A Paradigm of Wholeness

Offering Medication as the Primary—And Often Only—Treatment Isn't Working

Henry Emmons

More than 30 years ago, I chose to go into psychiatry because I’d always loved the humanities, creative problem solving, and collaborative teamwork. After earning my degree, I was thrilled to be hired by a staff-model HMO, where I had great colleagues, visionary leaders, and many grateful patients, whom I loved helping get better. But my role as a psychiatrist was clearly defined there as a medication prescriber, nothing more.

Feeling deeply that something was missing in how I was practicing, I left the HMO after five years to work in a primary care system, staffed with a progressive group of family physicians and nurse practitioners. I thought this would allow me to work more holistically. Instead, I felt isolated from my mental health colleagues and entirely overwhelmed by the demands for—you guessed it—medication management.

The kind of psychiatry I was practicing back then—the same kind I saw practiced all around me—was not what I’d envisioned when I’d chosen to be in this field. Through forces outside of my control, but with my passive consent, I’d unintentionally become a psychopharmacologist. My role was to make rapid assessments, do crisis management, prescribe medications, and manage those medications and their side effects. For psychiatrists, the 50-minute therapy hour had become the 15-minute med check.

I knew I needed to do something about my work. But what? I felt as if I was walking in a slot canyon, and with each step the walls were getting higher and the path narrower. If I kept going, I feared I’d become entirely stuck. How did it come to this? I wondered. And what’s the way out? I didn’t want to stop seeing patients, but the work seemed so soulless. Is it still possible to blend science with soul? I asked myself, realizing that’s what I wanted to do.

The Need for a New Psychiatry

Today, medication management remains the primary role of most psychiatrists. In my view, it’s not working well, either for our patients, or for ourselves. My patient Shelly is an all-too-common example of what I see every day in my practice. Twenty years ago, she left her well-paid but stressful job so that she could be at home with her three young children. At about the same time, her family moved to a house that needed a lot of work, and her husband unexpectedly lost his job. She was overwhelmed with anxiety, which morphed into depressive symptoms.

Shelly began seeing a therapist who referred her for a medication evaluation. She was prescribed the SSRI citalopram (Celexa), and her symptoms improved. But after a few years on citalopram, she felt increasingly sluggish and emotionally flat. Wellbutrin was then added to boost her energy and mood. She stayed on that combination for 15 more years. She gradually gained weight and never felt very happy or energetic, though her mood was stable. Then about three months ago, she abruptly went off both medications. At first, she felt better, but by the time she’d come to see me, she was feeling more anxious and depressed than ever.

Medications, if needed, should be used briefly, while these other measures take hold. But that’s not how they’re commonly used today. Like Shelly, more and more people are taking antidepressants long-term and not being guided toward dealing with the sources of their stress.

Let me be clear: I believe there’s a role for medications in treating all forms of depression. However, offering them as the primary—and often the only—treatment for years and years is simply not working. And that’s what we’re doing on a very large scale. We’re in the midst of a massive, uncontrolled experiment with prescribing, and the outcome doesn’t look good. Recently, the National Health and Nutrition Examination Survey showed that about 35 million American adults took antidepressants between 2013 and 2014, nearly half of them for longer than five years. It would be one thing if that were the end of the story, except millions of people stay on meds long-term, even when they stop working, or, as is sometimes the case, make things worse.

It may take a few months to show up, but several common side effects that develop from long-term use of medications can easily be confused with ongoing depression: flatness of mood, low energy, weight gain, apathy, loss of interest in sex, and lack of motivation, to name a few. I often interpret these problems as a sign that the medication dose is too high, but I fear many clinicians see them as signs of ongoing depression and respond, as with Shelly, by prescribing more medication.

A New Psychiatry

After a bit of meandering, I’ve found my professional home in Partners in Resilience, an integrative clinical and teaching entity, where I collaborate with several therapists, an integrative nutritionist, a health coach/spiritual director, yoga teachers, and others. We offer resilience-training programs for adults, teens, and health professionals, as well as holistic, integrative work with individual clients. It’s where I do my clinical work, which I now approach in a new way. There’s more joy in it for me, for sure, and I believe there’s more joy in it for my patients.

Begin with a Paradigm of Wholeness. It’s hard to imagine a health condition that affects more aspects of the human condition than depression. And I now work from a model, developed over many years, that delineates three stages in the path from depression to joy: nourish, move, awaken.

Stage one of nourishing involves providing whatever is needed to return to a healthier state. I think of it as the recovery stage, where what’s been depleted is restored, stress-management skills are learned, and patients begin to shift from isolation to connection with others. In our program, we use diet, nutritional supplements, and medication to address the physical; mindfulness skills to address the mind and emotions; and practices like metta meditations and group experiences to open the heart.

Stage two of moving shifts from recovery to prevention. Hopefully, most of the original symptoms have resolved enough at this point, allowing the patient to take action—wise action—to create more lasting and meaningful change. This includes physical movement, like walking, yoga, or breathing practices, but also creating movement in stuck mental and emotional patterns. Good psychotherapy is part of this stage, and so are groups or classes devoted to deepening mindful awareness, self-acceptance, and the cultivation of positive emotions, such as gratitude and compassion.

Stage three of awakening I consider the thriving stage. One can awaken the senses and enhance their capacity for pleasure, the mind’s curiosity and creativity, and the heart’s capacity to learn how to love well and live more authentically. Some may say that this isn’t the purview of the mental health profession, but I’d argue that going beyond a return to baseline functioning to a state that more resembles joy can be a necessary protection against depression’s recurrence. I believe it should be an essential part of our work.

Offer Individualized Solutions. I think we tend to see depression as a singular condition, but it’s not. If our diagnostic labels were more sophisticated, we might be better at identifying the underlying causes for each individual’s depression and then offering specific recommendations best suited for that person.

I see depression as having three different patterns, or subtypes. Most patients fall into one category, but sometimes they have features of two, or even all three: anxious mood, agitated mood, and sluggish mood. The anxious mood is the most common pattern, in part because it’s driven by stress. It often represents an adjustment disorder, rather than outright major depression. People in this category often have trouble sleeping, especially falling asleep, become easily overwhelmed and reactive to stress, and feel insecure or insufficient. They tend to withdraw and find it hard to put themselves out into the world.

The agitated mood is often missed because people don’t usually come to your office and say, “I feel agitated.” They describe their mood as “bad” or “depressed,” and you have to ask questions to tease it out. This is important because agitation can increase the risk of self-harm or suicide, especially when first starting an SSRI antidepressant. It’s characterized by an edginess to the mood, as well as anger or irritability, often accompanied by physical restlessness and impatience. Sleep is a common problem here as well, but the pattern is more often waking in the middle of the night and ruminating, sometimes for hours.

The sluggish mood best fits with what used to be called melancholia or melancholic depression, where people have a hard time getting out of bed or off the couch. The mood may be sad and down, or just flat and apathetic. The mind can feel lethargic, and it can be hard to get motivated or to experience pleasure. Sleep may be excessive, and getting up in the morning can be difficult.

Don’t Forget Your Own Self-Care. I almost burned out earlier in my career than most, but I clearly wasn’t alone in how I felt about my work at the time. I didn’t see much joy in my colleagues, either. A recent Mayo Clinic survey bears this out. It found that 54 percent of physicians now show signs of burnout. The reasons for this are complex and include long hours, changing reimbursement, and a sense of loss of control over one’s practice. Also, I believe it reflects a lack of meaning and purpose in the day-to-day work, and I don’t think we’re good at practicing what we preach: we don’t attend well to our own self-care.

It isn’t easy to sustain oneself for a career of service to others. Relieving human suffering from mental and emotional distress is an enormous task and responsibility. None of us can do it alone. We need each other for support and inspiration, continuing to expand our thinking and capacity to do our work in the fullest way possible. When you find your right fit for practicing, and the right place to do it in, you may realize that Thoreau had it right after all. Maybe joy is the condition of life.

***

This blog is excerpted from the article, "The New Psychiatry," by Henry Emmons. The full version is available in the July/August 2018 issue.

Listen to an interview with the author and the Networker's Lauren Dockett:

Henry Emmons, MD, is a psychiatrist who integrates mind–body and natural therapies, mindfulness, and neuroscience into his clinical work. He practices with Partners in Resilience in Minneapolis, and is a cofounder of NaturalMentalHealth.com. He’s the author of The Chemistry of Joy, The Chemistry of Calm, and Staying Sharp, and a workshop and retreat leader for both healthcare professionals and the general public. 

Lauren Dockett is senior writer at the Networker.

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Illustration © Roy Scott

Topic: Professional Development | Psychopharmacology

Tags: alternative medicine | antidepressant | antidepressants | anxiety and depression | buddhist meditation | burnout | clinical psychopharmacology | coping with depression | Depression & Grief | Diet & Nutrition | guided meditation | Holistic medicine | integrative mental health | medication | meditating | mood disorder | mood disorders | Mood Problems | motivation | nutrition | nutrition and therapy | overweight | prescription medication | Prescriptions | psychiatrist | Psychiatry | psychopharmacological | Psychopharmacology | relapse prevention | self-care | stress reduction | wellness | Wellness programs

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2 Comments

Saturday, July 28, 2018 9:54:01 AM | posted by Beth Craft, LCSW, LMFT, LAC
Great article. Thanks for all you are doing in your field. I strongly support a holistic approach in treating shared clients/patients. My specialty is in offender populations and addictions and most have not encountered anything close to holistic in their lives much less healthcare. I strive to teach holistic approaches in my practice. Again, thank you for addressing the needed changes.

Tuesday, July 17, 2018 6:18:47 AM | posted by Karanita Boling, LCSW
This would be the ideal solution would it not? Or at the least one where the therapist and prescriber could work together collaboratively. It would be as if the prescription would include such things as yoga,or meditation, or mindfullness. Just as an Orthopedic surgeon and physical therapist work together to heal a bone or joint. With the ultimate goal being no medication, and the return to optimal functioning.