Lithium, the GOAT: More about our Guest, Rif (+Disclosures Discussion)

Ethan: So, now Rif, tell us a little bit about your personal journey.

Rif: There isn't much to that. It's all, like you said, personal. But, my wife and I, we’d been together since we were both 21, went to school together, University of Illinois, that's where we met. And we were dating since we were both 21. We were both born in 1956. And so, she, unfortunately, died a couple of years ago now. There's so much of life that I took for granted, that required her death for me to realize how [01:00] important it was. And so, I guess that's the biggest thing in terms of my personal journey, but I do have a couple of kids and now a couple of grandchildren. Father's day was just a couple of days ago, and I got a T-shirt from them that says ‘Grandfather of twins,’ classic overachiever, I've already worn it. It was only a couple of days ago, but I've already worn it for 2 days. I need to wash it, but it's fun. Yeah, things are good.

Ethan: I appreciate you sharing that. How many grandkids do you have?

Rif: Just the two.

Ethan: And you have 2?... Is it sons?

Rif: 2 sons, 1 who's the father of the twins and the other’s not in a relationship.

Ethan: Yeah. Just curious, what did your parents do growing up? What kind of influence did they have on you?

Rif: I already mentioned my mom told me, ‘Go to medical school.’ My father was a civil engineer, and my mom actually never went to college. Her sister was a physician, but she [02:00] herself never went to college. I was actually born in Egypt. My mom, of course, was Egyptian, and it's a traditional sort of society, and she was an attractive woman, and if you’re an attractive woman, you don’t have to go to school, right, because you get to marry. So her parents never supported her going to school, although she had 3 sisters, and actually 1 went to college, 1 became a physician. So it wasn't that the parents were so against a female going to school, it was that my mom was an attractive woman and she didn't have to go to school. But, she had always admired education and thought education was important. And wanted her kids to get a good education. And all of us, of course, went to college. My brother became an engineer. [03:00] My sister studied religion. She taught in college up in Chicago. And I went to medical school. The only role model I had was actually my uncle. I guess it would be an uncle-in-law, my mom's sister was a physician and she married a physician. And, unfortunately he actually also recently died just a couple of months ago his name is Dr. Farris, Nagib Ferris, and he actually saved my life when I was born. I had aspirated my own meconium. And he was the doctor in charge of my recovery. The OB Doc, of course, just did the delivery, and of course, this is Egypt and you don't go to a regular hospital. You just sort of are treated in private clinics, and so the person that oversaw my recovery was my uncle. As I grew, and went to medical school, it was [04:00] very gratifying for him, sort of, the circle getting completed; he's the last person in that generation. And he died a couple of months ago.

Ethan: Sorry to hear that. Yeah, I'll go out on a limb here. I didn't see it this way at the time, but when I was 16, my mother passed away after a in-and-out remission-relapse of leukemia, and, you know, I struggled with it for a long time, but as I've gotten older I think it really does now help give me a lot more perspective than I ever would have had. (Rif: Yeah), and it's a hell of a trade off. There's definitely still, you know, especially with having 2 young ones now, the desire for them to be around and experience that, but there's always that flip side of the coin, that it does drive your perspective, and it makes you appreciate what you do have, so.

Rif: Yeah, adversity is actually quite underappreciated as an important [05:00] factor in giving us, really comfort with our lives.

Ethan: Yeah, if you think about them creating the words, happy and sad, or whatever variations on them, they had to come together. Neither of those come isolated, and I think our society now drives, I should be happy all the time, but if you were, your whole baseline for happiness would be skewed much further in that direction.

Rif: You can't actually appreciate happiness. By appreciate, I don't mean recognize, literally appreciate, because if all you have is happiness, you can't ever realize how lucky you are.

Ethan: The freedom that you allow your students and residents to have, do you think that comes from Dr. Wyatt?

Rif: He certainly gave me a lot of freedom.

Ethan: You always gave us more freedom, even if you didn't agree with what we were doing, you would allow us, as long as there wasn't going to be harm to the patient; that empowers students and residents, and helps them to [06:00] learn a lot more than when you're just dictated to.

Rif: There is also another aspect to that. In the field like psychiatry, decision-making is really difficult. You have to be cautious to never get to the point where your arrogance really interferes with your judgment. And, people can see things that you can't see, and it's not necessarily a matter of experience or knowledge. It just has to do with point of view. My students teach me all the time and it's one of the reasons that I really enjoy teaching, not because I teach, but I learn.

Ethan: You hit on a couple of the only bargaining points that I have with a, usually a hypomanic patient, because when people are severely manic, bargaining goes out the door, but the bargaining chips of untreated, this can damage your brain tissue. And also, there are 2 sides [07:00] to this illness. We call it an illness, but there's also this huge association with creativity, imagination, and you can run down this long list of really influential artists and other creators that have driven the world forward, towards progress, and part of that I think is because of the way that their brain works, the connections that they're able to make, that those of us without bipolar illness, just don't have the biological capability of making.

Rif: Having a mood disorder gives you a couple of advantages, one is what you touched on, which is just being able to make associations that you cannot make in a more traditional way of thinking, if you will. But the other is actually the illness itself. Because when you're manic or depressed, you actually view the world [08:00] through very different eyes. Imagine, for example, you're looking at a bird. And you can look at the bird from the ground, you're depressed and you're looking at it's belly. You're manic and you're looking at the bird from above or you're euthymic and you're looking at the bird from the side. And now, all of the sudden you actually are able to understand the bird in ways that people who are just looking at the bird from the side can't understand because you're seeing things, experiencing things that folks who are euthymic all the time, we'll say, which is the majority of folks, can't really comprehend. So the emotional aspect of things also drives imagination. And I think, of course, Kay Jamison probably is the person that has sort of talked about that the most in her work [09:00]. Touched with Fire was mainly about Vincent Van gogh, and she's written about several authors, in addition to her books about her own experiences. So, I think the disease itself gives people the opportunity to see the world in a way that folks who are not diseased are unable to do.

Ethan: Do you have any disclosures?

Rif: Oh, yeah. It's interesting how science changed. The scientific world I grew up in the 1980s, 1990s, where I was still a young clinical scientist. In those days, it was actually encouraged for clinical scientists and academics to work with industry. The idea was that the collaboration between academicians and industry was going to make our field grow, our solutions grow, our [10:00] knowledge gets integrated, which is absolutely true. And I'm not sure exactly when that whole idea became corrupted. But at some point in time around the turn of the century, the idea that if you're working with industry, you were somehow contaminated. Industry is driven by profit and if you were working with industry, then you were, again, contaminated. You didn't think about science in the same way. And so, there's a really false impression about potential conflicts of interest. And, I'll tell you the major conflict of interest is actually not that you work with somebody who has a different point of view, and different drives. The major conflict of interest is actually not doing that. It's actually [11:00] having prejudice against people who reach out, if you will, I'm going to use a political analogy, across the aisle. I think that goals of finding solutions to disease are the same. 1 person wants to make money off of it, the other person wants to treat their patients with it, but the goals are still the same. You and I might share a car to go up to Chicago. And I might be going to a concert and you might be going to work. That doesn't mean that it's somehow we contaminate each other in the car ride going to Chicago. We're going, we are sharing the same goal. So that's a very long winded way of saying that I don't see these as conflicts of interests, but I find that the best way that I learn about something is to speak to the people that know [12:00] the most about that. And when new medicines come on the market, the people that know the most about the new medicine are usually the scientists working with the company that created that medicine. I have reached out, for my entire career, to industry, and I've been funded by industry to do all sorts of clinical studies.

But right, now I have a lot of relationships, funded by a company called Sunovion, we're actually doing a study with bipolar illness, with a drug that isn't on the market that they have developed, and that study is ongoing. I just came off of doing a study for a company called Janssen, with a long-acting, injectable anti-psychotic. So, I have these situations where they've given me money to do either their studies or my own studies. In addition to that [13:00], I'm a speaker for several companies. What we do as speakers is really educate. So, I see it as an extension of my university position. The university doesn't see it that way, but I see it as an extension because instead of teaching students or residents, I'm actually teaching folks that are out practicing. And, in this particular case, I'm teaching them very specific things. As a speaker, I talk about maybe a specific drug for a specific indication, and specific disease. I don't see that as bad. I see actually it as good. I speak for gene testing company that makes Genesight (Myriad Genetics). I speak for Axome, which is a new company that developed a new antidepressant, Lundbeck, Otsuka, Janssen, Novin, which makes topical medications [14:00], Teva, which is an Israeli company, started out as a generics company and is trying to get into developing its own drugs, Intra-Cellular, which is a company that was actually set up by a Nobel Prize-winning neuroscientist, Paul Greenard, who got his Nobel Prize for figuring out how dopamine works, what it actually does inside the cell, and named his company, Intra-cellular Therapeutics, so I'm a speaker for them as well.

Ethan: That's a really good point. There has to be nuance when we talk about things like disclosures or conflicts of interest because, human nature, we have this desire to create order in our world. It makes it to where I want to know, is the industry bad or are they good? When, the reality is that clinicians and industry are necessary bedfellows [15:00] and yes, there is corruption, but a few bad apples does not mean that we can separate the 2. There's got to be a lot of nuance and we've got to try to drive that with the American public, because I don't think it's good to believe everything that comes out of industry's mouth, and I don't think that it's good to just say everything that industry does is evil and corrupt.

Rif: It's absolutely not evil and corrupt, but you're absolutely right. One of the things to understand is the data is the data. It's how you interpret the data that is really important. And what separates a good scientist from a bad scientist isn’t not understanding the data, although that sometimes happens, it is not understanding what the data is telling you.

“If all you have is happiness, you can't ever realize how lucky you are.”

         -Rif El Mallakh