brain.

The latest issue of the journal Neuropsychoanalysis provides an integration of psychoanalytic thought and contemporary developmental and evolutionary science. The article by Myron Hofer, and the accompanying commentary contain an abundance of evidence for the significance of early relationships.

Michael Meaney, a father of the new and rapidly growing field of epigenetics, offers this comment.

As Hofer noted, “maternal- infant interactions ... regulate the basic physiology of developing infants (such as sleep states, body temperature, autonomic balance, level of general motoric activity, and adrenal and growth hormone levels)”. These studies also revealed that these same maternal regulators were a source of information that shaped long-term phenotypic adaptation [gene expression and individual charcteristics.]

But all the science in the world may fall on deaf ears if our culture does not support parents in being present with their infants in the way the research suggests is critically important. 

If we pass laws condoning 8-week maternity leave, how can we take in and apply this abundance of research pointing to the significance of the early weeks, months and years? If, rather than addressing the problem of parents feeling overwhelmed and alone, and offering meanignful support, we are quick to diagnose them (and their children) with ADHD and prescribe medication, opportunities to make use of this wealth of scientific evidence are lost.  

Beatrice Beebe, a leading researcher in infant development whose detailed videotapes of mothers and infants offer elegant evidence for the richness and complexity of early parent-child relationships, praises Hofer's integration of theory and research. But Beebe, in conversation with a colleague of mine who is a general pediatrician, suggested that video be used in every 4-month well child visit. This comment represents a kind of disconnect between science and reality. The science certainly supports this kind of investment in time and attention to parent-child relationships in infancy.  But in today's fast-paced world of primary care, where clinicians are under pressure to see more and more patients in less and less time, such a suggestion is almost laughable.

In his concluding remarks, Meaney points in the right direction:

Developmental psychobiology established the conceptual framework within which to better understand the biology of early experience. The challenge is to now translate the emerging scientific advances into psychiatry and clinical psychology.

It seems like a kind of chicken-egg phenomenon. If as a culture we can place value on parents caring for themselves in order to be present with their children; if we value time for listening to parents and children together in the setting of primary care as well as mental health care, we may be better able to hear what the science is (and has been) telling us. 

ADHD treatment gone wrong: when prescriptions replace listening

Now that the letters to the editor in response to the New York Times article Drowned in a Stream of Prescriptions have been published, I am going to take advantage of this blog to publish mine.

There is one glaring error in the generally well-researched and deeply disturbing article Drowned in a Stream of Prescriptions. In a record review of Richard’s treatment the reporters found none of  “the more conventional talk-based therapies that experts generally consider an important component of A.D.H.D. treatment.” If only this were true. Just last week, AAP Smartbriefs, a review of newsworthy events in pediatrics, offered this headline Non-Drug ADHD Treatments Don't Pan Out in Study. The “psychological treatments” the study refers to are cognitive and behavioral training and neurofeedback. Talk-based therapy isn't even mentioned.

What is noticeably absent in Richard’s treatment is not talking, but listening. In the age of the 10-minute med check, there is no room for listening. If Richard was truly a well functioning person until mid-college, was his primary diagnosis schizophrenia? Was there some kind of trauma? In a world where ADHD is so quickly diagnosed, there was no time given to fully hear his story. That time that might have saved his life.