13.1 What's Wrong with Modern Psychiatry - Interview 1 with Josef Witt-Doerring

[00:00:00] Hi, I'm Dr. Yosef Widurung. I'm joined today by Dr. Ethan Short, a psychiatrist a couple years behind me in You know coming out of training and all of that and he reached out a couple months ago and I guess after seeing my channel and I

[00:00:20] Was really pleasantly surprised to see that we were on the same page about quite a few things I was so excited so that I said hey, you know, we should jump on and do a podcast and talk about the

[00:00:32] state of psychiatric training at the moment as someone who's kind of gone through and Ethan Kindly agreed. So that's what we're going to be talking about today. So Ethan, thank you so much for Coming on and speaking with me

[00:00:45] Disclaimer this podcast is for informational purposes only the information provided in this podcast and related materials are meant only to educate This information is not intended as a substitute for professional medical advice

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[00:01:06] Diagnosis or treatment all listeners should consult with a medical professional Licensed mental health provider or other health care provider if seeking medical advice diagnosis or treatment or put more simply you need help Like this guy call your own doctor Somebody get this guy some help

[00:01:21] Absolutely, it was a big relief to be able to find your podcast and some other podcasts to Just kind of know that I'm not alone in my opinions. I mean, I you know try to scour the work of

[00:01:45] A lot of you know better known psychiatrists that I have a lot of respect for So I knew I wasn't completely alone, but it's nice to find somebody who's also

[00:01:54] Relatively new out of your training. I think you told me you're about is it five six years out something like that Yep, and talking about the same ideas and then you know, we talked for 15 or 20 minutes on the phone that one night and

[00:02:11] Yeah, we were just kind of fanboying back and forth on Different issues that that we kind of aligned on and I think we have a very similar Overall view of psychiatry and recognize a lot of major problems within our field but also

[00:02:30] probably both recognize that you know, the anti psychiatry movement goes a little bit too far and You know under recognizes some of the more biologic problems that we see in psychiatry So yeah pleasure to be on here. And then of course I'll be

[00:02:48] Doing a reciprocal here and featuring you on my podcast as well renegade psych which was started because I had to have some sort of outlet for kind of some of the problems that I saw in the field and that that

[00:03:04] Maybe I'm not you know taken as seriously as a second year out Attending psychiatrists with some of my peers or some of the folks that you know, I'm working with as a young psychiatrist Great. So I think Well, look, you know

[00:03:22] I want to just jump jump right in and kind of throw a massive question at you and and we'll see where we go Go from there. So Ethan tell me what do you think about the state of psychiatry in the US? Today the way it's practiced

[00:03:40] Well, I would say the word abysmal comes to mind I think we are just And I don't think it's just medicine. I don't think it's just psychiatry I think we're living in a society that is being sold and oversold everything I think that has

[00:03:59] filtered its way into the field of medicine in the field of psychiatry in particular because We're kind of shooting at targets that are a little bit hidden We don't have great biologic explanations for our illnesses and That leads to kind of a situation that's ripe for

[00:04:20] Corruption and you know, I think you and I are both aware of so much corrupted research out there Kind of empty promises seems like the same story plays out over and over where you have a drug that gets approved

[00:04:36] It's touted as a hundred percent safe a hundred percent effective and 20 years later when data comes out that it's not as safe or it's not as effective as we originally believed all of a sudden the pharmaceutical company that you know had a exclusivity on that

[00:04:55] Patent for their brand when that runs out 20 25 years later. They don't really care at that point But I think it's really sad that we keep seeing the same type of situation play out over and over and I know you've talked about the

[00:05:11] issue with big tobacco and you know trying to create this illusion of doubt that nicotine or cigarettes are Causative factor in lung cancer. So this is something that's been going on for 50 60 70 Probably, you know more years than that

[00:05:31] So you're touching on the fact that it's you're getting the sense that Medical research is maybe not as forthright and honest as it ought to be and that's kind of leading leading leading the practices straight

[00:05:49] What I want to ask you about is how does this affect the person in the clinic from what you see? You know in training or what you've seen You Colleagues and all of that. How does this?

[00:06:02] Crisis in the confidence of the the evidence basis behind our medicines affect the patients Well, I think you come out of medical school and you know, I think we're all a little bit green to some of this stuff

[00:06:17] You know, we believe that they're that were there to help people To you know that the field is there to help people and I think we're we can be a little bit naive to the the financial interest

[00:06:32] That are kind of existing in the in the background. Well, maybe used to be the background now in the foreground of health care. I think it's tough when You start to see others questioning data and you look at

[00:06:46] Some of the information that they're presenting and there's a lot of factual nature to it and you know we go through medical school as you know, you take all kinds of tests most of which are multiple choice and

[00:07:02] You get in the habit of picking the right answer, right? It's either a B C D or E or a host of other, you know answers And I think that kind of tricks us or it creates this illusion that there is a right answer so often

[00:07:19] What I've found is that there are maybe multiple right answers or multiple shades of right and wrong answers and It's tough to have a lot of what you learned in medical school a lot of what you have answered on these multiple choice tests and

[00:07:37] Have that kind of foundation shook To become more comfortable with a lot of the uncertainty that goes into what we do I mean, I think a prime example of that is a

[00:07:53] Drug like lithium I talk about lithium a lot on my podcast because I think it's probably got evidence of any psychiatric medication yet medical school and into residency I Was really taught to fear it I wasn't taught a whole lot of nuance about dosing

[00:08:16] You know it took a while for me to understand that it's the only real medicine we have outside of you know Clause a Pina a typical antipsychotic that is very difficult to use that reduces the risk of suicidality

[00:08:31] That I remember that in residency and training that being such a point of contention for me That I would ask so many of my attending Psychiatrists about you know, why am I? Medicine like an SSRI that's first line for depression

[00:08:48] But it's got a black box warning in adolescents and young adults for Being a causative factor in suicide Like I mean, I'm not the most you know intellectual person in terms of understanding You know really in-depth pharmacology

[00:09:05] I think that one of my strengths is that I do have some kind of wisdom and overarching concepts and One of those is that you know this these SSRI drugs. They don't know when you turn 18 They don't have some mechanism that knows when you become an adult

[00:09:23] So that you know that was kind of one of the I think major The major thing that I think that I think that I think that I think that I think that I think that

[00:09:31] So that you know, that was kind of one of the I think major issues that really Started to make me question a lot of other things in the field Let's actually start there really I want to When did you start? I guess waking up to some of the

[00:09:49] Some of the problems in psychiatry was this in med school was this during residency? Tell me the personal story that you went through To kind of make these discoveries Well the personal story I think goes way back I think I I Understand a lot more about myself

[00:10:09] In the in the eyes of my field and that kind of My own nature. I think I come from a family That has a pretty significant deal of you know, what I think is the better classification calling it manic depressive illness which

[00:10:28] I think it's so important to conceptualize that way because you didn't ever have to have episodes of mania to be on that spectrum but it guides a lot of uh of treatment and so anyway, i'm i'm kind of giving that background because

[00:10:43] I think that i've always had this sense of Depressive realism and kind of a skeptical nature about everything And it's not that I don't Believe you know everything that i'm told it's that I just want to remain a little bit open-minded um

[00:11:00] I guess I think of things uh internally in terms of like percentages And if i'm 95 sure of something, that's pretty good But if i'm only 95 sure that somebody's not going to Uh attempt suicide That's not good enough. Um, so there's there's kind of nuance there

[00:11:18] But i've always been a little bit skeptical of things. I've always asked a lot of questions been very inquisitive and in residency, uh I think that is met in a couple of different ways

[00:11:32] Um one is kind of you know, sit down and shut up or I was thinking about this this morning I don't know if you follow the nba at all, but um Lebron, uh james has his showtime A series called shut up and dribble

[00:11:46] And I think early in my residency. I started to feel a little bit of that same sentiment Like, you know shut up and do your work shut up and prescribe these meds um Do it based on guidelines

[00:11:59] But at the same time I had a couple of very very crucial influences Uh really positive influences That helped me to establish Um a good bedside manner and most importantly in our field of uh, you know was pushed to critically think about Everything that I was doing

[00:12:19] um my first year I was working in the psych er and university of louisville where I went to medical school and did my psychiatric residency is At the time was one of 10 or 12, uh Places in the country that had a dedicated Psychiatric er

[00:12:37] And i'm sitting there, you know in my First couple of months of residency. I really don't know what i'm doing I've got an upper level on one side and i've got an attending psychiatrist on the other Um and a patient comes in we evaluate the patient

[00:12:52] They leave and we're amongst ourselves talking about you know, what do you want to do and the attending says You know, dr short, what do you want to do? And I said, oh I want to start this medicine. I wish I could remember what it was

[00:13:05] He said well, why do you want to do that? And of course i'm sitting there shaking in my boots and uh, you know I say Uh because it's fda approved for that condition

[00:13:16] And he steps back and he says it's one of the worst reasons that i've ever heard somebody say Is why they want to start a medication? Um, and so that kind of funny story That was kind of an impetus for you know

[00:13:35] Him telling me you don't you can't just trust the fda approval um Got me kind of thinking and being a little bit more skeptical about uh, the field

[00:13:45] I don't I don't know if that really answered your question or not. It was a little bit roundabout. It's it's good. Yeah, and um I guess you know what what do you think he was pulling for really? Uh, you know with his question with this question

[00:13:59] Well, he's a huge critic of um, he was on one of my episodes about lithium actually his name's riff al malik He was just a huge critic of our training system

[00:14:13] Um and the fact that you know, we are taught to memorize these things like I alluded to earlier with the the testing But not taught to necessarily critically think And years later with where i'm at now

[00:14:27] I kind of wonder if that is built into the system, um intentionally You know you you have this entire population of You know really high achievers really competitive people And then you throw them in together

[00:14:44] And they're competing uh to be these high achievers to get the best grades on the test all whilst Accumulating a significant amount of debt Um, and I think it kind of creates this, um culture of Feigned certainty

[00:15:03] You know being a I remember being a medical student on rounds and you get asked a question and You really want to be correct. You want to prove your worth? um

[00:15:14] In hindsight, I think what a lot of uh attendings were looking for was more of that critical thinking skill But I think the whole system kind of filters us into this you need to be certain about what you're doing

[00:15:28] And you need to display that certainty to your patients um in To be completely honest. Those are some of the worst providers In any field that I see that aren't able to keep an open mind about Even things that they were very certain about throughout their training

[00:15:47] Um being presented new information and be able to change their opinion on it Yeah You know you mentioned uh el malik and um I imagine It's quite unusual for someone to to have an attending who may be more critical

[00:16:03] You know about psychiatric medication because you know, I am familiar with his articles on It's tata dysphoria is a concept that he kind of um, you know brought forward which I think is a really interesting one Um And so i'm just curious tell me about rift el malik

[00:16:21] What what is he like because I know he's he's not quite as public as the other people who are out there You know what and um, I I do know he says critical things at least in the in the literature

[00:16:32] But i've always been curious on knowing a little bit more about him as a physician and kind of And you know how he practices and all that tell tell us about um rift Um, so you know Somebody that I think was somewhat split amongst the residents

[00:16:50] Uh, because he did push you. I mean he asked a lot of questions and I think It it was easy to kind of shut down around him But I think I recognized early on that he wasn't trying to be critical of the trainee sitting in front of him

[00:17:07] He's trying to be critical of the system. He's trying to push us to You know really think about what we're doing And appreciate the fact that we're manipulating people's chemistry people's biology In prescribing the drugs that we prescribe

[00:17:22] And sometimes, you know like with his work with tardive dysphoria uh, you know He's putting it out there that we may be causing more harm in some classes of patients than others but On a whole nother note, you know he is

[00:17:40] He does work with industry and he's worked with industry for a long time And he talks about it in a little bit different light uh, you know that

[00:17:50] This has been going on forever and done the right way. It's it can be really useful to have a system where People do work with industry Of course it I would encourage you to listen to our back and forth on it. It's really

[00:18:03] Pretty interesting because he does acknowledge that that these are, you know major problems But I think he also comes from a different time where there wasn't as much ability, you know in the the 70s 80s early 90s to manipulate the research there was a little bit more separation

[00:18:24] And you weren't seeing, you know 10 of 11 or 11 of the last 12 fda commissioners Uh going within a couple of years and working for big pharma So I think he kind of he recognizes it Uh, but he doesn't see it as big as

[00:18:41] As big of an issue as I do Um, we're supposed to go to dinner next month and i'm excited to To hear our discussions on it. Probably my favorite thing about the man is that he's willing to discuss anything He wants to discuss anything

[00:18:58] So tell him that we spoke and ask him if um Ask him if you'll come on my on my show to talk about tartar dysphoria I have there's no doubt in my mind he will

[00:19:08] Um, the other thing about him is he's one of the most driven people that i've ever met I mean he You know, of course, I don't agree with every opinion every clinical decision that he makes Um, and i'm sure he doesn't agree with mine either but

[00:19:28] When you see the way that he interacts with his patients Um how much he cares for each individual and He's the only attending that I worked with That you know, he had a bipolar clinic every um thursday afternoon that starts at one Anybody else with a specialty clinic?

[00:19:48] outpatient Out of there by five maybe 5 30 He's regularly there until seven or seven thirty And yeah, some residents like to you know, bitch and moan about that but At the same time he's there because he gives Time to each patient when they have questions

[00:20:10] He'll hang around. He'll answer them. He'll He'll meet them where they're at uh, so I always had a held a lot of respect for you know that critical thinking aspect and then also just the way that he

[00:20:23] Obviously cares about his patients and you know has this intellectual curiosity about things that um, I think is just Wonderful characteristics for a for a psychiatrist or a physician in general Not to mention he also he also trained under uh, k jamison

[00:20:43] who did a lot of the you know, really crucial work in Eliminating the other kind of positive side of bipolarity or bipolar illness Or that manic depressive illness And I think you know wrote several books about her own experience with bipolar But also about how many poet laureates?

[00:21:07] were Qualified as being on that bipolar spectrum Yeah Sort of interesting how how um how these how these chains go through because I Maybe you would have gotten there anyway

[00:21:22] but I always think it's interesting that you you came across a riff and uh, you know who I know who was very critically minded at least from what i've read of him and uh Of the impact that had on you and well

[00:21:34] Let me ask about your colleagues because something I was interested in during our initial conversation was that you didn't feel so alone can uh You know, which was my experience in residency I felt like I

[00:21:46] You know really was the only one who was having a problem with how psychiatry was being practiced I got the impression that you were in a cohort of uh psychiatrists Who did have an open mind and who were questioning things? Can can you tell me more about?

[00:22:01] Uh about that Um, yes, I will but i'm really curious to hear uh first about kind of your experience with it um You know what what kind of was the light bulb or the the the light bulbs for you in terms of recognizing that?

[00:22:19] There are major problems with um With the field and and with what we're what we're doing Sure. Yeah, so Let me see what's what's my story, um I would say that

[00:22:39] I've been interested in mental health probably because i'm interested in personal development and i've been interested in that for a long time since I was Since I was growing up I don't know why but I mean naturally it

[00:22:52] It it occurred to me that you know, if i'm having problems and things like that I'd look to books maybe it's because my family read a lot, you know, and I um, I even

[00:23:03] I even remember finding like a tony robbins book like in my bookshelf growing up. So i'm like oh self-help This is kind of interesting and My dad read a lot of philosophy, which really is also a kind of self-help mind, you know mindset type of um

[00:23:19] You know a lot of literature is in that in that way and so From a pretty young age. I was interested in that I had like most psychiatrists, you know

[00:23:27] My own my own kind of problems and my own insecurities and my own things that I struggled with then I would turn to books and When I was in medical school, I I remember thinking well, you know, what specialty should I choose?

[00:23:43] Maybe i'll do psychiatry. Uh, you know something about that Would dovetail nicely with my interest in personal development Psychology, you know the world Existentialism kind of all of those things, you know how to live how to live a nice life Healthy life and such psychologically and um

[00:24:04] I mean to my horror I entered residency and there was none of that really and I remember thinking And this is not like something that I had read or an expectation that was told to me by anyone who was more of

[00:24:17] My intuition was like yeah. Sure. We're going to use these meds sometimes Um judiciously and and cautiously for some people But mostly we would be kind of really getting to the root of why people were having problems understanding them pointing them in the right direction in terms of

[00:24:35] Uh, you know social services psychologists things like that. Anyway, um, you know No surprise to anyone listening right now or anyone that's interacted with american health care or much health care in the western world That's not what it is. You know, it's um

[00:24:50] In many ways, it's a conveyor belt. Um and um because it's I think because it's expedient, uh, you know, we end up relying on medications and also because um I think there's a strong desire to kind of fit in with the group and uh to sort of um

[00:25:13] You know work efficiently You end up going um, let me try and connect the dots here a little bit better you know when when you're training you've got to be quick and when you're

[00:25:25] Quick with uh, you know seeing your patients and things like that you you need you end up trusting people and you know trust what your attendings do and you kind of fall back on them and

[00:25:35] Um in the way you practice and sometimes it's like oh, yeah, you know five out of nine symptoms subscribe this med Uh and and go for it and that's just kind of how we efficiently move through things we go

[00:25:46] Okay. Well, I trust this doctor he does it this way and so I will do it as well And that's what allows me to kind of get through things but Slowly over time, you know because I had that little itch inside where I was like this

[00:26:01] This really doesn't seem right. I started looking for answers and You know eventually the more I looked the more I found out that actually you know Much of the way that we practice has been um, you know doesn't really make a lot of sense. In fact, we are

[00:26:18] Constantly being kind of pushed a narrative that you know, the drugs are safer than they are Less risky than they are they can be prescribed very easily And that's really just not what the evidence shows and I know, you know

[00:26:31] My backstory was at the fba in industry for a while studying these drugs So I know what the evidence basis is for using them. I know how long they study them and you know What the maintenance studies look like and essentially was just bullshit

[00:26:44] so the more I sort of looked at it the more I realized, you know, we ended up in a place where we had You know a whole workforce of doctors who? kind of

[00:26:54] You know want to fit in with one another, you know, they've been educated by essentially marketing masquerade masquerading as science, um and um And uh, you just had a real problem with that

[00:27:07] I mean another story is like I took xanax for about five months as well myself, you know Just prm, you know one every now and then but you know The way that story ends is you know

[00:27:19] Eventually one becomes two a week then three a week four a week and five and then you take it every single day It fucked me up. Um, and it works great for the six or eight weeks that they study it though, right?

[00:27:30] Yeah, it works great for the six to eight weeks. They study it But then I started having obsessive thoughts where my mind would just carousel, you know The most shameful embarrassing things that had ever happened in my life, you know before my eyes and um

[00:27:43] And I can talk about caffeine and nicotine this as well because that also plays a role in my story But I want to kind of keep it to the point But you know, I do have some personal experience

[00:27:53] with the medications but honestly where everything came from for me was just like I know how to I can I can smell like a fraud I can spell a lie and it gets under my skin and it gets itchy and

[00:28:04] I'll pick it until it comes out and I don't know why that was me, but it just was you know, it just There was something wrong about what was what was going on

[00:28:14] Yeah, I think you and I share that that it like it really does get under my skin And sometimes I wish it didn't sometimes I know You've talked uh kind of semi recently to adam urato and

[00:28:27] I just talked to him and have his uh, you know series coming out relatively soon I wish I could be more like him on a on a personal, you know

[00:28:37] You know his jovial kind of upbeat nature even though he's fighting a very similar fight to the one that we're fighting But I was curious. I wanted to ask you because of my own experience with you know shedding the certainty and opening my eyes to

[00:28:55] Uh all the things that I used to be certain about and now I have questions about you know, some of the most basic things that I learned That was pretty hard for me personally It It it was really disheartening

[00:29:14] Uh to to see the field as a whole and kind of wonder is there anything I can do um, and I and I find myself getting very frustrated to go back to your uh question earlier about With others and trying to educate them in so many different ways

[00:29:32] uh, and maybe it's because you know, i'm a Young physician, uh young psychiatrist and you know talking to even you know mid-level practitioners that have been doing it for 20 years Maybe they're past that window of embracing the uncertainty and kind of questioning their own belief systems But

[00:29:55] That aspect of kind of my personal journey has been pretty tough to navigate and has had Uh, certainly some ups and downs uh in terms of Yeah, just trying to educate people and then feeling a lot of the time like people just don't care

[00:30:11] You know, they just want to live in their little bubble go about their day Do their job make their money Spend time with their family all you know things that are all very important, but

[00:30:24] I guess for me at the end of the day at the end of my life, um Even if i'm not able to really move the needle uh I just it's something that's so important to me to try to do but Damn, it is so damn frustrating sometimes

[00:30:43] Yeah, it is. Yeah. Yeah. And so How how do you take that personally like how do you manage that? Uh frustration? No, I think um I'm just going to shoot from the hip and just give you some some general Thoughts that i've had about people

[00:31:02] Uh, you know what what motivates the way people do things? I think some people are really motivated by you know wanting to understand things And it's like they want to know it inside and out And i'm not trying to say this to be

[00:31:16] Kind of dismissive or even rude but that I don't actually think that's the motivation That's a primary motivation for a lot of people although people do expect that from health care providers

[00:31:28] What I do see is I think the prime uh, big motivation for a lot of people could sometimes be to fit in Can be to do a good job and you know

[00:31:36] And they may not think about how everything's going on. They may be thinking more about efficiency and speed and practicing in alignment with their peers and and you know with their supervisors and Being accepted in the group and things like that

[00:31:49] I think that there can be a very strong social pressure that Leads to a group thinking that makes sense, you know from a biological perspective You know, we we want to stay in the herd in many respects because once you leave the herd

[00:32:04] You know people say oh well, you know, they criticize, you know now they're criticizing us. You're going to stick out You're going to be practicing outside of things and I really don't think people like that um, and so you know to

[00:32:19] To be more comfortable with practicing in a different way and to have these these beliefs I mean there's risks associated with that which a lot of people just like no

[00:32:28] No, thank you. You know, i've you know, i've got a nice life. I have a nice income and respected by my colleagues You know, i've got the hang of things at work

[00:32:36] I'm probably just going to hang on to that because I don't really care enough to get you know That's not that's not a priority for me and that's hey, that's just the way the cookie crumbles like that's Just the way some people are so I um

[00:32:54] Anyway, so the way the way I dealt with it. Ethan was essentially I I had to leave, you know I you know, I had to start a practice

[00:33:02] I had to hang up my shingle as someone that's just doing deep prescribing and I think it'll be interesting to you know Maybe to talk a little bit later on about this, but I probably

[00:33:12] I don't think I would be prescribing drugs like lithium any more than short-term even things like Closaril and I am aware of the suicide benefit, but I I do In many ways my journey is one where I think I've you know, the deeper i've gone in this hole

[00:33:27] I think the more I actually I have become someone where i'm just like no I'm not going to start any meds unless it's for this really short period of time You know, we'll do it for like a couple months. We'll get you through it

[00:33:39] Unless there's some exceptional circumstance. I don't think I ever put someone on long-term psychiatric meds. That's That's kind of where I ended up landing and so that sort of influenced my practice where i'm like hey

[00:33:50] If you want to come and work with me, you have to drink my pool aid You know, you have to be someone that's like I'm looking for something else. I'm looking to come off meds or at least i'm looking to minimize my medication burden to the extent possible

[00:34:03] And now I only work with people who are who share that same Same same belief because yeah, it's it's frustrating to work in a system Where people are working against your mission? And so I I constantly just moved into that direction and now i'm sort of fighting to

[00:34:21] To have a successful practice in that area and it's a fight but it's been really rewarding Yeah, I think one thing that I kind of mentioned Yeah, I think one thing that I kind of mentioned or left out didn't mention

[00:34:36] Is that during my residency? I was also exposed to some of stephen hay's work University of nevada the the act therapy Kind of a godfather if you will but I was much more interested in the underlying theory about act relational frame theory and kind of

[00:34:56] How the the different parts of our brain understand? language and some of his Talks really you know set a set a light bulb off for me Understanding what my internal experience was And using that, you know so much more heavily moving forward. I remember, you know

[00:35:20] I don't know about your experience, but we had a weekly therapy clinic and we were just kind of thrown in You know with the wolves, hey go do therapy and it's like well how what do I do? um without a whole lot of specific direction

[00:35:35] And I kind of really struggled and stumbled through those uh half days a week for Really probably a solid 18 months in my residency And then I came across Uh rft and act and I remember listening to stephen hay's talk and I was sitting there my skeptical nature for 15

[00:35:55] minutes was What the hell is this guy talking about? He's not really making any sense and he's jumping all over the place and then he he uh, you know, I had what what he calls the click of uh understanding and I think that really has

[00:36:13] Shaded my understanding of how people's minds work in it in general You know the fact that we've we've got this voice that we don't have control over when it inserts Our itself into our stream of consciousness

[00:36:27] Um, and that voice also presents language in this very black and white way Uh very all or nothing way almost like you know, we talk about the the symptoms of uh borderline personality

[00:36:41] And almost as if the mind, you know, it tries to create this order in our lives To to make us I guess feel better really And you know, it's either this all or nothing thing

[00:36:55] It's you know, I always think about it like the mind understands the word happy the mind understands the word sad But it takes that consciousness that that kind of frontal lobe function and for us humans to understand the huge gray area between happy and sad

[00:37:11] Um in act, you know, it's called fusion If the conscious me that I hear and now, you know The the part of me that is sitting here talking to you and vice versa If that part of me is fused with the information coming from my mind

[00:37:26] Kind of that that supercomputer that information processor in a world that we live in a Massive amounts of information on a you know daily basis um See that play out in Our society in politics

[00:37:46] You know right wing left wing are you on for this idea or you off of this idea When I really feel like we all need to have much more of an appreciation for so much of that middle ground

[00:37:59] And I think honestly it kind of plays out with um lithium in general, you know, I use a lot of lithium but Most of the time I use it at very low doses A lot of supplement doses and a lot of the lowest prescription dose because

[00:38:18] That really has I mean people don't realize we're already taken in lithium through our environment. It's a trace element And kind of wonder if we've maybe restricted the the intake of lithium by trying to purify all of our food and water

[00:38:36] But it's that same idea and lithium is a great example because I've worked with people who really don't understand and they see the word lithium And I think it sends alarm bells off in their brain that this is this dangerous drug You know, you're gonna hurt the patient

[00:38:54] and it's again, I think there's a lot of incentive by industry with that drug to create that kind of culture of fear because I prescribe my patients 90 days of low-dose lithium Without insurance it's about eight dollars There's a lot of incentive for Us to not prescribe it

[00:39:15] And again, it's got data going back for you know, a long time. But anyway, I just use that example to Illuminate I guess some of the ways that I think I see society thinking and not appreciating this uh the the

[00:39:33] All the things that are stored in our minds And when relevant or kind of projected to our consciousness Uh, I just don't think there's enough of an appreciation for that and how that aspect plays into what we're talking about

[00:39:48] That desire for order and certainty because it makes us feel better If I know where I stand I at least have somewhere to stand first if i'm just kind of floating around in the milieu of uncertainty and You know not fully understanding things

[00:40:07] Difficult it takes kind of dedicated mental work to to become okay with that Yeah Yeah, I like I like what you said and I think it's um You know i've had i've had similar

[00:40:20] Well, I guess my overarching position is the more i've gone through this. I started to realize actually that You know as as great as the brain is, you know, it is it is really a

[00:40:31] Um a very economic organ, you know, and it does have its weaknesses, right? So You know the brain is trying to develop rules about the world and people and such, you know that it's learned over time

[00:40:44] And then it kind of wants to execute those rules without questioning them because you've got to be efficient I mean, you can't be using all your computational power to rethink things every single time you wouldn't you would you'd be less functional

[00:40:58] And and you know one of the interesting things about um Being in the business of helping other people Navigate life, which is what we do is that We get to see this the software

[00:41:10] You know the the ideas that have been downloaded into them from their life experiences how it helps them and how it harms them You know Probably the one people are really familiar with this trauma, you know how you know, you grow up in a family of

[00:41:24] You know childhood sexual abuse things like that and it absolutely destroys your ability to have um relationships in some cases because you know if you if you learn the rule that Even those people who are meant to care for you the most

[00:41:39] Can all of a sudden turn around and do horrendous things to you. You're always going to have this feeling of distrust That will hold you back And and that rule can be extrapolated too right it doesn't just have to be the primary abuser

[00:41:55] Um, it's the mind the mind can take that and it can become any authority figure um And so you can find yourself reacting to things later in life that they don't really make total sense to you

[00:42:10] And you may not draw that connection between a trauma with one individual and then a later kind of re-experiencing of that trauma or reacting like you're in a traumatic situation Even though consciously you may realize this is a totally different situation

[00:42:26] but the way that you feel kind of that mind that emotional center that You know, uh, invalational thought center Uh, they're You're not as in tune with that you don't understand that it all kind of comes

[00:42:42] That's it. That's that gut feeling, you know something feels wrong, you know, and that's where it's coming from right? Um the prior trauma and Maybe you know if someone's listening to this in your audience who may not be familiar with trauma maybe another more

[00:42:59] Accessible example of this which some people may be more familiar with is is how your family deals with money. So i'm I'm more miserly with money. It's something that i've had to learn You know Develop ideas about it, you know It's I think about my dad

[00:43:18] He's austrian grew up in the wake of the second world war, you know in in austria inside that loss, right? And what it was like for him and his mother to survive, you know And how penny pinching and how careful they had to be with food

[00:43:33] when my mom Comes from the you know fairly I would say, you know, uh, you know working-class backgrounds as well and so The way I look at money is completely different from my wife who grew up pretty well to do and um

[00:43:49] You know, I have a lot of these ideas of you know, we shouldn't spend this we shouldn't spend on that When obviously it makes sense in some situations where it's like why would you save money here when

[00:44:01] You know if you would just spend this money you would have more time. It would be better You know, there's more enjoyment and so I mean there can also be other things that you you learn and you don't question and they kind of just sit

[00:44:12] With you and they make up your programming and that and I think that's happening with all things in life You know that that we are learning these patterns

[00:44:21] For efficiency and we don't question them and a lot of times we don't actually see how they fail us because they feel so right to us Yeah, it's interesting. You and I do have uh, some shared experiences I I grew up in a family that did have money

[00:44:40] but my Father who's a physician a urologist? came from very little His his dad died when he was six years old and so he was left to his mom to carry multiple jobs and raise the four children

[00:44:57] And he was you know kind of the the only male in the family was kind of thrust into this role at an early age So I remember growing up. I didn't understand uh Why I couldn't go on certain field trips knowing that we had the money but

[00:45:14] in hindsight I understand that you know, it's being taught very very valuable lessons About money, you know that it It isn't just something that everybody has and I look at that a lot differently now than I did back then um, you know

[00:45:33] Stephen Hayes has a i'm sure this isn't I don't know if this is his work or not, but he talks about an experiment where they have two groups of uh grown adults And they Go into separate but identical rooms with a game

[00:45:50] And group one gets a very basic rule about the game And group two gets nothing and so in that, you know first room with the game Group one is able to figure it out

[00:46:03] It still takes time but they're able to figure it out a lot faster than group two group two eventually through trial and error Uh figures out this this game, you know unspecified game but then Of course every cool experiment like this. There's a part two that is more

[00:46:22] Illuminating than part one they go into a second room and there's a different game And it's unique from the first game and they tell the participants this Uh, but when they go into that second room group two who got no rules in advance

[00:46:39] Uh, they're able to through trial and error figure out this second game a lot faster With the idea being that group one was still stuck with that rule Uh ingrained in their minds for that first game

[00:46:53] And as much as they didn't want to they're trying to apply the rules of the first game to the second game and I think this is something that We can never fully understand all of the rules That have been paved in our minds

[00:47:10] Our job is just to continue to try and our job professionally is I think the biggest job we have is to try to help our patients on that journey of Understanding themselves and understanding the influences That go into their decisions outside of their conscious awareness

[00:47:29] You know, it's so interesting because I I think that I think that It was kind of an unexpected gift in many ways of of doing um Ending up in psychiatry Because I I mean you don't

[00:47:48] I feel like i've learned so much by working with people and just being exposed to all the different ways People think about things and how different I am. Oh my god from from other people's and you know how I tick And I and you know, and I think

[00:48:04] Probably the best therapists and all of this stuff. I mean it's really hard to learn this stuff I mean, I think the only way you learn it is by talking to a whole lot of people who are really different from yourself and

[00:48:15] seeing how they respond to things what their gut feelings are how it serves them in different situations and It's it's a shame that we we don't really talk about that as a psychiatrist anymore

[00:48:27] You know, we're so stuck on the meds but um, I mean that really I think is Probably one of the best things about being in this career. You know, it's just learning that part of it Yeah Yeah, absolutely um, I got one thing to add that I

[00:48:45] Kind of slipped my mind talking about um I guess what what got me questioning things happened really? uh in medical school and in learning about the state of addiction in the united states and the state of addiction and I mean Kentucky and and the areas surrounding Appalachia are

[00:49:08] Just absolutely rampant And these are things that I saw growing up here in Louisville but in going to medical school and seeing the numbers of overdoses and the numbers of um HIV infections hepatitis c Endocarditis or heart infection

[00:49:25] um all the different complications of it and kind of you know, the the curtain being lifted on Purdue pharma and what they did with oxycontin. I think that was really the impetus for me to Really start to question everything because

[00:49:46] That's something that has been you know, very revelatory and we've revealed a lot of information about Um kind of what they were doing in the background trying to say that an opiate which opium has been around for

[00:50:01] centuries and centuries was somehow not addictive and being able to sell that to doctors and the american public And the passion part for me is I graduated high school in 2007 um I went to a good high school We had uh, it was all boys high school we had

[00:50:25] to 350 uh graduating in my class There's a dozen people from my class that are dead now from overdoses um You know or if not dead they're they've had their lives derailed by opiate addiction by different drug addictions so that really hits me and like I I take a

[00:50:50] personal offense to that Um because there's grew up with that aren't here anymore And it's not just purdu pharma. I mean this is This is something that you know the more that i've investigated with my podcast and doing the research for each series and

[00:51:10] Getting different guests with credentials that are Way more impressive than mine That have decades of experience working in the field uh That that was a huge impetus for me doing uh, you know going into psychiatry and wanting to work in addiction

[00:51:29] But then just seeing how the the whole field of addiction What we're doing isn't working yet. There doesn't seem to be um A whole lot of interest in seeking out different ways of doing it

[00:51:45] So anyway, that's something I just wanted to add because it really is a major Influence and a personal motivation of mine That that drives me Yeah, so I did have a question for you. Um sure so obviously you're probably not working with uh

[00:52:07] a lot of these types of conditions in uh outpatient but kind of where do you draw the the line on where Maybe the anti-psychiatry movement goes too far and i'll give you a little bit of uh, you know My kind of personal thoughts or background on it

[00:52:26] um, I hear people talking about Uh things from the anti-psychiatry movement. I think uh, you know, peter bregan is one that I think goes a little too far Um and doesn't appreciate some of the nuance

[00:52:40] I'm hoping to have a uh, I don't know if you're familiar with joe pierre at ucsf I think he's got a good kind of middle ground. Yeah, i'm trying to get him to come on I'm interested to hear what he has to say i've um

[00:52:52] I've listened to him on the carlott psychiatry report a little bit and looked at some of his uh posts on social media And I think he does a good job of kind of Writing a line closer to the middle between uh, you know

[00:53:08] What what you could call the complete pro psychiatry movement that you know follows every guideline and prescribes everything that they're Supposed to prescribe Versus the anti-psychiatry movement and I was curious to hear You know, where do you fall on conditions that I would say are very biologic? um

[00:53:29] Prime example being something like catatonia Sure. Yeah, let me give you give you my my my download On it is um, you know, I definitely believe there's genetic loading for certain conditions and you know that genetic genetic loading interacts with the environment and

[00:53:51] um, and then it causes a symptoms whether that's legit mania melancholic depression schizophrenia um, you know psychosis and uh catatonia and things like that, so The place where I get worried is I actually don't believe that medications help people long term

[00:54:13] And that's something that's taken me a while to get to and so why do I believe that well? It's because I think there's problems with tolerance I think

[00:54:25] You know due to homeostasis that eventually over time our bodies will push against those those forces and will adapt to them um And so that's one thing i'm worried about is that you know

[00:54:37] Most of the drug effect is probably going to be at the start but then long term it's Probably not going to be helpful And then I I worry about risks, you know risks, you know long-term risks of the medications whether it's

[00:54:53] Weight gain metabolic side effects, you know liver liver problems Things like that. So that's like another piece of it and so I guess Where I come to is that you know the long-term use of medications for me is always going to be

[00:55:09] First and foremost prm because you know, I've if someone has a bipolar episode or a mania or something like that um I guess where i'm at is um I don't know if I really believe that the meds

[00:55:25] improve their um their disease trajectory, you know for me it's it's more of a Okay, you're manic at the moment. Do you want to burn through this mania?

[00:55:36] Without meds or do you want to take something to get you through it at which time I would bring them off And then I suppose in some exceptional circumstances if someone kept on having problems, then maybe I would consider long-term use but it would be

[00:55:56] You know, I probably wouldn't feel very good about that and that's the same with psychosis, uh, you know, I would say that Okay, so what you know someone has schizophrenia psychotic illness their cognitive problems and also and also psychosis well

[00:56:12] I I see a lot of chronicity with the antipsychotics. I think they work in the short term. They can be blunting but they also have huge hugely negative effects on other aspects I think they make people depressed. I think they

[00:56:28] Zap any kind of motivation and and such and sure for some people they may be okay But in general, I actually think that they're quite negative and this is based on my own experience So it may not apply to you. This is what i've seen and

[00:56:43] And so my my advice to them would be you know use the meds as needed if you really need to I mean always always the ideal outcome for me would be learn to live with the the

[00:56:54] Voices um learn to live with the paranoia to the extent you can and and rely on the meds as little as possible I'm also not naive. I know that You know right now I work in a place where

[00:57:08] People are coming to me for them, but in most community settings You know, we've got a lot of psychotic illness and and their lives are pretty terrible You know, they're using drugs that have support their lives are incredibly stressful

[00:57:20] And they live in these states of psychosis and in them maybe for them, you know taking the drug long term it is it's Kind of helps but still in the back of my mind

[00:57:31] I'm just it's probably going to make this condition worse in the long run because they're going to become dependent on it They're going to need higher doses and then eventually they'll still be psychotic, but just massively on the drug and so ideally

[00:57:46] We have the social media and we have the social media and we have the social media We have the social supports to help these people in a way where they don't they don't they don't need to rely on the meds so heavily uh catatonia

[00:57:59] That's another one of those things. I think if someone has catatonia or a short course of Ativan or even ect sometimes is reasonable but So I think i'm totally on board with catatonia I don't even think we we really ought to be using any long-term medications for catatonia

[00:58:17] As I think it would introduce chronicity. Yeah, yeah, yo, so you you bring up a point that has always kind of um Nod away in the back of my mind and it is the homeostatic mechanisms that we naturally have That innately exist and

[00:58:38] We don't talk about that nearly enough Um tardive dysphoria is one example of you know changing your chemistry over time with long-term use of a Medication but i've always questioned even things, you know that are

[00:58:52] Supposedly extremely effective with uh, you know what we call now treatment resistant depression things like old drugs. Mao eyes I really do question what is the role of Using these long term and that that other lever that you're you know

[00:59:11] Innately have that is trying to restore you to whatever balance, you know your brain and your body think you're supposed to have Um that is not talked about long or nearly enough And similar to the fact that our drugs are not studied

[00:59:27] Intensively in a long term enough fashion probably because there's nobody that's willing to fund it more than anything But you know, I would say that You and I probably aren't too far apart on

[00:59:40] Again, it's not like uh this all or nothing thing. You're not that hundred percent. You're not that zero percent i'd say We're definitely in line with The fact that we recognize that everything in our field is over diagnosed everything is Uh over prescribed

[01:00:00] We rely too much on medication rely too much on This biologic component of mental illness But I do I think for me there's probably a few more conditions that Would respond to a little bit more prolonged treatment now. I agree with you the anti-psychotics. Uh, dr

[01:00:22] al malik actually Gave me some really good bits of education on this, you know, he said if you're a manic patient you're hospitalized and you know, I tell you I can give you this drug lithium that

[01:00:35] Uh will you know break your mania in a couple of weeks where I can give you an anti-psychotic that'll break it in a few days You know which would you prefer? and so he also educated me on the fact that um the

[01:00:49] State of illness that people are in with manic depressive illness bipolar disorder where their mood is at Should dictate ideally Uh how you use the medication you use for example higher doses of lithium when somebody's ramping up into a manic state

[01:01:08] And then because their brain chemistry changes when they return to a more normal state You drop that back down and you typically can get away with a little bit lower doses With the depressive pole of uh bipolar um, but

[01:01:25] You're absolutely right on that point of what are we doing with this chronic manipulation? If i'm giving you a for example that maoi that is increasing the amount of dopamine Uh norepinephrine serotonin available to your brain

[01:01:43] Well, there's got to be a feedback loop that says hey, this is too much Or when you come off of that, you're almost certainly going to be in a very depleted state Um, not to mention the other, you know risks of that and

[01:01:57] We could have a parallel with uh serotonergic drugs like the ssris So yeah, I mean I I hear you I think Some things like ect I think that there are good indications and it's a treatment that

[01:02:16] I've seen people broken out of catatonia that were not responsive to advan or other benzos That was one of the most incredible, you know aspects of my training was seeing multiple, you know depressed um with catatonia or bipolar catatonia patients

[01:02:35] A couple of ect treatments and somebody who wasn't eating drinking moving um, you know is is at risk for Severe muscle breakdown because you know, essentially they're in a state of contraction all throughout their body Uh, I think there are roles for these things but again

[01:02:57] maybe let me jump in there because I want to um I I you know, I don't want to come across as um Not Not getting it because uh, and I don't know I don't want people to feel bad if they're on the meds because the reality is that

[01:03:19] sometimes they're the lesser evil, you know and And and here are some things i'm thinking about think about autism, you know Aggressive autism which is a really difficult condition to treat It's it's all well and good for someone like me to say

[01:03:34] Oh, you know the meds are going to make him worse long long term and all of this and You know, you really want to stay away But what what like what else are you going to do? I mean unless you have substantial resources and you can afford

[01:03:48] To have someone there, you know watch and redirect your child which honestly 90 percent of people don't Then the meds are what oh what you're going to do and that ends up being the practical thing the realistic thing Same with dementia with behavioral problems as well

[01:04:04] You know if a little bit of serapool is going to keep your dad at home with you with people that he loves A little bit longer at the end of his life. He can't afford to have someone watch him and redirect him the whole time

[01:04:15] That that makes sense as well, you know if that's going to be How how are you going to reason that but as long as you know what you're getting into and you're making these These decisions in a thoughtful way. I think

[01:04:27] There definitely are places to use it. I just don't think it should for many cases should ever be What someone you know what? the ideal situation As for ect

[01:04:41] Ect i've seen people snap out of it as well and people feel really strongly about ect, especially in the drug-harmed groups and such I've seen ect work. But the the one problem that I have with ect

[01:04:56] Is usually it comes after multiple drug mistakes like you know, you've had someone in an ssri They've got type of dysphoria, you know, you kind of cycle them through a whole bunch of different drugs. It makes them worse. They're fully

[01:05:09] You know, they're depressed they feel terrible they're on high dose antipsychotics and antidepressants And then at that point it's like up treatment resistant depression give them the ect Where it's like well you broke their brain with the drugs first and how about

[01:05:24] Helping this person come off the drugs first watching them see if they're going to recover before you just stack another Intervention on top of it That's the problem that I have with ect. I think it's just You know the the last tool in the toolbox of

[01:05:39] Of just throwing Ineffective meds at people that's that's how I kind of see it But you know if someone just comes in severe depressive episode not on meds Although i've never really seen them before and they get ect

[01:05:51] And then kind of snaps them out of it. Then I think that's right, you know same with catatonia. I think Ect for catatonia really does work

[01:05:59] Um, but I think the way we use it as this treatment of last resort in many times after we've already harmed people with the drugs Again, i'm shooting from the hip here and no no words just kind of sharing things Somebody get this guy some help

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