His Lovely Wife in the Psych Ward: An Interview on Love, Writing, and Mental Illness (with Mark Lukach)
In this episode, we talk to Mark Lukach, author of the book My Lovely Wife in the Psych Ward: A Memoir, about his experiences as the loved one of someone with new onset symptoms of mania, depression, suicidality, and psychosis. Mark tells us the story of his wife Giulia and how their future changed unexpectedly when they were 27 years old and she was first hospitalized on a psych ward.
He describes why he wrote his article and then his book (no other books on caregiving in a romantic relationship! and feelings of loneliness), the response from others (including parents at his school!), and the role of writing in his marriage. He also shares it has been like in his relationship as a caregiver.
Mark details how he redefined what love is and the role of love in illness and pain, as well as learning to plan for a crisis in between crises. He also beautifully explains what’s it’s been like to be the caregiver and have his feelings and experience unacknowledged by so many—from her professionals to the mental health insurance system. He imagines what an ideal mental health system for caregivers might then look like—including redesigning the waiting room—and how maybe it could all be fixed with one word: inclusivity. Mark's website is here.
David Carreon: Hi this is David Carreon.
Jessi Gold: This is Jessi Gold.
David Carreon: And this is Psyched. Today we have Mark Lukach, a teacher and freelance writer. His work has been published in the New York Times, The Atlantic, Pacific Standard, Wired and other publications. He's currently the 9th grade Dean at the Athenian school where he also teaches history. He lives with his wife, Julia and their sons in the San Francisco Bay area. Mark first wrote about Julia in a New York Times Modern Love column, and again in a piece for Pacific Standard Magazine, which was the magazine's most read article in 2015.
David Carreon: Mark, thank you for joining us.
Mark Lukach: Sure thing, thanks so much for having me on. I really appreciate it.
David Carreon: Mark, tell us about this piece that you wrote about. What's the story behind it?
Mark Lukach: Sure thing. I actually don't initially identify as a writer. I really am a high school teacher, right? I met my wife Julia when we were actually in our first week of college. It was very much puppy dog love at first sight, like chasing rainbows into the sunset kind of thing, you know? It just felt like a fairytale in many ways. We ended up getting married, pretty much directly out of college, and moved to California soon after that. I thought the future was set. I had this amazing woman who I was in love with, who I was married to, we were gonna have a family. I was doing my dream career of teaching high school history.
Mark Lukach: Then when we were 27, Julia ended up having a psychotic episode. This was totally out of no where for us. It's onset was really disorienting and pretty terrifying, because we had no sense of what mental illness looked like. Julia was definitely always really ambitious and had some perfectionist tendencies and could be hard on herself, but in no way would that, to me indicate ... I didn't expect or have any reason to expect that she was gonna end up having delusions and be fully paranoid and have to get hospitalized.
Mark Lukach: How it all went down was that, she ended up starting a new job and for whatever reason the combination of the work stress and the self imposed expectations, she kind of got paralyzed with anxiety at work and had a hard time doing even fairly menial tasks. Day to day emails, she would overthink everything, she'd forward them to me to proofread these two sentence emails and say, "I've been working on this for two hours, because I want to make sure it was just right." That was nothing like the Julia that I had known before who was always so effective and efficient at work.
Mark Lukach: It started looking like that, and then it grew where she ended up experiencing ... she was having a hard time falling asleep. She lost her appetite, and then eventually she ended up not sleeping at all. I'm like, "What's going on. What's happening to you?" I actually had a friend who was getting a Ph.D in Psychiatry, and I checked in with him and he's like, "You know what, she's probably just adjusting to this new world, this new job." It was her most important job that she'd had.
Mark Lukach: So, we were kind of like, it's just situational, she's hopefully gonna settle in and adjust. I thought that was really good advice, but I had a hard time accepting that Julia couldn't just figure it out. I was like, "Julia, you're tired. You've been working hard, just go to sleep. I don't get it. Why can't you fall asleep if you're tired. And if you feel so upset, why can't you just relax and take it easy." I was really naive and unfortunately pretty unhelpful in that way too. I just thought, well when you're having a tough time, you take care of yourself, you get a good nights sleep, you step away from the stress, and then everything's gonna be okay.
Mark Lukach: It wasn't for her. She got rapidly worse. In the stop sleeping phase she ended up experiencing delusions. That's when I ended up taking her to the emergency room where they admitted her and said she was psychotic. I literally didn't even know what that word meant. I thought they meant she was like a psycho killer, or something, and so that she was dangerous. I didn't think she was actually dangerous to anybody, I just thought, this woman's really tired and really stressed out and needs to just rest.
Mark Lukach: My expectations of what was going to happen in the hospital were also very unrealistic. I thought that they would just give her the right pill or two and 48 hours later she'd be home and she'd be back at work within a few days. Just kinda back to herself. Instead, they experimented with a lot of different medications, she ended up being in the hospital for 23 days. I took that time off work. I actually took the semester off of teaching so that I could be there to support her through this.
Mark Lukach: She came home and was admitted to an outpatient program where at admission they said, "Our average time in here is like 4 to 6 weeks." And Julia ended up being in that program for 9 months, just because they continued to struggle to find the right medication that could support her. I was thrust into the world of caregiving.
Mark Lukach: Your question was about writing. This is a really long answer to get to that because, when Julia was hospitalized ... I'm a historian right? So I go and I research to find answers. I learned a lot about mental illness by reading books, researching the internet, et cetera.
Mark Lukach: I was really shocked to find that there was almost nothing out there about caregiving around mental illness, especially in the context of a romantic relationship. I did find some stuff about parents trying to support their children, which I think is really useful and mostly relevant, but I also think there's a really big different between a relationship between a parent and a child and a relationship between two partners who are trying to be equals. And who share a bank account and stuff like that.
Mark Lukach: I felt, of the many feelings that I had throughout this, just abject sadness and fear. All of it was compounded by the sense of loneliness. Even though I wasn't the only person in the world going through this, I sure felt like it, because I couldn't find anybody out there who was talking about it. I won't say that was my initial motivation to write about Julia's mental health and my caregiving of it, but when she ended up getting out of that outpatient program, we had the idea that maybe our story could help people. That Julia, if she was willing to share her experience, and if I was willing to share my experience as a caregiver, we could connect with people who also felt that sense of loneliness.
Mark Lukach: The first piece that I wrote was for the New York Times Modern Love column. It got published and it got a lot of attention, there's no question about it. I ended up getting a lot of emails because I think it struck a nerve with people who are like, I'm in a really similar situation, and I haven't found people who are writing about this.
Mark Lukach: Then, a few years later, I ended up working on a magazine piece that detailed not only Julia's first episode, but also her second episode and how it was connected to the fact that we had become parents in the middle of it. That was called "My Lovely Wife in the Psych Ward." It was in Pacific Standard Magazine. I hate using this phrase, but for lack of a better term, that piece went viral. It had a few million reads within the first week of it. For a few weeks I was getting over 100 emails a day, and almost every single one of them said thank you for writing this, now here's my story. It was amazing to see how many other people felt that loneliness that I have felt.
Mark Lukach: That magazine article lead to me having the opportunity to turn it into a full book. The book's been out for about a year now. It's actually coming out in paperback in early May. It's had, what has been for me, a pretty similar effect, where it's just presented me with these amazing opportunities for me to speak to people who are also in a family dynamic that's impacted by mental illness. Whether it's someone who they themselves have been diagnosed, and I've gotten feed back that it's just given them a little bit of a sense of perspective on what their family members might go through. Or, the caregivers.
Mark Lukach: I'm so humbled that people have taken the time to read this, because the fact that its making people feel a little less alone is just such an amazing sense of like, yes, that's exactly what I wanted to do this for. Because, the tragedy of mental illness is that we are people who are scared to talk about it. Even though we are suffering and struggling, we add that extra layer of difficulty, because we think it's something that's too scary to share with your friends or share with others. As a result, you lose perspective on how many people are going through this. And how, if you actually do open up and talk about it, you can support each other, you can swap resources, you can share strategies, et cetera, et cetera.
Mark Lukach: Where we are today in 2018, Julia has been hospitalized a total of 3 times. That first one was back in 2009, her second one was in 2012, and then the third was in 2014. They've all happened in the fall. They've all followed a very similar trajectory of starting with psychosis and then being followed by a very lengthy suicidal depression. Her official diagnosis is Bipolar 1. To support that, she's on Lithium, which has turned out to be really great for her. It feels like it helps to manage the illness without creating unwanted side effects.
Mark Lukach: We're cautiously optimistic that we have found a way to manage this in our lives. And to still get to be the type of individuals and family that we had always dreamed about. Julia is back to thriving in her career, and that hasn't been an issue. I'm still a high school teacher. Our first born is almost 6 years old. And seven weeks ago, Julia gave birth to our second child-
Jessi Gold: Congratulations.
Mark Lukach: Things are going really wonderful there. He's an awesome little guy, and Julia loves being a mom. I never want to think, "Oh, this is behind us." Because, I know that Bipolar is a lifelong condition. There's always reason to have to be cautious. I do feel really hopeful that through these really difficult years we've learned how to care for ourselves and each other, so that her Bipolar does not have to be something that ruins our family. We fell like regardless of how many future hospitalizations there may be, we think that we can make it as a family.
Mark Lukach: Again, you literally asked one question and I just took off and ran with it. I hope that's okay. That's the context of our family's story and the writing I've done about it.
David Carreon: Mark, thank you so much for telling us that story. It's such a powerful story, and one of the things that just strikes me about how you tell it, is you started the story with the puppy dog rainbows into the sunset love and that's apparent and palpable in the way you tell the story, that you are in love with your wife.
Mark Lukach: Yeah. I am. I don't know what else to say other than yes, I agree with you.
David Carreon: I love that. It's often hard for people, as we see people who have mental illnesses, it's often hard for them to ... for people outside of the field to realize that there are real lives and real stories, and people can get back to thriving. That doesn't always happen, but that happens.
Mark Lukach: Yeah, exactly.
David Carreon: It's such a good balance between yeah things are hard, but that doesn't change the fact that she's a person who you're in love with, who can be back to thriving despite some very serious challenges.
Mark Lukach: Yeah. Through her diagnosis I had to redefine what love is, and what caring for someone you love looks like because my original thought was when someone you love is in pain, you wrap them up in a bear hug and you become their cocoon against the harshness that is hurting them. I also thought that it meant problem solving. I thought, hey you're sad, so I'm gonna help you feel better. Hey you're feeling suicidal at this moment, I'm gonna change the topic so that you don't have to think about that and you can think about something else.
Mark Lukach: I had to learn in response to both of those views is, for the first one I really had to learn the limitations of myself. I saw a therapist though out this and she used to always say, the good news and the bad news is that you're just not that powerful. I had this expectation that as her husband I was going to fix her, which is ridiculous, but I still felt it. I had to let that go and trust the process a little bit more, still be fully informed and researched and in communication with the doctors as much as I could, but also understand that the human brain is way more complicated than something that just a bear hug can fix.
Mark Lukach: I think the other thing that I really had to learn was that when people are in pain they're not necessarily looking for a problem solver. If I'm having a crappy day, and I want to talk with someone about it, it's not necessarily helpful for them to be like, well let's come up with a five point plan for how to make your day go better. A lot of times what people are actually just looking for is someone who's gonna sit back and listen to them, and not judge them, but just let them feel that way. And that the mere acknowledgement of your pain can help to heal that pain.
Mark Lukach: It's so interesting because I, myself, come from a family of doers. We're hands on lets get there and fix it. The act of listening looks like a very passive activity, because you're literally just sitting there, but I've realized that it's not only really difficult to do, but it's one of the most helpful things you can do, is to shut up, not try to solve things, but just to be there and to listen, became one of the most important things that I could provide to Julia. If she was fearful about a relapse, that I shouldn't get in there and try to talk her out of that fear, but just to let it be. And if she was feeling suicidal in a moment, as long as I was with her, and I knew she was physically safe, those feelings couldn't ... they were sad, they were hard to hear, but that didn't mean I needed to deny their existence. Instead, I needed to do the exact opposite.
Mark Lukach: I really do think that what our love looked like when we met and got married, has changed a lot over the last 10 years as it's been reshaped by this, her mental health diagnosis.
Jessi Gold: I'm struck by a lot of what you've said. One thing I was thinking was you mentioned that a lot of people write about this, the parents writing about children, and often times when people get sick they take on the parental role for the person that they love. It sounds like you tried to not do that, as much as possible because you still-
Mark Lukach: I think I very much did in the beginning. I think it was instinctive. On the one hand I get where I was coming from. If Julie was left to her own devices, she would have stayed in bed all day, or she would have done something much worse, like drive to the Golden Gate bridge and jump off because she talked about that all the time. I know that's something she wanted to do.
Mark Lukach: There had to be a part of this where I was controlling and dictating how she spent her time, in the way that a parent does a child. I had to learn the balance of saying, yes, I'm here to keep you safe but that doesn't mean I'm going to try to run your life. I didn't do that well at all in the first episode. The first episode I very much ran the show.
Mark Lukach: After the first episode, when Julie was healthy and balanced and stable in between, she was really mad at me, and I couldn't understand why. I was like, I just basically gave up my life for almost a year to take care of you, and you're mad at me? How does that work? It was because she felt like her voice was not listened to during that care. If her doctor said something, and Julia said something I was going to instinctively listen to her doctor. I would write off Julia's perspective as well she's sick, right? She doesn't get it, the [inaudible 00:20:05] is worth it because the medicine are helping stabilize the psychosis, so you'll be fine Julia, don't worry about it.
Mark Lukach: Instead, I had to really see and experience her resentment about how I had treated her to snap out of it and realize, I'm not helping by treating her like a child. I'm not supporting her by parenting her. I actually need to let her have a voice in this whole thing. It's hard to let someone have a voice when they think if you come near me you might get infected by the same devil that has infected me.
Mark Lukach: This was really what that magazine article I wrote was really about, was that we needed to basically work in between the crisis to plan for the crisis. If we faced a crisis, I would be able to advocate for Julia's point of view because she had already shared it with me. As compared to not talking about the crisis, getting into it, and then I just have to act on instinct and hope that I'm acting in Julia's best interest, but not actually know that for certain.
Mark Lukach: It took a lot of failure to get to that point. I tried to be honest about that in my book because I'm not saying that to judge myself and beat myself up, but because that's just the process it kind of has to go through. You kind of have to learn by doing, what it is to support each other, because you don't know what that support needs to be until you actually face it.
David Carreon: The way you approach your story and looking at your own part in how things could be better, I think this is partly what you were talking about before in what we've experienced a lot too in terms of the stigma. "Oh, well they're just crazy." We are the ones whether it be Psychiatrist, or the institutions or society, we know best the people who have mental illness, they don't need a voice because we're going to be their paternalistic doctors or-
Mark Lukach: Right.
David Carreon: We're gonna be the ones who get to say what happens. I really appreciate your reflections on why can't you just approach to people who are suffering it isn't necessarily helpful but at the same time, the other side of it which is well, nobody talks about this so how could anybody know what the right way to approach somebody with a mental illness is?
Mark Lukach: Exactly. You have to stumble your way through it because there isn't a roadmap out there. I wrote a memoir, I didn't write a how-to book, but my hope is that people can learn from the mistakes that I acknowledged that I made in order to, hopefully, modify how they might approach this if it faces their family.
Jessi Gold: Yeah, and you mentioned when you wrote your story that all these people started writing in saying thank you so much for telling your story, here's my story. What do you think stopped other people from doing it? And then what was it really like for you to have made the choice to become a voice for that.
Mark Lukach: I get it. We as a society are not very respectful towards mental health. I distinctly remember being, when Julia was in the hospital the first time, and she was experiencing auditory hallucinations, hearing voices I on the radio heard a commercial where it was like a bunch of celebrities saying how crazy the prices were on a new car. And the person was like no, what's crazy is hearing celebrities tell you to buy this car. It's like the entire premise of the ad was to make fun of auditory hallucinations, right? Here was my wife at that moment in the hospital experiencing those and there was a marketing scheme built around what she was going through and suffering through.
Mark Lukach: I totally get why people want to keep this to themselves. And I also understand people are private. I, of course have things that I want to be private about, but I'm just generally more okay with sharing. I don't think this means that the best solution for everyone is to go around and broadcasting your story to everybody, but I do think that if you feel like you trust people then you can let them in and they might be able to help in a way that you wouldn't expect if you're too afraid to let them in, you know?
Mark Lukach: The reason Julia and I wanted to go more public is because at the core I trusted that I was telling this story in a way that respected Julia's dignity and that was protective and nurturing of our marriage, that I wasn't at this to vent about the way things have been, even though there's certainly moments where I'm frustrated.
Mark Lukach: Even though, most people who read this book I don't know them personally, I'm still secure enough in how it's written that I trust how they're gonna read it. I don't think they're gonna go there and be like, wow this dude's exploiting his wife's illness just to write a book. I know that's not what I was doing. I'm pretty comfortable that that's not how it comes across.
Mark Lukach: Just being out there has been interesting, because I'm a teacher, my kids all know this book is out there. Many of them have read it, many of their parents have read it. I think I operate in my school a little differently as a result. I have certainly had families have shared with me things that they probably wouldn't have otherwise, because they see a little bit of a kindred spirit now. It's funny, let's say I'm a party, and they're like, "Oh what do you do?" I'll say I'm a teacher. But if I say I'm a writer they will ask well what have you written? And that's gonna lead to a much longer conversation that I'm not necessarily always up for in a social party.
Mark Lukach: It's really funny, Julia and I have this thing there's some people where it's like yeah you've read our book no big deal, but there're other friends we're getting to know, we feel like we have to share this at the right moment because you want to make sure you actually have the time to get into this whole background, and it's not necessarily something you always do with casual acquaintances if that makes any sense.
David Carreon: Absolutely. I think I've had that experience, "Well what do you do?" "Well I'm a Psychiatrist." And sometimes they'd say, "Oh well I have a question for you." It's like "Oh no, this is an Uber. I just wanna go to the airport."
Mark Lukach: Yeah exactly.
David Carreon: I'm curious about how telling your story ... so there're changes in how you, professionally as a teacher, how does this change? How does it change, if at all, your relationship with your wife?
Mark Lukach: I think that the book was, the writing which took many years, was something that may have in fact helped save our marriage. Because, it became the way that we could communicate about this. I said earlier after the first episode Julia was really mad at me for how it had felt to her. I was really wounded by that because I felt that my experience was really invalidated. In those two feelings we had a really hard time communicating about what we had gone through. We couldn't sit there and talk about it face to face.
Mark Lukach: I came up with idea, well what if I write to Julia about it, because then I can make sure that what I'm saying has been edited and is presented in a way that is more thoughtful than what I might just say in a conversation. Then Julia could read it in her space, and that could be the invitation to have the difficult conversation because a lot of it's already out there.
Mark Lukach: The writing for me and the reading for Julia was a conduit to a lot of healing for the two of us. Then what I would say further is that it's also become an anchor of the standard we want to have for our marriage. Which, obviously is not always lived up to. Marriage is certainly not perfect, and there's a lot of frustrating moments. I think there's a lot of idealism in this book about what a marriage is and how two people in a partnership can and should treat each other.
Mark Lukach: A lot of times when we're not being great to each other, one of the things that might check us is like, hey lets not forget what we agreed we wanted in this book about how we want to treat each other. Let's try to return to that way of being and not this less kind way that we're being right now.
Mark Lukach: It was kind of like a declaration of this is what we want our marriage to be like, unconditionally supporting, listening, hearing the hard things, and not getting mad at each other for them. Of course, we don't always do that in practice, but at least we can remember that we have done that before. We want to aspire to that in the future as much as we can.
Jessi Gold: Were there times when you were writing this story where you remembered something and she was like, "That didn't happen." Or "I never said that." Or a time where you remembered something and she was embarrassed that that had happened?
Mark Lukach: Oh yeah, definitely. Julia had the first veto power for what ended up in the book, and the process was always kind of funny. I'd work on a section and I'd send it over to her, and she might not read it for a few days, so I'd be working on a different section. I would just hear her like, "What? You want to put this?" So then we would have to talk it out.
Mark Lukach: Yeah, we definitely remember differently, but that's okay. I think Julia got to understand that this book is from my perspective, I think that's what makes it different, and I think that's why it's resonated with readers because it is from the caregiving experience. There's a lot of stuff that Julia remembers from being in the hospital that's not in there because I wasn't there, and those aren't my memories.
Mark Lukach: There's a lot of ways that I interpreted situations that Julia may have interpreted differently but she gets it, like really at the core, while this is about us and this is about our marriage and it's about her illness, it's through my lens. That is the lens that is so, I believe, underserved.
Mark Lukach: It was good, and even just that process of editing it, like I said, it forced us to have these difficult conversations. I think it forced us to confront something that is so painful, and your natural instinct is you just want to move on from difficult times and bury them in the backyard and not have to deal with them. But we kept forcing ourselves to reexamine them over and over again, and I think that puts us in a place where, now, we both feel like we've really accepted what we've gone through, and don't continue to feel the pain of it anymore.
David Carreon: I really like that way of putting it, that it was not feeling the pain of it anymore that you've come to some conclusion or some resolution.
Mark Lukach: It does kind of feel like that. Yeah, the book does feel like a conclusion in a way, even though we know that the journey still has a long way to go, at least the trauma of mental illness feels like, it's not traumatizing anymore.
David Carreon: As you describe this, I imagine some of these lessons might be more broadly applicable to, two people in a relationship have different perspectives on a particular event or having to come to terms with strong feelings or challenges. Have you gotten any feedback from people who read your book who might not be in the caregiving role or people who might find, well this was accepted as a New York Times Modern Love column, not necessarily a Psychiatric Times Modern Love column.
Mark Lukach: Yeah, no for sure, I actually do think although this book is about mental illness, it's primarily a love story about a relationship. What I'd say is that I've had readers who have reached out to me saying this speaks to my experience so much. Then I have others who just like at a book event they might be like, well I haven't experienced mental illness, but, I'm in love and I'm in a relationship. So it still felt like it was really relevant to them.
Mark Lukach: That is also really ... to something as you know, this piece of work that I put out there, the fact that people are reading it, whether they've confronted mental illness or not. It's interesting because the title makes it very clear what this book is about, right? "My Lovely Wife in the Psych Ward." You know you're gonna be reading a book about mental health.
Mark Lukach: At first Julia and I wished that maybe the book title could be more subtle, and maybe not so avert about setting the parameters of what the topic was gonna be. But now, both of us really understand the value of the title, which my publisher was pushing very hard, because it's an invitation to see mental illness in a different way, but also to see how universal the experiences of caregiving and being in love are regardless of what the circumstances are.
Jessi Gold: You've also mentioned that being in a caregiver role in a hospital can be complex, and sometimes non-acknowledged. Can you talk a little bit more about that, and what your experience was when she was sick and in the hospital and you ... even maybe in the later times where you knew a lot more about what was going on and had more opinions and had her opinions too.
Mark Lukach: Yeah. That's a great question because, unfortunately the day of admission, I felt just so ignored. Like we showed up and they're all focused on Julia, which I get, but they basically were like go away, to me. Like we got this, we're gonna handle this, just come back during visiting hours. Without really orientation to me of where we were or what was happening, any of that stuff. I found that to be really frustrating.
Mark Lukach: I did appreciate that there was a social worker who was dedicated to Julia's case and I was allowed to communicate with the social worker, that was helpful. She helped me make sense of it, but honestly, I just had to go see a therapist in order to, not only help me process, but even just understand the logistics of what was going on.
Mark Lukach: I called my insurance company and said, "Hey, my wife's been hospitalized with a psychotic episode, I'm basically going through an existential crisis and I would love to speak to a therapist through this." And their answer was, "Sorry, you don't have any diagnosis, so the most we can give you is 30 minutes of therapy a month." Which to me was infuriating. I ended up just paying out of pocket, because caregiving itself is not acknowledged as a burden, as a medical or psychiatric burden, even though it obviously is right? Caregivers have sacrificed their own health to take care of someone else and then end up having their own health issues, whether they're physical or emotional.
Mark Lukach: Julia's been hospitalized three times and it was not until the third hospitalization that I had one of her doctors ask me how I was doing. I think that was really ... when it happened I realized how desperate I had been for one of her professionals to treat me as if this was also difficult for me, and that maybe I needed to be acknowledged in that front, you know? It's really hard.
Mark Lukach: Also, I say this, and I don't want to blame the doctors who Julia has come across, because I absolutely know that they were clearly professional, doing the best they could in the circumstances they were in, which is often way too many patients, not enough time to get to know your patients. How do you even possibly have the time to get to know the patient's family and to be able to support the patient's family at the same time.
Mark Lukach: If I had one wish it was that, we just create more time and space for the professionals, the nurses and the doctors, to not just have to treat their patients as individuals but to be able to treat their patients as interconnected family members and friends and professionals and all those other things, so that they could be inclusive in how they were able to treat their patients. Of the perspectives of those who care for them and worry about them and want to help out.
David Carreon: I couldn't agree with you more. I think this is such an important and overlooked, I'm probably guilty of this myself as, when I was on the in patient board, it is difficult, but on the other hand, Psychiatry as a system needs to take seriously the fact that we're not doing most of the work. It's family members and parents and siblings and neighbors and the other people in somebody's life that are doing the heavy lifting of the day to day stuff. They'll see us once things settle down maybe once a month or once every few months.
Mark Lukach: Exactly.
David Carreon: There's every day between those things. I am glad you're telling your store, this really is an underappreciated, and frankly underdeveloped part of the mental healthcare system. How do we better partner with the families and friends and romantic partners?
Mark Lukach: And I get that too, because as a teacher, I often treat my students as students. I don't always treat them as children who have parents who are worried about them, or children who have siblings, and who when I'm at my best as a teacher, it's remember that and not just interacting with the kid, but also taking the time to reach out to their family and see how this is going for them, and how they're supporting them at home and how I can partner with them as an educator. That's when I'm at my best. But it's so rare that I have the time for that right? Because I got a stack of papers, and I've got a lesson plan and all of that other stuff. I think education has those same challenges that mental health has. It's definitely a team effort but the members of the team rarely have the time to actually talk to each other.
David Carreon: If we get a start over, in all the bureaucrats and paperwork and all of that, if we could do it right, what would you want? What sorts of groups or support or therapy or team meetings, what would be best? What are some things that you've imagined or wished for happening? Certainly yes, the doctor to give you the time of day, that's nice. I hope we can meet that and exceed it. What are some hopeful things that we might be able to do in the future?
Mark Lukach: Well that's a great question. I think waiting rooms need to look a whole lot different than they do. I think waiting rooms, there's just so much dread and unknown in them. Usually the only person there is either a security guard or just like the person who processes the paperwork. What if instead you actually had people in the waiting rooms? Whether it's volunteers who say, hey I've been in your chair so I want to be here available to talk to you, or whether it's trained professionals who are able to answer any questions.
Mark Lukach: Because the waiting room is where it all starts. And when it starts on a tone of, the doors closed we'll let you in when we're ready for you, otherwise we're just going to be doing this work off out of sight. That tone becomes pervasive throughout.
Mark Lukach: I also think that, like when Julia was admitted, they basically, well it's really hard though too because you need to think about the privacy rights of the patients, but I wasn't allowed to be there at Julia's admission, and I wish I had. I feel like they were diagnosing the experience of her symptoms, that maybe I could have contextualized them and provided a timeline that Julia wasn't able to provide because she was so psychotic and delusional. She's not able to chronicle what she's going through, she's just experiencing it. So they're labeling it. I felt like maybe the initial start could have been better if it wasn't just about symptom treatment, but about hearing the whole perspective.
Mark Lukach: Honestly, I'm not sure too much beyond that because here's the place I get stuck, I want to be more included, and have my voice heard more, but I also don't want my entire life to revolve around my wife having Bipolar disorder. There's times where like, especially as the author of this book, I don't want to be a mental health advocate 24 hours a day 7 days a week. I don't want to be doing nothing else beyond supporting her Bipolar. I also want to chill out and have fun and get to turn that side off. I think it's a hard thing between inviting people in and also not mandating it. There are some people who probably aren't as talkative as I am and maybe they just need to have their space.
Mark Lukach: It's really hard to get into strategies other than I just wish the system was more inclusive. If there's one word that I think is so lacking, it's inclusivity. We need it, we need more voices in the room, if they want there. We need more time to hear each other out and not just be told, this is the prescription because, and good luck getting them to take the pills they don't like.
Jessi Gold: Yeah.
David Carreon: Yeah.
Jessi Gold: It's interesting to me because it sounds like, as a Psychiatrist we often feel like we have an emotionally heavy job and we're dealing with stories that are sometimes hard to explain to other people, and sometimes we choose not to because they are heavy or dark. But you already shared it. How do you keep those boundaries for yourself and really practice good self-care with your story out there anyway?
Mark Lukach: That's a great question. That is one that's exacerbated, I think that's the word, by the emails that I get, which are so difficult to read. They're so heartfelt and clearly full of pain, and I feel an ... I should put that in the past tense, I felt an obligation to respond. I would beat myself up if I didn't. I wanted to honor with an equally emotional reply and so just managing email became, for me, impossible. It really did. I felt stuck. I felt constantly moping because I was hearing all these stories and feeling like I wasn't responding to them in a way that was meaningful enough. So, what I've had to do is make peace that I can't actually respond to everybody. I can't be there for every mental health crisis that everyone else is going to go through. Obviously, I can't.
Mark Lukach: My hope is that even just them writing and knowing that someone read it, hopefully that enough is a start for them to heal a little bit. That's a way where I have to take care of my mental health and my sense of stability, and not take on the challenges that everyone else is facing. I've had people who they're like, hey I'm in the [inaudible 00:47:38] too, I'd love to meet. Do you want to go get dinner? I'd love to treat you to dinner. I've never done that, because, it's not that I don't want to meet new people, I just know that I'm not a professional, I'm just a guy that wrote this book and I'm really pleased and honored that you read it, but that doesn't mean I can necessarily help beyond just writing that.
Mark Lukach: I think it's this acceptance of what my therapist said, good news, bad news right? You're not as powerful. For me that's a good news one because it's like, I don't have to take all these situations on, I still can focus on being a dad and a husband and a teacher and also just an active person who likes to play outside. And that's okay because that's allowing me to be the best person I can be, even if it means I can't respond to everyone who reaches out.
David Carreon: That's a great answer, and I think important certainly in the domain of mental health care, but probably for everybody.
Mark Lukach: For sure, and I can imagine the way your day feels. You need to shut it off and not just spend all night fixating on it because otherwise you're gonna go down, and probably have to process your own stress. The school that I teach at, some people live on campus, I do not, and a few of my colleagues, their partner also lives and works on campus. I've just kind of thought that probably means it's really hard to get a break from teaching, which is also a pretty emotionally draining job. I actually realized how lucky I am that my partner is not in education and so, I can go home and not feel like I need to keep talking about my job, talking about my job. Instead, I can just give an update as it feels right, and otherwise, be in whatever our family moment's in and be able to step away from the emotional demands of my work.
David Carreon: We appreciate your perspectives on so many diverse issues, touching on your story. We've got a few more rapid fire question before we wrap up. So in a sentence or two, what is your favorite book?
Mark Lukach: So my all time favorite book is "Infinite Jest" by David Foster Wallace. I read it for the first time in college, and I have read it two subsequent times. It's over 1000 page book and it's really dense and I just adore that book. I think it's so brilliant and funny and heart breaking and so well written.
Jessi Gold: Yeah. You've mentioned some of these but what do you think Psychiatry gets wrong?
Mark Lukach: I think that Psychiatry gets wrong treating someone who's sick as if they are an island. I also think Psychiatry gets wrong that medicine, someone often has to be there to administer medicine. If it's really unwelcome medicine that's a really difficult situation to be in, to have to be the husband who loves someone and more or less force them to take pills that they don't want, without training, without the opportunity to talk about it with the caregiver. I really think the exclusion of the caregiving perspective. I hope you're gonna ask what I think Psychiatry gets right, because I don't wanna just be totally bashing Psychiatry.
Jessi Gold: Sure, yeah what does it get right?
Mark Lukach: It saves lives, there's no question about it. The advancements we're making in the understanding of the brain, although there's still a lot we'll probably never learn about the human brain, there's no question about it, the Lithium that my wife takes has kept her alive, it's allowed her to thrive in her career and as a mother and as a wife. It's been through compassionate doctors that have helped her get to finding that pill that's saved her. I think that what Psychiatry gets right is that the people I've come across in it are good hearted kind people who want to help and are dealing with an infinitely complex issue of the human brain and are just giving it their best. I've never had an experience that would lead me to conclude that Psychiatry is out for anything other than helping.
David Carreon: Great. Who is a hero of yours? Either alive or dead, fictional or real?
Mark Lukach: I'm gonna go with the generic one which is probably both my mom and my dad. My dad is the most optimistic, upbeat human being I know. He gives me a lot of motivation to practice gratitude and celebrate the joy of life. My mom is probably the person who I modeled my caregiving after. She's so unconditional and reliable in a crisis. We counted on her so much throughout these years of parenting and mental health. I really admire them as heroes for sure.
Jessi Gold: What tips would you give to someone who is love with somebody who has a mental illness?
Mark Lukach: That's a good one. I would say first the most important tip I would say is to listen. I think everything else is under the category, the umbrella, of having the courage and the patience to listen, to really hear the experience of the person you love. Even if they're mad at you. Even if they don't like what you think is help, even if they think that the help is hurting, you have to hear that stuff. Listening, I think, is one of the most pure acts of love. Mental illness, what they might say can be really scary, really hurtful, really worrisome, but just listen. I think everything else from there will fall into place.
David Carreon: All right. Well, thank you so much for joining us-
Mark Lukach: For sure.
David Carreon: And, we want to just appreciate you and appreciate all of the perspective you've given us.
Mark Lukach: Yeah absolutely. I really appreciate your interest. I especially like the opportunity to talk to professionals or an audience of professionals because you all know this field. The fact that you didn't think I was being mean to you in this book, I'm so relieved. I was so worried when I wrote this that people might read it as boy, Psychiatry is really bad. These people are doing bad things. That's not it at all. It's flawed, I tried to look at some of those flaws but it makes me hopeful that people in the mental health field also see those flaws and want to do something to make them better. So thank you so much.
Jessi Gold: Of course. And we also want to encourage people to go get your book if they want to learn more and read more and read your columns to also get to see your voice on paper.
Mark Lukach: Awesome, yeah well thank you for that too.
Jessi Gold: Of course! Thanks for joining us.
In our interview with Carol Tamminga, MD, we discuss biological psychiatry and the evolution of the field of psychiatry to now include a greater understanding of the neurobiologic underpinnings of disease through brain imaging, genetics, and circuits. We talk about the "battle" between biologic and psychologic and whether this should exist.
Dr. Tamminga also discusses her groundbreaking research on schizophrenia and how trying to find biological confirmation for DSM diagnoses led her to finding "clusters" or "biotypes" instead. She details how she hopes her research will inform treatment in the future, as well as measurement of treatment response. She adds information about early intervention approaches for schizophrenia treatment and the role of cannabis in schizophrenia development.
Dr. Tamminga is Lou and Ellen McGinley Distinguished Chair and the McKenzie Chair in Psychiatry at the University of Texas Southwestern Medical School and the Chief of the Translational Neuroscience Division in Schizophrenia at University of Texas Southwestern Medical Center, Dallas, TX.
Links referenced in this podcast:
A dimensional approach to the psychosis spectrum between bipolar disorder and schizophrenia: the Schizo-Bipolar Scale
Identification of Distinct Psychosis Biotypes Using Brain-Based Biomarkers
Brain Structure Biomarkers in the Psychosis Biotypes: Findings From the Bipolar-Schizophrenia Network for Intermediate Phenotypes
Associations between adolescent cannabis use and brain structure in psychosis
David Carreon: Hey, everybody. My name is David Carreon.
Jessi Gold: And this Jessi Gold.
David Carreon: And are sitting with Carol Tamminga, the Lou and Ellen McGinley Distinguished Chair and McKenzie Chair in Psychiatry at UT Southwestern. She's the chair of UT Southwestern's department of psychiatry, and Chief Translational Neuroscience Division in schizophrenia.
David Carreon: Thank you for joining us.
Carol Tamminga: Well thanks a lot for inviting me I appreciate being here.
David Carreon: For those psychiatrists that are not terribly familiar with biological psychiatry, what is biological psychiatry?
Carol Tamminga: Biological psychiatry I guess would be that group of people who are interested in the biology of the brain that underlies psychiatric conditions. This is a very, very old society that's gone up and down, and their attention on different kinds of biology over the years. And now the biologic basis, the biologic understanding of the brain and its normal function has grown so much over the last 25 years, that is a very exciting time in biological psychiatry.
David Carreon: Yeah I think that's something that's interesting to me too about like biology 50 years ago mean molecules, and, you know, and serotonin or dopamine. Now what is for somebody who went to residency 20 years ago or 30 years ago, what is biological focusing on these days?
Carol Tamminga: Yeah biology is such a general term, and it's like the physiology of internal medicine or something like that. I don't think we have a better word to use right now, because we don't understand what the specific biologic ... perhaps pathophysiology would be a better word. We do not understand the pathophysiologies for our diseases, but as soon as we do then we'll be able to make that term, biology, more specific. And we'll be able to say that it's self-firing or it's circuit biology or something like that.
David Carreon: So is it that society's been around for a long time...
Carol Tamminga: It's a fairly long society. As you might imagine 50 years ago the biology that they talked about was fairly crude, and it was a little bit more than a black box when this started, but now there's so much in that black box, it's really fabulous.
Carol Tamminga: Brain imaging has opened up the world of biology. Human postmortem brain analysis have opened all of it up. Of course genetics and then the transcriptome analysis have opened up what we know about different regions in the brain, and their connection to function. It's an exciting time in biology.
David Carreon: I should say so.
Jessi Gold: I would assume that would make it an exciting time to be a psychiatrist too.
Carol Tamminga: It is. When I started out being a psychiatrist, and I would tell people about diseases, psycheat- what I call psychiatric diseases, I would really draw the brain in a black box, because we knew such a little bit about it.
Carol Tamminga: Then we knew a few things about things like dopamine, and serotonin, and got to know a little bit more about the synapse, and what was the structure of the synapse, and how cells communicated with each other. And then we thought it was really all about cells, and how one cell converted with another. But these days there's a real emphasis on circuits, and how different regions of the brain are connected with each other, and how they're connected with each other not only by neuronal connections, but by the characteristics, by the dynamic characteristics of the connections. The terminology that they use these days, I'm gonna have to practice a little bit offline on the connection that they- on the language that they use, it's very interesting, very interesting.
Jessi Gold: I'd imagine the language for all of this changes pretty rapidly.
Carol Tamminga: It does. Yes, yes.
Carol Tamminga: You know, the brain is the last undiscovered organ in the body. We know a lot about the heart, we know a lot about the pancreas. They're accessible to us, the brain has never been accessible, and it's much more complicated than any other organ. So it's taken a little while for us to get the brain ... for us to understand how even a normal brain works.
Carol Tamminga: And then we don't know the pathophysiology for any of our diseases, so we don't even how to segment psychiatric syndromes into understandable units.
David Carreon: Now that's something that I think I'd like to talk more about, because the average person thinks about something like major depressive disorder or schizophrenia as a thing, as an entity, as some thing existing in reality, like diabetes exists in reality. What's your perspective on psychiatric nosology or how these diagnosis work?
Carol Tamminga: So I used to think schizophrenia was an entity too, and I used to call myself a "schizophrenia scientist", I don't anymore. We did an experiment a few years ago where we took ... we decided to study the dimension of psychosis. So we took a number of different diagnosis and we did deep phenotyping on all the diagnosis. So we took people with schizophrenia, people with schizoaffective disorder, people with psychotic bipolar disorder. If we could've found enough people with psychotic depression we would've taken those too, but we didn't find enough.
Carol Tamminga: Then we did, we had, this was a study across five sites in the United States, so we had an opportunity to recruit quite a number of people. About a thousand probands, and about 500 normal people when we did deep phenotyping project.
Carol Tamminga: So we looked at brain based behavior very carefully, we looked at brain imaging, we looked at EEG brainwave analysis, we looked at eye tracking analysis, we looked at cognition. We looked at signs and symptoms of course. And our intent was to find some number of tests that psychiatrists could use when a patient walked in their office. A psychiatric patient walks in psychiatrist office, and a psychiatrist sits down and talks to them for an hour. You know, they walk into a neurologist office, the neurologist says, "What are your complaints?". And they'll talk to them for 10 minutes, and send them off for three tests, and then they'll come back two weeks later and they'll get a diagnosis.
Carol Tamminga: We kind of wanted a system like that, and we hadn't started out to ... not, we started out hypothesizing that we would find biomarkers associated with diagnosis, and we didn't find one. We had about 50 or 60 different phenotypes, and we didn't find one that clearly fell in a diagnostic way on any of these different psychotic diagnosis. So we were pretty disappointed, and we spent a little time being quite depressed, because it really meant that we didn't know anything. We didn't even know how to take psychotic disorders, and cluster them.
Carol Tamminga: So we finally got over that part of it, because we needed to get our grant renewed. So we just simply stripped the diagnosis off all the probands together into a single group of psychosis people, and we took the brain biomarkers. We took the EG, we took the cognition, we took the brain imaging, and we u- we didn't take any signs and symptoms, we took just took the brain measures, and we took them together, and we reclustered the people. And we came out with three groups of three total experiment groups. These are, we're not up to diagnosis or anything like that. These are just are experimental groups. But the experimental groups had very interesting biological characteristics, and so we decided to study them more, and now we're into a second phase.
Carol Tamminga: These are clusters of individuals, all with psychosis, as the diagnosis are spread through all the cluster, so why bother with that? The only reason we now have to really confirm that this makes sense for selecting treatments, or biologic sense so that we would have genes that perhaps, genes or epigenetic phenomena that categorize the groups. So we're now in the process of doing that.
Jessi Gold: Would you say that the initial failed experiment kind of forced you to rethink kind of what you had put on the diagnosis? Like being able to kind of shake up your thinking, and to clustering things, instead of just assuming that things fell into these nice diagnosis, that DSM created. Having the failed experiment sort of forced you away from that?
Carol Tamminga: Totally, totally. We never would've thought of it otherwise. Because we didn't start out making the hypothesis that we didn't know anything, in terms of how to cluster our patients in a group. If people have lesions, so, in Alzheimer's disease patients have plaques and tangles. It's at least a place to start, you may not know the complete path of physiology, but at least you have the lesion. Parkinson's disease, you know, if you have the VTA, the dopamine cell degeneration a lot, it's very simplistic, but at least it's a place to start. We don't have that in psychiatry for psychiatric diagnosis.
Carol Tamminga: So I think that the way that we did it for a long time is just by pure phenomenology. That we looked at people, we looked at their symptoms, we looked at their course of illness, and we assumed that that was meaningful way to ... divide people up. But it's turned out to not be a good thing to do, it's a little bit like dropsy in 1910. Dropsy is morbid obesity- excuse me, morbid edema. And dropsy is really a group of illnesses that determined my cardiac pulmonary renal disorder. So that's how I kind of think of psychosis. So now it's really back to the drawing board.
David Carreon: Now this is really astonishing. I mean if we think, I mean, there are some people that I've talk to who just start out skeptical. There are some people that I've talked to, that never since they were a young psychiatrist believed in DSM or the diagnostic categories, but it sounds like you're saying you were somebody who really believed at the beginning of your career that schizophrenia was a thing, and then over the course of your research you changed your mind.
Carol Tamminga: That's it. That's it.
Carol Tamminga: I don't know that I ever believed that schizophrenia, and schizoaffective disorder were very different from each other. That's seemed like a little wishful thinking, but I certainly understood, I always believed that schizophrenia was an illness. And now I really think that psychosis is a category like congestive heart failure, and that we'll over the course of the next, I don't know how many years find individuals.
Carol Tamminga: The three groups we've found we've named BSNIP biotypes. They're very different from each other, and they're very interesting, and I think that if each of these three different group hadn't been so interesting, from a biologic perspective, we would never have gotten caught on them.
Carol Tamminga: This BSNIP biotype one is a group of people that have very low cognition, they have very low brain EEG, and they have the highest gray matter reduction of the three groups.
Carol Tamminga: The group in the middle, which we call them biotype two, was a group with only modestly low cognition. And instead of low EEG, they had high EEG. So they had, instead of hyporeactive brains, they had hyperreactive brains. Both at rest, and in evoked potential paradigmes.
Carol Tamminga: And then biotype three was the most amazing of all the groups, because of all the biotypes that we used to measure, they were hardly abnormal at all. But their psychosis was just as bad as all the other people's psychosis. So it was ... it's a group of people who are kind of a negative control with the same clinical presentation.
Jessi Gold: What do you think that actually means?
Carol Tamminga: We were wondering. And we were sitting around a table thinking, so this is all of the 5 PI's, and all of the friends and stuff. So we were thinking.
David Carreon: Paint this picture, where was this table?
Carol Tamminga: We get together once a year. And we get together once a week by telephone and talk about a lot of practical things. And once a year we get together and sit around in a library. It was a kind of old fashioned not very updated room, where we're sitting on chairs that are falling apart, you know. We have a lot of coffee around the table, and there's a little bit of fruit in bowls in the middle.
Carol Tamminga: So we're talking about what clearly the people who are very, very low cognition, very low EEG people look like. What we had all probably imagined psychosis or schizophrenia was gonna look like. We were surprised in the second group by modestly low cognition, and very high, we didn't expect people to have very high EEG. It wasn't synchronous EEG , so we didn't imagine that the EEG was productive in some way. That those were people who were smarter in s- they weren't smarter, but they had high EEG anyway.
Carol Tamminga: Then we were puzzling about what was happened to this third group, and one of the guy's all of a sudden said, "I know those are the potheads". So there was one of the five sites, it just happened to be mine, that taken a careful enough marijuana history, because one of the people at our sites is interested in marijuana. And this was in fact, the statistics aren't very strong because it was just one of the five different sites, so it was not nearly a thousand people. But in fact they were, there was a good, a very high percentage of early cannabis use. And there was a 90% of that third group had at least some adolescent cannabis use, not even early adolescent cannabis use. So now in our second iteration of going back and looking at these things we have a very careful, especially early cannabis, early psychosis screening.
Jessi Gold: When you look at that, and then you see all these people coming and saying like cannabis no problems, and cannabis is-
Carol Tamminga: Oh boy I really worry. It looks to me, and most of our studies. It looks like the worst time for cannabis is somewhere between 9 and 15 years of age. And that ... still a vulnerable time for cannabis is somewhere up to 20. But if you smoke cannabis after 20 it doesn't look like much bad happens. So it's clearly a vulnerable window for cannabis. It may be a vulnerable window for other things too we don't know, but we're studying it.
David Carreon: With this, I mean this transition from the DSM to ... I guess this is some people would categorize what you're doing, and maybe explicitly as being under the research domain criteria. Is that true?
Carol Tamminga: Well we got started before Doctor Enzo had suggested the RDoC, so we call ourselves "pre-Doc". But I think the RDoC principles must've been emerging all at the same time. They must have been emerging at the same time as we had developed measure where we could really distinguish, brain measures where we could distinguish one person's brain activity from another.
Carol Tamminga: We now have, we took fibroblast from at least some of these people. And we transformed them to iPS cells, and now we're growing them to matur-
David Carreon: What's a iPS cell?
Carol Tamminga: Pardon?
David Carreon: What's an iPS cell?
Carol Tamminga: It's stem cell. So we took fibroblast and transformed them to stem cells, and then we took stem cells and transformed them to neurons. So now we get a chance to see whether between biotype one, two, and three, we can find cellular fingerprint of what we're, of some kind of pathology. I mean it would be very nice to have some kind of pathophysiology for all of this.
Carol Tamminga: Still, I don't think, I don't think at all that these three different categories, we're still in the process of figuring out how many categories there outta be, and figuring out- these are still hypothetical categories I should say it that way. We don't think that those three categories are even gonna be diagnosis, we think that each of those three categories have buried in them perhaps a hundred different diagnosis, maybe. It would just be a guess without any, based on no knowledge.
David Carreon: And I guess, what is the average practicing psychiatrist to do with this information? I mean we see people every day who have a you know, they come in and it's a you know, 34 year old patient with schizophrenia. What does that, what am I supposed to take that as if I'm in the emergency room or if I'm in clinic? What does that mean?
Carol Tamminga: So psychiatry doesn't have tools that are specific and selective enough to bother with the kind of data I just talked about. So what we would like to do with these data is find out what the pathophysiology is, and find out what the target for drug development is, and then find you new drugs, find psychiatrists new drugs to use in the emergency room. So that when somebody walks in, and they, the doctor can do more than say, "You have cancer". I mean if you walk in we would like to say, "You've got this kind of cancer, and these are what the cells look like, and your cells are responsive to the following medication".
Carol Tamminga: So really it's almost premature to learn about what I'm saying, because we can't do anything about it anyways. Well we could tell teenagers never to use marijuana, but this is for sure good advice, I know that. What we would hope to do one day is to work backwards to pathophysiology, and then use pathophysiology to move forward to provide new treatments.
Jessi Gold: To make our treatments a little bit less like a dartboard that you just shoot at depending on side effects?
Carol Tamminga: Exactly. Sometimes it's not, it's most of the time it's much less precise than exactly what you're talking about. In ... I work at the state of Texas, and there's clearly not enough psychiatrists there. When psychiatrists see patients they treat the serially, and one person will give them an antidepressant, one person will give them a mood stabilizer, another person will give them antipsychotic. And no doctor really takes away what other people have hade before.
Carol Tamminga: So you see these people on, in fact in this particular study where we had probands, we psychotic probands, we had a wide range of diagnosis. So people always say, "Well you must've found that people in different diagnostic categories were treated with different drugs?".
Carol Tamminga: And the sad part about it is the answer to that question is, "No". We found almost all the patients treated with almost all of the drugs that we have. So how wrong is that?
Jessi Gold: Something's wrong.
Carol Tamminga: But it's unclear how to tell somebody how to do it in a better way.
Jessi Gold: Do you feel like that's because we also don't know how to really measure response?
Carol Tamminga: You're exactly right. And response comes ... not right away. I mean we work with symptoms ... where it may take a while for the drug you have the person to work, but you don't know how long it's going to take, and you don't how long to wait. Most people wait maybe two weeks or something, before making a change.
Carol Tamminga: The kind of symptoms that psychiatrists look at are, that first of all, are poorly treated and generally treated by the drugs that we have. So that's clears. And then they ... we don't know what the relationship is between the background of the illness with the drugs that we use. We're pretty lucky to have the drugs that we use. We could have nothing, because we don't know pathophysiology. I'm not gonna say we don't know anything, but we don't know pathophysiology.
Carol Tamminga: The drugs that we have were just accidentally discovered, and then very well exploited from their discovery, but we need to know a lot more to get more precise drugs.
David Carreon: And I think, I'm interested also, I think there is almost this feeling in psychiatry sometimes that it's a battle between the biological psychiatrists, and the people who care something about psychology. And that these, you know, people are dismissing each other, there's these two camps and battle lines are drawn. But would you say your perspective on this ... ought there be a battle?
Carol Tamminga: No, no, no. Not a battle at all. In fact all behavior is based on brain behavior, so even psychological phenomenon, even though we look at them as psychological phenomemon are totally based in brain behavior. And I'm not psychologically oriented as a psychiatrist, but I would think that there's a huge area of looking at the relationship between brain changes and psychoanalysis that could really be looked at. Because psychoanalysis can't be anything other than changes in brain regional plasticity. And they would be very, very easy to study. Every time I interact with my psychoanalyst colleagues I try to talk them into doing brain imaging, and other kinds of tests.
Jessi Gold: When you were in training, did you know that you weren't like psychotherapeutic minded, and you wanted to be more focused on biology, like the whole time?
Carol Tamminga: I did. I'm sorry to say. I studied Freud when I was a resident, I think all residents really do. And I asked biologically oriented questions of Freud to my teacher, and I quickly learned that that was not the proper student attitude. This was a long time ago. So I stopped asking questions. But I, you know, I, even Freud himself said all of these big behaviors are gonna be explained by brain activity in the future. So Freud himself when he was was explaining in using psychological phenomenon to explain to his students, he was very biologically oriented himself.
Jessi Gold: And I know that, maybe, even if you're not so much like a therapeutically minded you are really early intervention minded, when it comes to early psychosis.
Carol Tamminga: Yes.
Jessi Gold: What does that look like? Can you explain that a little bit more?
Carol Tamminga: Well this is another kind of phenomenon that I've only come to realize recently. You know when you talk about cancer care, early detection is what it's all about. You don't let the cancer develop and loo at where the metastasis go, and how fast they grow, before you decide treat it. That's what we do in our field. Somebody gets a little bit psychotic, and you wait for it to develop a little further. You see if the psychosis is paired with affect changes. Whether the affect changes started before or after. Then you let it go a little bit more, and see what their social function is. If their social function deteriorates fast, deteriorates slowly.
Carol Tamminga: And finally we do most of our testing for new drugs, and a lot of our research, we do in people who are 30 to 40 years old, and have had their illness for 15 years. And I think that the realization that we really need to get to all of this very early, and we need to get to people who are psychotic early to stop their psychosis, and particularly stop the psychosocial deterioration early. And then they'll stay better for longer. We're still in the process of testing whether they really stay better for long, and we'll have tweak our treatments so that they help the people stay better for longer. But I have no doubt that we're on the right track.
David Carreon: You know, and that's something that also I, at some point in my career that I've heard lectures about schizophrenia that are rather fatalistic. It's this, you know, it's a biological illness, which has a 1% chance, and it just if you happen to have the unlucky gene at birth then you're just kind of up a creek, and so no point in early detection because it is what it is, and there's no turning, you know, changing it.
David Carreon: Is that a true view of schizophrenia?
Carol Tamminga: So I think that's wrong. I don't think that there would be a lot of psychiatrists who would be so ... fatalistic, would see it as such a single path forward. I don't think that we can take every person with a diagnosis of psychosis or schizophrenia and turn their illness around and cure them. We can't take everybody with cancer and cure them. We can't take everybody with heart disease, and give them, even do a transplant and get them cured. But we can do our best in tryin to predict which people to do the complex early treatments with.
David Carreon: And what is that, for those who may never have heard of the early intervention, what does that involved? And I guess how, just very superficially or overview wise, how could that change somebody's course? Somebody on track to another or would get what we call schizophrenia? How would that change
Carol Tamminga: So a lot of people, these studies started in Europe and most European countries. Probably in the 1990s, and there were several studies that studied at them, giving intensive interpersonal psychosocial, and constant antipsychotic treatment to people with early schizophrenia. These studies happened in Europe.
Carol Tamminga: There were a couple of scientists in the U.S., Lisa Dickson being one of them, who kept and eye on those studies, and who was very interested in early treatment. And she was very interested in treating early everything that was, all of the psychological and medical burdens of people with early psychosis. So she paid attention to drug abuse in early schizophrenia. She paid attention to not only just the psychosis, but of course she treated the psychosis too, but she cared about families, and family patient interactions, and things like that.
Carol Tamminga: She's the one that was the inspiration RAISE Study which then got completed around the country. Which was a two year early intervention study. Where people who with psychosis got, they were watched very carefully over two years. They had ... very intensive treatments, both psychological treatments, and the pharmacologic treatments, and family treatments, and CBT, and cognitive remediation for two years. And at the end of the two years, the people were better
Carol Tamminga: Why they're better is unclear. It could be, it has to be that they watched very carefully by a group of people who were treating them, and therefore they stayed on their medication more. That must be a possibility. And another possibility there's just nothing that's worse for psychosis than drug abuse. So that drug abuse was given some attention, and people were treated for their drug abuse. Whether or not the cognitive remediation turned things around cognitively in the brain is a big question.
David Carreon: Okay well we are coming to the end of our time. I wanna as-
Carol Tamminga: Well it's been nice talking with you guys.
Jessi Gold: You too. Thank you for making time.
David Carreon: We have some rapid fire questions to close it out.
Carol Tamminga: Okay.
Jessi Gold: What's your favorite book?
Carol Tamminga: One of my favorite books is Elyn Saks' book "The Center Cannot Hold". And Elyn Saks is a lawyer, very accomplished person, brilliant, brilliant person. And she has what she always thought was schizophrenia for her whole life, and she was, she had a rather typical schizophrenic course. She was able to partition her psychosis to a part of her life, so she still had, she could still go through law school and come out in the top of her class, and she can get her job at University of Souther California. And you guys may know her, do you?
Carol Tamminga: And then she always said she was never gonna telly anybody she had schizophrenia, because she'd never get a good job. So she came to California, got a job at the university in the law school at U.S.E. And she went from assistant professor to associate professor, she finally got to be full professor with tenure, and then she wrote her book.
Jessi Gold: Oh that's awesome.
Jessi Gold: Is one of the reasons you like it because she is so high functioning, and tells a different story of schizophrenia?
Carol Tamminga: She talks about her, in one of her books, "The Center Cannot Hold", she talks about the nature of her symptoms. And she's so bright, she can explain it so that you and I can understand it. And she can tell you what her experiences are. And people who are a little less bright, can't quite say it very clearly, and their own symptoms interfere with their articulation of it, but she's really brilliant.
Jessi Gold: Our next quick question is, what would be your best advice to psychiatry trainee?
Carol Tamminga: Oh learn about the brain. Oh without doubt, absolutely.
David Carreon: What is your favorite psychiatry word?
Carol Tamminga: Biotype.
David Carreon: And last but not least, who is your favorite hero, either from history or fiction?
Carol Tamminga: My favorite hero from history or from ... I mean it could be a good writer or something like that?
David Carreon: It could be.
Jessi Gold: Or like a role model or anything that you remember someone, like looking up to someone.
David Carreon: Spider-Man, I mean.
Jessi Gold: Wonder Woman.
Carol Tamminga: Wonder Woman, no. I'd have to think about that for a while too. I think I maybe have ... I probably have to many people to be able to think of a single person. I'll thin about that.
David Carreon: You could do top five also.
Jessi Gold: But I would a better, maybe a easier rephrase of the first question might be, what's the most common question you get about psychiatry that, you like repeatedly have to answer, that you wish you didn't have to answer?
Carol Tamminga: Well some people don't think that psychiatry, and psychiatric syndromes have neural basis to them. And a lot of neurologist simply think that as soon as we explain the biology of our illnesses, they'll become neurological illnesses. I just drop my jaw at that. No. These are psychiatric illnesses, they're psychiatric syndromes. We will explain their biology, we're already on our way to explaining them.
Carol Tamminga: And so I don't ... actually what's happening in Texas, and it may be happening in other places too, is that the public is getting quite interested in psychiatric phenomenon. They see them in their own children ... their children's involvement with drug abuse. They suicides where there shouldn't be suicides. And they're really becoming in tune now. And the public's interest, the public itself wants to know what the neurobiology of our illnesses are, so we need to get on this stat.
Jessi Gold: Yeah we're lucky to have people like you fighting the good fight.
Carol Tamminga: Thank you.
Carol Tamminga: And like you, you guys will do it tomorrow.
Jessi Gold: Hope so.
David Carreon: Thank you for joining us.
Jessi Gold: Thank you so much.
In the final part of our discussion with Janae Sharp, Janae further discusses the loss of her husband and how best to support others through grief. She details some unique differences in responses by others when her husband died by suicide (eg, no GoFundMe pages, but requests for donations!) and emphasizes the importance of other survivors and their stories to her and her new community. She responds to the question of whether she is "sensationalizing" her husband’s death, but focuses on her ability to do good as a result. She is particularly interested in digital solutions and discusses a few that she has been working on here. Finally, she explains what she feels the role of psychiatry is in this important topic.
Welcome to Psyched!, a podcast about psychiatry that covers everything from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in.
David Carreon: You've been through such a difficult experience just in what happened, but what are things that people did or didn't do that were helpful after the suicide? How did people support you or fail to support you? And maybe more generally, how do people support or fail to support families who've had someone die by suicide?
Janae Sharp: Oh, that's a great question. It was hard because the first few days, people ask you what they can do. The first few days, you're really in the closet, not recovering at all. That was hard and it was hard for me to feel like my children were getting less. That was heart-breaking how some people supported it. People who had lost someone though, they were really good at following up and being thoughtful.
I had a friend who would send me articles about grief, and she did that for several years after John's death, just randomly saying, "Hey, I saw this and I was thinking of you." That's something I always tell people is important to schedule something further out, like six months from then and say ... Think of what you would do right after someone dies. Maybe you would go to their house and help them. Maybe you would make them a meal. Don't do it the day after, schedule it for a year later. Schedule it for the next birthday of that person, for any holiday is hard for people.
Purposefully do something instead of asking what you can do because we're socialized to not accept help and when you have grief, you don't always know what you want, it's too overwhelming. The people that were the most supportive were the people who had been through some kind of death and understood the cyclical nature, that some dies will be hard and some days are easier. That it's harder the second year when everyone has forgotten, and you're still taking your kids to a grave, or talking to your kids about their dad who's dead. So just keep that in mind.
I did have some friends who were really supportive and still understand that it's a permanent loss. It's not always permanently devastating. It's not always so immediate as right when they die, but they're still gone. So that's what I tell people.
Jessi Gold: Yeah. And then you mentioned that you were surprised afterwards, like some of the bad reactions, or some of the lack of things that you maybe thought would be around or given to you that weren't.
Janae Sharp: Oh yeah. Well, some of that is surprising because like with suicide prevention, some people they'll reach out to you. Some people asked us for money to donate to suicide prevention, and that was really overwhelming. If you look up things like GoFundMe, they raise less ... or like a memorial for kids ... they'll do it a lot of times if someone dies of cancer, but not necessarily with a suicide death.
That stuff was hard and then it's so strange talking about finances ever. When you're like, "Oh, wow. That's interesting that my kids didn't have a memorial fund." But then, you survived so what do you say? It's this horribly tacky topic where like, "Oh, that's weird." And then people are asking you for money for like awareness and ... Actually, Loss Survivors are the number one funder of suicide prevention initiatives. You're also a number one funder then for a topic that is really hitting you personally, and it kind of makes you ... it's kind of off-putting, but it's also ... now I like want to help those things. It's like the people who are hurting you in some ways, also some of those people were the most supportive. I don't know if that answers the question.
David Carreon: No, it does and I think that I've heard mental illness described as the no potluck disease. The no casserole disease.
Janae Sharp: We did not have funeral potatoes.
David Carreon: Yeah, it's like you get cancer and you get a casserole. You have a broken leg, you get a casserole. But you get mental illness and you get no casserole.
Janae Sharp: Yeah, you just can't post on Facebook, "Guys I just really could use a casserole today because of my depression. I am sad about something from five years ago still." Oopsies.
Jessi Gold: I can imagine, too, that like some people can say posting at all is sensationalizing a personal topic. What would you say to somebody who would say that?
Janae Sharp: Maybe it is. Maybe I should post something like, "Oh, and this is an inspirational story," and also life-coaching. If you think about it too ... because I thought about that. We've started like MD Suicide where people are sharing stories, and I shared our story and talked to my friend who helped me create that website, you know, "Do we want to make sure we're protecting stories of the children?" And I did talk to my kids and get their input on it. But in the end, I'm paying for my children and creating their world, and that's a choice everyone has to make for themselves. If they feel like they're sensationalizing it, then hopefully they're sensationalizing it and trying to help people at the same time.
If not, it's sad that we're so stingy with our attention and positive energy, that we think someone asking for help or asking for attention, is something negative. I also think, in terms of sensationalized stories, it's interesting when media wants more views, but they don't necessarily want to help. Like if someone wants to sell software, but they don't necessarily care about your story.
When people are sharing their own story, you know that they have a personal interest, so take that for what it is. Like I do have a personal interest in this, and it has impacted my life directly. That also means that ... maybe it is just sensationalizing them.
Jessi Gold: Right.
Janae Sharp: That's how it is. Like you get to pick-
Jessi Gold: Sensationalizing for good or something.
Janae Sharp: Yeah, I mean, people should maybe worry a little less about that and share their own story. I don't think that hurts people as much as lying about something and carefully remaining silent. Some of the stories that people shared online, that I read after John died, made a huge difference for me. So you have to find a balance. Everyone has to find a balance.
Hopefully, I have friends who will call me out if they feel I'm getting too wrapped up in those things and I do. I also have to make that decision for myself. Is that bad? You're like, "So people can say it's just for attention." I'm like, "Well, maybe it is. Maybe it is for attention." You share your story to be able to share it, and for people to know your story, and know you. I think that's a very basic need with humanity, to be known and to connect with people. I think that when you have suicide death, that need for connection and to be known is not met.
David Carreon: Yeah, I think you're absolutely right about the need for connection. Sort of, a lot of the things you've talked about and mentioned today have been about how sometimes community has come around and supported, but sometimes it hasn't. But I guess, how has this changed the community that you had before or put you into communities that you hadn't been?
Janae Sharp: I think it's actually had a huge impact on my community. I've been able to meet some people who are really supportive and Suicide Prevention, amazing people. Some of the friends that I'd had for a long time had a harder time dealing with the death, and they didn't have that same connection. That's really hard to see how it will change your support group but it's also ... It's good and bad, but I feel like I've been able to connect with people who really care too about burnout, and about improving a system, and care about doing that work, and want to do stuff together. That's been amazing.
Jessi Gold: I know you're really interested in digital solutions to things. What do you think is different about that, and what do you think makes that a kind of an untapped resource for this community?
Janae Sharp: Oh, I think digital solutions are interesting just because we have lower barriers. If you think about it, the things you'll say to someone on your Facebook posts, you might not say to them online. Or the things that you'll text people, you wouldn't always say that to their face.
There's a place to be more honest, but also if you feel like you have these questions about depression or about suicide, and you don't know who to talk to them about, then digital tools can offer you that community support that might not be available somewhere else.
I think one of the other important things to remember, for me, is how quickly some social media tools or those things can connect you. Because if you have a question about something, you can find answers a lot quicker. So I think it's a great opportunity, like we set up a virtual support group, which it's better with your time, but it also helps people in terms of that barrier to entry being lower.
I do think in-person connection is best, but there are people who would never have those connections because they don't have time or they have some other barrier that would keep them from being involved. I think it's important to ... digital tools can enable them to be involved when they might not otherwise get any help.
David Carreon: Yeah, I think that's a fascinating new dimension. I know that a lot of the talk has been around how there's some ... at least in our field ... magic in the room if you're physically face-to-face present. Some people say even if there's a video camera present for training purposes, that that takes away the magic. Certainly being in a different room when you're doing teletherapy, that completely ruins things. Your experience with the online support group has been that there is ... maybe not as good as face-to-face ... but there is still something there?
Janae Sharp: Yeah, it might not be as good as face-to-face, but some people don't wanna be face-to-face because they aren't really ready for that level of directly combating their problem. Maybe they're not ready for that.
Jessi Gold: And from your perspective, I know that maybe your support groups aren't run by psychiatrists, right? What do you think the role of psychiatry is in all of this?
Janae Sharp: I think they can help.
Jessi Gold: In what way?
Janae Sharp: No, we work with a licensed clinical social worker currently and psychiatrists ... we're always looking for people to get involved. I think psychiatrists should be more involved, and I think they should be overseeing most of the clinical development, and we worked with a psychiatrist to develop some of it. Obviously, they have expertise in identifying medications or identifying things that other people might miss.
I would need to talk to more psychiatrists about how they should improve it. Because I have talked with some about improving the measurement tools, and improving the design, and making sure the tools are efficient but not as much about how to really work together.
David Carreon: Well, we really appreciate your coming on to talk with us and just wanted to give you one last opportunity to ... Is there anything you would say to a young doctor or young trainee who's just getting started? Any advice you'd have?
Janae Sharp: I think my advice to them is to keep an open mind and to actively seek out the best workplace solutions that they can. If they find themselves getting hopeless, to be brutally honest, more than they would normally be and think of that. I also think new physicians are less tolerant of some the things that are creating these horrible environments. They are great activists for improving the mental health and improving the workforce for all physicians.
Jessi Gold: Yeah. If there's one thing that you would say like what psychiatry gets wrong, what would you say that is?
Janae Sharp: I think psychiatry also takes itself too seriously.
Jessi Gold: Totally.
Janae Sharp: They take it so very seriously, and they're already a group where they've been fighting for validation. If you can't diagnose many of your classmates with some form of crazy, then I don't know if you really went to school. But I would tell them to be more vocal about how psychiatry interacts with burnout, and be more critical of other specialties, and be really self-aware of their own limitations. Is that bad to tell them to be more critical? I probably shouldn't do that.
Jessi Gold: I don't think so. What's your favorite book? This is a random question.
Janae Sharp: My favorite book? Well, I really like Tad Williams. He's a fantasy writer.
David Carreon: Nice. And another rapid fire question. Somebody who you admire, a hero of yours either from fiction or real life?
Janae Sharp: Oh, that's a great question. I have a lot of people that I really admire. One of the people in suicide activism that I really like, her name's Dese'Rae Stage, and she shares stories of attempt survivors, Live Through This, and she was super supportive. So she's someone that I really respect in the space as someone who cares about individuals. That's one person I really admire.
David Carreon: Our last question for the interview. What is the largest quilt you've ever made?
Janae Sharp: Largest quilt? You know it's interesting. When we lived outside of Philadelphia, we made about 2,000 quilts for under-served people, and the largest quilt I've ever made is just little bit bigger than a king size quilt I made for myself.
Jessi Gold: 2,000's a lot.
David Carreon: That's a lot of quilts. I was not expecting 2,000 quilts.
Janae Sharp: We made a bunch. It wasn't just me, but it was a really cool thing to be involved in.
Jessi Gold: Totally.
David Carreon: Excellent. Well, Janae, we really appreciate your time and thank you for joining us on Psyched!
Jessi Gold: Thank you.
Janae Sharp: Thank you.
Janae is always looking for collaborators (she wants more psychiatrists!) and donors, so if you are interested in getting involved contact her at Janae@sharpindex.org. For additional information or to learn more about Janae’s work for physicians, survivors, and families please visit the following websites: MDsuicide.com and Sharpindex.org. Find her on Twitter @CoherenceMed.
In the second part of our interview with Janae Sharp, she discusses why she feels she has been a different kind and less restricted voice for physician suicide awareness. She notes that it is important for physicians to speak on this issue and that there is true power in community. However, she feels physicians are more silent on this issue as they tend to avoid "unsafe" and "uncertain" topics and are ultimately afraid of the potential repercussions to their licensure. Using her background in social determinants for health, she also answers a challenging question of whether physicians "deserve" our attention and help.
Welcome to Psyched. A podcast about psychiatry that covers every thing from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in.
David Carreon: I think there is a lot of bravery in approaching this topic no matter where you come from or what your background is and I think that especially so, when some people might say that this is kind of a intramural problem, that this is a physician problem and physicians need to deal with it. Or maybe alternatively that this is a health care problem and so physicians need to deal with it. What would you say to that perspective? Are you, you said you've been silenced, but should this be something that is only for physicians to talk about?
Janae Sharp: The difficult thing about having physicians be the only people who talk about it is that a physician has a direct financial impact in their lives by this topic. If you have a serious mental illness as a physician, that can mean you lose your job. If you have a financial incentive as a health care system to not employ a physician with a mental illness, what does that mean in terms of disability rights and what does that mean in terms of our ability?
So I think physicians know a lot. I think they're super accomplished and I think they really value academics and I really like that they want things that are validated, I like the healing belief. I also think they don't have the freedom that the system, the system isn't designed for them to criticize itself. It's designed for them to perform. Or not perform.
So someone like me, it had the biggest direct financial impact as like the loss of the, you know the loss of all that medical school and all that training directly impacted my kids financially, obviously, and I had a bigger loss than a specific physician would have. I mean not a physician that's losing their job, or passing away, but those voices are sometimes lost and the people in the conversation can't, they aren't as unfettered as we want to, we need them to be to make honest decisions and discuss that honestly.
Jessi Gold: But you feel less limited by external forces, because it's your life and your story not some story controlled by their job?
Janae Sharp: Yes. Like this is something where I don't have to put it on my licensure, my complete mental health history, which I think in 29 states they ask you to do that, even in your renewal. I don't have to report to my employer. When you've already had a suicide loss, there's nothing to do lose anymore. And physicians want that stability and they want that safety that they've confined in academic medicine and within knowing what's right and wrong, but this isn't a safe topic.
So I think it's important for people like me, to be there and say, "Yeah, but, you guys are saying all this stuff." Even when you talk about it sometimes, it's like an alternate universe. They talk about it as if physicians are all saints or all so sad, instead of they're really just human, you know. Some of them are jerks. Some of them that you work with, you don't like and you can talk to nurses and doctors about that. So maybe it needs more sarcasm.
David Carreon: Oh, I don't know if I've ever met a nurse or doctor that I don't like.
Janae Sharp: Never. Never. I've never, I've literally never met an unreasonable either and neither have you.
Jessi Gold: It's just like, you know, it's the same. Like there's sad ones, there are happy ones, there are people who get better, there are people who don't. It's the same.
Janae Sharp: Right. Yeah. Like everyone knows that one guy who they just didn't like, and like how when we're talking about mental health and when we're talking about a healthy system, we need to separate those two. So it's not just like that one selfish guy who thought he was the best person ever, now he's talking about how he's the best person ever with mental health, and he's going to make things better for everybody if you were just more like him. You know? Because that's a little off putting.
Jessi Gold: Yeah.
Janae Sharp: Yeah. So I think it's, I actually think it gives me more freedom, because I can say things like, "Yeah, but it was shocking to me how much some of the people that I've met in medicine do coke, or other performance enhancing drugs and they don't think it's a big deal because they're just enhancing their performance." So I can talk about the culture but not be controlled by the culture, because I don't have the same requirements for having the best school, having the best resume, having those things to check off my list, because I was just married to one. And I wasn't trying to compete with everyone.
So I think that it's been positive for me in a lot of ways to be outside that, because I, because they're not threatened by it and I'm not competing with them. Like the one-up-manship, I'm like, "Well, that's too bad, you went to medical school, that sounds brutally awful. That sounds like something I would not do."
Jessi Gold: And you didn't.
Janae Sharp: And maybe I would. You know? I thought about that. We never know where life will take us. And so yeah, that's a great question too, because I think part of the stigma is that no one wants to hear the rich doctor whining either. Like, because they do in a lot of ways have a lot of privilege and they have a lot of respect and authority in the community. So hearing them say how hard it is sometimes, please are like, "Really?" You know, it's hard. It's hard for people to really grasp that.
David Carreon: Yes, say more about that. I think that especially nowadays there's this idea of sort of that we get a lot of attention and probably justly to those who are victims, or those who are underprivileged, or in fact even some of your own work on social determinants of health and outside of work hours, physicians have pretty good social determinants of health, usually. So how do we balance giving our I guess presumably limited stores of compassion, why should physicians get any because we make a lot of money?
Janae Sharp: That's a great question. I think no one has to be compassionate to other people, first of all. That's bad to say. I mean they don't have to be compassionate to physicians. The reality is a lot of them have tons of debt. Some of them have great social support. Some of them have crippling anxiety and desire to perform. If you're living in poverty where you can't feed your children, sometimes you forget that other people are struggling, but you're not able to remove yourself from the immediacy of your pain.
And that's a triage that our society isn't very good at. We aren't very good at allowing people to have pain if we have pain. And I think some of that is a little bit competitiveness. When John died people would say, "Oh, I'm having a bad day but I don't want to tell you about it." And there are two things that I learned there. One, if I was in a very bad place and didn't have a lot of energy to give, I wasn't as good at being present with them. I just wasn't. And two, that didn't lessen the fact that they were hurting.
So we can say, "Oh look, they have a lot more money than I do, they have a great car", and they're still having enough mental pain that they die by suicide. That's something that we need to be able to talk about. How can we come together and have enough community support that we can allow everyone to have a healthy life and not say it's a limited commodity. And that's something I think about with social determinants of health. They say your community support has a huge impact on whether or not you're going to survive an illness, whether or not you're going to make it through a burnout, or your risk of suicide. And that lack of support can exist at any level and any socio-economic status. And just because I have less doesn't mean someone with more doesn't also have more mental pain than they can manage.
Jessi Gold: So like you're saying community support's important.
Janae Sharp: Yeah.
Jessi Gold: But you're also sort of criticizing the physician community a little bit on how we deal with things. What do you think we're doing wrong, what do you think we need to do better as a community to be supportive of this as a thing?
Janae Sharp: Oh, that's a great question. I think as a community they need better support but also more honest dialogue. So I mean criticizing the community is difficult, because a lot of people really want to do what's right and I think of it in terms of the suicide prevention community too. A lot of people involved there have lost someone by suicide and if you haven't lost someone by suicide you don't assume that it touches you and the physician community is kind of the same way, where you don't want those things to touch you.
And if you treat it like leprosy, like something that is contagious, that's really difficult. And I think a lot of the times, people want to be safe. Like in the physician community too, they want to be safe, they want to have their job. They've done a lot of work, to accomplish what they do, and they want to achieve something. And everyone is that way. They want to be safe and they don't want to have the things that they love threatened.
And in terms of society fixing that, we can, we need to re-evaluate our standard of measure for success. That's not saying that people won't be very successful or we need to lower our standards. It's saying, what can we do to make a place where people can talk about thoughts of suicide and some people that are physicians will think of that every day of their career, and is that something that you should talk about.
And we need better integration with ... And I think some of this is understanding. We don't really understand or since I like data, we don't have very good data or very good math models to predict your suicide risk or to predict your mental health. And you see that with pharmacology, people don't really know 100% what's going to happen with your prescriptions and medicine doesn't like if they don't have good data that they can back up all their decisions and say this is for sure going to be the outcome that we want.
So maybe it just needs more attention and better research so that we can have better data, but maybe we also need people who admit that they don't know everything and that this is an unpredictable thing.
David Carreon: So you're saying that maybe the metrics of how many hours have I continuously been awake or how many hours above a 100 did I work this week might be bad metrics?
Janae Sharp: Well, we don't really use those metrics though to predict like, you don't ... There are some ways that you could use metrics like that to avoid scheduling and those would have a direct impact on physician burnout, if we treated it more like how are we going to optimize someone's health and get some neurologist in there, what happens to your brain and your performance after you've worked 100 hours? How can we manage and develop the work flow and our workforce to look like that?
That would be success. I'm saying we don't know exactly what's happening to people after those 100 hours and them taking a stimulant and continuously working. What's going to be the impact on your ability to interact with people and to relate and to maintain a level of empathy seven years from now, if you're doing that to yourself now.
David Carreon: Yeah. No, it's sort of the slow burn, or the burn out, I suppose is the metaphor that we're using.
Janae Sharp: Yeah.
Janae is always looking for collaborators (she wants more psychiatrists!) and donors, so if you are interested in getting involved contact her at Janae@sharpindex.org. For additional information or to learn more about Janae’s work for physicians, survivors, and families please visit the following websites: MDsuicide.com and Sharpindex.org. Find her on Twitter @CoherenceMed.
Surviving a Physician Suicide: Imperfect Grief and Shaping the Narrative for the Children Left Behind (part 1 of 3 with Janae Sharp)
In Part 1 of our 3-part interview with Janae Sharp—a physician suicide loss survivor and the Founder and CEO of the Sharp Index, a nonprofit dedicated to better physician mental health—Janae shares her story of loss, grief, and her call to action to start her non-profit.
She discusses how suicide loss is different from other losses, in part because it is a "messy topic," but also how grief itself is imperfect. She details the experience of telling her 3 children and why she feels compelled to create "better memories" for them. She constantly reinforces the power and complexity of humanity.
Janae is always looking for collaborators (she wants more psychiatrists!) and donors, so if you are interested in getting involved contact her at Janae@sharpindex.org. For additional information or to learn more about Janae’s work for physicians, survivors, and families please visit the following websites: Mdsuicide.com and Sharpindex.org. Find her on Twitter @CoherenceMed.
David Carreon: This is David Carreon.
Jessi Gold: This is Jessi Gold.
David Carreon: And this is Psyched!, a psychiatry podcast. Today we have Janae Sharp. Janae is a physician suicide loss survivor and the founder and CEO of the Sharp Index, a non-profit dedicated to better physician mental health.
Her main work involves health care data and analytics marketing to improve health care outcomes for the underserved. Python is her preferred code language, but her true passion is match making companies to create elegant health IT systems and to improve health.
She's worked with interoperability and social determinants of health and is an expert on patient and physician engagement. Janae has 3 children, enjoys hiking, triathlon and quilting. Janae, thank you for joining us.
Janae Sharp: Thank you. I hate writing bios as well. I feel like that's important.
Jessi Gold: Yeah, it is really important.
David Carreon: We should have added that to your bio.
Janae Sharp: Yeah.
Jessi Gold: And writing a bio was not your favorite thing to have done.
Janae Sharp: Hearing my own bio I'm always like, "That's a terrible bio. Someone should rewrite that. That poor lady."
Jessi Gold: Well, okay, so how about we start with you just telling us more about you and your story and then as much as you feel like telling us, yeah.
Janae Sharp: Oh, well, that could be pretty long, but so the story of starting the Sharp Index, I can talk about. Like it says, I have a background in health care IT, and I've worked with people creating data products and worked in social media a lot, and I am also a physician suicide loss survivor.
My former spouse, John Madsen, was a physician. He died by suicide, and we created the index actually in his memory and through my experiences with his death. We have 3 children, and I've been able to share a lot of our story and trying to create good memories and, really, how that type of loss was pretty different in terms of the support that my kids got.
It was really frustrating. I felt like people didn't really know what to say or had a lot of advice that wasn't helpful or advice that really was hurtful in some ways. And we wanted to create something that brought awareness to physician suicide but also addressed that, created a better place, and that's really our hope, to have better memories for people.
But also, the index is focused on reducing burnout. So you can look at scores and information about your burnout risk or reasons for that or mental health. And we want to create a network of peer support that's outside of your employer because when … physicians are really driven to succeed and to accomplish a lot, and that doesn't always ... You don't always want to tell your employer you're really struggling.
And in addition, people aren't always aware. If you've always been really in a work environment where you have a lot of stress and you've been a higher achiever, you aren't always aware and in touch with things that might put you at risk.
So that's been kind of my personal story is just that we had just kind of this impossible situation, and I wanted ... And when people would ask me, “What should you do? What are solutions?” I didn't feel like there was a lot out there that was focused on a realistic approach and not just doing lip service to the topic, especially since I was a family member and didn't have any of those stigmas where I can't talk about it.
I won't lose my job talking about it, so the stories that people will tell me are different than the stories that they tell their licensing committee. So, that's some of my background. Yeah, is that helpful?
David Carreon: Thank you for telling us about this. It's got to be a difficult place to be in, where on the one hand you're advocating for other people to prevent suicide or to improve health care systems, while at the same time having this have been a personal struggle for you, something that you're ... It's personally affected and been a challenge in your own life.
Janae Sharp: Yeah, it's interesting too because sometimes I do find myself getting more worked up. Like it's more personal, like people don't want to do much. I kind of feel ... I take it more personally than with other things, and that's been a challenge to find that balance of making sure you find the right people who want to help move things forward and to make sure that I'm respectful of their needs and vice versa.
So sometimes throughout the process of telling the story, I've had to take breaks, and it does take an emotional toll, but it also, I think, is really powerful, and it makes me feel like I'm giving my kids a better memory for their dad. So they know that it's important and that other kids who go through that, or people might not have to go through that because of stuff that we've done and to honor that and to work on that huge problem.
Jessi Gold: Yeah. I'd imagine that speaking to your kids about their father's death was complicated to say the least?
Janae Sharp: Oh, it was terrible. I did a terrible job. I'm like in the example. I feel like part of me doing this is I'm the example of what not to do in a lot of ways. I quit my job. I kind of fell apart. I didn't always keep it together. If I was angry, sometimes I would tell people, and that's part of grief, but I think we only want to hear grief stories when they're very cleaned up and very done.
Yeah, telling my kids, I, yeah. I tell that story where ... I told that story actually on a podcast only once, where on the ZDogg show, I said how I just screwed it up. I felt like I screwed it up because he died in a pretty graphic way, and I was in shock still.
So I just told them, I was like, "Your dad died in a fire." And I'm like, "That's probably going to be the most traumatic possible way to tell your children." And then, I kind of dropped it for almost a year, and they were going to start a counseling group that one of the requirements was you had to say that they had actually died by suicide.
And they explained that it can retraumatize a child if they feel like you've lied about how they've died, and once you have that mental health support, it's good for them to be able to work through their feelings. So I told them, but then, normally, you would just ... I had practiced saying, "His brain was sick, and then he found a away to make his body end" because my children were quite young at that time.
And they still are. Right now, they're 10, eight and six, and it's been almost 3 years, so it was a real experience kind of coming because you are also traumatized. You don't always handle things the way that is quote/unquote "best," and it's really ... You don't know what to do.
So telling my kids was ... really difficult and watching them grieve and not always being able to be as supportive as they needed. That was a really hard thing to watch and to realize about yourself that when you're in such a bad place, you're not really there for people.
David Carreon: No, and it just hard to imagine how difficult a experience that was for you, that is for anybody who has to do that, and-
Janae Sharp: I know, and you guys talk to people like that for ... They come to you. You guys are the experts, so I couldn't imagine that. I would not be good at that job. I think it's really humbling because you realize how important humanity is. Grief is something that teaches you that there are human needs that are bigger than what you should or shouldn't do or your list of to-do lists or your goals in life.
There are just some points in your life when you're kind of knocked on your feet, and you realize the power of humanity that there are things that will happen to you that will change you, but also, you can't ignore them, and you can't just put them on a checklist and go away. They'll heal on their own time.
David Carreon: I want to hear more about what you said about something like having a better memory or having your kids be able to remember things in a better light or having a better memory. How do you tell a story of tragedy well? Or how do you advise people to?
Janae Sharp: Oh, that's an interesting question. I don't know. I don't know the best way to tell a story of tragedy. For me, I didn't want to talk about such a graphic way to die without always offering support that there are people who will help you talk about suicide and thoughts of suicide, and I always tell people to be patient with themselves and to be honest as much as they can.
With John, it was frustrating not feeling like some of the people he knew were offered a lot of support, like all his classmates. They were in their residency, and it felt like they weren't really reached out to to have offer of counseling or a way to deal with those feelings.
So you might not have the prefect thing to say, and you can try to talk anyway. That's what I like to tell people a lot. Suicide and burnout, those are messy topics that we don't like to talk about because you can't always package them up in one neat little bundle and say, "This is how it's going to get better."
And talking about those messy topics is important, so I advise people and think in John's memory, we need to remember that we aren't perfect and that we are going to have to find a place to have those messy problems, where there isn't one solution, and there isn't one cause.
The more we can talk about those and connect with solutions that already exist, the better things will be for people like my kids. And it's hard for them to tell the story, too. They don't want to ... My daughter even said that the other day. She's like, "I don't want to make people feel sad or make people uncomfortable," and that's a real problem that we aren't able to deal with difficult things, and we have such a strong desire to make people feel not uncomfortable.
And I'm sure I've made some people feel uncomfortable and hope that they are patient with me or that they do what they can and make sure to protect your own ability to handle things but also we don't need to always talk about sad things, but we need to be able to accept more complexity of problems and emotions within to our narrative. We need to not just put someone into the good or bad bucket and realize how complex humanity is.
Jessi Gold: Do you think that around the time that John died, your initial reaction was to not tell people how, or did you right off the bat know that you needed to do that, and you had this somewhat of a calling, I guess you could say to not fall into the stigma and to actually say it was suicide?
Janae Sharp: It was on the news that he died, but not everyone wanted to talk about it at all, like some friends were very uncomfortable with even talking about how he died, and I wanted to be aware of the loss everyone had because that's a serious loss, and people want to go through the memories that they have and honor those.
But I also felt like the memories my children had and their experiences were more important, honestly. So I didn't know that I would speak about it at a health care conference or anywhere else, but I did know that it was an impossible experience and that I didn't find that acceptable.
I knew that I wanted to find a way to make things better. Especially in health care, where we say that mental illness is real, and we actually are trying to heal people, It doesn't make any sense to have a workforce and training experience that controverts everything we know about health.
So some of my desire to talk about it was the desire to have a voice where I felt like I was silenced when it first happened. But I didn't know for sure I wanted to talk to people about it because I'm not perfect, just like anyone else. But I did feel like it was a huge opportunity to create a space to talk about those hard things and be brave.
Charles Nemeroff, MD, PhD, discusses the role of social influences on biology, using the example of early life trauma. He explains brain changes, inflammation, and genetic risk factors that modulate the development of PTSD or depression in patients with a history of trauma.
Keeping in line with epigenetic theory, Dr. Nemeroff discusses what happens to genes during psychotherapy, exploring the interaction between attachment to the therapist and how this contributes to the efficacy.
Finally, he answers our rapid-fire questions and describes the challenges without parity in mental health care. He leaves us with excitement and hope for what he feels is the “golden age of psychiatry.”
David Carreon: I think that on the positive end, I think there's more research to do, but I think thinking about this relationship between the mind and the body, and the person's experience ... It makes me think of things like a difficult childhood, child abuse, or something like that could very well increase a person's stress level and inflammatory markers.
Dr. Nemeroff: Well, you're prescient, because that's exactly what the data show. There's a wonderful meta-analysis by Andrea Danese at the Institute of Psychiatry in London. We've confirmed the findings in our own studies. Early life trauma is associated with a very persistent increase in inflammatory markers, and it's probably one of the reasons why those patients have a poorer response to psychotherapy and pharmacotherapy.
Jessi Gold: And what counts as early life, and is it one trauma, multiple traumas, or is it different?
Dr. Nemeroff: So another great question. The data is still being generated, but overall pre-pubertal abuse and neglect. The more severe, the worse the outcome, both in terms of inflammation, but also a host of other factors. Neuroanatomical changes ... The human brain doesn't mature until age 24, and we know that developing protoplasm is susceptible to insult. Susceptible to lead toxicity, susceptible to fetal alcohol, and in my way of thinking, it's susceptible to behavioral teratology, namely child abuse and neglect. So it's not surprising that we've seen these robust effects that we have.
David Carreon: Yeah, and I think there's been an interesting body of literature developing around the social influences on biology. Rats that are isolated versus rats that are in paired housing versus rats that are in enriched environments have entirely different profiles of how they do and how they behave, and what that means for them. And I guess thinking about that both in childhood, but throughout the life, that environment plays a huge role ... And social environment plays a huge role in-
Dr. Nemeroff: Well, remember that for major depression ... Not talking about bipolar disorder, but for major depression, about 35 to 40% of the risk for the disease is genetic. That means 60 to 65% is environmental, and I think a lot of this has to do with attachment. I think early life trauma disrupts attachment, and I think subsequent life stressors disrupt attachment, and if you follow these kids who've had terrible early lives, it's a very rocky adolescence and adulthood indeed.
David Carreon: Is it possible that somebody who has had a difficult childhood would be able to overcome that and fully remit or fully…
Dr. Nemeroff: Yeah, so most of our studies in this area have focused on trying to uncover genetic risk factors, that interact in a gene environment way to increase or modulate the risk for depression or PTSD in adulthood. What we've discovered is that there are some critical genes, of which certain of the SNPs, the variants, unfortunately markedly increase your risk for depression if you've been exposed to early trauma, and then their counterparts which are resilience genes that prevent it.
So I believe many of our patients are probably patients who've just had pretty bad luck. They've pulled a bad hand. They have three, four, five or six of the vulnerability genes coupled with early life trauma that result in an increased risk for depression. What's really interesting is in our studies, in the absence of early life trauma, these genetic variants have no impact on whether you get depressed or not. It's only in the face of early life trauma. It's sort of like ... Imagine the guy who has the risk gene for lung cancer but never smokes, right? No effect, right? But smokes three packs a day and 80% likelihood. That's what Caspi saw with the serotonin transporter gene. It's we've seen with the CRH and the FKBP5 gene. I don't want to bore you with the nomenclature, but there are gonna be a category of genes.
Now there is some data that both epigenetics is important, so the notion that life events change gene expression, not by changing the structure of the gene but by changing the expression of genes. That could be good or bad. It may be, if I was a betting person and I was Jessi's age, what I would do is I would like to look at the epigenetic consequences of psychotherapy. 'Cause I suspect, in my view, psychotherapy is a biological treatment, and I think it probably changes gene expression.
David Carreon: That would be a fascinating thing to circle back on in a few years. I imagine people are already doing work like that. That sounds ... Maybe the inverse of what you're saying about the epigenetics of child abuse, that at least we tell ourselves in psychotherapy that we're filling this role or that this relationship is analogous to the nurturing relationships of childhood.
Dr. Nemeroff: Well, it's absolutely essential, you know? I think we must be clear that genetics is not necessarily destiny. That genetics can be overcome, and gene expression can be modulated. There was a very nice study done in Seattle some years ago that I wrote a commentary for in the American Journal, which looked at two different foster care systems. One was funded by a foundation and was very high-end and hired the very best case workers, and every student in that program was guaranteed a full four-year college education if they completed it. That outcome was compared with a sort of standard foster care system in the public sector.
Obviously, and I'm not casting any aspersions on the public sector, but the fact is when resources were put into place to guarantee a selection of case workers, foster care parents who were rigorously screened for the best of intentions, the outcomes were better. So I think attachment really does matter, and you can't overcome adversity and genetics.
Jessi Gold: It begs the question whether social support or psychotherapy is somehow activating the resilience pathway or resilience genes in some other epigenetic way.
Dr. Nemeroff: You know, it's interesting having been brought up academically in the psychoanalytic era, and then seeing the pendulum swing. Every study of efficacy of psychotherapy has always had the same conclusion, which is it's the quality of the relationship between the psychotherapist and the patient that is the best predictor of outcome, regardless of whether you're using cognitive behavior therapy, interpersonal psychotherapy or psychodynamic psychotherapy. In my mind, that's exactly what it's about. It's about the attachment. It's learning how to trust people, it's having somebody help guide you in a certain way and a safe environment when you haven't experienced that. There's no chance on Earth it doesn't have an effect on your stress system, on your endocrine response to stress, and on inflammation.
David Carreon: I think that's a very optimistic note to shift into our last phase of questions here. We do rapid fire questions for our guests. So if the next two questions you could answer in one or two sentences. What's an area that psychiatry's going wrong, or an area that psychiatry can improve in?
Dr. Nemeroff: So our treatments just simply aren't as good as we would like them to be, and we have to be upfront and honest about it. If only 28% of patients are in remission after monotherapy with an SSRI, we have a problem, and we must teach practitioners and the community to be aggressive about treating depression with whatever it takes. RTMS, psychotherapy, ECT, any of the FDA-approved treatments. We haven't been good at that. That's one.
The second really quick answer has to do with the fact that we don't have parity. It's just simply a societal disgrace that our patients cannot get adequate treatment, and the notion that parity laws have passed and President Obama signed them ... The bottom line is my faculty get paid through third-party payers, minuscule amounts for their time compared to say oncologists or ophthalmologists or neurosurgeons. I have nothing against my colleagues in other branches of medicine, but if our patients can't get their treatment, and we can't pay our faculty, and practitioners can't get paid in the community, and companies are constantly denying medications we prescribe because everybody wants us to use generic medications, how can our patients get well?
Jessi Gold: Yeah. Just for people listening, before I ask you the next question, what would be the price difference for, let's say, going to a psychiatrist and getting reimbursed versus even just going to primary care or something?
Dr. Nemeroff: Well primary care's not a good example 'cause they don't get paid very well. Psychiatrists, pediatricians, general internists, family docs are paid very poorly. But depending on the plan and the state, Medicaid pays very poorly. As much of a help Obamacare was for many states, there was no provision for illegal immigrants to be paid. So many of us, particularly us in Miami but also in California, ended up seeing a lot of patients who were coming to the emergency room extremely sick, and there was no opportunity for them to be reimbursed at all. It's our job to take care of everybody, and so it's a pretty serious problem.
Jessi Gold: Yeah. The next question is, what's your favorite book? ...
Dr. Nemeroff: ... So I highly recommend ... One of my best friends is a novelist named John Katzenbach, whose father was Nicholas Katzenbach, the Attorney General of the United States. He writes really great psychiatric, psychological thrillers, and really delves into the minds of the characters. So I would highly recommend him. I would be remiss if I didn't mention that the fifth edition of our textbook of psychopharmacology was just released here at the APA.
But yeah, I tend to enjoy fiction very much. I just read a fabulous novel by a guy named Peter Heller called Celine. It's about a 62-year-old woman who's a private detective. Very cool.
Jessi Gold: Cool.
David Carreon: What advice would you give to a young doctor?
Dr. Nemeroff: So this is the golden age of psychiatry. All of the advances in neuroscience, molecular biology and genetics are now being applied, and in the next 10 years there's gonna be a sea change in terms of treatment. We're gonna develop personalized medicine in psychiatry. You're gonna see a patient, you're gonna get their genetics, you're gonna probably get imaging on them, you're gonna get inflammatory markers and based on those results, you'll be able to optimally match them to the best treatment and not have to play trial and error. That's gonna be a whole new world for us.
Jessi Gold: A lot less dart-playing.
Dr. Nemeroff: Alright.
Jessi Gold: Yeah. And the nice question is, who is a person, fiction or history, that you consider a hero?
Dr. Nemeroff: So ... Boy, that's a great question. I'd have to say Hank Aaron. I was in Atlanta for many years and Hank Aaron had the most incredible grace under pressure, at the toughest time. Here was somebody who broke Babe Ruth's record in baseball. The salary was never what the salaries are today, but he held his head high in the face of racial slurs in the most difficult time, particularly living in the South wasn't easy. I just respect the heck out of him.
David Carreon: I guess this is also related to another person, who's somebody who is, in history or the story of someone who had a depression and was able to push through?
Dr. Nemeroff: So there have been many folks in Hollywood that have suffered with depression. Some have been upfront about it, others have not. Certainly historically, we know Vincent van Gogh suffered with terrible depressions. ... Clearly Lincoln suffered with depression.
Probably the best example was Churchill. The black dog of depression, he's the one who named it, and went through just periods of melancholia that were just so severe. His biographer actually said that to liken his depressions to sadness was actually the same as likening a canker sore to a carcinoma. That's how severe he viewed his depressions.
David Carreon: Wow. Thank you for joining us on the show today. We really appreciate your time.
Jessi Gold: Yeah, thank you.
Dr. Nemeroff: It's my pleasure. Thank you.
Depression is a killing disease: the effects of depression on the body beyond suicide
In the first part of this interview, Dr. Charles Nemeroff, Director of the University of Miami Center on Aging and Chairman of the Department of Psychiatry and Behavioral Sciences at University of Miami, discusses depression, including its symptoms, epidemiology, and the link to other physical illnesses like cardiovascular disease and diabetes. In particular, he discusses the role of depression in clot formation and inflammation. He then looks ahead to future studies and treatments that might target inflammatory factors, including stem cells, and argues for psychiatrists to consider obtaining inflammatory marker labs on every patient that they see.
Welcome to Psyched, a podcast about psychiatry that covers everything from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in.
Welcome to Psyched, a podcast about psychiatry that covers everything from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in.
David Carreon: Hey, everybody. This is David Carreon.
Jessi Gold: This is Jessi Gold.
David Carreon: And this is Psyched, a psychiatry podcast. Today, we have Dr. Charles Nemeroff, the Leonard M. Miller Professor and Chairman of the Department of Psychiatry and Behavioral Sciences at the University of Miami. He was born in New York City and graduated from City College of New York in 1970. He earned his PhD in neurobiology and his MD from the University of North Carolina at Chapel Hill. Dr. Nemeroff has received numerous honors during his career, including the distinguished Menninger Prize from the American College of Physicians and the Research Award from the American Foundation for Suicide Prevention. He's published more than 1100 research reports and reviews. Dr. Nemeroff, thank you for joining us on the show.
Charles Nemeroff: It's a really pleasure to be here with both of you.
Jessi Gold: Thank you.
David Carreon: You've got an incredible body of work here. We'd like to start the conversation off about depression. For our audience that does have a pretty broad range, what is depression? What is its essence? What does it look like?
Charles Nemeroff: Depression is a syndrome, a collection of symptoms like any disease. It happens to be a very common disorder, so that about 11% of men and about 21% of women in their lifetime will suffer with what we call major depression. The constellation of symptoms, of which you have to have five of nine in the DSM-5 criteria, include such symptoms as sleep disturbance, difficulty falling asleep, having trouble staying asleep, waking up too early, although a small percentage of patients oversleep. A very clear decrease in appetite. Most people, a decrease with body weight loss. Some small number, an increase. Difficulty concentrating, thinking, making decisions.
Obviously, the symptom we worry about the most . . . is suicide. Suicide is the 10th leading cause of death in the United States. It's the only one of the top 10 causes of death that are increasing in number. All the others, including stroke, cancer, heart disease, are decreasing in number. And we can talk about that, if you'd like.
But depression is this terrible syndrome. Its cornerstone is the inability to experience pleasure. If you think about the worst day of your life, loss of a loved one, lost your job, breakup of a relationship, think about feeling that way every day and not knowing why. There's a feeling of hopelessness and helplessness associated with depression that, of course, then leads to suicidal thinking.
David Carreon: It's a pretty devastating condition and something that both Jessi and I have seen plenty of patients with. I guess, from your perspective as somebody who's done a lot of research in biological psychiatry, what does depression look like in the brain, from your perspective?
Charles Nemeroff: Well, before I answer that, let me just interject a couple of other things about depression for the audience. First, one of the really important facts to know is that depression is a systemic illness. It affects the whole body. Part of having depression is being very vulnerable for other medical disorders, including diabetes, heart disease, certain forms of cancer, stroke. Depression is a killing disease. Not only does it kill you by suicide, it kills you because your life expectancy is shorter because of the biology of the illness. What I mean by that is the biology of depression is not just in the brain. It's in the whole body.
David Carreon: I think that's an important thing to emphasize. Certainly, on some popular levels, it's all in your head, just snap out of it. But you're saying that it's something much more than that. It's not even just in your brain. It's a widespread disorder across the body.
Charles Nemeroff: Well, first, even if it was just in your brain, you couldn't just snap out of it. We don't generally tell patients with epilepsy, "You know, you just ought to stop having seizures." Right?
Jessi Gold: Right.
Charles Nemeroff: So, this notion that you could snap out of it is just . . . One of the cardinal features of depression is incredible fatigue. I'm always wondering, when people say to severely depressed patients, "You need exercise." Well, yeah, it's hard enough to exercise when you're not depressed, right?
Jessi Gold: Yeah.
Charles Nemeroff: But if you're morbidly depressed, if you have a Hamilton score of 35, and you're not sleeping, and you can't concentrate, and nothing feels good, you think you're going to go out and run? No. Yes, you're absolutely right. The notion that you can just get over it, it just doesn't make any sense.
David Carreon: What are some of the key things? I think we don't talk as much about the increased risks of dying with depression. We talk a lot about suicide, at least in psychiatry. We don't talk a lot about some of these other things, things that primary care has to deal with. Do you think that that's been a perspective that's been . . . How do you think we got into that way of thinking?
Charles Nemeroff: For many years, I conducted research on trying to understand why depressed patients were at risk for heart disease, myocardial infarction, and stroke. It took almost 20 years of negotiating with the American Heart Association before they were willing to actually list depression as a risk factor for heart disease on their website.
Jessi Gold: Twenty years.
Charles Nemeroff: And the conversation, I wish I had recorded the conversations with leadership of American Cardiology because one of the issues that came up is we were almost there, like 15 years ago, and the then-president of the AHA, who will remain nameless, said to me, "Well, you know, actually, the reason we can't list it as a risk factor is because you have not demonstrated yet that, if you effectively treat depression, then you can actually obviate the risk." I said, "Wait a minute, you have genetic risk factors on your website. We haven't shown that you can modify genetic risk factors, and therefore change risk." And that was sort of the end of the conversation.
But, in the end, long after I was president of the American College of Psychiatrists, in the end, we managed to get this listed as a risk factor. But there is a general bias about the notion that psychiatric disorders are biological illnesses, and that they have alterations in the body, as well as in the brain.
Jessi Gold: Would you say that the risk factor is just physiologic? Like I have depression, I'm tired, I'm not exercising. Or is there actually something going on in the body and the brain because of depression that's leading to-
Charles Nemeroff: Oh, there's no question about it. Many years ago, when you were in elementary school, we published a report showing that drug-free depressed patients have a clotting diathesis.
They have a fundamental abnormality in the platelet clotting cascade, in several steps in the cascade, in the initial platelet activation phase, but also in the final clot formation stage, so that depressed patients simply have a diathesis for forming clots. They're much more likely to form a thrombus than non-depressed patients.
That's one abnormality. There are five or six others in terms of oxidative mechanisms. Then the big factor right now, which we and others have spent, now, several years focusing on, is the fact that a very sizable percent of depressed patients exhibit marked increases in markers of inflammation. And inflammation is involved in the pathophysiology of all of the diseases we talked about, right? Diabetes, stroke, heart attacks.
There have been many meta-analyses done that have looked at this already, but the fact of the matter is depressed patients have markedly abnormal inflammatory markers, C-reactive protein, Interleukin-6, tumor necrosis factor. Not all, but clearly a sizable percent.
Jessi Gold: And at a level that somebody who might not understand all those markers would understand what does inflammation ... How does inflammation work for depression?
Charles Nemeroff: Well, so the American Heart Association has a cut-off of three for C-reactive protein as a risk for myocardial infarction. A substantial percent of depressed patients have levels of three and above.
Jessi Gold: That makes sense.
Charles Nemeroff: Very clear.
Jessi Gold: Yeah.
David Carreon: I think there's a lot of popular conceptions and a lot of popular misconceptions about inflammation and anti-inflammatory foods or anti-inflammatory dietary supplements or things like that. What is inflammation at its core level? Why might the body be doing this in depression? What is its purpose or intended outcome?
Charles Nemeroff: We have to remember that inflammation is an evolutionarily important adaption. It's there because it fights bacterial and viral invaders. It's there, fighting against certain kinds of cancer. The immune system is an extraordinarily component evolutionarily, and it's probably partly responsible for the increased survival of our species.
We also know there are a number of inflammatory diseases. The classic ones are sarcoid, Sjogren's disease, rheumatoid arthritis, lupus, …. We know that these diseases are in fact diseases of inflammation. We also know that Alzheimer disease, stroke, heart disease, certain forms of cancer are unfortunately accompanied by increases in inflammation.
We were the first group to report in the '90s that depressed patients and depressed patients with cancer showed an increase in inflammatory markers. This has now been confirmed time and time and time again. Why this is the case is a great question. I wish I could answer that. But any more than I can answer why inflammation's involved in the pathophysiology of Alzheimer's Disease or epilepsy or stroke or diabetes. We really don't know why some patients and some diseases are affected with it or not.
What we do know is that patients with inflammatory diseases have high rates of depression, and people with depression have high rates of inflammation. If you give somebody a treatment to increase their inflammatory response, for example, treating someone with malignant melanoma with interferon in order to create an inflammatory response to fight the cancer, one of the major side effects is robust and severe depression in a sizable subset of patients. There is this link.
Jessi Gold: I bet originally when that was determined, people just said that was a drug side effect or something like that, instead of thinking more about the mechanism.
Charles Nemeroff: It was first noted . . . it was really interesting. David Rubinow, who's the Chair of Psychiatry at the University of North Carolina, was in charge of consult psychiatry at the National Cancer Institute. When they started using interferon for treating certain cancers, he started getting called to come to the clinical center to see these patients who suddenly became severely depressed and suicidal.
I was in a meeting in Luxembourg, of all places, or in Germany right proximal to Luxembourg. There were two suicides of patients given interferon for the treatment of cancer there on the same day. It made it to the front page of the paper.
David Carreon: Wow.
Charles Nemeroff: I looked at it, and I thought, "What is going on here?" That led to our New England Journal of Medicine article on characterizing depression associated with inflammation that was produced by interferon, and then learned that we could pre-treat patients with SSRIs, beginning two weeks before the interferon and ameliorate the depression.
David Carreon: Do SSRIs affect the inflammatory state of the body in non-interferon patients?
Charles Nemeroff: This is a great question, of which there's very little data. SSRIs have multiple effects, one of which is to inhibit platelet aggregation and coagulation. We've always wanted to do a study, giving incredibly doses of SSRIs, like maybe a milligram of escitalopram, to see it if would work better than aspirin at preventing myocardial infarction in the general population because it wouldn't have much of a side effect, sort of a Framingham-like study. We could never find anybody that was willing to fund such a study.
But it also begs the issue that you asked me that I sort of avoided earlier, which is what about many of the lay public, who believe in anti-inflammatory agents, natural foods, fish oil, etc. and are they effective? It begs the question of whether anti-inflammatories are effective antidepressants, right?
David Carreon: Yeah.
Charles Nemeroff: First, I'm completely agnostic, as far as treatments. I'm just insistent on science.
David Carreon: Mm-hmm.
Charles Nemeroff: I'm willing to test any hypothesis that sounds reasonable, whether it's an integrative medicine approach, a psychotherapy, pharmacotherapy, food, diet, exercise, as long as it's a well-powered study, and we can get the answer to the question. And remember that the plural of anecdote is not data. Just because you treated a patient with some regiment and they got better doesn't mean that this is a controlled study or even a case series, right?
David Carreon: Sure.
Charles Nemeroff: I'm open-minded about this. I'd love to see more studies in this area. We're embarking on a very novel approach in this area, and that has to do with the following. There have been a few studies of anti-inflammatory agents that were very targeted, in particular, tumor necrosis factor inhibitors. A reasonable hypothesis, because tumor necrosis factor is one of the inflammatory markers that has repeatedly been shown to be abnormal in depressed patients. There are a few tumor necrosis factor antagonists that are on the market approved for other indications—namely, rheumatoid arthritis, for example, and treatment-resistant psoriasis.
There was a study done by Ranga Krishnan at Duke many years ago. Etanercept is a drug that's used to treat psoriasis. It's a tumor necrosis factor monoclonal antibody. He infused it to patients with psoriasis and depression, who had failed antibiotic therapy. In a placebo-controlled study, he found that it had anti-depressant properties. It's pretty exciting.
There was a second study done by Andy Miller, Chuck Raison, and their colleagues at Emory, in which they looked at different TNF Alpha antagonist called infliximab. Interestingly, in the patients with elevated CRP levels, indicative of inflammation, the drug did have anti-depressant properties.
My approach has been that, because multiple inflammatory markers have been shown to be abnormal in depression, I was looking for a more pan-inhibition kind of strategy, one that would quiet inflammation down in a broader way because I was concerned, if you block TNF Alpha, what about aisle 6? What about CRP? What about the inflammatory markers?
As you probably know, there is a huge, burgeoning database on the use of stem cell therapy in regenerative medicine, that you can give intravenous infusions of mesenchymal stem cells derived from bone marrow. These cells travel to sites of inflammation, where they quite down inflammation locally. At Miami, our stem cell institute director, Josh Hare, has done this post-MI. He's done it in congestive heart failure. He's done it in frail elderly. He's done it in COPD. He's done it in arthritis. You infuse these cells, and they literally go to the hot spots, your knee, your chest.
We've done a study in frail elderly. In the study in frail elderly, we saw a six-month reduction in tumor necrosis factor levels after a single infusion of 200 mesenchymal stem cells. No side effects of the treatment at all. And an increase in a sort of crude measure of well-being. They weren't depressed. And an increase in their capacity in terms of frailty.
The Stanley Foundation has just agreed to fund a pilot study for us, looking at treatment-resistant depression, looking at these patients who are treatment-resistant to, say, SSRIs and have elevated inflammatory markers. We're going to do that, and I have an NIH application in to look at a very unique population of patients who ought to have robust inflammation, which are patients with comorbid alcohol abuse and depression because both alcohol abuse and depression are associated with robust increases in inflammation. I'm pretty excited about this.
David Carreon: That's a fascinating approach. Just to kind of think about this more concretely, where do you expect, hope, predict, imagine them to go? If I've got an aching knee, it's going to go to my knee. What is inflamed? Where?
Charles Nemeroff: First of all, we know that peripheral inflammation increases depressive symptoms, both from the interferon studies I've told you, but then from a variety of other studies that have been done by Janet Kiecolt-Glaser at Ohio State. She's shown that artificially increasing inflammation by giving, say, LPS, lipopolysaccharide to college students causes a robust inflammatory response, and their mood plummets.
Stress can do it, as well. I think, by blocking information peripherally, we should, in fact, see a bonafide improvement in depressive symptoms, particularly the cardinal vegetative symptoms. Think about what you feel like when you have the flu. You're at home, you feel terrible, but you're not working, but you can't concentrate. You can't read, you can't watch TV, you're lethargic, you're listless. That's sort of part of the depressive syndrome. There may be some cardinal symptoms of depression that respond to this kind of treatment. A big issue, which was cloaked in your question, is is there a direct effect on the brain?
David Carreon: Mm-hmm.
Charles Nemeroff: There's a huge amount of controversy about this. There's an investigator at the University of Virginia named Daniel Kipnis that, this year, for the first time, discovered a direct link between the periphery and the brain, as far as the immune system, which had hithertofore not been understood.
It looks like there is a tremendous amount of communication between the periphery and the brain and the immune system. Secondly, you'll remember from your basic neuroanatomy . . . that there are seven circumventricular organs in the brain that have leaky blood/brain barrier passages that do not have tight junctions separating the brain from the periphery. They are, just to remind you from the Latin, they are the median eminence, the subfornical organ, the area postrema, which controls vomiting, for example. That's why you vomit when something in the periphery is upsetting you. The organ laminosum, the lamina terminalis. I know you'd like that.
David Carreon: Thank you.
Charles Nemeroff: These areas allow immune cells to enter. Then, lastly, the brain has its own immune system, which is the equivalent of macrophages in the brain, or microglial cells. They also make inflammatory markers.
Jessi Gold: Do you envision that like, I'm working in a hospital, someone comes in with depression, I would be looking at their inflammatory markers to decide treatment in the future?
Charles Nemeroff: First, because a third of your patients don't have another doctor, you should be doing it anyway because our patients are at risk for heart disease and stroke. I get CRPs on all my patients, just to make sure. And you'd be stunned at how many of them are in the risk range and don't know it.
But yes, I think this will end up being sort of part of personalized medicine in psychiatry. I think, in psychiatry, we had this notion that monotherapy was good. Then, when the treatment studies like STAR*D came out, we discovered that only 28% of patients treated with citalopram actually got into remission. That's not a good number.
If you go to an oncology clinic, nobody's on monotherapy, right? Everybody's on triple-drug chemotherapy, radiotherapy, whatever. Why would the brain, as complicated an organ as it is, with a syndrome like depression that affects certainly different brain areas, circuits, neurotransmitter systems, why would we think that one antidepressant would bring people into remission?
I think we're going to see patients show up, you're going to evaluate them, you're going to end up getting inflammatory markers, maybe one of these anti-inflammatory treatments will be part of the depression regimen. We'll find out better whether psychotherapy affects inflammation. It's not out of the bound of reason that maybe effective CBT maybe helps patients reduce their inflammatory markers. These are all active and important avenues of investigation.
In the second part of our interview with Melissa Arbuckle, MD, she continues to discuss active learning methods. What makes interaction in a learning environment difficult for people? She then summarizes the use of quantitative measurement in psychiatric care, including in therapy. She details its effectiveness as a tool for self-monitoring in patients and whether it can predict relapse and to quantify a "baseline." She further mentions the use of the Working Alliance Inventory as not only an outcome measure but also a teaching tool. Can doctors learn to tolerate that not every patient likes them?
Dr. Arbuckle is Vice Chair for Education and Director of Resident Education in the department of psychiatry at Columbia University and the New York Psychiatric Institute,
Intro: Welcome to Psyched!, a podcast about psychiatry, that covers everything from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in.
Arbuckle: I remember the first grand rounds I did, where I decided I wasn't going to do a lecture, and I think it kind of shocked people in the audience, that no, we're actually going to do something different, and yet they walked away saying, "This was fun. Wow."
David Carreon: Tell that story. Where were you, who invited you, and did they know what was coming?
Arbuckle: The first time I did it, it was for a quality improvement curriculum that I teach, and the idea ... I asked everybody to come up with something they want to change in their own life and use that as a prompt for walking through the steps of quality improvement and how you set aims, how you measure outcomes.
For example, if you're going to set a goal for yourself ... My favorite goal that residents always say when I say, "Oh, let's set some goals," it's always read more. That translates into, probably nothing's going to happen. So if you think about it in the context of a quality improvement paradigm, then you're going to think about, what exactly am I going to read, how much am I going to read, what's my goal, what's my timeline for doing that, and it's far more likely to happen.
So we use that framework, I use that framework for teaching about quality improvement. So I did that exercise in a grand rounds and people played. I said, "You're going to pair up with a neighbor, and I want you to talk to your neighbor and report back," and it was fun.
David Carreon: Where was it? What was the room like? Tell us more about that picture.
Arbuckle: It was a traditional auditorium, so people were sitting in seats in an auditorium and kind of scattered about the room. I think the one thing that I sometimes have to do is get people to sit next to each other. So sometimes I say, "Okay, you're going to have to move, to sit next to somebody, because we're going to do something interactive." I think it takes people off guard. I think people are still a little uncomfortable about it. I did some interactive stuff, here at the APA, and a couple of people snuck out of the room rapidly.
Jessi Gold: I noticed that, too. Not in yours, but I was noticing that it was like as soon as the workshop part started, everyone was like ... some people just snuck out.
Jessi Gold: Yeah.
Jessi Gold: I wonder what ... I mean, I guess it's scary to have to actively do something. I don't know.
Arbuckle: Well, I think there's a piece of this thing that we're all afraid of being found out as a fraud, that we don't really know something, and perhaps, if you have to do something with someone else as part of an exercise, you're going to feel stupid or people are going to realize you're not the expert you're supposed to be. I think there's some performance anxiety that comes with that.
Jessi Gold: Probably scary for all levels of whatever for different reasons.
Arbuckle: Absolutely, yeah.
Jessi Gold: Yeah.
David Carreon: I mean, if somebody find out that we're not all omniscient, how are we going to be able to keep our jobs?
David Carreon: Another thing we wanted to talk to you about was the ... In psychiatry, I mean, medicine in general, but particularly psychiatry, we like to not measure things. We prefer to just sort of go along without measuring things and particularly in psychotherapy training. There's a lot of thought, particularly in psychodynamic or those sorts of approaches, that it really isn't science, and so you really can't measure things. I know that some of your work has involved trying to measure that and trying to improve that.
David Carreon: How would you even approach ... ? I mean, with all of the squishiness of the psychodynamic approach, how do you nail that down into something that is quantitative?
Arbuckle: Well, I think it depends on, with any treatment, what your goals are. Many patients that come to us for treatment have depression, anxiety, and there are standard rating scales available that you can use to measure those things, and to track them over time.
One of the classes I've taught is measurement based-care, and we literally talk about, how do you integrate this into a weekly treatment? Like, how often would you want to do measurement based care and how would you integrate it into a psychodynamic treatment, and it's not really any different than any other treatment. They fill out the scale at the beginning of the session, you look at the scale, you can a conversation about the scale, and then you can talk about their mother or whatever.
Jessi Gold: That's usually where I go, from scale to mother.
Jessi Gold: Yeah.
Arbuckle: But I think it's actually incredibly valuable to measure outcomes with patients and actually not just your own subjective impression about how a patient's doing. It provides you with more objective data about how a patient is progressing over time through treatment, but it's also incredibly tool for self monitoring for patients. They can see when they start to relapse, what are the first things on the scale that they struggle with?
One of my patients who has bipolar, we know it's sleep, so we're tracking that item really, really closely. One of my patients who has OCD ... I mean, I think the challenge was, for her, was, even though we both would have a subjective impression of how she was doing, the numbers were far more useful for the both of us. She would say, "Oh, ... " We would talk about, should we make a medication change, in terms of her treatment, and she'd say "No, I actually think this is probably my baseline. This is probably as good as I get." We pushed the medication, she got better. So for both of us, it was useful to say, "Oh, no, that wasn't your baseline.
This is your baseline. This is as good as you get, so let's keep this as our marker and our goal in your treatment."
I think no matter what kind of treatment you're doing, you want your patients to improve, and having real data for you and your patient to track that over time is helpful.
Jessi Gold: I know that also, there's ways to measure whether the patient likes the doctor, or feels like they're doing a good job, and you've been trying to integrate that some, as well.
David Carreon: Yeah, and that's challenging to our idea that we're always good doctors to all of our patients.
Arbuckle: Right. Right.
Jessi Gold: Right, or as a trainee, that we're never good doctors to any of our patients.
Arbuckle: Yeah, right. Yeah, so the Working Alliance Inventory is one particular tool where you can track how that's going, and I think that's particularly useful for trainees, in terms of ... And that's probably one of the most useful indicators of outcomes, is how good of an alliance, working alliance you have. I think that probably translates into treatment adherence and lots of positive contributions in terms of outcome. So having that kind of feedback early on could be really helpful. Yeah.
Jessi Gold: Also, could kind of kick your ego down a little bit.
Arbuckle: It could.
Jessi Gold: Yeah.
Arbuckle: So a couple of years ago, our residents did a quality improvement project, where they did patient feedback surveys. Patients filled out the surveys anonymously, and then residents got a graphic report back about how their feedback was, relative to their peers. But what was interesting is that some people got feedback from only one patient and some people got feedback from 20 patients, and actually the more positive feedback was usually from people who got feedback from lots of patients. So I think the challenge with that kind of data is, if you have one data point, not to overestimate the value of that data, whether it's positive or negative. For me, the take home point was really that the more data you have, the more accurate of a representation it's going to be.
And as a psychiatrist, I think we also ... you have to learn how to tolerate that every patient is not going to love you and make a connection with you, for all hosts of reasons. Maybe it's complicated, so we're talking about counter-transference, or maybe it's that they haven't come to terms with the illness they have and they're ambivalent about treatment altogether, so I think learning how to work with patients who are ambivalent about treatment is also a very useful skill to develop.
David Carreon: Well, we're coming toward the end of our time, and we like to ask a few rapid fire questions at the end.
David Carreon: And so we will ask you to keep your answers to one to two sentences, and this is very hard for psychiatrists and affiliated people-
David Carreon: ... so if we can try to keep it to two sentences, that'd be spectacular, so ...
David Carreon: First question is, what is something that psychiatry as a field can improve in, or an area that we, as a field, kind of get wrong?
Arbuckle: Wow. One or two sentences, huh?
Jessi Gold: If you want to talk longer, it's okay.
Arbuckle: No, it's okay.
Jessi Gold: Does that mean you have too much to say?
Arbuckle: No, I think that ... I wouldn't say that we get it wrong, I just think there's all these things on the horizon, that's coming down the pike, that we need to be paying attention to, so whether it's neuroscience training and the impact of neuroscience on our field, whether it's thinking about new healthcare delivery models and integrated care, or thinking about resource manager, these are all things we could do better and we need to do better.
Jessi Gold: What's your favorite book?
Arbuckle: Wow. I'm probably not ... I'm not a good person to ask that. You know what it is? It's Better.
Jessi Gold: By Atul Gawande?
Arbuckle: Yes. I love that book.
Jessi Gold: It sort of goes with quality improvement.
Arbuckle: It does. I quote his stuff in my presentations all the time.
Jessi Gold: Yeah.
David Carreon: What's advice you would give to a trainee?
Arbuckle: I think it would be about setting a framework for lifelong learning. I think they think ... you think, "Oh, I've got four years and I've got all this stuff to learn," and it's true, I think your learning during medical school and during residency is really exponential, in terms of all the things you learn, but there are going to be extraordinary advances in the field in your lifetime, and you need to be prepared to adapt to those changes. So I would recommend approaching learning in a way that really embraces a lifelong effort.
Jessi Gold: And who is a person, either living or dead, or fiction, non-fiction, whatever, who you consider a hero? Or someone you look up to?
Arbuckle: Wow. Well, there's a couple of different people that came to mind when you said that. I mean, I look up to my mother as a hero. She was a single mom for much of my childhood, raising four kids, and really struggled financially. I think that she was ... still maintained her compassion, and so I look up to her.
I would say I also really have been so fortunate to have Maria Oquendo as a mentor. She, just so selflessly, has been invested in my career and supporting me in a way that, I think ... She's just an amazing, busy person with all these other things she's doing, and the fact that she always set aside time to mentor me, I think that was incredibly special, so people like that.
David Carreon: You'd mentioned having fun is important. What's something fun that you've done, either as a child, or as an adult?
Jessi Gold: Just one thing.
Arbuckle: Just one fun thing ... Well, I have a seven-year old and an eight-year old, and ... I don't know, just spending time with them is super fun. My seven-year old just learned how to ride a bike a couple of weeks ago and seeing his excitement at figuring it out finally, that was really fun.
David Carreon: Great. Thank you for joining us.
Jessi Gold: Yeah, thank you.
Arbuckle: All right. Thanks. Bye.
Neuroscience Education: Relevant, Stigma Reducing, and Fun to Learn (with Dr. Arbuckle, part 1 of 2)
In the first part of this interview, Dr. Melissa Arbuckle, Vice Chair for Education and Director of Resident Education in the department of psychiatry at Columbia University and the New York Psychiatric Institute, discusses neuroscience education for psychiatrists and the general public. She focuses on an innovative teaching curriculum that she co-developed called the National Neuroscience Curriculum Initiative and the ways in which this curriculum makes neuroscience accessible, clinically relevant, and interesting.
She describes how understanding and teaching neuroscience can actually reduce stigma towards psychiatric illness (eg, addiction) for patients and decrease countertransference in psychiatrists. Additionally, she broadens the scope to discuss active teaching methods and adult learning principles in general. In rejecting lecture as a good teaching method, she also discusses what is so "scary" about teaching and "making" participants interact with each other.
David Carreon: Hey, everybody. This is David Carreon.
Jessi Gold: This is Jessi Gold.
David Carreon: And this is Psyched! Today we have Melissa Arbuckle with us, the Co-director of Resident Education in the Department of Psychiatry at Columbia and the New York State Psychiatric Institute. She went to medical school at the University of Oklahoma and did a residency at Columbia. She served as a New York State Office of Mental Health policy scholar, 2009 to 2012, exploring the implementation of standardized patient assessments and measurement based care in the clinical practice of residents in training. She directs the quality improvement curriculum for the residency training program. Thank you for joining us.
Arbuckle: My pleasure.
Jessi Gold: You have a correction?
Jessi Gold: What is it? It's okay.
Arbuckle: I'm now the Director of Residency Training and I'm the Vice Chair for Education, so, yeah, that hasn't been updated.
Jessi Gold: So a promotion?
Arbuckle: Yes, a promotion.
Jessi Gold: That's always good.
David Carreon: Congratulations.
Arbuckle: Thank you.
Jessi Gold: Congratulations.
David Carreon: So, well, thank you for joining us, and we've got a lot of ... I'm excited to talk to you about a number of things, but particularly the role of neuroscience in the psychiatry curriculum.
David Carreon: What are your thoughts on why that's a good idea or not?
Arbuckle: Well, I think our knowledge, in terms of neuroscience and its relevance to the clinical practice of psychiatry, is increasing daily. The research in neuroscience and psychiatry is really exploding, and if that research is going to reach patients, it's going to require a clinician workforce that understands that work and can speak that kind of language.
David Carreon: So, say more about what are some of the ways that neuroscience can be integrated into a curriculum. I mean, what would that look like?
Arbuckle: In terms of medical training?
David Carreon: Yeah.
Arbuckle: I think that, as part of the National Neuroscience Curriculum Initiative, we've been developing teaching resources, and that started in terms of thinking about how we teach neuroscience in the classroom, and particularly how we make sure that neuroscience for a medical audience feels clinically relevant, that it's taught in a way that capitalizes on adult learning, and that it's experience near to trainees and their role with patients.
When we first started, we were really thinking about how to do that in the classroom, but most of your training is in clinical settings, so more recently we've moved towards developing short videos, in terms of teaching core neuroscience topics, that can be used in clinical settings with both the teacher and the trainee together.
I think we have this model for education where the teacher is supposed to be the expert, teaching something to a student, and for neuroscience, the field is exploding and most clinicians are not neuroscience experts and feel uncomfortable teaching. So we've developed really short educational videos that teachers or faculty and trainees can watch together and learn together. So it's really a different way of teaching.
David Carreon: Yeah, no, I think that's definitely ... The old model, or at least the traditional model of expert trainee is ... that kind of turns it on its head. I mean, are these videos that are available online or what's-
David Carreon: What is the project?
Arbuckle: Yes. In 2014, I joined with Mike Travis and David Ross to develop the National Neuroscience Curriculum Initiative, and in that project we put all of these open resource videos, papers online. Anyone can log in, create a login to access the materials, and the idea was to really disseminate neuroscience education in a way that was accessible and clinically relevant and all of those things.
Jessi Gold: Do you feel like neuroscience has the potential for people that are in psychiatry to feel like it's boring?
Arbuckle: In terms of the way it's currently taught?
Jessi Gold: Yeah.
Arbuckle: Yeah, so I think that's one of the major challenges in teaching neuroscience, is that the way it has been historically taught is, in our traditional models, that the expert will come in and do a lecture, because scientists are used to teaching to a scientific community, and that's usually ... that dissemination is usually a PowerPoint slide set. So they come in with their talk from their latest meeting, ready to engage medical students or residents, and I think they miss the mark a lot of times.
They don't really realize the lack of foundational knowledge that medical trainees have, so they make a lot of assumptions about what clinical trainees know and don't know, and within a few minutes, trainees are often lost and it doesn't feel clinically relevant. It's about their latest rat study and they don't make that effort to say, "This is how this matters to the patient that's going to be in front of you tomorrow." I think that's been a huge challenge and partly why neuroscience in education has not been so great, up until now.
David Carreon: Is this something that ... ? You said these modules are online, is this ... ? Some of our listeners are psychiatrists, but some of them are not. Some of them might be patients or family members. Is this something that you're hoping everybody can use?
Arbuckle: Absolutely. When we first started, we had this idea that we would create different modules for different learners. So we would have some basic stuff that was more for the lay public, we'd have some intermediate stuff that might be for medical students and residents, and then perhaps expert level content. What we found is, really, everyone's kind of at the lay public level, that we don't know anything about neuroscience, and so all of these resources are incredibly accessible to anybody.
One of our modules that I think is particularly great is called Talking Pathways to Patients, and in these sessions a ... in one, it's a trainee, in another it's a faculty member, role play what they would say to a patient. One is about the neuroscience underlying addiction, and the idea is that they're demonstrating what you could say to a patient, but there's no reason why those videos couldn't be directly useful to the patient population that they're targeting.
David Carreon: Now, have you gotten any feedback from non-doctors or non-trainees about the modules? Do you know of anybody who's used these or who's gone through these modules, that's not a medical affiliate?
Arbuckle: So, I don't know ... Our main outcome measure we've been looking so far is just uptake and we don't really know who's using the modules so far, but certainly the people who have been using them have been incredibly enthusiastic. We also have several resources that we've shared over Facebook and when we're getting the highest hits, in terms of the things we disseminate, my suspicion is that it's the lay public that's really doing the uptake, as opposed to faculty and trainees.
I think it's a huge potential target for the work we're doing, and a lot of interest ... I think patients really want to understand what's going on, and to have a medical model that explains addiction in the context of the reward circuit, I think, can really decrease stigma, self stigma, and can be a really powerful treatment tool.
Jessi Gold: It probably does patients a bit of a disservice to really, really dumb it down because we don't understand it ourselves.
Arbuckle: That's right.
Jessi Gold: Yeah.
Jessi Gold: Wow.
David Carreon: With that, the stigma piece, from one perspective they could say, well, the dopamine sort of ... there's too much dopamine, simplistic 30-year old story. How would the neuroscience version of that, or the circuit based model of the past, you know, updating things, how could that reduce stigma even further than what's already been done, say with the more simplistic dopamine model?
Arbuckle: Well, the current session that we have posted online really talks about the neurocircuit and different areas of the brain, and with happens with a heroin addiction. So what is the normal reward circuit, and then what happens and how heroin can hijack that circuit, and how different areas of the brain are upregulated and different control mechanisms are downregulated. I think that it explains why patients can find themselves with a lack of control over something that they feel they should be able to control. I think having that perspective can take away some of the self blame, the guilt that patients experience. It also provides a really robust model for thinking about how we can target each area of that circuit with different treatments, whether it's medication or psychotherapy. I think it's a model that brings together a lot of different treatment modalities in a unifying model.
David Carreon: This is sort of a story that's more compelling, say, then a more simplistic biological version from the past, or a moralizing version from maybe the present.
Arbuckle: Yeah. I think it's also helpful for physicians, in terms of counter-transference, that when you're working with patient populations where there is a lot of relapse, it can be incredibly frustrating, and particularly when it's associated with ineffective behaviors. So for clinicians to reframe what's happening with your patients, that your patient who is, quote, unquote, "drug seeking" isn't in your office to torture you, but there's something going on at a biological basis in their brain, I think it just reframes your own empathy for that person and could be really helpful in that way, as well.
David Carreon: So there's a few ways to approach the counter-transference relationship and I think that, certainly, there's been some evidence to suggest that a neuroscience understanding, or a biological understanding, can sometimes increase stigma, that if you say, "I am this way because of stuff that happened to me in childhood," rather than, "I am this way because I have a brain disorder," there are some studies suggesting that there's even more stigma ...
Arbuckle: Right. I think it's important to keep it balanced so that, you know, neuroscience isn't just about underlying genetics, but epigenetic changes, so it really is ... When we say that neuroscience and biology is a part of that, experience shapes biology, so these are not one or other.
The other thing is that there's been some really interesting research looking at stigma and what shapes stigma, and some of the data suggests that if you pair psychiatric illness with a message of hope that there is treatment available, that that can be incredibly powerful in decreasing stigma. I think that when we start talking about these biological models, one of the things we've done in the sessions we've developed is really talk about how that biological perspective can inform treatment, and so pairing it with this message of hope and there's something we can do about it, and this how this transforms into treatment options for you and how we can frame treatment options within the context of the neuroscience, I think that could be very powerful.
David Carreon: So sort of trying to take the fatalism out of biology.
Arbuckle: Exactly. Exactly. Yeah.
Jessi Gold: I noticed, also, that you've done some work with teaching trainees how to explain drugs and the side effects of medications to patients as well, and I'd assume that this falls into the same realm for you.
Arbuckle: I think the things that they have in common is really thinking about active teaching approaches. I think medical education, in general ... I probably unfairly targeted the neuroscientists, coming in with their slide deck. This is actually what all of our professors do, right. They come in ... for psychopharmacology, let's say, they come in with their slide deck and they're going to run through, "These are the drugs, these are the starting doses, these are the side effects," and I can't imagine a more boring way to spend an hour, than having someone lecture on something I could look up in a book.
So for teaching, in terms of talking to patients about psychopharm, it's really about using active teaching modules. So residents role play talking to each other, one playing the role of the physician, one playing the role of the patient, and saying, literally, what would you say to a patient when you're going to start a certain medication, in terms of informed consent? What do they need to know about the starting doses, the side effects? How do you talk about really scary side effects in a way that's not going to contribute to medication non-compliance? And that just transforms what was previously a passive learning experience into something incredibly active and incredibly applicable to clinical work. I think that's what's in common, is really thinking about different ways of teaching.
David Carreon: Yeah, and I guess that gets into something that goes far beyond psychiatry, but you've mentioned a few times adult learning and ways that we, just as people, as human beings, remember things better. What are some principles that you've come to appreciate from your work in adult education?
Arbuckle: Well, I think that learners have to be actively manipulating information. So being a passive recipient and not doing anything to actively manipulate information ... The data suggests that if you're sitting in an hour-long lecture, you might remember 5 to 10 minutes' worth of content. When we're pressed to teach so many thing in training, we can't afford to have wasted time, so it's really about getting trainees thinking and coming up with solutions themselves. If you can come up with a solution yourself rather than someone telling you the answer, that's more likely to stick. If you can learn something in an experiential way, that's more likely to stick.
For example, in the neuroscience education, one of the modules is on the fear circuit, and prior to a conversation about the fear circuit, and how we understand the fear circuit, everyone watches a short horror film. Once you've had your own fear circuit activated then talking about what just happened in your brain, that's a very different experience than passively having someone lecture to you.
Jessi Gold: And probably more fun.
Arbuckle: Well, that's the thing. I don't know what happened in education, that somewhere between kindergarten and medical education we decided that learning shouldn't be fun. I'm a big fan of learning being fun, so as part of the NNCI we have trainees make brains out of play dough and it's fun. It's really fun.
David Carreon: So let me get this straight, you have people with advanced degrees making play dough brains?
Jessi Gold: I think we did that.
Arbuckle: You did it. I'm sure you did.
David Carreon: Yeah, it was spectacular.
Arbuckle: But, you know, it's funny, because I originally thought ... My anxiety about doing play dough brain and having people make a brain out of play dough was not that they would think it was too hokey and be unwilling to do it, but they just wouldn't know how to do it. When Dave Ross suggested we were going to do this, and we were going to create brains out of play dough, I said, "Well, I wouldn't even know how to start." He said, "No, no. We're going to make a video. We're going to show people how to make a brain out of play dough," and it was not only fun, it was incredibly useful.
Usually, when you're sitting in a grand rounds, you're looking at some two dimensional image and you're trying to orient yourself, "Okay, they're pointing at something. What is that?" And actually, in this exercise, I discovered I'm a kinetic learner. I really learned in this way of manipulating objects in space was really a useful learning tool for me, so ...
Jessi Gold: I think it's interesting, too, you mentioned kindergarten to college, like if you never tried any of these methods of learning, you wouldn't know that you were a kinetic learner, right?
Jessi Gold: But you just kind of go with whatever the people do.
Arbuckle: Yeah, right. Right.
Jessi Gold: Yeah.
David Carreon: So you're saying that most people are not dry, boring-slides-from-a-PowerPoint-deck-that-are-presented-monotone learners?
Arbuckle: That's right. That's right, most people are not. That's probably the least effective way to teach, and yet we do it everywhere.
Here: Part 3 of 3 with Emeran Mayer, MD, PhD on the mind-gut connection. Dr Mayer talks about the role of the gut in psychiatric illnesses and mood-from a history of forced colectomy in psychiatric patients to an inflammatory diet influencing mood. He answers the question: are we happier when we don’t eat sugar or gluten and should we all be gluten-free? Dr. Mayer is a pioneer of medical research into brain-gut interactions and author of The Mind-Gut Connection: How the Hidden Conversation Within Our Bodies Impacts Our Mood, Our Choices, and Our Overall Health.
David Carreon: Let's also talk about nutrition and diet and microbiology of psychiatric conditions. I know there's been some discussion and some work that you've ended up with around depression and probiotics or depression in the microbiome. How good is this evidence, or what is the relationship between something that we would consider a psychiatric illness and the gut?
Emeran Mayer: As you know, some 100, 150 years ago, there were psychiatrists who are actually obsessed with the role of the colon and fermentation and it led to this unfortunate situation that many psychiatric inpatients in hospitals had to forcefully undergo colectomy and many died because ... There was a phase where psychiatry was actually very much interested in the microbes playing a major role in the psychiatric disease. That obviously has completely disappeared. Today, there's something new that's sort of come up, and that's the role of diet in influencing the nervous system. Felice Jacka in Australia has recently published the SMILE Study. She and her colleagues found that in a randomized study, if they compared the outcomes of patients, I think it was with major depressive disorder, who underwent conventional therapy and their regular diet vs with conventional therapy with a Mediterranean-type diet, there was a significant difference. She has written about this topic.
One explanation of that is related to this concept of an inflammatory diet. We know that high fat, high sugar diets change the microbiota in a way that there's a whole series of events. Increased permeability of the gut is the result of that, increased access of micropolysaccharides or other pro-inflammatory molecules, the gut-associated immune system, which then creates a ... It's not full-blown inflammation, like in inflammatory bowel disease, but a low-grade inflammatory state which then often becomes systemic, so you have circulating LPS levels. My opinion, that's most plausible explanation. As you know, neuroinflammation has been so implicated for depression and other psychiatric diseases as well, so it could well be that diet plays a role in exacerbating it. Certainly not diet is the cause of psychiatric disease, but it's a significant modifier.
Jessi Gold: I've heard people say that when they went on sugar-free diets, or when they went on gluten-free diets that their mood improved. Do you think that's true with what you're seeing in research? Is it totally subjective and they just believe in the diet?
Emeran Mayer: There's certainly, with anything diet, a huge psychological dimension. I think there's few things that have such a placebo effect as diet has. The high-sugar phenomenon, I do believe, because we know a lot about this. High sugar, high fat, it's sort of like opiates. It makes you feel better right away. That's why people almost self-medicate when they're stressed out you crave for something like that. In the long-term, it has these detrimental effects and leads to this low-grade inflammatory state. I think when people say that when they switch their diet to a healthy diet that they feel better, I certainly believe that. In terms of the gluten, that's a whole other story.
As a gastroenterologist, I'm obviously fully aware of the seriousness of celiac disease. It does appear now probably also related to the microbes and the early interaction with the immune system that people develop more and more hypersensitivities and even allergies to food items that 20 years ago nobody ... Like the peanuts and wheat ... If you have that condition, if you eliminate any agent, most likely you will feel better as well, but then you have, it's like 40% of the US population now, who thinks gluten is toxic for them. That's really unsubstantiated. There's nothing that's been found, sort of like IBS, you can take biopsies, you don't find any possible pathological or pathophysiological mechanism.
There was an interesting phenomenon. This really started with a book that came out by a person, an author, won't mention the name, that before was really on the candida connections. This was an early phase that people say all your symptoms, including IBS and fibromyalgia and everything was related to candida and it was due to the high sugar. The same group of people that promoted that like some 20 years ago, are now promoting this gluten-free diet. All the things before there was sugar across all these orders, now it's gluten. That single book, called The Grain Brain, I personally think is responsible for most of that worldwide, I like to call it hysteria, really, which is centered in the US, which is interesting. You go to any other part of the world, people love bread, couldn't live without bread. Whenever I go to France, I ask people, "Have you heard of a gluten sensitivity?" They just laugh at you.
Like many things in science, there may be a certain truth to it. Give you this example about the candida connection, so now that we not just measure the microbiomes, as people have started to look at the virome and the fungi, there is now scientific evidence that people have increased levels of certain fungi, including candida. It would be sort of an amazing thing that 25 years after this non-scientific theories came out that we would support this. That could happen with gluten as well. I have a personal opinion, but as a scientist, I like to say nothing is impossible.
Jessi Gold: Yeah, it's crazy to think one person could write a book and then everyone stops eating bread.
Emeran Mayer: Yeah, it's amazing. An amazing phenomenon.
David Carreon: Yeah. We are running low on time, so we'll have a few more rapid-fire questions and if you can answer in one or two sentences max, we'll go through these questions. Before we do, I also wanted to ask you to say a little bit about the book that you just published. What's it about and who should read it?
Emeran Mayer: It's called The Mind-Gut Connection. It's written for the lay public and I would say it's not just for the lay public, it's also the lay public, but also for a lot of professionals who are not microbiome experts and have not been aware of the science that has involved brain-gut connections and brain-gut microbiome connections. It has a lot of different things in it, different topics in it, from neurobiology of gut feelings, emotional regulation, early life events and influence to diet and optimal health, which is the final conclusion. I think everybody should read it. Even for experts in the area, there's parts in it, including patient anecdotes. Interesting thing to me, now a lot of patients come to me that have heard about the book or read the book and they say, "I am so-and-so in your book. I don't have to tell you much about my symptoms. I'm so-and-so in your book." I think it must have resonated a lot with patients.
Jessi Gold: As a psychiatrist, which sort of patient in my clinic should I recommend would read your book? Is it any illness, anything?
Emeran Mayer: I would certainly say patients with depression, anxiety, particularly if they also have experienced GI symptoms. Autism spectrum disorders, those would be the three main that ... There's also a lot of evidence, Parkinson's disease playing a role. I would say you could probably recommend it to every patient.
David Carreon: Good. I think that sounds like a fascinating book and I'm looking forward to reading it myself.
Jessi Gold: Me too.
David Carreon: First rapid-fire question is, in a sentence or two, what does the field of psychiatry and mental health, where is it that we go most wrong? What is the biggest oversight or mistake that we make?
Emeran Mayer: I don't see patients in a psychiatric clinic. I would say to kind of stop at the neck or not go into the body is, in my opinion, a big flaw. I'm sure there's some psychiatrists who do that. I see the same patients from the opposite end. Most of them have anxiety and depression and compulsive disorders, but I start at the body. I always see the symptoms at the body. They're clearly both there, and I think with psychiatrists, that would be an important lesson.
Jessi Gold: What is your favorite book?
Emeran Mayer: My favorite book, I would say The Black Swan by Taleb. Realizing the complexity of the world and the more complexity, the more interconnectedness and the more unpredictable it becomes. I think our brain functions, also discusses in the book, is a prediction machine that tries constantly to make predictions and if that's done in a linear way, they will almost certainly go wrong. In a complex world as today, it's no longer possible to do that.
David Carreon: What advice would you give to a young doctor, a trainee?
Emeran Mayer: I would say listen to your patient. Most things that the patient will tell you can be explained in a holistic model of brain and body. I would say listen to the patient and don't reject things that don't fit your textbook description. Most textbooks will become obsolete in 10, 15 years. What the patients say, I've experienced this in ideas, research, has stayed the same, and now we're finding so many answers.
Jessi Gold: What is your favorite food and what is your favorite food to recommend to patients to feel better?
Emeran Mayer: While writing my book, I've become a big fan of the Mediterranean diet for various reasons. Since then, since I pay a lot more attention now to dietary factors, it seems there's almost universal agreement that a Mediterranean-style diet, it doesn't have to come from Italy or Spain, many traditional Asian diets have the same composition of 75% plant-based foods and small amount of meat, protein. I would recommend, even in psychiatry now I think it's the same that's in the study showing the slowing of Alzheimer's progression, depression seems to be universal truth to that. It's tasty, you don't have to eat strange things or elimination diets. It's a tasty diet and it's probably one of the best documented health benefits of anything.
David Carreon: What is your favorite species of bacteria?
Emeran Mayer: That's a tough one. There's one, one out of several, that's called Akkermansia muciniphila, funny name. The second name, you can hear the recent connections. They are a bacteria that stimulate especially the cells in intestines that put mucin, mucous, and that's a very healthy thing because the thicker the mucous layer is, the more we're protected from a leaky gut and Akkermansia goes up with a high plant-based diet. It's the food that nourishes these organisms.
David Carreon: Excellent.
Jessi Gold: The last question is, is there a person that you would consider a hero, either living or dead or fiction, somebody that you would consider a hero?
Emeran Mayer: In the microbiome field?
Jessi Gold: Or in anything, really.
Emeran Mayer: That's a tough one. I would say, let's limit it to the microbiome field, Martin Blaser from NYU, who has sort of been the main driving force behind revealing the detrimental effect of antibiotic use, inappropriate antibiotic use on microbial diversity. He's written a phenomenal book, Missing Microbes, which I would recommend to anybody because you will change your antibiotic prescribing behavior dramatically once you've read this book.
David Carreon: Excellent. Thank you for joining us on the show.
Jessi Gold: Yeah, thank you.
Emeran Mayer: It was a pleasure.