What Does the DEA Drug Trafficking Report Really Mean?

 

The DEA just published a significant report on the drug threat in the United States. I read the entire document and will review a few of the high spots here highlighting why it is not too relevant for most parts of the country.  I am on record in several places on this blog making similar comments. My basic argument has not changed significantly and that is that the demand for illegal and often fatal drugs is driven by the culture in the US and I would not expect law enforcement to make much of a difference. The case in point is Prohibition and the ban on alcohol.  Of course it was not a real ban.  Criminals still bootlegged alcohol into the country, religious groups found a way to circumvent the law, and there are always people producing illegal alcohol as a significant percentage of alcohol consumed every year.

These facts are most often distorted into the argument that Prohibition or any War on Drugs is doomed from the outset. That argument is most frequently used to implicitly suggest that any attempt to legally restrict intoxicants will be righteously overcome by people with a natural right to pursue intoxication.  That is extrapolated to practically any scenario short of negligent homicide due to intoxication or drug dealing. But even the drug dealing scenarios are being rapidly modified to allow possession of certain amount of cannabis or in some cases legitimizing drug dealing as a useful occupation. The direct and indirect costs of drug use to both individuals and society are typically ignored by anyone without a medical or public health interest. Intoxication is a cultural right, a right of passage, and every effort of being made to expand the availability of intoxicants to everyone in the US.

The DEA (1) states their role is to expand awareness, preserves lives, and provide intelligence to law enforcement that might be useful for resource allocation and prioritization.   Synthetic opioids and stimulants are described as the biggest threats.  Both can be easily mass-produced by the cartels in Mexico.  Fentanyl alone has accounted for a massive increase in mortality due to its potency and low therapeutic index – accounting for 74,225 deaths in 2022.  China is implicated as the main source of precursor drugs to produce fentanyl.

The report clearly states that two Mexican cartels are responsible for the drug flow into the US and the most significant drug crisis in the history of the US.  Further – the cartels have penetrated most states in the US to varying degrees.  The Internet has facilitated drug sales in the US and made these transactions more difficult to track.  The cartels are also producing methamphetamine leading to an increase in stimulant associated deaths.  There is also a China connection.  Chinese criminal operations supply precursors for the synthesis of opioids and methamphetamine as well as money laundering operations to make the money from illegal drugs sales useable. 

One of the strategies these criminal enterprises are using is adding additional intoxicants to the drug that users are purchasing.  This has the effect enhancing the intoxicating effects but with a much higher risk of overdose and death – especially if the user is naïve to that drug or the seller is ignorant about the potency of the additional intoxicant.  I became aware of this phenomenon about a decade ago when I was being told that users witnessed fentanyl being pressed into alprazolam tablets and sold as alprazolam.  A secondary phenomenon was that many people were not averse to fentanyl but actively sought it out to enhance the period of intoxication.  The DEA report describes the following combinations:  

Fentanyl plus:

Heroin, cocaine, methamphetamine, xylazine, Counterfeit prescription drugs: (oxycodone (M30, Percocet); hydrocodone (Vicodin); or alprazolam (Xanax)

 

The DEA report addresses many of the logistics of the substance use problem and it does raise awareness – especially of the dangers of getting adulterated drugs and the severe side effects including death. It also highlights drug counterfeiting and it gives a great example of an Adderall tablet counterfeited from methamphetamine (see below).  That is especially problematic during a time of Adderall shortages from legitimate suppliers.

 

The unaddressed problem is American culture.  I don’t want to suggest that large groups of sociopaths intent on making money no matter how many people they kill don’t bear some responsibility. I also don’t want to suggest that reducing the availability of these drugs by any means is not a good idea.  But one of the takeaways from reading this report is that law enforcement is clearly not winning and it is a huge burden on them in both the US and Mexico.  Former President of Mexico Vincente Fox characterized the problem well as “America’s insatiable appetite for drugs.”  Right now, it is a multigenerational chronic problem. People can get effective treatment and recover but too many die and too many become chronic users. There needs to be an effective strategy for primary prevention or preventing use in the first place. Suggestions along these lines typically end up caricatured as the 1980s “just say no” public service ads or the "failed war on drugs", but this strategy was clearly effective in reducing cigarette consumption and decreasing the population of smokers. It has had the expected effects of decreasing smoking related mortality in both the general population and in smokers who quit.  The same population-wide benefits would be expected from any public health measure that effectively reduced the use of alcohol, stimulants, opioids, cannabis, or any other intoxicants.  What are the cultural factors that keep this drug epidemic going?  Here are a few:

1:  Cultural acceptance of substance use as a rite of passage:  The stories are endless. Fraternity and sorority hazing involving excessive alcohol use.  High school graduation parties associated with multiple driving while intoxicated deaths. Incarceration from assaults and homicides from barroom fights. Consumption of alcohol and other intoxicants in high school well before the legal age for consumption has been reached. Much of this has to do with immaturity.  The Decade of the Brain did inform us that just on a biological basis human brains do not mature until the mid 20s and in the case of men possibly even later. Immersing an immature brain in intoxicants is generally not a recipe for success and may be a developmental risk for substance use disorders and mental illnesses.

2:  Consumerism and the selling of intoxicants:  This is a widespread phenomenon in the US.  Alcohol commercials typically suggest success, sexual attractiveness, popularity, sophistication, and glamour.  Identification with Hollywood A-listers is a plus and many of them are marketing their own brands to capitalize on that fact. The expensive packaging is often more significant than any difference in taste or quality. The only downsides are a very brief allusion to the Surgeon General’s warning about alcohol use in pregnancy or a disclaimer to “use responsibly.”  Not much about alcohol poisoning, cancer, cirrhosis, pancreatitis, cardiac problems, dementia risk, or substance induced psychiatric disorders. For a long time alcohol was hyped as a heart health beverage.

3:  Your right to intoxicants:  The subculture of users has a mixed agenda in promoting this idea.  There are a few people who believe that their lives are better by using drugs or alcohol, that they are using these substances in a controlled manner and “not hurting anybody.” And therefore, anyone should have the right to use them under these conditions.  On the face of it – few people would argue that point – even though it does assume that self-report about use and its consequences are always accurate.  A subgroup is promoting widespread intoxicant use as a business.  Many in this group see it as a get rich quick scheme. Many see it as a diversity equity inclusion (DEI) issue.  That is – minority groups sustained harm from excessive legal penalties against cannabis and other drug possession and therefore they should be given advantages in setting up businesses that profit from legalization.  Many want to extend cannabis law changes to include all drugs and legalize access to everything. The DEA report stands in contrast to mass legalization because it estimates how much the country would be awash in fentanyl if it was legal. It also ignores why substances were controlled in the first place and what happened when physicians started to prescribe more opioids both as "dope doctors" in the early 20th century maintaining people in addiction and in the late 1990s leading to the beginning of the current opioid epidemic.

4:  Cannabis misinformation:  There has not been much reflection of the medical cannabis period of the early 21^st century.  Cannabis was touted as a miracle drug whose benefit was being neglected due to archaic drug laws and the lack of modern research. Nothing was said about cannabis being around for over 700 years and having no clear cut indications for use or the fact that earlier cannabis compounds fell into disuse with modern therapeutics. That led to a patchwork of state-level medical cannabis laws, making each of those states a Mini-FDA with their own indications for use and in some cases limited forms of cannabis that could be dispensed for those indications.  Just as it became apparent that cannabis really was not much good for medical applications or even pain – the real motivation for the medical cannabis Trojan Horse became apparent.  That was of course recreational use. The Biden administration is currently considering rescheduling cannabis from a Schedule I to a Schedule III substance. That takes it off the experimental/no medical application category but still suggests that it will be prescribed and supervised by a physician.

5:  Widespread promotion of hallucinogens and psychedelics as miracle drugs: Building on the success of promoting cannabis as a medicine – we are now seeing frequent hype about the wonderful effects of psychedelics along with practically no discussion of the side effects. MDMA and LSD are being seen as wonder drugs that successfully treat depression, anxiety, PTSD, and substance use disorders. The cannabis promoters successfully promoted cannabis as a nearly completely benign substance and the hallucinogen/psychedelic promoters have used the same tactic.  I only recently read an account where the following side effects during a clinical trial of an LSD based drug were listed: illusion, nausea, euphoric mood, headache, visual hallucination, mydriasis, altered state of consciousness, anxiety, blood pressure increase, and abnormal thinking (all in significant numbers). In my clinical experience I have treated people with permanent side effects from this drug class after a single dose.

6:  Better living through chemistry:  There is a current wave of euphoria in the popular culture about GLP-1 agonists like Ozempic and Monjauro. It has been accompanied by FDA approved indications but also a very public reexamination of the usual prescriptions of diet and exercise for weight loss. The pendulum seems to have swung to the point that all excessive weight is a disease state that can only be approached with a powerful drug that has potentially powerful side effects.  From a cultural perspective this class of drugs reinforces the American dream that we can tune our bodies like we tune our cars and if we have the right drugs – we can have whatever kind of body or mind that we want. More longstanding evidence of this attitude is evident from anabolic androgenic steroid use and stimulant use for - both for performance enhancement.  All three are grand illusions. Hominid biology has evolved to incredible complexity over the past 2 millions years.  Any group of people may look alike but there are hidden differences in physiology and pharmacological response. One person’s medication is another person’s poison. As a result there are very few miracle drugs and some intoxicants have been around for centuries making it even less likely.

7:  Sobriety as a subculture:  In most societies certain religions and life philosophies are the most likely promoters of sobriety.   Most sobriety in the US is not thought about too much.  There are about 60% of people who never drink. There is a group of people in active recovery who had a problem with intoxicants and were successful in discontinuing them.  There is a small movement right now of young people who are not in recovery promoting sobriety.  The cultural resistance against substance use in the US seems trivial compared with the promotions.

8:  Treatment is secondary prevention: A standard political approach to the drug epidemic these days is to suggest that more availability of treatment centers and providers is a needed approach.  This is correct in so far as treatment for these conditions has always been deficient. Treatment has had a role in terminating localized drug epidemics in both Chicago and Washington DC.  There is a question about how well it will work now that just about every county in the US is awash with opioids and methamphetamine.   A logical approach may be to prevent new users from entering this cycle – in other words decreasing the incidence of the problem. Unfortunately there are fewer resources to address this problem and a lot of pessimism about that approach.  

9: Intoxicant use is a choice: Even though there is obvious evidence out there that a significant percentage of the population develops uncontrolled use of drugs and/or alcohol denial and rationalizations about this continues to persist. It has to in order to maintain the myth that people with substance abuse disorders really have a moral defect rather than a biological propensity.  In other words – repeatedly telling them to stop and blaming them for the problem is all that is required. That approach ignores the real problem that if you are biologically disposed – all it takes is access to substances to keep that process going. The moral approach also allows for a legalization position by simply stating that the people who cannot control their use are irresponsible.  

10:  Deaths of despair: This concept was popularized by Dean and Case (2) to explain increased mortality due to intentional injury and drug overdoses caused by hopelessness due to economic problems and the associated stress. Deaths due to alcohol and drug use were seen because of economic stress rather than a consequence of excessive use for other reasons including the cultural factors that have been specified. The concept minimizes the fact that severe alcohol and drug problems exist in populations that have no economic stress and that most of the people with severe economic stress do not have drug and alcohol problems. It also minimizes the fact that we are still in the midst of a multi-decade drug epidemic and there is no end in sight.  

11:  Legalizing drugs will put the cartels out of business:  This has always been an extremely naïve argument.  Alcohol and tobacco sales are legal and taxed but that does not prevent their illegal sales.  Prescribing opioids, stimulants, and benzodiazepines does not prevent their illegal sales.  The DEA report highlights continued involvement by organized crime in cannabis production and sales - even after it has been legalized. Illegal production has led to violent crime and adverse environmental impact.  These same organizations are currently producing counterfeit name brand pharmaceuticals.  There is no reason to expect that legalizing very high risk drugs will stop criminals from producing or selling them.

12:  No education about who may be at higher risk:  To an addiction psychiatrist seeing people after acute events the risks are obvious.  People who use intoxicants and get extremely euphoric or aggressive to the point that it impairs their judgment are clearly at high risk and should consider not using them at all. Unfortunately that self examination often does not happen until there has been a life changing event.  People with a strong family history of substance related problems are another high risk group.  Some individuals come to the conclusion that intoxicants are too risky for them to use.  I have heard this in many psychiatric evaluations: "My father and his father were alcoholics.  I knew I should probably not drink on that basis."  But this knowledge does not seem to be widely disseminated.  

Where does all of this leave us?  Not in a very good place. The DEA is describing its efforts to intercede in what is a massive effort originating from several countries to import highly dangerous substances into the United States. Although it is never overtly discussed this is clearly a national security problem. The immediate problems of deaths and morbidity from drug addiction seem to depend very little on how successful the DEA is in its efforts. The reason for that is the massive promotion of drugs at the cultural level both in direct advertising and false political philosophy equating drug use with freedom. It parallels the use of the Second Amendment to promote the widespread dissemination of firearms – even though there is no similar amendment for drug use. All the popular myths about drug use need to be actively countered and the advantages of a sober life need to be promoted. Those myths are a more subtle but equally dangerous threat to what the DEA is describing in this report.   

 

George Dawson, MD, DFAPA

 

References:

1:  Drug Enforcement Administration. National Drug Threat Assessment.  US Department of Justice.  May 2024.  57p.

2:  Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015 Dec 8;112(49):15078-83. doi: 10.1073/pnas.1518393112. Epub 2015 Nov 2. PMID: 26575631; PMCID: PMC4679063

The Retired Consultant Redux – A Conversation With Two Internists

In retirement I run into colleagues who are interested in the process and how it is going. I was greeted with a “How is my favorite retired psychiatrist” yesterday. It originated from a highly qualified subspecialist who was immersed in hospital work when I first met him. We talked briefly about his changing roles over the years going from hospital based acute care practice, to an outpatient specialty practice, to his current role of tertiary consultant seeing the most difficult problems in his field. I told him that was the role I miss the most – seeing the most difficult to diagnose and treat cases and being the one to figure out what to do.

It is not an easy life – especially if you are as neurotic as me.  It involves constant research and revision of approaches. It involves close follow up.  It involves sleepless nights and anxiety.  It involves balancing innovation against not wanting to make a mistake.  Sometimes it involves convincing other people to go along with you when they may be reluctant. It also involves tolerating the suffocating routine of excessive documentation and jumping through unnecessary administrative hoops as well as the occasional overt harassment. But in the end – you end up being a physician that both your patients and colleagues can count on and that’s something.

We discussed the nature of treating these populations. He told me he likened his practice to neurology because of the reputation that the level of esoteric diagnoses are not matched by esoteric treatments and often there is not much that you can do. I never understood this degree of pessimism.  I have been confronted with people who told me their last doctor told them: “Look there is nothing more I can do for you.”  And we were able to make some progress.     

Finally – we discussed the 2 year milestone and how many people leave retirement and have to go back into active practice at that point.  He made the observation that this seems to happen across professions where possible – and it seemed to depend on attitudes to retirement and whether you had anything to do.  He did not think retirement would be a problem.  I estimated he had about another 8-10 years of practice left.  I had my usual thoughts about all of the people I knew who never made it to retirement.  I also thought about retirement from physically taxing work and the problems that involves - not the least of which is adjusting caloric intake to prevent excessive weight gain.  

The second conversation was more technical. It was an opinion about gabapentin.  The patient in question was taking it long term for back pain and had a history of back surgeries. More recently she was on diuretics and other medications for atrial fibrillation and congestive heart failure. She was seeing several specialists and they were dutifully getting all of the correct labs but nobody seemed to notice the gradual increase in creatinine to 1.7 and 2.4.  That correlated clinically with increasing somnolence, ataxia, and falls.  After reading the package insert on gabapentin he called me to discuss a dosage adjustment with renal insufficiency.

I recalled a healthy young man I was treating who became acutely confused and ataxic after he was started on simvastatin by a consultant. In psychiatry, this scenario raises suspicions of intoxicants even in a hospital setting. But given the circumstances I decided to also look for a cause of delirium.  The acute labs showed that he had acute renal failure as an idiosyncratic reaction to the statin and he was transferred to medicine to treat the problem.  The acute renal failure led to the accumulation of gabapentin and the delirium and ataxia.

As we discussed the cases, the internist pointed out the difficulty with today’s fragmented medical care.  All of the medication were ordered and the labs were done – but nobody seemed to be paying any attention to how the patient was doing. It reminded him of a quote from one of his mentors George Magnin, MD who used to say to his Medicine residents: “What are you going to do until the doctor gets here?”

That quote struck me as genius both as a motivating factor and the immediate reality of the situation. When you are confronted with a patient who is having a problem – you need to be able to do something about it. That doesn’t mean that you will always know what to do – and if you don’t you at least need to know how to triage the problem so that the patient gets the correct care.  We try to increase the likelihood that will happen by specialization, subspecialization, and settings to match the illnesses with the specialists, but those matches are far from perfect.

I had this experience to illustrate.  I got a call from an emergency medicine physician who was seeing a patient I was treating for bipolar disorder. I knew him and his family very well from years of treatment. The ED doc wanted me to hospitalize him for acute mania but his wife who was with him said he was not manic and she did not want him admitted to a psychiatric unit.  After a brief description of his symptoms I said: “Put him on the phone so I can talk with him.”  Within 30 seconds I could tell he had a fluent aphasia with paraphasic speech errors.  When the ED doc came back on I told him that this was not mania – but most likely an acute stroke syndrome and he was hospitalized on Neurology where the stroke diagnosis was confirmed.

“What are you going to do until the doctor gets here?” – means that doctor.  The one who can diagnose and treat your problem.  That is the one that matters.  In this era of health apps, checklists, self-diagnosis, electronic health records, telemedicine, and so-called artificial intelligence that is still all that matters.

Being that person is hard to attain and hard to walk away from.

 

George Dawson, MD, DFAPA 

Image credit:  Wikimedia Commons per their CC licensing the details of which are available by clicking on the graphic.

Additional:  The identities of the physicians were anonymized in this post. I doubt that any physician benefits from being associated with me or this blog.

Rick Sings - poetry by Phill Taggart

“Well I woke up this morning and I had myself a beer.” Roadhouse Blues (1970) Jim Morrison Lyrics The Doors Composition

Many years ago, I was asking a patient about his morning routine and he replied with the Roadhouse Blues lyric and started laughing. At the time he was taking medications that I prescribed but also seeing a naturopath who was giving him a complex solution of minerals that was supposed to treat his mental illness. His family was more concerned about him than he was concerned about himself.  Severe mental illness leaves a person focused on irrelevant pieces of information out in the environment for amusement/entertainment/meaning while ignoring the basics – like self-care and not standing out too far in public.  Clinicians refer to some of that as inappropriate social behavior, but it is a complex multi-layered problem. The same process can result in a great deal of difficulty staying focused on the necessary day-to-day routine. In that mix, there are boundary problems that can contaminate the most altruistic impulses and affect personal safety.  Phil Taggart does a great job of painting that picture in his book of poetry Rick Sings.

In a brief introduction we meet his brother Rick.  Rick has a severe mental illness that clearly affects his ability to function. I am writing that after reading the entire book and all the poetic descriptions. We find out that Rick has a lot of problems in living, managing his self-care and medications.  There are times when he is not eating well, where he is in an agitated state, where his hygiene is affected, and where he puts his housing security at risk by taking in women who have lost housing or were the victims of violence. His brother is a force to help keep him on track and check in with him.  Those encounters are the basis for this book.

The first images we get are family chaos – the product of mental illness, alcoholism, aggression and violence, and the death of a young sibling.  Rick’s modern-day world is tied in with that early history. Here are two stanzas from the poem Morning Coffee

 

The rest of this poem has stark images of people who come into your life and leave with you liking or not linking them or yourself along the way.  At some point it is hard to know if the memory is that sad or current sadness clouds the memory.

I recently read an essay on how art can be rhetorical in the persuasive sense. This poetry consists of observations and emotions that the imagery elicits. There is no hint of bias – only the empathy elicited by images and situations.  I had not thought of this before but Taggart’s poetry is the perfect medium to communicate the major problems facing people with severe mental illnesses and anyone trying to help them. You can’t help being pulled in when he advises his brother to stay away from the police for his own protection or when he has to let a security guard know that “he’s with me” to avoid awkward social situations.

There is a stream of consciousness flow to the poetry with associations across the lifetimes of Taggart and his brother. I liked this feature because it is the way a lot of people (including myself) think. Focus on the present and in some downtime – think about an event that happened in 1975. When your brother is in the picture – think about common events. Several of those themes run through this book of poetry and it is masterfully done.   No associated explanations – just a description of an event with a universal emotion.

I liked this book of poetry.  In keeping with my book reviews, I like the idea of conditional recommendations.  In this case – liking poetry will help.  It will even be better if poetry stimulates your mental imagery and emotions. I call the writing style of this poetry free verse like E.E. Cummings.  The phrases are also arranged differently on the page to emphasize different thoughts and actions.  If you like that style, you will like this book even more. Beyond liking poetry, this book will potentially help you understand the problem of severe mental illness and its effects on people and their families. Even though there are efforts out there to decrease stigma and attributing stigma to a lack of understanding of the problem – stigma has always been a problematic concept for me. If more people experienced what Phil Taggart puts into his poems there would be a greater understanding. He is a strong voice in this area.  Read this book if you are interested in a deeper understanding the problem.

 

George Dawson, MD, DFAPA

 

Reference:

Phil Taggart.  Rick Sings.  Santa Barbara, California. Brandenberg Press 2014: 67pp.  https://philtaggartpoet.com/

 

 

What The Economist doesn’t know about Psychiatry

It is always good to take an in depth look at articles in the popular press about psychiatry – because of the clear antipsychiatry bias. An article from the Economist was posted recently that seemed to get a positive reception in some areas.  In my estimation that reception was not warranted.  Interestingly the same principles of analyzing rhetoric can be applied to this article as the last post on this blog about “doing your own research.”  I will use the same concept by concept approach to examine this article that I used for that video.  At the time the article was posted I read it for free online and I hope it is still available so that any reader here can appreciate the full text.  The author was not listed.

1:  “But her local hospital, in Durham, England, was dismissive, suggesting she had anxiety, a mental-health condition, and that she was probably spending too much time watching videos on TikTok. Her mother describes the experience as “belittling”:

The author begins with a story about an autoimmune condition with many neuropsychiatric manifestations Pediatric Autoimmune-Neuropsychiatric Disorders Associated with Streptococcus (PANDAS).  This is a condition that is known within psychiatry for at least 25 years and is covered in major psychiatric textbooks.  The author proceeds to conflate the lack of a definitive diagnosis with deficiencies in psychiatry as if it is totally unknown in the field. It is not and the pathophysiology and neuropsychiatric manifestations are known and taught within the field.  Secondarily if I had to speculate on the medical specialists who are most likely to see people who are told by a physician or family member that “it’s all in your head” – they would be psychiatrists.  We tend to see more of these people than anybody else.  

2: And infections are one small piece of the puzzle. It is increasingly clear that inflammatory disorders and metabolic conditions can also have sizeable effects on mental health, though psychiatrists rarely look for them. All this is symptomatic of large problems in psychiatry.

Psychiatrists have always been more interested in inflammatory and infectious conditions affecting the brain than most other specialists.  Griesinger mentions inflammation as a mechanism affecting brain function in his 1845 text on psychiatry (2). It is highly likely that in any community - psychiatrists are making more of these diagnoses than primary care physicians because they know the manifestations and they need to rule out physical causes of mental illnesses to make a psychiatric diagnosis.  All psychiatrists are trained in making these diagnoses and not mistaking them for a mental illness occurring in a healthy person or a person with chronic illnesses not affecting brain function.  The only large problem here is the lack of knowledge about how psychiatrists are really trained.

Inflammatory disorders were used as treatments in the early 20^th century.  In the pre-antibiotic era, 5-10% of asylum admissions were due to neurosyphilis and the associated psychiatric manifestations. Some of the early treatments were based on inducing fevers.  Austrian psychiatrist Julius Wagner-Jauregg was awarded the Nobel Prize in Medicine in 1927 for successful treatment of neurosyphilis by inoculating patients with malaria (2).  This work was replicated and additional agents were used to induce fevers by other investigators with similar results. In addition to the experimental results, this represented a sea change in the general attitude of treating psychosis in asylums where a previous biological treatment did not exist.  Subsequent innovations occurred when neuromodulation techniques were introduced in 1932 (5) and psychopharmacology in 1952 (6).

The early focus on gross neuropathology and transition to microanatomy led to the discovery of Alzheimer's Disease in 1906 and Binswanger's Disease a form of vascular dementia in 1894.  Both Alzheimer and Binswanger were considered psychiatrists - Alzheimer by his own designation and training and Binswanger was eventually appointed to head an asylum by age 30.  

As far as "rarely looking for them" goes the top 4 medical conditions I diagnosed in newly seen patients were probably Type 2 diabetes mellitus, hypothyroidism, hypertension, and atrial fibrillation. Any psychiatrist practicing in the last 30 years is aware that psychiatric disorders and pharmacological treatment can be associated with metabolic syndrome and the need to monitor for and prevent that condition. 

3:  Chronic conditions are poorly treated – apparently because they are not cured (paraphrased):

This is always an interesting rhetorical sleight-of-hand. In what other specialty is the expectation that chronic conditions will be cured? It does not take a lot of research to show that nobody is curing most diabetics, hypertensives, asthmatics, arthritics, or patients with a multitude of other chronic conditions. In fact most of these patients remain symptomatic even when they are treated. These are all conditions with clear cut laboratory tests and other disease markers.  These are all conditions where there is at least a speculative biological hypothesis of pathophysiology.  And yet – there is no expectation of cure and in fact much more expected mortality in other specialties. Why is psychiatry different?  It is not.

4:  Some people in the profession believe that biological psychiatry will lead to better characterizations of psychiatric problems including pathophysiology, drug treatment, and pharmacological targets/precision psychiatry (paraphrased):

It is obvious that biological psychiatrists have been at it for decades and much longer.  The journal Biological Psychiatry was founded in 1969 but biology has been a focus of psychiatric research dating back to mid-19^th century when attempts were made to observe brain dissection correlates with behavior.  Griesinger (2) documents efforts by both Pinel and Esquirol to document brain abnormalities in severe mental illnesses. In his text he documents brain diseases leading to psychiatric care and associated organ dysfunction at autopsy in patients identified as having severe mental illness.

In the days of asylum care before biological psychiatry, delirious mania had a mortality rate of 75% (7).  That has essentially been reduced to zero with advances in modern biological psychiatry including electroconvulsive therapy and psychopharmacology.  There is probably no better example of advances due to biological psychiatry occurring over decades.

Like all other medical specialties, biological psychiatry is an active area of research with new journals like Molecular Psychiatry (1997) and Translational Psychiatry (2011) that are focused on the latest innovations in biological psychiatry and potential treatment applications.

5:  The DSM or the Bible of Psychiatry does not specify pathophysiology

Any time you see that the DSM is the “Bible of psychiatry” that is a red flag that indicates the author either lacks knowledge about the Bible or the DSM.  Here is a brief primer on the DSM to correct some misconceptions.  That primer emphasizes that the person using it (typically for diagnostic codes used for administrative purposes) is a trained professional and understands its limitations. Chief among those limitations includes ruling out medical causes of psychiatric symptomatology and understanding that it is not a guide for everyman to use for diagnosis and treatment.  Kendler (8) and others have taken it a step further to point out that it is an index of disorders and therefore a starting point – rather than an actual diagnostic guide.  In other words, meeting criteria for a diagnosis is not that same as having the diagnosis.  This is generally true of all codified systems of medical diagnosis.  An example would be the American College of Rheumatology classification criteria.  There is an extensive discussion of these classification criteria compared with diagnostic criteria and why the ACR currently endorses only the former (9).  It is basically the same discussion that Kendler uses in describing the indexing system – that there is sufficient heterogeneity in clinical presentations over time and geographical areas that every case needs to be individually considered. Here is the rationale from the leading text on systemic lupus erythematosus (SLE) (10):  

“The classification criteria do not contain a complete list of all the possible manifestations of lupus.  The manifestations of SLE often develop over a period of time, sometimes years, making the diagnosis more difficult at initial presentation. The diagnosis of lupus is made on clinical grounds, supported by laboratory data and depends highly on the physician’s knowledge and experience. (author’s emphasis)”

Despite the title, the DSM is not a guide to diagnosis or treatment. People who do not “meet criteria” are not automatically excluded from treatment consideration. Separate knowledge about psychopathology and diagnostic formulation is necessary. Speaking to the author’s concern about the lack of specific etiologies – even the skeletal classification and indexing framework of the DSM has chapters on clear medical, toxicological, and neurological causes of mental disorders.

The Economist dates psychiatry’s “Bible” back to 1952.  That would have been the DSM-I.  I encourage anyone who is interested to read the 6 page Forward to that document.  It started initially to standardize nomenclature. Each training program was using their own version of nomenclature as well as the military.  When trained psychiatrists went out to practice in the community – there was no standard nomenclature being used to described similar phenomenon and the requirements of military and civilian nomenclature were different. The secondary goal was to use this nomenclature to collect statistics that could be used to improve the necessary infrastructure and resources to treat these disorders.  All of this can be done without any specific reference to pathophysiology in both psychiatry and the rest of medicine.    

And here is a news flash from the DSM-5,  my estimate is that 69% of all of the diagnoses listed have a clear pathophysiology or medical test equivalent to any other branch of medicine.  Given the classification problems with all medical diagnoses that overall figure probably compares well with any other branch of medicine.   

Whatever your take away from this post, The Economist knows very little about psychiatry and medicine. But that should not be too surprising.  The tone and factual content clearly resemble much of what you see on the Internet and in the press about psychiatry. That does not make it any less wrong.  If you are really interested in what is going on in the field – I would recommend reading the general literature in the field or summaries about it. The popular press – newspapers and magazines – is clearly not up to the task.

6:  Attempts to find causal mechanisms for mental illnesses have failed (paraphrased):

News flash – that is true of every other complex disease as well as the medication used to treat them.  This post illustrates that fact with medication used to treat multiple sclerosis.  The table lists 18 FDA approved drugs – many of which modify the course of the illness but in every case the specific mechanism of action of the drug is unknown.

7:  Genetics has been a clinical “flop” (paraphrased):

It would probably be a good idea to get the opinion of an expert in psychiatric genetics.  The article seems to focus on the issue of polygenic risk analysis (PRA) and those studies generally have low effect sizes due to the number of genes studied.  Any commercial assessment of a genome will result in hundreds of these profiles – most of them for non-psychiatric illnesses. The example given above illustrates polygenic risk scores (PRS) when the small risk factors (both protective and potentially causative) are summed and compared to a standard sample so that 100% is highest percentile risk in the sample and 0% is the lowest. This is only one approach and there are major psychiatric initiatives in this space doing ongoing research. PRA/PRS is accepted science at this point but the widespread clinical utility is not known for practically all polygenic disorders.

Recent examples given by Kendler (11) in his commentary on whether psychiatric disorders are brain diseases points to the importance of genetics in psychiatry.  To this day there are endless debates, typically by people who are not trained to be psychiatrists that psychiatric disorders are somehow independent of brain substrate. In other words, even though it is widely acknowledged that a brain is required for mental life – there is no evidence at the molecular level that an alteration in brain function causes mental illness. Contrary to The Economist, Kendler states: “I use the most robust empirical findings in all of psychiatry—that genetic risk factors impact causally and substantially on liability to all major psychiatric disorders.”  He quotes the recent literature illustrating that risk variants for schizophrenia are located only in brain tissue.  Similar evidence is accumulating for bipolar disorder and major depression. This correlation of strongest known risk factors and brain substrate location is good evidence of specific genetic effects in the brain. Similar work is being done to identify signaling systems, proteins, and physiological processes underlying the DSM classifiers.  Once again, this is similar to the approaches being taken with all complex non-psychiatric diseases. 

8:  Biology is coming, whether psychiatry is ready or not:

When I saw this caption – it seemed like a joke.  Over the 40 years of my career there has been a constant battle based on the false dichotomy of biological psychiatrists and psychotherapy focused psychiatrists. That left out important additional identities including medical psychiatrists, neuropsychiatrists, and community psychiatrists. Practically all the criticism in the press has been that psychiatrists are too biological. I could probably write a book about this – but in this case suffice it to say that The Economist has not done much homework. The smattering of research projects listed in the last several paragraphs about immunology and metabolism ignores that this type of research has been going on for decades and gradually making progress. 

Every psychiatrist is trained in the biology of medicine and psychiatry - just like me.  We are willing to incorporate the latest research innovations and look forward to them. Biology comes as no surprise.

 

George Dawson, MD, DFAPA

 

 

 

References:

1:  “Many mental-health conditions have bodily triggers: Psychiatrists are at long last starting to connect the dots.:  April 24, 2024.  In the print edition this story is under the general heading "Psychiatry’s blind spots".  No author was listed for the online version that I read.

2:  Griesinger W: Die Pathologie und Therapie der Psychischen Krankheiten: für Aerzte und Studirende. (The pathology and therapy of mental illnesses, for doctors and students). Stuttgart, Germany, Verlagvon Adolph Krabbe, 1845  https://www.deutschestextarchiv.de/book/view/griesinger_psychische_1845?p=47

3:  Wagner-Jauregg J. The treatment of general paresis by inoculation of malaria. J Nerv Ment Dis. 1922;55:369–375. [Google Scholar] [Ref list]

4:  Tsay CJ. Julius Wagner-Jauregg and the legacy of malarial therapy for the treatment of general paresis of the insane. Yale J Biol Med. 2013 Jun 13;86(2):245-54. PMID: 23766744; PMCID: PMC3670443.

5:  Gazdag G, Ungvari GS. Electroconvulsive therapy: 80 years old and still going strong. World J Psychiatry. 2019 Jan 4;9(1):1-6. doi: 10.5498/wjp.v9.i1.1. PMID: 30631748; PMCID: PMC6323557.

6:  Ban TA. Fifty years chlorpromazine: a historical perspective. Neuropsychiatr Dis Treat. 2007 Aug;3(4):495-500. PMID: 19300578; PMCID: PMC2655089.

7:  Bell, L., 1849. On a form of disease resembling some advanced stage of mania and fever.  Am. J. Insanity 6, 97–127. 

8:  Kendler KS. The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria. Am J Psychiatry. 2016 Aug 1;173(8):771-80. doi: 10.1176/appi.ajp.2016.15121509. Epub 2016 May 3. PMID: 27138588.

9:  Aggarwal R, Ringold S, Khanna D, Neogi T, Johnson SR, Miller A, Brunner HI, Ogawa R, Felson D, Ogdie A, Aletaha D, Feldman BM. Distinctions between diagnostic and classification criteria? Arthritis Care Res (Hoboken). 2015 Jul;67(7):891-7. doi: 10.1002/acr.22583. PMID: 25776731; PMCID: PMC4482786.

10:  Rudinskaya A, Reyes-Thomas J, Lahita R.  The clinical presentation of systemic lupus erythematosus and laboratory diagnosis. In: Lahita RG, Costenbader KH, Bucala R, Mani S, Khamashta MA.  Lahita’s Systemic Lupus Erythematosus. 6^th ed.  London, England:  Elsevier, 2021: 316.

11:  Kendler KS. Are Psychiatric Disorders Brain Diseases?-A New Look at an Old Question. JAMA Psychiatry. 2024 Apr 1;81(4):325-326. doi: 10.1001/jamapsychiatry.2024.0036. PMID: 38416478.

Why “Reading” and “Doing Your Own Research” are not nearly enough….

 

 

Medical training is an exercise in repeatedly meeting people who know a lot more about the field than you do and hoping to learn something in the process.  It happens regularly – often several times a day.  It is a common occurrence to meet people with encyclopedic knowledge – not just of textbooks and papers but disease patterns and presentations as well as the best treatment approaches.  The knowledge can be obtained through straight didactics, informal seminars, bedside interactions, and direct observation.  It can be affiliative or adversarial. In other words, you might get the attending physician who asks you a series of questions until you run your knowledge base dry or you might get the attending who realizes that your life is difficult and details the pathophysiology while pointing you to the latest review to read.

All that dynamic learning happens in a certain time frame where everyone must focus on the problems of the day.  The recent COVID-19 epidemic is a striking case in point. During the years of my training and practice the pandemic of interest was the human immunodeficiency virus (HIV-1, HIV-2). I started to see those patients in residency training – typically for the neuropsychiatric manifestations. At the time there were full isolation precautions and we had to wear surgical gowns, caps, and masks to see the patients. There was also the concern about needlestick injuries and injuries sustained by during surgery on HIV positive patients – that was subsequently shown to be a rare occurrence.  

All primary care and specialty physicians need to have a knowledge of HIV/AIDS – because of the potential protean manifestations, the need to maintain medications, and for infection control purposes.  It is also useful to recall epidemiological and infectious disease concepts – the most relevant being that for a while the infectious agent of the disease was not known.  Early in the course it was characterized by epidemiological features. When the virus was eventually isolated – steady progress was made in the development of antivirals to the point where the virus can be suppressed and is no longer detectable.

Over the course of learning about the illness and its treatment – I observed a heavy toll on treatment providers. There were no effective treatments early on.  I had lunch every day with an infectious disease team who ran one of the early HIV/AIDS clinics. Providing care in that setting took an emotional toll on them.

Against that 40 year backdrop – Aaron Rodgers recent press conference stands in tragic contrast.  For a time, Rodgers assumed the role of inscrutable new age guru.  He refused to state his COVID vaccine status but talked in detail about the rejuvenative properties of ayahuasca.  But I want to focus on his 208-word commentary on HIV, COVID, and Dr. Fauci. The full video is linked above for viewing.  I will address his commentary on a subject-by-subject basis.

1:  There was a “game plan” in the 1980s to create a pandemic with a “virus that’s going wild.”

Multiple lines of evidence show that HIV resulted from cross species transmission of Simian Immunodeficiency Virus (SIV) existing in African primate species. The transmission occurred through infected blood or bodily fluid exposure from hunting (1).  The key concept is that many human pandemics originate from cross species transmission.  Further – there is ample evidence that the cross over to humans occurred decades before the first AIDS fatality occurred in the US in the 1980s.  The only "game plan" in place was evolution in nature - over millions of years.

2:  Dr. Fauci was given $350 million dollars to research this:

Dr. Fauci was appointed head of the National Institute of Allergy and Infectious Diseases (NIAID) in 1982. NIAID is one of 27 institutes and centers of the National Institute of Health (NIH).  The funding for AIDS research is available on several sites. In this paper Tables 4.2 and 4.3 give the research dollars as well as the distribution by institute. In 1982 for example – there was $3.6M in AIDS funding.  Looking at the 1990-1991 allocation NIAID got 53.1% of the research allocation. The detailed allocation of that grant money consists of intramural and extramural research funding as well as funding clinical centers of research with adequate patient numbers to advance the field. From that paper:

“The need for more—and more appropriate—facilities specifically for AIDS work was acutely apparent in early 1988 when NIH director James Wyngaarden and NIH AIDS coordinator Anthony Fauci testified before several congressional committees (U.S. Congress, 1988a:259, 1988c:331). Their concerns were echoed in the June 1988 report of the Presidential Commission on the HIV Epidemic. The commission noted that plans for AIDS office and lab space were seriously delayed, and recommended that intramural construction and instrumentation needs be assessed and made a high priority in future budget requests…”

When Dr. Fauci assumed control of NIAID, the total budget of that agency was $350M.  He described it as a relatively secondary institution, that he built up to a $6.3B agency over the next 38 years (3). 

3:  The only drug they came up with was AZT:

 Azidothymidine (AZT) was developed in 1964 by the National Cancer Institute (NCI) as a potential anti-cancer therapy.  It was ineffective but was included in screening as an HIV treatment where it stopped viral replication without damaging normal cells.  It was the first FDA approved drug to treat AIDS in 1987. Advancing Clinical Therapeutics Globally for HIV/AIDS and Other Infections (ACTG) was founded at that time along with other networks though NIAID to conduct clinical trials in therapeutics for AIDS. Subsequent trials established more safe and effective doses as well as demonstrating a delayed onset of AIDS in HIV infected persons with AZT making it the first effective HIV treatment.

NIAID funded research for combination therapy, triple drug therapy and novel agents to the point where there are now 30 anti-retroviral drugs and new classes of therapeutic agents.  During Dr. Fauci’s tenure at NIAID, research has gone from antiretroviral treatment (ART) based remission to clinical trials looking at strategies for potential ART-free remission of HIV or cure (4).  That goal has not been realized but there is no question that the research work on HIV has been productive resulting in reduced transmission and mortality.

 4:  An “environment” was created where only one drug worked

The environment was a research environment looking for treatments at a time where there were so many AIDS related deaths that it led to public outcry and activism. AZT was discovered as effective in a standard screening protocol, but additional clinical trials were necessary to establish doses, safety, and efficacy for FDA approval.

5:  Just like HIV – only remdesivir worked for COVID until there was a vaccine

Just like HIV – additional therapies became available for COVID (SARS-CoV-2) including nirmatrelvir-ritonavir (Paxlovid), simnotrelvir-ritonavir, and high titer convalescent plasma.  A recent review of the issue of vaccine versus pills for COVID concludes that it is a false dilemma and that they may have complementary roles (5). There is active research continuing in SARS-CoV-2 antivirals and no reason to expect that there will not be many additional medications.

6:  Dr. Fauci had a conflict of interest because of a “stake in the Moderna vaccine.”

Dr. Fauci has no stock in Pharma companies. The “stake” in vaccines are royalty payments that researchers are obligated to take, the majority occurring before the COVID pandemic. That standard and the average payments have been documented in the medical literature where Dr. Fauci is on record as having donated payments to charity (6).  Without having a detailed list of royalty payments, what they were for, and the outcomes it is difficult to make any additional comments except to say that there was no violation of NIH policy – in fact not accepting the payments was a violation. Royalties are based on discoveries and not getting products to market, FDA approval, or sales.  My further speculation is that the royalties are a small fraction of actual sales and company profits and the original NIH policy was probably designed to retain talented researchers who would otherwise be lost to private industry. Major universities and research institutes generally allow their faculty to accept consulting and royalty fees. I have worked in several settings where those arrangements were spelled out in the initial employment contract, including intellectual property ownership.

7:  Pfizer is also “criminally corrupt” based on a fine that was paid.

Large fines against pharmaceutical companies are the rule rather than the exception.  In looking at this list of the largest settlements most of the fines are based on regulatory laws having to do with off label promotion of drugs beyond what is indicated in the FDA package insert. Practically all of the penalties have to do with marketing rather than research or production. It has been well known for decades that Pharma companies aggressively market their products to physicians, hospitals, clinics, and now direct-to-consumer advertising to potential patients. You could look at a list like this and decide against using a company’s product – but it might mean not taking a potentially safe and effective drug.  The same type of enforcement actions are taken against companies in other fields such as information technology.

8:  People who can “do their own research” and “read” are commonly vilified for that if they question authority

There is a basic difference between authority and expertise. The only vilification that I have noticed is of experts. Dr. Fauci is an extreme example but during COVID it extended to many local public health officials. It was a direct product of the minimization of COVID by President Trump and many of his officials as well as the MAGA movement.  Further it has led to political violence that includes threats of physical harm to Dr. Fauci and many other public health officials.  These threats are unprecedented and have been attributed to right wing political rhetoric.

9:  Why should science be trusted if it can’t be questioned.

Science is continuously questioned and this is probably the most significant public misunderstanding.  Science is a process where results are continuously challenged and updated. The politization of the COVID pandemic illustrates what happens when people who are not trained in the scientific method get involved. Suddenly each scientific modification means that somebody was wrong or lying. Scientists are treated like politicians and the politicians feel free to say anything that is not grounded in science. 

That is not how science works. It takes actual observations over time to test hypotheses.  As one example – I have collected about 200 hypotheses on the pathophysiology of depression over the past 40 years and to date – there are not sufficient observations to prove or disprove them and get to the level of a theory of depression. An equivalent scenario is the endless speculation of the lab leak hypotheses versus the cross-species transmission hypothesis of COVID origins.  Although the probability lies in the direction of cross species transmission – there are insufficient direct observations to prove one versus the other and ample discussions of the lab leak hypothesis by people with a complete lack of expertise.

Finally, with the errors in Rodger’s statement – I would be remiss if I did not mention Brandolini’s Law. Simply stated:

“The amount of energy needed to refute bullshit is an order of magnitude bigger than to produce it.”

This is true – especially when the false argument does not have to be based on facts, process, or rigorous standards. The politization of COVID and many other health issues by the extreme right wing should be a lesson that is not forgotten.  This video clip is a case in point.

 

George Dawson, MD, DFAPA

Supplementary 1:  The NIH policy on royalty payments to inventors can be viewed at this link.  The abbreviation IC stands for the Institutes and Centers of the NIH.  More detailed information can be found at this link.  The NIH also has conflict of interest policy (see conflict of interest in Appendix 1).

 Supplementary 2:  A few relevant titles from my library - note dates. 

 

References:

1:  Sharp PM, Hahn BH. Origins of HIV and the AIDS pandemic. Cold Spring Harb Perspect Med. 2011 Sep;1(1):a006841. doi: 10.1101/cshperspect.a006841. PMID: 22229120; PMCID: PMC3234451.

2:  Institute of Medicine (US) Committee to Study the AIDS Research Program of the National Institutes of Health. The AIDS Research Program of the National Institutes of Health. Washington (DC): National Academies Press (US); 1991. 4, Supporting the NIH AIDS Research Program. Available from: https://www.ncbi.nlm.nih.gov/books/NBK234085/

3:  Anthony Fauci: a scientific adviser's role from HIV to COVID-19. Bull World Health Organ. 2023 Jan 1;101(1):8-9. doi: 10.2471/BLT.23.030123. PMID: 36593776; PMCID: PMC9795384.

4:  Schou MD, Søgaard OS, Rasmussen TA. Clinical trials aimed at HIV cure or remission: new pathways and lessons learned. Expert Rev Anti Infect Ther. 2023 Jul-Dec;21(11):1227-1243. doi: 10.1080/14787210.2023.2273919. Epub 2023 Nov 8. PMID: 37856845.

5:  Papadakos SP, Mazonakis N, Papadakis M, Tsioutis C, Spernovasilis N. Pill versus vaccine for COVID-19: Is there a genuine dilemma? Ethics Med Public Health. 2022 Apr;21:100741. doi: 10.1016/j.jemep.2021.100741. Epub 2021 Nov 23. PMID: 34841029; PMCID: PMC8608621.

6:  Tanne JH. Royalty payments to staff researchers cause new NIH troubles. BMJ. 2005 Jan 22;330(7484):162. doi: 10.1136/bmj.330.7484.162-a. PMID: 15661767; PMCID: PMC545012.

7:  Mehellou Y, De Clercq E. Twenty-six years of anti-HIV drug discovery: where do we stand and where do we go? J Med Chem. 2010 Jan 28;53(2):521-38. doi: 10.1021/jm900492g. PMID: 19785437.

8:  Burke RV, Distler AS, McCall TC, Hunter E, Dhapodkar S, Chiari-Keith L, Alford AA. A qualitative analysis of public health officials' experience in California during COVID-19: priorities and recommendations. Front Public Health. 2023 Sep 13;11:1175661. doi: 10.3389/fpubh.2023.1175661. PMID: 37771831; PMCID: PMC10525347.

9:  Ward JA, Stone EM, Mui P, Resnick B. Pandemic-Related Workplace Violence and Its Impact on Public Health Officials, March 2020‒January 2021. Am J Public Health. 2022 May;112(5):736-746. doi: 10.2105/AJPH.2021.306649. Epub 2022 Mar 17. PMID: 35298237; PMCID: PMC9010912.

 10:  Royster J, Meyer JA, Cunningham MC, Hall K, Patel K, McCall TC, Alford AA. Local public health under threat: Harassment faced by local health department leaders during the COVID-19 pandemic. Public Health Pract (Oxf). 2024 Jan 24;7:100468. doi: 10.1016/j.puhip.2024.100468. PMID: 38328527; PMCID: PMC10847788.

 

The Consolations of the Forest – Alone In A Cabin on the Siberian Taiga

 

I thought I would review a book sent to me by a friend who I emailed about the concept of suffering. At issue was whether suffering was useful or not. That issue was used as a social media cudgel against psychiatrists – specifically that psychiatrists are trained to alleviate suffering but if they did not people would benefit from it instead. That is obviously an overly simplistic argument by a person who does not know very much about psychiatric practice.  I don’t want to get too far afield from the actual book.

The author is Sylvain Tesson who is generally described as a world adventurer who writes about those adventures. He wrote this book over the course of 6 months living in relative isolation on the shores of Lake Baikal in Siberia when he was 39 years old.  He is currently 51.

Lake Baikal is in the Southern region of Siberia and it is the world’s oldest and deepest freshwater lake. Irkutsk – the 25^th largest city in Russia in on the main outflow river from the lake – the Angara River about 45 miles from the lake. Irkutsk has a population of about 600,000 people and is probably best known to people of my generation from the board game Risk where it is a separate region rather than a city.  After reading the book I did research Tesson’s academic background and he has a degree in geopolitics. He is obviously well read and provides many of those references in the text.

Tesson’s previous exposure to Lake Baikal led to his interest in a more prolonged stay at a rough time of the year.  He documents what occurred along with his associations in diary form beginning on February 14 when he arrives on the lakeshore and ending on July 28 as a boat sent to pick him up is coming in from the horizon. He describes his motivation for this adventure in the introductory chapter. The climate in that area is temperate and comparable to Canada and the upper Midwestern states in the US.  He stayed during winter and spring and temperature ranges from -20 F to above freezing. He did this with the intention that living as a hermit would lead to desired changes – while documenting the day-to-day effects of the climate, changes in the ecosystem, occasional social contacts, his hiking and outdoor adventures, and the necessary work to maintain himself. It is presented mostly as a document of what he experienced and the associations (both autobiographical and literary) that he has with those experiences. At no point was this an argument that we can all be saved by living the life of a hermit.  It is more of a document about a part of that experience and what others have said about it.

He was well supplied for this adventure including 6 months of food and solar panels for recharging batteries and a satellite phone. Despite the relative isolation he describes plenty of traffic on both the frozen and thawed lake providing visitors and, in some cases, additional supplies. There was abundant wild life but he did not have a firearm apart from a flare gun for scaring off bears. His main protein source was fish from the lake.  He did not hunt any mammals or birds.  He had 67 books that were compromised mainly of humanities titles, but also some fiction and descriptions of surviving winter in Siberia. 

He described high levels of activity across terrain elevations and temperature ranges.  Much of the terrain was difficult to navigate because of the presence of underbrush, deep snow, and dwarf pines.  Tesson was undeterred by temperatures in the – 27F range.  He makes detailed observations and descriptions of the nature and scenery.  On some days he is trekking 10 miles to get to a fishing site, on others he is going 80 miles on a 6-day round trip.  He acknowledges that his levels of physical exertion and the resulting pain and exhaustion are high at times.     

What is it about hermitism that is life changing?  Tesson believes it is silence against a background of the splendor of nature existing forever in an idyllic setting. One of his last observations:

“It is good to know that out there in a forest in the world there is a cabin where something is possible, something fairly close to the sheer happiness of being alive.” (p. 232).

It seems apparent that he knew this all along and had to prove it to himself.  Full circle back to the theme of suffering.  Tesson suffered but that he tolerated it to attain a goal. At any point he could have called the nearest neighbor, called it off, and gone home.  The suffering is over at that point.  That is no equivalent to the suffering that accompanies medical problems that can seem random and senseless.  In many cases – people are expected to expend energy and tolerate suffering not toward any higher goal or advantage but because there are no effective treatments or they can’t access them.  It is also not the same as acute and unpredictable stress like an accident or natural catastrophe.

Despite seeing his hermitage as transformative he is circumspect about the experience.  He quotes Aldo Leopold that “hermitism is elitism”.  It is not a solution to the ecological problems of modern-day life because any mass exodus to the wild would destroy the forests. In fact he talks about how some of that had been done.

There is no description of the potential limitations of hermit life.  As a physician – medical emergencies and access to care is at the top of that list. To an extent that is age dependent but even a healthy 30-year-old can come down with acute appendicitis or break a bone.  He is very conscious about dying of exposure and guards against that.

In writing about the advantages – he does not consider alternatives.  For example, I was born and raised on the shore of one of the largest freshwater lakes in the world and could experience much of what Tesson experiences by walking 6 blocks to the lake.  There were no bears but plenty of fishing, ice transitions, and winter sports every year.  And all of that occurred in a town of 8,000 people and homes full of modern conveniences.  The largest close city was Duluth about 70 miles away with a population of 100,000.

A secondary observation is that the hermit in the woods is a more honorable position to be in because there is a smaller carbon footprint.  The hermit only uses the resources they need and does not squander energy or material goods.

One of the thought experiments prompted by Tesson’s hermetism is the characteristics of a transformative environment.  Each of us can probably think back to several of the environments in our life and not have to think too much about the impact it had on us.  Taking the histories of thousands of people illustrates how varied those environments are and how varied the responses can be to environments that are qualitatively similar. I spent a week hiking through Glacier National Park with a friend of mine when I was in my 20s. The scenery was magnificent and it was rigorous hiking at altitude (5393 ft). It was also populated by grizzly bears and you could always see them at a distance. There were bear warnings every day and we took them seriously. My friend thought I was too serious about it until we encountered a ranger in a fern filled valley loudly banging a shovel and his hard hat together to “warn the bears”. The effect it had on me was “great place to visit but I don’t want to live there.”

As a physician – the training and work environments are striking. Medical school was probably the most.  Going from the lecture hall to seeing people dying in front of you to being responsible for preventing those deaths probably had the most impact on me than anything. That is probably the closest I can come to an environment that Tesson describes as “changed myself completely.”  It was my equivalent of the Russian taiga.

It also raises the question of what is suffering and these days – what is trauma? There are a lot of variables. One of the critical dimensions seems to be voluntariness – whether people choose to suffer or not.  If they do – is there enough information ahead of time for true consent?  In this context – there is knowledge about what to expect and probably some experience in tolerating the environment. The example I am most familiar with is athletes where painful effort is required and career ending injuries are always possible. Tesson’s hermetism seems to fit this model compared with unexpected serious illness or injury.  The latter can also be life changing in unpredictable ways but it is not possible to predict whether the individual would consider the event a net positive or negative.

A second consideration is what increases our tolerance or in the more popular vernacular - resilience to the stress. In Tesson’s case he seems to attribute much to solace, silence, freedom, and the beauty of nature as a counterpoint to the noise, artificiality, regimentation, and excesses of modern life.  There are Darwinian considerations that he does not cover – primarily that many people in populations everywhere could not survive in such an environment.

Thirdly, people often view trying times much more positively in retrospect. I think back to another experience in my 20s – climbing Mt. Kenya with a coworker and friend. We were both habituated to 5,000 feet and ran regularly at that altitude. I have a single grainy photo of me climbing the scree at about 12,000 feet. We were poorly prepared and knew very little about mountaineering. The first night we stayed in a hut at about 10,000 feet and I had altitude sickness. That night hyraxes – small rodent like mammals weighing 4-10 pounds scurried about the hut running over us as we tried to sleep. I was able to recover the next day and continue the ascent but at the time it was a miserable experience and I could not wait to get off that mountain.  I recalled a quote from Pirsig that Zen happens in the valleys and not on the mountaintops.  In retrospect – I really like that old picture.  But at the time I was not sure I was going to make it.

Tesson’s literary and social observations are as interesting as his social and ecological ones.  I was interested in his take on DH Lawrence’ Lady Chatterley’s Lover. I have not read the book since college. It was widely considered to be an advance in explicit sexuality and was high controversial in the early 20^th century.  It was banned as obscenity in several countries including the US. Some opinions focused more on sexual life as being part of the larger life picture.  Tesson describes it more of a “requiem for wounded nature.”  He focuses on the effect of mining and the industrial revolution on the landscape and how the main protagonist describes the adverse effects on the environment and the human spirit. (p.89).

Boredom was always an interesting topic to me as a psychiatrist. No matter where I am it seems to be a completely alien feeling. I can’t recall ever being bored. Tesson comments that he was warned that boredom might not only get the best of him in solitude but that boredom can kill. (p. 79).  He did not take the warning seriously.  He discusses why the solitary man must be a virtuous man.  He describes a “double penance”  that can occur and quotes Rosseau: “The civil man desires the approval of others, the solitary man must of necessity be content with himself, or his life is unbearable. And so, the latter is forced to be virtuous.”  The double penance occurs at both levels.  Contemporary theory just focusing on the cognitive aspects of boredom suggest that spontaneous thought is a factor and, in that department, Tesson never seem to be lacking.

Should you read this book?  If you have read any of my past book reviews, I try to make things as conditional as possible. I recently read a paper on how many people read books after they graduate from high school or college.  It is a surprisingly low percentage and the same survey looked at how many people read assigned texts in college and that percentage was far below expected. This book is logistically straightforward to read. It is arranged in diary form. Some days are described in a paragraph and the more detailed days takes several pages. It can be read by dates or months. It is a unique book that ties in life in the wilderness with literary references.  Some of the books referenced you may have read.  The others are interesting enough to investigate. Following Tesson’s lead – I like the idea that there are people living successfully in the Russian taiga and that he wrote about his adventure and philosophy.  It is good to know how one man experienced personal growth and the sheer happiness of being alive in such a setting.

George Dawson, MD, DFAPA

 

Supplemental:  I also want to credit the translator of this book from French – Linda Coverdale, PhD. There is a 7-page addendum - Translators Notes – that adds significant details about geology and the history of the area as well as literary references.

 

Reference:

1:  Tesson S.  The Consolations of the Forest – Alone In A Cabin on the Siberian Taiga.  Rizzoli International Publications, Inc. New York; 2014.

The Joy of Basketball – And What Is Humanly Possible…..

 

In addition to the clinical work – psychiatrists need to have their finger on the pulse of popular culture.  Not just the content – but the process of it all.  How else can you talk with a young patient who is describing their experience of a rock and roll lyric and what it means for their life?  Or patients who are caught up in the latest cultural movements – whether they are useful or not.  Sports of course are a big part of the culture and in the last few months there has been no bigger sports phenomenon than Caitlin Clark of the Iowa Hawkeyes basketball team.  As I type this – she and her teammates are scheduled to appear in the NCAA Women’s Basketball Championship tomorrow afternoon. 

If you are just catching up that is a small part of the story. The statistics leading up to this game are readily available elsewhere and I will just mention a few highpoints without specific numbers.  Clark is the all-time leading scorer for men and women who have played NCAA basketball. The Iowa team has set both live attendance records and records for television viewers - as the most watched basketball game in the history of ESPN and the second most watched non-football event on that network. With that demand the tickets prices for games have also increased greatly sparking new enthusiasm for the viability of women’s sports at all levels. 

What is it about this player and her team that have cause all this excitement? I preface this by saying that I am not a big basketball fan.  I played it in intramural sports and for two years I was one of the statisticians for my high school team.  I have never followed any team consistently but have usually seen the US Olympic teams and a lot of clips of the great players from the NBA. NBA players clearly have a high degree of athleticism and much greater than usual height and physical stature. I recently learned that if you are over 7 feet tall - one person in 6 plays in the NBA.  My maximum height as an adult was 5’10”.  At that height only 0.117% of men play in the NBA.  Currently only 2 of 560 total players in the NBA are 5’9” or less.

The average height in NCAA women’s basketball is quoted between 5’8” and 6’1” by various sources although there are some very tall players ranging from 6’5” to 6’7”.  Caitlin Clark is 6’0” and the team range in height is 5’9” to 6’2”.  Watching Iowa and their closely matched competitors play – physical size fades into the background.  They obviously have the form and the skillset of accomplished basketball players.  I watched NBA star Steph Curry comment on Clark that she is more than just a shooter – she has an excellent ground game.  Seeing clips from her high school games – she had it back then.

There will be the invariable comparisons between men and women.  About how Clark could “never play in the NBA.”  That misses a huge point – there are highly accomplished woman athletes that are every bit as skilled as men.  As an observer of mostly individual sports – it doesn’t take much critical ability to realize that you will never be able to skate like Bonnie Blair, or ski like Lindsey Vonn, or play tennis like Serena Williams, or swim as fast as Katie Ledecky.  More than that you can learn something from watching them.  As a speedskater – I read everything I could find that was written by Bonnie Blair on training. I had the same thoughts about Caitlin Clark describing her jump shot and the left hand component consisting of a thumb flick maneuver.  If you watch her videos, it is so fast it is barely noticeable.  Even as an old man I want to try it. I can imagine that there are boys out there thinking the same thing and wanting to learn how to handle the ball like her.  Like everything else in the world – whether academics or sports – women add greatly to it and that recognition needs to be automatic rather than qualified. People should not give it a second thought.  It is not a “battle of the sexes” and it never has been.

The greats in any field are more than just technically competent.  They set a bar that encourages everyone else.  People start thinking: "That is not something I can do – but I am going to try it." Clark, her coach, and her teammates all consistently say this in post-game press conferences.  There is the realization that an inspirational teammate makes everybody better and that the team is more than just one person no matter how good they are.

What about the average person who has no sporting aspirations? There is a team loyalty factor.  But beyond that – it is inspirational from the standpoint of being a member of the human race. To watch someone accomplish something that nobody has done or done as well before.  Back in the early days of this blog – I posted a link to a video clip that I thought was a good explanation. It involves seeing someone perform so well that it feels uplifting. I get that feeling watching Caitlin Clark ball handling and shooting from well outside of the 3 point line.

The current state of women’s collegiate basketball as well as the abundance of great women athletes is also a reminder that 40 to 50 years ago things were not this good. They were not even close.  I was a high school athlete at that time. Most women’s basketball teams were intramural. Almost all of the high school resources were focused on boy’s football, hockey, basketball, wrestling, and baseball.  In 1972, two female high school athletes who were highly competitive in tennis, running, and cross-country skiing sued to be able to compete in those programs at their high schools. Since there were no programs available for girls – they sued to participate in the boys’ program.  Judge Miles Lord in a landmark ruling (1) concluded that they should be allowed to compete in those programs and compete with boys because discrimination in sports programs solely based on sex was a violation of the 14^th Amendment. He was backed up in appeal by the Eighth Circuit Court of Appeals (2). This ruling led to the development of far more resources for girls’ and women’s’ athletic programs than were previously possible. This ruling illustrates that when given the resources it leads to the development of the expected high caliber of competition and athletes. 

Are there any downsides to these developments?  I do not see any.  As a physician I have seen women athletes with significant and disabling injuries from both contact and non-contact sports.  Anyone watching the current basketball competition realizes that contact and injury can occur even during a game that is considered a non-contact sport. Judge Lord initially emphasized the availability of non-contact sports but today the question comes down to whether girls and women should be able to choose to risk injury by participating in the same way that boys and men do.  I cannot think of a reason why they should not have that freedom of choice. 

There has been criticism for trash talking, posturing on the court, and the usual differences of opinion about what players say in post-game press conferences. I have not seen any behavior to the level of what men's teams have been doing for decades.

I wish Caitlin Clark and all her teammates a great game tomorrow. I have the same wish for their opponents.  If I tune in and sit back to watch great basketball – I will be thinking:  “This is what happens when women have the chance to develop and compete in any field.” 

I am glad I lived to see it….

 

George Dawson, MD, DFAPA

NCAA Woman’s Basketball Postscript -

I watched the last half of the game yesterday. I am not a basketball analyst so I will not give my impressions of what happened.  It is likely if you are reading this that you have heard numerous opinions about this from friends, family, and coworkers. I first noted detailed post-game analyses at the hospital where I used to work. Every day after rounds I would take a break and walk down to the coffee shop for my usual tea or mocha. If it was a Monday – it was a safe bet that I would hear a detailed analysis of the Sunday football game by staff members of multiple disciplines. In some cases, it would involve criticism of the coaching staff, suggestions about who should be drafted, and of course criticism of players.

The post-game comments of the coaches and players of the South Carolina-Iowa game had none of that.  In fact, some of the commentary was the most enlightened commentary about organized team sports that I have seen anywhere. And it was all presented matter-of-fact – no gnashing of teeth or excessive self-criticism and sadness.  Several themes were apparent.

First, the importance of the coaches both on and off the court. Both sets of players emphasized good relationships with the coaches.  They were described as maternal figures and women who had done a lot for the game of basketball.  Both coaches in their Q&A emphasized their interest in growing the game and making sure their players got a lot of out the game besides winning. They emphasized developing a culture where the players know what to say to players, where everyone feels supported and in the case of Coach Staley – where there is extended family involvement. She emphasized recruiting players who had respect for their parents, how those parents had access to the coaching staff, and how both were focused on players succeeding.

Second, confidence at the player level was an important point. The coaches and players talked about it  - how it is instilled and how it develops. It was described as a significant factor is being able to compete irrespective of statistics and related concerns.  Coach Bluder pointed out how Clark came in to their program confident that they could get into the Final Four and despite the naysayers was able to convince everyone that she was correct. 

Third, respect was a frequently used word.  Respect for coaches, teammates, opponents, and fans was an important part of the equation. Numerous examples were given at all levels including previous players who advanced women’s basketball.

Finally, there was an overall plan and formula. This was probably best elaborated by coach Staley who emphasized that the staff who worked with her in implementing these plans were extremely important in the overall success of the team.   

 All things considered NCAA woman’s basketball is an impressive sport no matter what way you analyze it.  Women clearly know how to play basketball.  They know how to win and they know how to lose.  They know exactly where basketball is in the scheme of things.

We can all learn a valuable lesson from that…

 

George Dawson, MD, DFAPA 

 

References:

South Carolina National Championship Postgame Press Conference - 2024 NCAA Tournament  https://www.youtube.com/watch?v=tULkNrlqkI8

Iowa National Championship Postgame Press Conference - 2024 NCAA Tournament  https://www.youtube.com/watch?v=NE6rI8Dkcvw

 

References:

 1:  Judge Lord ordering a school district to allow high school girls to compete on boys' sports teams: Brenden v. Ind. School Dist. 742, 342 F.Supp 1224 (D. Minn. 1972).

The District Court,

“Miles W. Lord, J., held that where plaintiff high school girls wished to take part in interscholastic boys' athletics in tennis in one instance and in cross country and cross-country skiing in second instance and it was shown that plaintiffs could compete effectively on those teams and there were no alternative competitive programs sponsored by their schools which would provide an equal opportunity for competition for female plaintiffs, application of rule prohibiting girls from participating in boys' interscholastic athletic program as to plaintiffs was arbitrary and unreasonable, in violation of the equal protection clause of the Fourteenth Amendment, and application of rules as to plaintiffs could not stand.”

https://www.upress.umn.edu/book-division/images/other-images/equality-for-women-in-high-school-sports_1

 

2:  Eighth Circuit affirming Judge Lord: Brenden v. Ind. School Dist. 742, 477 F.2d 1292 (8th Cir. 1973).

“The Court of Appeals,· Heaney, Circuit · Judge, held that where · high schools attended by plaintiffs, two female students, provided teams for males in noncontact sports - of tennis. – and cross country skiing and running but did not provide such teams for females and where . plaintiffs were - qualified to compete with· boys in such sports, application  of rule -prohibiting females from participating in the boys' interscholastic athletic program as to plaintiffs was arbitrary and unreasonable and in violation of equal protection clause of Fourteenth Amendment. · Affirmed.”

https://www.upress.umn.edu/book-division/images/other-images/equality-for-women-in-high-school-sports_2

Graphics Credit:  Click directly on the photo for the Wikimedia Commons page.  Details from that page include:

John Mac, CC BY-SA 2.0 Caitlin Clark three-pointer (cropped).