14.1 Interview with Dr. Nassir Ghaemi, MD, MPH

[00:00:00] Disclaimer, this podcast is for informational purposes only. The information provided in this podcast and related materials are only to educate. This information is not intended as a substitute for professional medical advice while I am a medical doctor and me of my guess have extensive medical training and experience nothing stated in this podcast norm materials related to this podcast including recommended websites, texts, graphics images or any other materials should be treated as a substitute for professional medical or psychological advice diagnosis or treatment all listeners should consult with a medical professional license mental health provider or other healthcare provider if seeking medical advice diagnosis or treatment.

[00:00:27] Alright, so today I have on the podcast an absolute pillar of academic psychiatry a psychiatrist who is in the running in my opinion as the goat of modern psychiatry Dr. Nassir Ghaemi

[00:00:43] Somebody get this guy some help. He is one of if not the top world expert on mood disorders such as bipolar disorder and major depressive disorder

[00:01:03] is an expert on the use of lithium with 30 plus years of clinical experience and has been a long standing in vocal critic of the invalidity and unscientific diagnostics, statistical manual or DSM.

[00:01:16] Use by mental health providers to diagnose mental illness. He got a BA from George Mason University then later a medical degree from the medical college of Virginia completed his psychiatric residency in 1994 at Harvard Medical School in the McLean Hospital Residency program followed by a one year fellowship and mood disorders at Massachusetts general hospital.

[00:01:40] Later when on to get a master's of philosophy from Tufts University and a master's of public health or MPH from Harvard. He is published more than 300 scientific articles or book chapters with an H index in the high 70s and 15,000 plus citations.

[00:01:58] He served on the editorial boards of numerous journals as author of several books including a first rate madness about how world leaders with mood disorders are actually better at leading their nations during times of crisis and chaos and is available free on Spotify found out in its entirety.

[00:02:18] Also other books on the philosophy and history of psychiatry including the rise and fall of the biosycososcial model, reconciling art and science and psychiatry.

[00:02:29] My personal favorite concepts of psychiatry, a pluralistic approach to the mind and mental illness as well as several clinical textbooks including mood disorders, a practical guide and a clinicians guide to statistics and epidemiology and mental health measuring truth and uncertainty.

[00:02:48] He currently directs the mood disorder program in the psychopharmacology consultation clinic and serves as a professor of psychiatry. All at Tufts University and Medical Center in Boston and is a clinical psychiatry lecturer at Harvard Medical School.

[00:03:04] Dr. Gami has been featured on CNN, MSNBC Fox in the New York Times and other major media outlets. He speaks regularly at conferences, gives lectures and also has a podcast with an easy to remember name, the Gami Psychiatry podcast which I highly recommend for providers and curious patients.

[00:03:26] And as I'm reading this, also realize why you haven't released enough episodes lately. At this point, I feel like the guy announcing Tiger Woods before he tees off on the first hole at a major as I didn't even touch on so many of your professional accomplishments and accolades.

[00:03:44] And, you know, Dr. Gami seriously on a personal note, you've been incredibly influential on the way that I as well as several of my residency cohorts practice psychiatry, helping us to understand the importance of the manic depressive illness concept as well as appreciating the difference between disease modifying and symptom modifying treatments.

[00:04:09] This is the first time I've ever spoke with this year directly and if you can't tell, I'm pretty excited to have you on as my guests today. So without further ado, Dr. Gami, how are you doing? I'm doing okay. Thank you. I appreciate the chat with you.

[00:04:31] Absolutely. Absolutely. I've got a warning. I've got some lengthy questions stems in order to demonstrate things that I already know. Or things that I already think I know. But I'll keep the first question pretty straightforward.

[00:04:44] Tell us just a little bit more about your professional journey and what you're most passionate about at this stage of your career. Well, let's see, the professional journey to try to be brief about it.

[00:05:02] I think I went into psychiatry in medical school, keeping an open mind about other specialties but always feeling in the back of it, my mind that I probably was going to go into either neurology or psychiatry because I was interested in the brain and behavior.

[00:05:20] Equally, really, part of the reason that I wanted to psychiatry rather than neurology was it was some just a brain that I was interested in. What makes people tick?

[00:05:31] I was lucky to be able to get into the clean hospitals, psychiatry residency program and the Harvard Symphony in the early 90s, which is truly an incredible program. Much better than it is now, by the way.

[00:05:46] And partly because of that air in the 90s, there was this transition happening between the more psychoanalytically run profession of the 60s, 70s into the more biologically essential of the form of philosophy run profession.

[00:06:03] Of the, we might say, 80s and 90s is when it started, but really took over 90s into the 2000. There was this transition period between the 80s and 90s where a lot of the psychoanalytics were still around. And by a lot of people also were reaching their prime.

[00:06:22] So we got exposed to both groups in a lucky way, I think. Because I think since the 2000, it's most of the psychoanalytics community has decreased in size and influence, even though obviously they're around. There were nowhere in prison for one children and available.

[00:06:39] Now that, you know, I was among those and still am who put aside that psychoanalytic, how gemony of the past. But as a training experience, it was good.

[00:06:49] It was very useful to interact with people with that level of expertise around the more psychological and specific authority in aspects of our profession. So for me, residency training was just a joy, learning from all these different kinds of people and learning about myself.

[00:07:10] So my journey was partly in the beginning, a lot of it was learning about myself and more about who I am as a person and privilege of being able to translate that into a profession at the same time.

[00:07:25] And then as I was in the field and learning about it as a resident and in my early years, of course I was more interested in research and psychopharmacology because that's where new knowledge was happening. I thought it was important to have that kind of knowledge, obviously.

[00:07:42] By polar illness became a focus of mine because that's where I felt there were the least knowledge at the time and still is. And where the most impacts could be had.

[00:07:53] There were dozens of antipressants and dozens of antipsychotics for depression and schizophrenia but there was only lithium for bipolar. And depot was new when I was a resident.

[00:08:03] And then Tecritol just come out and the McDill came out a few years later and that's still all we have actually for the four mood stabilizer. People were using antipressants one time as they still are making these patients much worse.

[00:08:18] And I was shocked to find out as a senior resident that that was the case. And figured well I could probably educate the profession and make things better by getting people to stop using antipressants.

[00:08:30] Thirty years later I can say that with the statistical data nothing has changed and people have not learned but I've spent a career at studying that and trying to talk about it.

[00:08:43] So really the journey event became about these specific clinical topics, especially in the field of bipolar illness, antipressants, new drugs. I got to know Fred Rodriguez Goodwin who was an expert in the field, former director of the NIH first author of the main textbook, man.

[00:08:59] I got to know him in the late 90s and you just left and I had late and gone to George Washington University where I had was working for a few years.

[00:09:12] And his mentorship was central to my career and made me having trained in the Harvard system. I thought I knew a lot but learning people, learning a lot more from the greatest minds in the field like him really continued my education.

[00:09:30] And he was my closest mentor until he died two or three years ago. And he introduced me to other people like Hagga Pekiscal and later I found out she was a cyclopoulos in Rome who I met in mid 2000.

[00:09:50] So by then I was in my I was nearing 40 and I had been in the field for about 15 years but again I was continuing to learn more from people who knew a lot more than I did.

[00:10:02] And that changed a lot of my thinking as well and eventually what happened right around then by time DSM 5 came out in 2011. I realized that clinical topics of debate that had been my focus for the prior 10 to 15 years matter but there were deeper problems in the profession.

[00:10:23] It wasn't just that we were misdiagnosing bipolar relative to a unit of depression which is something I focused on.

[00:10:30] But that actually the whole concept of so-called major depression was false and in fact all of DSM almost all of it exceptionally, training and maybe and some extent bipolar or false concepts and the sense that they're invalid that they're not real.

[00:10:47] And DSM 5 process was what read me to that conclusion in addition to learning more from people like O'Copoulos and Europeans who had knowledge about what psychiatric diagnosis was outside of the United States post 1980.

[00:11:06] And DSM 3. And so then the last 10 years or so of my psychiatric journey have been going into my 50s a time we're realizing that the profession is more radically problematic than I thought it was diagnosis of the central issue.

[00:11:25] But also treatment with the medications because the other thing I learned after spending four years at Novartis and the private pharmaceutical industry about seven years ago I did that.

[00:11:38] And I got some very new insights about psyched from a pathology that I never had in academia. One of what was this whole distinction between symptomatic virtues that you've modifying effects which we really, I really had not understood and had not heard other people really disgruntled.

[00:11:54] For me that's a radical change in how I think about how we should be using our medication. And so now those are my points of focus. I think we need to get serious about moving away from DSM for the future.

[00:12:11] Instead of having a DSM 6 which is already in process, we need to really get away from that.

[00:12:19] And I think regarding the medications we need to have total change in our way of thinking about drugs instead of just getting a super Thailand all that's better than Thailand all by ketamine or fellow five and versus SRIs. That's all going faster down the same dead end alley.

[00:12:39] We need to really think differently and look for disease modifying drugs. We're not doing it.

[00:12:44] And unless we do all that, I don't see how our profession in the next 20 or 30 years is going to be radically better than I've had in the past 30 years as I've observed myself up close. That's my summary of what I've been and how I've done right on there.

[00:12:59] So I can't tell you how lucky I feel for being exposed to your ideas and some of the ideas of the folks that you mentioned, a kiss gole.

[00:13:13] Kukupalose, Kukapalose, you talk about how, for example, anxiety is not a diagnosis and your criticism on the overdignosis of ADHD ADD.

[00:13:25] And then to take another look at so many of the diseases that I've been trying to treat throughout training and early in my career and saying are these related to a mood illness or, you know, even a sub syndrome, mood illness that you've talked a lot about.

[00:13:44] You know, you've taught me to rely on three major aspects of the clinical interview to glean information that helps me distinguish one diagnosis from another. That being course of illness, family history and response to medications.

[00:14:03] And coming out of residency, I was a little bit despondent by not seeing patients getting much better.

[00:14:10] And I think we're in a very tough field for that. It's not as simple as lowering blood pressure or lowering blood sugar, but since I have changed the way that I practice. I have a new vigor for what I do and excitement for the future.

[00:14:29] But before we get into that because you know, I want to talk to you a little bit about Lipy, I'm especially at Lodosis. Tell me, why do you think the DSM exists like it does now and why do we have so many invalid and unscientific classifications?

[00:14:48] Because I know that not everybody in our field, not all of the scientists are trying to make these invalid unscientific classifications. So why what does that exist?

[00:15:02] Well, I mean at a very basic level, even DSM is the way it is now is because of an inherent conservatism of the human mind.

[00:15:11] We tend to accept the status quo and it takes a lot for us in any profession, any group, on any topic. It takes a lot for people to overturn the status quo and take a risk on something completely different.

[00:15:26] We're risk-averse and we respect our parents and our grandparents and our forepairs and our teachers. They all taught us all this, so we just continue it. It's a very, very rational, very natural.

[00:15:39] But also very unscientific, the scientists all about paradigm shifts and blowing things up and being revolutionary. But that's also why, even scientific change happens very slowly and major changes are not very, very infrucumly.

[00:15:56] Because it goes again the grain of nature and society. We tend to be sociable, human being or conformism is a good thing for social purposes but for bad things, for intellectual and social purposes.

[00:16:12] So I think what happened with DSM was that in 1980 when DSM 3, the 3rd of a person came out. It was a radical change. The people who made it were not conformist. They were actually changing the way psychiatrists, which at the time was this very psychoanalytic for the end of the Japanese.

[00:16:30] I mentioned, and in that sense it was a good thing and they thought they were doing a good thing. And they were, to some extent, for instance, a friendly concept established in a much more scientifically reasonable way requiring chronic psychosis for, since it's went along or, whereas before people used the phrase, the front end of psychoanalytic community, they use it if you have a panic attack, so you're trying to have a normal thought.

[00:16:57] So that was good. But in part what happened was, if DSM became a victim of a tone success and also, as with every revolution after the revolution is over, the revolutionaries become very conservative and they then become dictators and tyrants.

[00:17:16] So what happened was the DSM 3 leaders who were leaders of pain in 1980 became with DSM 4 and afterwards, protectors of that as well. They didn't want their DSM to change anymore.

[00:17:30] Whereas they had claimed when they made DSM 3 that they admitted that they didn't have validity data, they only were establishing reliability agreement. And they said that this dictionary would change over time with research and then it would become gradually more valid.

[00:17:49] Well the problem was that the success was people liked it so much, nobody wanted to change it. And when DSM 4 came out 14 years later in 1994, the leaders actually set out a victim to all the members of the committee that they should not change anything.

[00:18:05] Except for very minor changes, they had a huge amount of evidence for it. So it got set up so that 90 to 95% was the same in 4th edition and then in 5th edition similarly, 90 to 95% was the same.

[00:18:19] So you have this stagnation, a conservatism that built into the system because people like it so much without realizing that by doing so they're actually betraying the original intent which would depend over time and make it more valid.

[00:18:35] And then when someone like me comes along and says, hey, not valid they get mad. But they don't have any scientific basis stand on all of the DSM field trials or only establishing reliability, not a single one looked at validity.

[00:18:49] And that's because the liberties a lot harder to show. If they did, they would find that they're not very valid and then they'd have a problem. They'd have to try to sell diagnostic criteria with the admission that it wasn't true.

[00:19:02] Whereas now they sell it by saying, hey, we all agree on it. Let's use it. And they leave the question of its truth or falsehood on state.

[00:19:13] Yeah, it's, I think it's difficult for us humans to deal with uncertainty and we are in a field that still has a rampant amount of uncertainty.

[00:19:27] I mean, you know, to go back to Thomas's, what is mental illness? That is still a very valid question. And we have some answers but we have a lot more pseudo-answers.

[00:19:41] That are that are propped up by experts saying that they're the answer like you're pointing out without the actual evidence behind it to prove that validity.

[00:19:55] One of the kind of most influential clinical practice changes that I've made since I got out of residency actually is conceptualizing mood fluctuations on that manic depressive illness spectrum.

[00:20:10] And we're loosely correlating to what we call bipolar disorder and major depressive disorder today, not to be confused with minor depressive disorder.

[00:20:19] And if I understand your reasoning, the most important facet behind this conceptualization is that it allows clinicians to recognize those patients that are most at risk of the worst outcome that we can have in psychiatry death by suicide.

[00:20:37] Can you give that statistical breakdown that you've given before on suicide and expound upon why we move to the less scientific bipolar and major depression classification?

[00:20:53] Well, let me take a second part first. In 1980 one of the radical changes that was made with DSM3 was to create the term bipolar disorder and major depressive disorder in terms were not used for MDD, at least major depressive disorder was not used by the term bipolar was used but bipolar was seen as a subtype of manic depressive illness.

[00:21:17] So the phrase that used to be used was manic depressive manic depressive depressive depressive, in other words you could be manic and be manic depressive or you could be just depressed and be manic depressive not manic at all.

[00:21:29] But the DSM group decided to take that second group that was just the path and label them differently major depressive disorder. The other phrase that was used for them was unipolar depressive bipolar and unipolar were both same illness. They were not different illnesses.

[00:21:44] They were parts of the same illness which was an overarching term manic depressive illness. So most Americans psychiatry knew that before 1980, the DSM3 had not yet separated out but most Americans psychiatry either forgot it or never learned it since 1980 and so people think bipolar and MDD are too legitimate and obviously different concepts for us in fact they were viewed as the same thing for 100 years.

[00:22:13] And for reasons we can get into side typically they aren't different in my view the validity of studies do not really support them being different. Suicide of course is something that happens with depression but you can be unipolar or bipolar with us.

[00:22:31] Unfortunately because of the DSM distinction between bipolar and MDD, the thought is that the one that the person needs to be treated differently than the other.

[00:22:40] So with the so called MDD patients you give so called an adpressants like surgeon and reuptate can have a recension right with the bipolar patients who you give mood stabilizers shouldn't give any of the presence even though people do.

[00:22:54] But at least people also get mood stabilizers often like lithium and others. Well it turns out that lithium is proven to prevent suicide that's the only drug that's proven for vansuside and randomized trials.

[00:23:05] So it is an effective drug and it is an useful drug for suicide prevention very very very likely. And so when it's given to the bipolar patients it may help them but it is withheld from the MDD patients because they're seen as a different kind of pressure.

[00:23:31] And so not helping them we're not getting a film furthermore the yes or eyes that we give to them actually can make some of them worse in the sense that because they have if the humanity's president of the concept was correct.

[00:23:46] Some of these people were labeling unipolar depression actually same illness is the one for bipolar illness and we know that any of the presence can make people manic or make them have mixed faith or the manic and the presence symptoms at the same time.

[00:24:01] A lot of these unipolar patients actually have mixed symptoms they have some manic symptoms along with their depression not enough to meet the DSM definition of bipolar which is totally made up anyway.

[00:24:12] For day cut off that has no scientific oven for it but enough that people think not bipolar so it's okay to give them a surprise.

[00:24:20] They get mixed and then they get suicidal and so this debate about whether rain and presence cost us at all the over the years.

[00:24:27] It's been always a pro and time we love the drugs we hate the drugs as opposed to really a critical mission which I think it is.

[00:24:35] Some people with so-called unipolar depression actually have mixed state they get worse on it that's our eyes and they get to get more suicidal.

[00:24:44] So that's another way we're not helping the suicide problem because we're not giving the driver can prevent it lithium and in some people were giving drugs that were shouldn't be as far as.

[00:24:57] When you add it all up 95% of more people will sue so radiation will not time by suicide. So suicideality is a general phrase that people use for suicidal ideation thoughts suicide attempt an attempt that is non-fatal and completed suicide and a type of fatal.

[00:25:18] About half of patients who have depression severe depression will have suicidal ideation but a half done of the people that have suicidal ideation 90% never make a suicide attempt. Only 10% do. Other people will make suicide attempts 90% never have a fatal attempt.

[00:25:38] Kind of person do. Other people who have completed suicide 50% half of them have never made an attempt before. So you don't have a history of suicide attempts and half of patients so the first attempt is the only attempt. So if you're saying we're going to prevent actual suicide.

[00:25:57] But attempts is not a good option. It's half of them have no prior attempts. Suicide ideation is not a good option because when you add it all up 95% or more people will sue so radiation will not time by suicide.

[00:26:10] It's a hard thing to study and usually the numbers are low enough when you start cutting down these numbers that you have to have huge studies for a long amount of time to be able to prove it,

[00:26:20] which is why Lithium's only one proven because there have been a lot of studies that you added up in the meta-analysis. You can get large enough numbers.

[00:26:28] But even there in the meta-analysis of Lithium, there were something like 3 suicides on placebo and 3 on lithium and 11 on placebo if you add them all up. And this is 50 years of research for housing to patients. I probably mentioned this on every other episode that I do.

[00:26:51] It never made sense to me and yet I was the one that was made to feel crazy about the fact that I was supposed to use a drug for a depressed and suicidal patient that has the risk of making them more suicidal or pushing,

[00:27:07] and tipping them over the edge to actually attempt suicide in lieu of a drug that has a 4 to 5 times reduction in the risk of suicide.

[00:27:19] And that not only bothered me but then to be told that that idea was silly for me to want to use even a low dose of lithium in a depressed patient, which I personally believe should be the first line medication based on the benefit to risk ratio.

[00:27:39] I may come back to my next question in a minute, but now that we're already on it, I mean, one of my biggest kind of early in my career clinical philosophies is start with a drug that offers the best benefit to risk ratio.

[00:27:59] And to me, lithium is without question, the best drug at preventing severe mood fluctuations in what we now call bipolar disorder with the largest effect size.

[00:28:11] It's the most preferred agent by patients with the condition and it's much safer at high doses than what I was taught in my medical training. However, I'm more interested in your views on the therapeutic potential of low and extremely safe doses of lithium.

[00:28:30] For those patients who would have been considered manic depressive illness spectrum in the past, despite never experiencing those overt manic episodes. Just to give a little bit of context here for listeners, low doses of 150 to 300 milligrams a day compared to bipolar doses of 900 to 1500.

[00:28:52] Or even supplements containing lithium orate, which is more neuropenotrating, have led to some pretty incredible results in my practice. I alluded to having a new vigor for what I do.

[00:29:06] It certainly does not lead to an incredible result in everybody, but for example, in the last year, I've had a woman who suffered from severe PMDD, formerly called PMS, for about 20 years with severe mood swings, emotional turbulence, suicidality in the week leading up to her menstrual cycle.

[00:29:29] I started her on the lowest dose of prescription lithium, which is 150 milligrams of lithium carbonate. She's now had three different back-to-back menstrual cycles without any sort of emotional turbulence. I've had early potential success in a suspected CTE patient, which I know that you've talked about a lot.

[00:29:57] Honestly, one of the kind of crazier responses I got was actually an autism patient, autistic spectrum disorder.

[00:30:05] I did therapy with this patient for nearly two years and he had a lot of rigidity in his thinking and ended up leaving the therapy or not coming back for about six months.

[00:30:18] And he came back with his parents, and this is somebody who would dress essentially in Gothic clothing at every single appointment. We started him on that after talking to his parents. I said, I don't know if it'll help but I think it may have the potential to help.

[00:30:40] Four months later, his parents have said that he comes up and asks them how they're doing, how their day went. Very pro-social behavior. He told me at one of our recent appointments that he's thinking about getting a new wardrobe and expanding his...

[00:31:01] ...in I never, ever had been taught that. I never would have thought that it would have been successful but after using it in so many patients without any major side effects or any real concerns on a safety profile issue.

[00:31:17] I've started to use it a lot more and some people think I'm crazy for using it that much but they just hear that lithium. They just hear that word lithium and there's all this other connotation that goes with it.

[00:31:30] Dementia, what other uses do you think it has the most promise for? Yeah, so it's an important topic. I would say, first it's worth commenting that traditionally lithium has always been used at high doses.

[00:31:51] John Cain, who discovered a tooth in psychiatry in Australia in 1949, he gave it to think about 10 people, two of them I think died. He actually got investigated by his hospital for harming patients with a toxic drug.

[00:32:09] After that he refused to prescribe it. He never gave it to him but he'd even though he became famous for lithium.

[00:32:16] It was the work of others, Logan Scow from Denmark in the 1950s and Sam Gershon in Australia who figured out that you had to check a level as you couldn't go above a certain level.

[00:32:28] And so on, it's a toxic drug but even so they still were giving it at levels that were very close to toxicity.

[00:32:35] To think about it, if we use it at the point A to 1.0 level with people views therapeutic, it clearly toxic at 2.0 which is twice as much as that. And you start getting more in line to let you see one point of having above.

[00:32:48] And of course, you know, lithium would never come to the US market today. The current regulatory guidelines of FDA, throughout the FDA guidelines, drugs that are being developed in a pharmaceutical industry are in early phases. If you can show animal toxicity, human toxicity usually though animals enough.

[00:33:10] If you take it to phase one human trials, you have to show that there's no toxicity at hand times higher than the therapeutic dose. No toxicity at 10 times higher than the therapeutic dose to take it forward.

[00:33:25] That would mean that lithium would have to be non-toxic at a level of 8, just fatal. So lithium would actually ever pass mustard to come to the market based on safety in the US today.

[00:33:39] The only reason we have it is because it predated the FDA regulations, which started in the 60s, 70s and lithium 10-wong in the 60s. By the way, same thing with MCETA means which are clearly neurotoxic and kill brain cells.

[00:33:52] They would never be approved by the FDA today even though we widely prescribed them. That's not to say we shouldn't have these drugs that are toxic. There's an old saying from Parasel, who's the great founder of modern pharmacology with all ages.

[00:34:06] He said that all drugs are toxic, but it's only the dosing and indication that makes them therapeutic. So I do not claim it all that lithium is safe. It's a toxic drug. But if you get the dose right and the indication right, it's very therapeutic.

[00:34:22] And that holds for actually every drug. It's just a little bit more toxic than others at the doses that are constantly used. Point eight is too close to 2.0 in my view. And that's another reason I like to use lower doses now.

[00:34:38] I learned about from the top of the list. You know, only 10 or 15 years ago pretty far along in my career. I had been pretty skeptical about it. I followed all the rules beforehand. I was constantly titrating people up to 900 milligrams and more and getting the levels around 0.8 to 1.0.

[00:34:55] But in the last decade as I followed, co-craft doses advice to try lower doses first. I found that if you went slow enough and low enough, put that better before you needed to go higher.

[00:35:08] And that confirmed for me that he was right that we didn't need the higher doses. And I think it's a residue of just 40, 50 years from the 1950s to the 1990s. When lithium was the only drug approved for bipolar illness, more available.

[00:35:24] And people just use it at higher doses because that's all they have. They want to maximize its benefits. But the other point that you're making besides the fact that it works at lower levels for a voodilness by polar and unyutipolar pressure.

[00:35:37] Is that it may work at these lower levels for lots of other things. Now I'm not going to say you're in say, it's your own for everything which you give it for everything. But I will say that those who are so skeptical about it,

[00:35:50] I should know that there is no real disprove. It very least is ought to be used and studied in autism and other things more carefully. All we ever have is case reports and those are usually high doses.

[00:36:03] It would be interesting to see how it does at lower levels for a lot of different things. The one place where I think we do need more data but I think we have, you know,

[00:36:13] we have the beginnings of these and data and a lot of my own kind of hoax training. Those are with immune temperance. So just find me a high-perit, find me when people are a mildly man called the time. Stalkle, find me.

[00:36:26] And this can be measured using the temps of scale, EMPS, just goes out. And that I've revised to make it clinically useful when I get in cut off. I increasingly have been giving this scale to all my patients and the patients that come to me

[00:36:43] who score high on hypersimia and cycle of pimeon. Tentable people, not necessarily who were diagnosed with bipolar or even viewed as being in the bipolar spectrum. But usually diagnosed with ADD, generalized anxiety disorder and sometimes so called MDD.

[00:37:02] Some might joke the equation is that if somebody comes to you with the diagnoses of the comorbidia, GAD, MDD and ADD, then they have cyclophilia. And that's what I find a lot. And they come in on benzoes, that's alright and that fetemines and you give them 300 of lithium

[00:37:21] and take all the other stuff away and they're much better. Or 500 of the depot, low doses of lithium is up to them, it seems to help a lot of these people. That's the group that I think there's a rationale that's pretty good diagnosedically.

[00:37:36] But it's interesting to think it's really about understanding temperaments more. You're treating the temperament but you're not treating the mood symptoms really. You're treating the effects of the mood symptoms because they're always up and down in their

[00:37:48] huge manic or depressive to a mild degree in psychophilia and hyperphimium. And they have the effects of the tractability, sad mood, down mood and anxiety. So the effects are being diagnosed by our current diagnostic system and symptomatic drugs are being given for the effects.

[00:38:07] It would be like people having fever chills and night sweats and getting Tylenol and anti-chills until an anti-nice wet pill instead of treating the underlying pneumonia. Similarly for us, we're treating the symptoms of attention, mood and anxiety and we're not treating the cause which is the mood temperament.

[00:38:29] And that's where the low dose, not just lithium but low dose depot 2 probably is helpful. And that's a lot of people that bring diagnosed with GADMDGDD. That's a lot of people these days. And in my routine outpatient, private practice now, that's at least half of people I see.

[00:38:50] And 20 years ago, I would not have known to do what I'm doing now with them. So I think it's a pretty big change if one of the challenges is that's going on. It can change really how you see patients and how you treat them for the better.

[00:39:07] Because if this is all correct, they end up on low doses of one drug instead of high doses of three and they do a lot better. And the reduction in polypharmacy, the lack of very many, definitely very many major side effects at these extremely low doses.

[00:39:27] It really, I can't say enough. It has reinvigorated me for what I do and for the potential in the future. You know, I think that there's a lot of factors that go into this demonization of lithium.

[00:39:43] I mean, I always thought it was strange that I get all these electronic medical record warnings about lithium with serotonin syndrome, which if you talk to the leading serotonin syndrome or toxicity, better terminology serotonin toxicity experts, the lithium does not cause any sort of serotonin toxicity.

[00:40:05] And there's so many different warnings that go into it. I think the lithium chloride catastrophe with cardiologists and heart health in the 1940s right around the same time as John Cade was making his discoveries, which that's a whole other incredible story on its own.

[00:40:23] But I think all of these kind of play into this fear of lithium. I use it, the example I use with patients or even other providers who think that I'm using something dangerous is

[00:40:36] Lithium's in the same column of the periodic table as sodium, which is right below it, as potassium, which is below that. And if you have too much or too little sodium in your bloodstream, you can see these.

[00:40:53] If you have too much or too little potassium in your bloodstream, your heart can stop. So my philosophy is that absolutely too much lithium and getting anywhere close to too much lithium can be toxic and potentially fatal.

[00:41:10] But the nuance there is, are we, are some of us in a lithium deficient state? And do we need a little bit more lithium? And if you give it enough time, riff al Malek hammered into my brain that lithium gets into the neurons.

[00:41:28] And it doesn't have a great transport out of the neurons. So it can accumulate in neurons. And if you give the low doses enough time, I think that's why we see these other anti viral and anti inflammation effects that build over time with the drug.

[00:41:49] If you have the time, you can get incredible results without running that kind of risk of the patient safety. But can you comment on how safe you feel like that 150 milligrams dose is, or even lower than that the supplemental dose?

[00:42:09] Yeah. So if you take the FDA rule, which I think is a good, I think that's a very conservative guideline, tenfold of the dose should be safe. So ten times 150 would be 1,150, or 1,500. Yeah. That's the higher end I would say of safe dose.

[00:42:30] So 150 probably is a safe dose. Certainly less than that is so if you go to lithium or rotate over the counter usually comes in 5 milligrams, 5 milligrams of lithium or 8 is equivalent to about 25 milligrams of lithium carbonate.

[00:42:47] Ten times that is 250 milligrams, which is a safe dose. So I think the supplemental lithium doses that are available over the counter definitely safe dose. There's nothing harmful from taking that. There's never been shown any harm in humans.

[00:43:02] And I've been letting people take it. It's not prescription, but I've had patients who want to take supplements and subscribe lithium. And I also follow people who doctor the won't subscribe lithium to them. So I don't get supplements instead.

[00:43:17] And we follow their kidney function and thyroid function. We haven't seen any worsening of kidney or thyroid function in over the counter supplement doses of lithium. I'm pointing out that those dosive five milligrams of elemental lithium, which is what's in the supplemental lithium or a thing.

[00:43:36] That's equivalent to 25 milligrams of lithium carbonate is 5 milligrams of elemental lithium. That's a high dose from a dietary perspective. Our diets were supposed to get about a milligrams of lithium a day. So if you get five milligrams, that's five times more than the average amount.

[00:43:52] And that's actually a lot of lithium, but it's very safe. It's not anything that would harm you. Many people do have a deficient diet where they have zero lithium or practically zero lithium.

[00:44:04] And there are lots of geological studies. I know you're aware of the good food and the audience to hear about. The show that they look at places in the world all over the world, US, Europe, Asia, Latin, and you can basically measure lithium in the drinking water.

[00:44:24] And so people who live in that area have zero lithium in the drinking water, they're compared to people who have more than one milligrams a day, usually two to three milligrams a day.

[00:44:33] But they look at it's high level. Which would be kind of equivalent to taking one less than one milliphym or a take perlade.

[00:44:40] And the high lithium in the world is so called high, which is still stream below. They have one half the suicide rates, more they're a good thing to do.

[00:44:50] And there's one study out of Scandinavia now that shows they also have one half the dementia rates when the people are living in the deficient.

[00:44:58] So there's beginning evidence that very low dose of lithium may help prevent dementia. We already know lithium prevents dementia at standard doses based on food illness studies.

[00:45:08] In the studies where people have depression and bipolar illness if they're on lithium, they don't have increased dementia rates compared to the general population. Whereas if they're not on lithium, we have about a two to fourfold increase rate of dementia.

[00:45:22] So lithium really prevents dementia and people with mood illness. And I think it should be given practically to all of them at least to the low dose.

[00:45:29] But it's also suggest that it's very low dose, meaning the supplement point dose is that it may have preventative benefits for dementia. It's very, very likely it has preventative benefits for suicide based on literally over a dozen replicated findings on geloc studies.

[00:45:46] So I keep in mind these are not randomized trials, so you will find couple studies that don't find a benefit. That's always the case with observation research.

[00:45:54] But the majority of studies find benefit and since we do have randomized data that lithium prevents suicide versus placebo standard doses, as I mentioned earlier, it's logical that the benefits is a real effect.

[00:46:07] Again, it's not definitive because it's not studied at these extremely low doses in randomized trials, but it's very likely. And is that a reference to Alec Coppins work? Coppins is one of the people who studied this, but very low dose lithium, you mean? No, the comparison with placebo.

[00:46:27] Yeah, there's been a couple meta now, see, over the last decade. The most definitive one usually cited was by Superyani and colleagues from the previous general, and I had a very high degree around 2013 or so.

[00:46:46] Some listeners may know that there was one last year from another British group that claimed to debunk this, since that lithium does not prevent suicide. But then they're meta analysis, they actually have the same benefit seen, which was an odd ratio about 0.4.

[00:47:03] So about a 16% decrease down to suicide with lithium is placebo. But they had you included a bunch of studies with no outcomes so that they increased the denominator to make it statistically non-significant. And by this trick, they claimed that there was no effect.

[00:47:20] But it's actually a mistake to do that because in meta analysis, if you include study, special huge studies, where there are no outcomes at all for your outcome, then you're obviously going to make it impossible to show physical effects. So I criticize that paper on that issue recently.

[00:47:40] And I think meta analysis are contrary to those who will skip Google, about drugs in general. I think meta analysis do show pretty concisely that lithium is a preventive effect for preventing a complete suicide placebo. And like I said, you cannot say that about any other psychiatric drug.

[00:47:59] Well, and I think the other factor here is that if you put your patients on lithium, they're going to come and see you less. They're going to have less reliance on other drugs and hospital systems.

[00:48:10] And that ends up hitting the bank account of some companies that are in pharmaceutical or hospital industry. I kind of wonder if there's an intentional demonization or a covert efforts to try to demonize lithium because these things are known at the highest, most intellectual levels.

[00:48:34] But we could talk about that for hours and hours. I doubt that to be honest even, you know, there's an old saying that you should never attribute to, to give a single level of what is better attribute to ignorance.

[00:48:53] My observation, having worked in the pharmaceutical industry and I've discussed lithium in detail with a lot of people and companies that I've worked on and with other. They just have no awareness of this at all.

[00:49:06] And to be extent they do have awareness of it. They're not critical of people that I've served in. And there is not this level of knowledge at the highest levels of private industry and whether insurance or anything.

[00:49:20] There's this business and they don't study the scientific, they don't like this. Many of them aren't even psychiatrists from any physicians. So it's not about that. I think it's more just a lack of knowledge as part of the reason.

[00:49:35] It'll don't know these things. And there is a subgroup of people within psychiatry, but especially outside of psychiatry who are just anti-drum, anti-psychetic attributes. And they usually blame the pharmaceutical industry because they can claim that there's some profit and pollution.

[00:49:53] But they can't do that with lithium. So it's never been the only drug that's come to the market without any drug company behind it.

[00:50:02] So they can't do that with lithium. But they fact that they still criticize lithium shows that their ideology is really not about economics, about a hatred of a drug's period. I'm all for criticizing drugs when they shouldn't be given, I criticize plenty of drugs.

[00:50:18] But I think it's obviously very harmful to have an ideology that all drugs are harmful in society. Yeah, and you just don't know the underlying motivations of people a lot of the time of companies.

[00:50:35] But to me it seems to make there's a large incentive to whether it is overt, covert or ignorant to not use lithium at the expense of other drugs, because it's so cheap, it's so natural, it can't be patented. And typically makes your patients better than most other drugs.

[00:51:05] But yes, absolutely. It's not something you can prove and that's good to hear, you say. I think we'll have topony-level drugs. They're not using lithium, they're developing other drugs. That's relevant more at the level of clinician, but even then I don't think it's relevant.

[00:51:22] I don't think clinicians are really focusing on how much things cost. By the way, you can patent lithium. You just have a version of it that hasn't been patent in the court. Technically, you could patent. I'm what you're analysts.

[00:51:38] Well, switching gears here, like I said, we could talk about lithium for hours, I'm sure. Switching gears here, one of the biggest travel-sees that I see in American psychiatry today is the rate that we are medicating our children.

[00:51:54] Ronald Kessler at Harvard back in the late 1980s was quoted as saying something along the lines of mental illness does not exist in children. And at that time, in that might be a little too extreme, but at that time, 0.2% of Medicaid-insured youths were on any psychiatric medication.

[00:52:14] And now the rate of medicating our kids is skyrocketed close to 20%. Or 100 times what it was in the late 1980s.

[00:52:23] And I fear that we're only masking symptoms and actually making their conditions worse in the long term, or even causing conditions that they never would have experienced by altering that brain chemistry at such an early age.

[00:52:38] The way that I view most mental health conditions, excluding things like autism or trauma, is that they require a higher level and development of consciousness and self-awareness that only comes with age and further brain development.

[00:52:53] And just briefly to use schizophrenia as an example, it seems logical to me that with the timing of synaptic pruning or the trimming of connections in the brain, allowing for more focus and intentional thought and action.

[00:53:08] Of the frontal lobe occurring just prior to enduring the emergence of negative and cognitive symptoms of schizophrenia, with a similar pruning in maturation of the auditory cortex two to three years later, corresponding to the emergence of positive symptoms, which are most typically primarily auditory hallucinations.

[00:53:31] It seems that the best way to describe those are as neurodevelopmental conditions.

[00:53:37] Unfortunately, that's all one statistic from a colleague or somebody who trained me that 2.5% of Kentucky children under the age of six had taken an anti-psychotic in that really infuriated me, especially having young kids in my own other conditions like bipolar major depression, OCD panic disorder.

[00:54:04] They also don't seem to me to emerge until after we reached that higher level of consciousness post-puberty. I personally believe it's kind of a puberty is a prerequisite for most mental illness, but what do you think should we be medicating our kids like we are today?

[00:54:23] I would broaden the critique. I think the general issue is that most of our drugs are symptomatic, they're like aspirin and Tylenol for headache and fever. They're not getting at the underlying cause of things. The exception would be lithium and moose stabilizers.

[00:54:39] And the way you know that they're getting at the underlying causes, they improve the long-term course of the illness. Those are the only correct for having to improve the long-term course of a psychiatric illness.

[00:54:50] Some people will disagree with me about that, but I could provide the evidence for it that any psychotics do not improve the course of schizophrenia and any depressive, including the course of so-called MDD. And then Fedamines do not improve the course of so-called ADD.

[00:55:04] If you look at the randomized trials of those things, which would be a complicated discussion, I would be able to blame why they don't actually improve the long-term course.

[00:55:16] In the case of bipolar illness and unicoled oppression, lifting has been shown for that mood episode of the prefect and going for Africa course.

[00:55:23] And a good number of people in more than placebo, so it's statistically meaningful. Same thing with the mojo gene and to some extent with foul-proated and poor management. So those are disease modifying drugs because they improve the course of the illness.

[00:55:39] It's like taking statins, anti-acupensives, the prevent stroke and heart attacks, like taking chemotherapys to get rid of the cancer, so it doesn't return. That's different than taking nitroglycerontrior chest pain, tall enough for your fever.

[00:56:00] And that's all we have with the rest of our psychoproket drugs and Fedamines and antipropinacnealidics and statics. That's just reducing your pain and fever. It's not improving the underlying disease.

[00:56:14] And that's the case whether you're 75 with MDD or 12 with MDD, whether you're 67 with ADD or 7 with ADD, you're the same. The my view is the same issue with adults and children.

[00:56:26] Children obviously you do have the added problem that you can't know what the underlying disease is and many times as you're describing until they're brain is developed enough to show the clinical symptoms in a way that's more obvious.

[00:56:40] It can be diagnosed. However, you do have the potential hint of the family genetics in the cases of genetic illnesses like bipolar illness. So let me just make up a case.

[00:56:51] Post the mother of the father in 27 aunts and uncles all had severe bipolar illness and they're all from the suicide and you have a kid at 8 who's got mood soon. You might say, I have stuff moods making an 8 year old but he got 27 relatives and parents.

[00:57:07] I mean that's an exaggeration but I think that's where family history comes into account as you said in the diagnosis process. But what we don't have in children is of course the illness than two young to really know the course of the illness yet.

[00:57:22] And that's why it's very difficult to know what they have. So one approach would be to really be conservative with them. We don't really know what the underlying disease is. To limit the use of medications and for a purely symptomatic otherwise.

[00:57:38] So the most severe symptoms for this worse amount of time if you absolutely have to. I think that's the reason we'll approach. Another approach would be also to say they do have a strong genetic capacity for genetic disease like bipolar illness or pneumonia.

[00:57:51] Then you might start treating that earlier than you might otherwise even though you don't have the full bone disease process yet.

[00:57:58] And there's some evidence that that's rational to do like with study time, poor drama psychosis, you know some of those studies so that you could give a tiny dose of a spare down and have a better course.

[00:58:08] And if you waited didn't give anything again that's not definitive because there aren't randomized trials and part of do. Metamod's rather long enough. But that's kind of recent we should be doing.

[00:58:19] But I agree with you that what we shouldn't be doing is saying, uh, take all these kids, take all their symptoms, give them all drugs for the symptoms and don't worry about it. Especially if we're giving them that set of means which are going to be toxic.

[00:58:32] I agree with you that we should be much more conservative than we have than we are being enough. Yeah, it became a lot tougher for me when I had my own kids. And it became a lot more real to me at that point as well.

[00:58:49] I had the same experience, I can say I've had two kids that I've parents have now and two young adults. And it was interesting to walk in an upper class environment and a very educated area in Boston, and lots of which was in private school experience.

[00:59:07] I'm interested to watch their peers, I would say that my guess is the majority of them along with the community. And there's no way that they all had so called MDD biologically.

[00:59:17] I mean, ADD, but I'm not sure if I actually don't even think ADD is a vowel comfort anyway. But the majority were on infedemines and pretty clear that they were getting it symptomaticly. And proving their attention was imperative for very shrieking.

[00:59:32] And so I deserve this myself and my kids. It's very hard in this culture in many places to raise children and not have them go on, something. And that's your mom and for me, whatever. And it's not always wrong to do that either.

[00:59:47] I'm not saying that I disagree with people who take this really anti-direct approach in a generic sense. And I'm not scolding anyone. So I do think that when you need to think much, much, more disturbingly about it. That's all I would say.

[01:00:03] And that's a huge theme of why I started doing this podcast is the field has tipped way on the side of overtreating and over-medicating and modifying symptoms instead of diseases.

[01:00:18] But just like so many things in life, the alternative, the other extreme, the anti-psychiatry movement often goes too far. To take out very useful treatments like Benzo's for Cedatonia, ECT for certain conditions. We've got to find this middle ground.

[01:00:41] And I think part of it has to do with how our minds work and how our minds like to order information in this all or nothing black or white way.

[01:00:52] And that information gets projected to that seed of consciousness or front-alope last to decide what to do about it. But you know, I think I see that play out a lot on a societal level, but definitely within psychiatry itself.

[01:01:10] One of the other kind of all or nothing newer treatments is this kind of, what's something you've pointed out, this fad of ketamine.

[01:01:23] It was so relieving to hear your podcast episode on ketamine and the extended clinical trial data in terms of this difference between suicidality and the actual risk of suicide completed.

[01:01:39] Can you briefly, I know you don't have a whole lot of time but can you briefly summarize the problems with the ketamine trials? And then if you have time I'll challenge you on the psychedelic side of things.

[01:01:54] I'm terrified to challenge you on it, but I do have some questions about that. But I'm more interested in the ketamine suicide risk. Maybe we can talk about both as our final come off issues here. There are a lot of ketamine psychedelic and so is marijuana.

[01:02:12] You know, if you think about it, I love this, this situation is that we have a spectrum of psychedelic drugs. By psychedelic and the phrase that would made up, all that really means with hallucinogenic drugs. These are drugs that make you satanic and they make normal people satanic.

[01:02:31] The only question is if you take psychiatric, the ill people can maybe safely use it all. And generally they make psychiatry or people even more psychotics and you would think they shouldn't be used in that population.

[01:02:45] Same is that some of them can be used in very low doses and have some benefits without making them psychotic or releasing a psychotic. By psychotic, I mean hallucinogenic solutions. Of course, in the case of marijuana, that was a reasonable plan playing with medical marijuana.

[01:03:01] But that was just a surgeon horse among the cultural movement, make these drugs available. Just as happy experience, just like alcohol and the medical marijuana laws were just surgeon horses for recreational marijuana, which we've gotten in Massachusetts and we have a lot of other places.

[01:03:23] And we know that marijuana when given to some patients make them more paranoid, cause it's panic attacks and some people can make them delusional. So especially if it's 98% TH which is so free to unnaturally.

[01:03:38] If the old statement, you know, all drugs are toxic, if the dosing in the case makes nervous. So if the dose is high and it's very potent even more so. But but also it's acceptable people, people that have the bio-opper susceptibility to paranoia delusion of depression and anxiety.

[01:03:52] Or the ones who are going to have the side effects. So yeah, it can be given it's for the whole population and safely used in very low doses for happiness. Just like alcohol is given to the whole population and safely used in low doses.

[01:04:06] But it's harmful at high doses and harmful when people at risk just like alcohol is. The equality does not mean safety and that's what the millennial generation doesn't seem to understand. And in generation X, like me, we know. I know you are quite mentioning it.

[01:04:26] I think there is a generation of issue. Generation X, no better. The baby boomers were all bunch of hip and pot users in the 70s so they know better but they don't like it so they support them. And we wanted to.

[01:04:39] Now the next step is ketamine. People haven't tried to legalize ketamine for entertainment purposes, but it is legal for treatment purposes. At least for anesthesia, it's off-label for depression. But those ketamine is now available and legal for depression in the case of syndrome.

[01:04:57] At low doses and again the FDA rule was that tenfold distinction. Now they knew that the doses given you get the association, but it's just mild enough that it's tolerable. That's what the FDA was thinking. So, ketamine I think is being overused and I think Mike will combine.

[01:05:17] Mike will see ketamine with Mike or take of silasciben and MDMA in any other psychedelics people want to ask. Basically, ketamine is not that they are addicted. My basic critique is not that they're toxic and harmful. Although they are all of those things that high enough doses.

[01:05:35] They may not be at low very low doses. And people say they're not addicted. They say they don't have withdrawal syndrome. Yeah, but they cost psychological addiction which is still addiction. So like, in federal means don't have withdrawal syndrome. Cocaine doesn't have withdrawal syndrome, but they're still addicted.

[01:05:50] So that's not a rationale. I'm saying that I'm addicted. But that's still not my main critique. My main critique is that they don't solve anything. My main critique is that they're just symptomatic, like Tylenol and aspirin and all the other psychotry.

[01:06:03] If a pro-zac is Tylenol, psilocybin is super Tylenol. ketamine is super Tylenol. That's not a solution. It's not transformative. It doesn't take the field anywhere better. You're just getting symptom benefit and you're quickly. Maybe better symptom benefit but still it's just symptom benefit.

[01:06:21] It would be like taking somebody with severe cardiovascular disease and saying, hey, you know what? This drug gets rid of your chest pain 10 times more and five times more quickly. They got to still have the heart attack. It's not going to be done.

[01:06:33] So you haven't changed that. And that's the way it is with so-called MDD and with depression and so on. With psychedelics and ketamine. It's not a long-term solution. Separate from the harm which was worth mentioning.

[01:06:46] I've called my case as a patient who's gotten manic and psychotic on Tatamine. I've gotten addicted to it by polar patients. I've sat a case of a woman, a young woman with ayahuasca. Won't who got take took ayahuasca, not treated but took it in a so-called,

[01:07:02] I don't know what they call it, you know, supervised setting with people who were experts at it. And she developed psychotic depression followed by catatonia for four months hospitalized, requiring ECT and still has not completely recovered.

[01:07:17] So the claim that these drugs are safe and there's no problem, this just fatteningly false. The question only is how unsafe are they and what doses compared to how much benefit you get?

[01:07:26] And since the benefits only symptomatic and it's super-tallinal, that doesn't not weigh the harms in my view. I will say though that the once in area where they might be useful if it's proven is what people seem to say about PTSD

[01:07:40] from with silence, I've been in some of the psychedelics. If you can take a dose or two and then get, it's hard to believe that three sessions of psychotherapy is going to cure it. But suppose even a few months would be good of psychotherapy.

[01:07:53] And then you're markedably better for a year or two. That's worth it. Everyone would agree that that's worth it. These studies are not randomized for a year or two, and the placebo-psychotherapy to prove it.

[01:08:06] And until they prove it, I don't know why we should have unscientific low levels of thresholds for bringing these things to the market when they're harmful as well. That's my general view of psychedelics. Well you defended my follow-up question without me even asking it.

[01:08:22] That's what I was going to mention is, you know, I do think that there is tremendous potential for more neurotic or anxiety-driven depression as well as PTSD. I'm of the ilk that if I can give a treatment to somebody once or twice,

[01:08:39] that will keep them in remission for multiple years from their symptoms, it may not be diseased modifying in the ultra long term. But a couple of years is a pretty long term to not have to rely on other substances and medications. It might be a disease.

[01:08:59] If the data borrows that out. Yeah, it might be disease modifying. If your PTSD is a chronic long-term condition, so if you get someone notably better for a year or two, that's disease modifying. It's getting a bit something underlying in biology,

[01:09:13] and it's a fact that it's showing it in the clinical course. We don't have anything for PTSD and PTSD. So drug-wise at least we don't have anything this EMDR is actually pretty good treatment for PTSD with just a couple of months of treatment.

[01:09:25] If this can be another option to something like EMDR, that's great. And I've supported it. But I do think that there's a cultural aspect here which is, I'll think a lot of this medical talk is just subterfuge.

[01:09:38] For those who want recreational psychedelics, that's going to be eye will predict. You know, Massachusetts, we have a ballot question this year for medical use of psychedelics, of course given by non-physicians so we are physicians we oppose it.

[01:09:52] But I predict if it passes that in three or four years the same group that did this, which was the same group that got the marijuana laws passed, will come back with recreational psychedelics. And that might pass too because there's enough millennials and generations E people.

[01:10:08] Generation Z is going to be the biggest age cohort in the population in a decade. So if they go along with it with the millennials and the leftover baby boomers, that's enough people to pass these ballot questions. And I think that's the ultimate goal.

[01:10:23] People just want to use the shrumps. The claim that is sort of so medically beautiful is really at my view, a subterfuge for a larger cultural with to use it. And as far as I concerned people can do that, just don't attend that it's a medical,

[01:10:39] and a sea of, it's really just want to feel good. And if that's what the culture wants to do they can do that, although in psychiatry I think we have an obligation to keep warning people

[01:10:49] because we're the ones that you're going to be cleaning up all the harm that happens and they learn students. Yeah, I think that's very, very well said. I mean my philosophy is growing up in the,

[01:11:02] essentially the drug addiction capital of the world and not knowing it when I was growing up. You know, my generation has had drugs thrown at them. And so with where we're at in terms of this drug epidemic, which is a huge passion of mine, I really think that,

[01:11:20] I mean we have to legalize things and the most important thing to me is that we regulate them. That we don't have 98% THC that we don't have, you know, all these other drugs, cocaine, meth and fedamine that are cut with all kinds of substances beyond the obvious fentanyl.

[01:11:39] I was hoping you mentioned this on your podcast and I was always a little skeptical and thought it was weird that every time I heard about ketamine's impact, it was that it reduces suicidality. And you eliminated why they used the terminology like that.

[01:11:59] Can you tell the listeners what I'm alluding to? Yep, and if it's okay after that, Ethan, I think the probably should cut us from today, maybe. Absolutely. So suicidality is a general phrase that people use for this. The people use for suicidal ideation, thoughts, suicide attempt,

[01:12:18] an attempt that is non-fatal and completed suicide, and a attempt of fatal. About half of patients who have depression, severe depression will have suicidal ideation but a half done. Of the people that have suicidal ideation, 90% never make a suicide attempt, only 10% do.

[01:12:38] Of the people that make suicidal attempts, 90% never have a fatal attempt. Kind of person do. Of the people who have completed suicide, 50% and half of them have never made an attempt before. So you don't have a history of suicide attempts in half of patients.

[01:12:57] So the first attempt is the only attempt. So if you're saying we're going to prevent actual suicide, the suicide attempt is not a good path of them. Have no prior attempts. Sousal ideation is not a good proxy because when you add it all up,

[01:13:11] 95% or more people will sue, so ideation will not time by suicide. It's a hard thing to study and usually the numbers are low enough when you start cutting down these numbers that you have to have huge studies for a long amount of time

[01:13:25] to be able to prove it, which is why Lithium's only one proven because there have been a lot of studies that you added up in the meta-naf, as you can get large enough numbers. But even there in the meta-naf is a Lithium, there were something like,

[01:13:40] three suicides on placebo and three on lithium and 11 on placebo if you add them all up. And this is 50 years of research for thousands of patients. When you look at ketamine, you have basically two or three studies done by Jansson with us ketamine.

[01:13:58] You have a couple of hundred patients in each study. Not enough, not large enough to show differences on completed suicide. So that's why they didn't even bother looking at that. It's not even large enough to show differences on suicide attempts.

[01:14:11] So they really just looked at decreases in the suicide ideation scale, where they claim some benefit. But Mike, my critique at one level is that that doesn't translate to prevent from suicide for the reasons I just gave. And then it's worth looking at suicide attempts and completed suicide.

[01:14:28] Even though the studies don't have the size to prove it, and when you look at completed suicide, there was more on the ketamine arm than the placebo arm. I think it was like four cases of ketamine and more maybe six versus one or two with placebo.

[01:14:44] I don't know exactly, but they weren't all labeled as suicides. Some of them were suicides, some were deaths, like a motorcycle action, was one case. Well, you might assume that it wasn't a suicide, but maybe it was.

[01:14:57] And you don't know, opioid overdose, or dose, it's not counted as suicide in these studies. But opioid overdose sometimes is suicide. So if the ketamine showed zero suicides and placebo had six, I'd be deal better about it.

[01:15:12] But the fact that it's really kind of the reverse makes me more... Yeah, and again, I can't thank you enough for making me aware of that. It has been absolutely awesome to talk to you and hear some of your ideas on these things.

[01:15:30] And I think it's so important that voices like yours are raised up in the current state of psychiatry because, fully, things like this that are trying to reach directly to potential providers and patients

[01:15:48] to educate them on these topics that are not necessarily or really not in the textbook all of the time. So I would love to have you on again. I'd love to talk about consciousness and how we have all this all or nothing thinking

[01:16:06] and need to appreciate that gray area and host of other issues. But I really do appreciate your time and you've taken that time to speak with the people I'm to speak with me and my listeners today. So thank you so much. It's been absolutely pleasure. Thank you.

[01:16:24] Not to do. All right, have a go on. Somebody get this guy some help. Thanks for listening. For more social media content, check us out on all social media platforms at RenegadeSight. If you have any comments, questions, for challenges to the information we present here,

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