What You Need to Know About Medications from a Psychopharmacology Expert and Researcher – Dr. Rakesh Jain – HPP 73
The revolutionary developments in medication have tremendously brought massive significance in terms of treating our patients who are suffering from a myriad of mental health issues. While this positive force brings so many advantages, it does not yield a 100% efficacy, and worse, it may have led us to be rather too reliant on them, ultimately putting our patients at risk.
As providers, this certainly puts us at a difficult spot, and raises questions and concerns towards our practices and methods of treatment. What modalities can we try to allow healing? Is writing a prescription really effective and necessary? What are the risks involved? Finding the right balance between these could perhaps be the key towards total healing.
In today’s very insightful episode, we are joined by a renowned researcher and leading psychopharmacology expert, Dr. Rakesh Jain. Join us as we tackle advancements surrounding psychopharmacology and weigh the benefits versus risks, treatment alternatives, and interesting concepts that we should know about.
Medication In Psychiatry Today – 03:21
“It can be very helpful, though, of course, there is a great worry by many of us, including those of us who spend almost an entire career trying to develop new medications that there may be potentially an over use of them both in terms of frequency, as well as duration”
Keeping An Open Mind – 08:26
“And I think those of us who do believe in the sheer raw power of complementary medicine in wellness would be well served by an extra dose of humbleness. And humbleness is just because we believe that it is helpful for whatever percentage of patients and fellow human beings”
What You Need to Know Before Handing A Prescription – 17:19
“I now know that they no longer need it to the point that they can now no longer come off them without going back into profound panic attacks. So what questions am I asking? This is what I’m asking them and myself. What is the disorder? What is the severity? What is the family history? What are the patient’s preferences? Preferences really of course matter”
Medicating Depression – 22:36
“It may well be because we took too much of a biological angle to treating it. And when I say biological, I mean medication biological, there are many other biological interventions. That includes meditation—But for them, if $4 for a 30-day prescription medication evaporates their depression, so there we go. So, see how challenging this is”
The Self And Depression: An Interesting Insight – 27:14
“And I am resonating loudly with you that recovery from depression, the small “d” depression, which I do think is different from the big “D” depression does require going back to our ancient selves, because our ancient selves had a set of skills that we let go of once we landed in this industrialized nation model”
Defining Tardive Dysphoria – 32:50
“So, dysphoria forces sadness, Tardive would be late arriving. And the concept is very, very much like tardive dyskinesia, which is, you often get the opposite of what you are seeking, and opposite of what you originally got, just by staying on intervention for a long time. And there’s a lot of parallels with multiple other fields”
Understanding How Treatment Introduces Harm – 37:07
“if you get a fracture, have your leg, the orthopedists will put a cast on you. And that’s a good thing. But the orthopedist is going to be very quick to take it off the moment it is safe to do so why? Why not just leave it on for another six months? What’s the big deal? And the reason for that is leaving a cast on when you don’t need it actually weakens the very cause that you’re trying to fix. The very bones trying to heal, you have now made yourself weaker by doing something longer than you need it to”
Striking The Right Balance – 42:06
“They use what we call alternatives today, they call essential. That’s why I have such a problem with calling it complementary or alternative. And because complementary means it complements something that is essential. And it’s the other way around. It’s not complimentary. It’s essential, it’s baseline, it’s foundational to being a human being. And why do we call it alternative?”
Knowing The Risks Involved – 47:35
“We have sadly mistaken half-life of the medication for the rebound duration. I have not seen benzodiazepine withdrawal. The last two years, I have seen SSRI which is quote-unquote, non-addicting rebound last six months to a year, I’ve seen lithium rebounds that you can still hear the reverberations of, three to six months after you stopped taking it. So, psychiatry did not know about it”
Keith Kurlander, Dr. Rakesh Jain, Dr. Will Van Derveer, Dr. Rakesh Jain
Dr. Rakesh Jain 00:01
Just because you’ve been on antidepressants for a while, your brain; I mean, as a brain, I think I should perhaps narrow it down a bit. The neurons and the receptors that really are the currency, really the tools that the brain uses to communicate with each other may configure themselves in such a way that not only do you no longer respond to antidepressants, you may be depressed because of the antidepressants.
Dr. Will Van Derveer 00:37
Thank you for joining us for The Higher Practice Podcast. I’m Dr. Will Van Derveer with Keith Kurlander. And this is the podcast where we explore what it takes to achieve optimum mental health. I’m really excited to introduce today’s guest, who is a fellow psychiatrist and fellow traveler on the path. I feel deeply aligned with Dr. Jain around some of the struggles that we’ve both faced that we talked about in this episode as psychiatrists who really care about getting the maximum gain with the minimum pain. We’re going to cover some really interesting new developments and rabbit holes around emerging evidence that some people have a lot more trouble getting off of psychiatric medications than others. And the way that this emerging information has really shaped how Dr. Jain and I have made changes in the way that we prescribe medication for people struggling with emotional and psychological challenges. It’s a really fun conversation. I have a huge amount of respect for Dr. Jain and really delighted to have him on the show. Dr. Rakesh Jain attended medical school at the University of Calcutta, in India. He then attended graduate school at the University of Texas School of Public Health in Houston where he was awarded a national institutes Center for Disease Control competitive traineeship. Dr. Jain is currently involved in multiple research projects studying the effects of medication on short term and long-term treatment of depression, anxiety, pain, mood overlap disorders, and psychosis in adult, child and adolescent populations. One thing that I’m particularly impressed with about Dr. Jain is the massive depth of commitment and participation he has shown in his career, or clinical research of the effectiveness of medications in psychiatry. His research posters have been presented at the APA, ACNP, AACAP, US psychiatric Congress, among others. And he serves on several advisory boards focusing on drug development and disease state education. He was named Public Citizen of the Year by the National Association of Social Workers, Gulf Coast chapter in recognition of immunity and pure education and championing of mental health issues.
Dr. Rakesh Jain 03:18
Thank you for the warm welcome.
Dr. Will Van Derveer 03:21
Wonderful to have you. I’ve been looking forward to this conversation for a long time and following your work for quite a while. For those of our audience who are not familiar with your work, we’re really excited to have one of the world’s experts in psychopharmacology. Someone who’s done a lot of research on psychopharmacology and thank you for your contributions. It’s so important, the research. So, I’m wondering if you could if we could start the conversation with you giving us an overview of how you see the role of medications in present day psychiatry as we know it at the moment.
Rakesh Jain 03:54
I’d be happy to talk about it. So, I do think when you say medications, I suppose you mean psychopharmacology. And I do think psychopharmacology does have its very definitive role in helping fellow human beings who suffer from various mental health challenges. Life can be very challenging, right? The slings and arrows, as Shakespeare said, can be quite profound. It can be very helpful, though, of course, there is a great worry by many of us, including those of us who spend almost an entire career trying to develop new medications that there may be potentially an over use of them both in terms of frequency, as well as duration. But I do want to hasten to add at the very outset, there are very many people, very many. And some of them are actually my own family members who have been on medications for over 25 years, psychiatric medications. And they are only in their 50s. And I expect that they will live their entire lives with their medication. So, they most likely would spend 50 to 70 years if they’re so lucky to live that long with medications on board. So, it’s a complex topic. It is not as simple as saying it is overdone. It is under done. I think there are some situations where it’s over done. And there are situations where it’s under done.
Dr. Will Van Derveer 05:30
Thank you. Yeah, sounds like a great place to start.
Keith Kurlander 05:33
Yeah, I think that’s a good segue into maybe just seeing how your own personal treatment philosophy has evolved over time, and how you relate to medications, say how you’re relating to them decades ago, versus now? Has anything changed there for you?
Dr. Rakesh Jain 05:50
Great question. And the answer is yes. And if you ask me tomorrow, I will say it’s evolved even further. So, there’s a daily evolution I believe everybody should have. It’s a bit like driving. Even if you’re driving on a straight and narrow road, you still have to make minor corrections in both directions. I do catch myself, I really do on occasion delaying medications too long, and on some occasions, overdoing medications too long. But I do want to address your question quite directly. How have I evolved in terms of my relationship with medications? So, a bit of background on me, because it’s important to the conversation that we’re having. Even before I came into psychiatry training after finishing medical school, I actually did a psychopharmacology fellowship program. And then of course, I entered a residency program and then another fellowship that was very biologically oriented. So, when I came out of my training at the tender age of 31, I knew, I just knew there wasn’t a problem in psychiatry that I could medicate. It just wasn’t. I could medicate anything. And if patients didn’t get better, it was either I hadn’t used a high enough dose, or it was the patient’s fault. That was it. It was never a shortcoming of the medications. Of course, that has changed very significantly. But I think in a more fair, balanced way. I do think there are some disorders, some severities, that medication should play very little role, if any. And I’ll use a couple of examples, social anxiety disorder. I spent all 10 plus years of my life, trying to develop medications for Social Anxiety Disorder with very spotty success, until I truly encountered CBT and other behavioral interventions and obtained training in them. And then over time, I encountered other things such as wellness practices, and many, many, many types of complementary interventions. And then I started really thinking, there are some disorders, I think, are overdue medications. I hope you’ll forgive me for not being able to give you a precise answer other than to say, it’s a dynamic process, and you should not be afraid of the dynamism of the whole process.
Dr. Will Van Derveer 08:26
Thank you for that Rakesh It feels very parallel and similar in some ways to my journey as a psychiatrist from training on. I was also 31 when I finished and started my practice, and I had a very profound case that happened. Actually, I’d like to tell you about it. I’m curious about your thoughts on this. It was 2004. I had just finished my board certification. And for me, I was actually very frustrated. In retrospect, I would call it trauma resistance that was stacking up in my private practice and I had gotten involved with meditation and was taking some time off. And a patient who I had worked with for over a year doing weekly CBT and SSRI and PRN benzo who had very severe social anxiety. And this is what triggered the memory is your comment about social anxiety. We did mindfulness, we did CBT, SSRI, and a PRN benzodiazepine. And this is a person who’s very limited, couldn’t date, couldn’t travel. He got about halfway better maybe with what I did with him. And then after I left to take time off, he went and saw a naturopathic doctor and was tested for celiac disease, came back positive and stopped eating wheat. And within a few months, his anxiety had ebbed away. And then he went off of his medication and he still had no anxiety. So, it was an interesting experience for me as a young psychiatrist to be humbled that way about medical causes that I didn’t know about. And it ignited a fire in me of looking at other alternative explanations for anxiety in particular, but also that led into gut brain connection and hormones and inflammation and some of these more complimentary avenues.
Dr. Rakesh Jain 10:23
What a wonderful case, Will. What a wonderful case. And I too, have been humbled. And I’m as proud as you are to talk about my failures, as I am to talk about my successes. I admire you for talking about challenging cases, and not just these great, wonderful successes that we hang as trophies on our walls, right? Yeah, it has been humbling. But we should also acknowledge that there are as many people who don’t have a particular problem, who make the erroneous assumption that they do. Now, let’s just pick celiac disease, as you mentioned. For every one patient that I have detected with celiac disease, I have been able to rule it out in perhaps 99 people. Pendulum is an interesting thing. The beauty of a pendulum is it doesn’t just rest at the bottom of its path, it can go left and right. And I think those of us who do believe in the sheer raw power of complementary medicine in wellness would be well served by an extra dose of humbleness. And humbleness is just because we believe that it is helpful for whatever percentage of patients and fellow human beings, it is not a good idea, just that psychiatry made that error, we will not make that error, hopefully, of assuming, because it happened in my last five patients, the next five patients have exactly the same problem. I don’t know if you agree with me on this or not?
Dr. Will Van Derveer 12:17
Absolutely. I appreciate you bringing this forward. The way I tend to think about it is that there tends to be folks who embrace complementary and alternative approaches. A kind of, I told you so kind of attitude. But I also see that in people in a more conventional mindset. So, I think it boils down to what you said, is the word humble, and the kind of willingness to not know and to continue to be a student, as you said, ask you tomorrow, you’ll have a different answer, because you continue to grow. And that’s how we all should be. In a book about what it’s like to be a doctor. And I’m trying to remember the name of the title. I think it was being mortal as the name of the book. Yes, he mentions that a physician who doesn’t know the answer is a worthless physician. And that really hit me between the eyes because I think that we have such a fear of saying, I don’t know. Let’s keep looking, let’s keep our minds open to what could be going on here. I think we need that kind of more of that, as you say, in every camp, right? And you could take this to a bigger political landscape as well of how difficult it is for people who disagree to speak with each other anymore in this country. It’s a big problem.
Dr. Rakesh Jain 13:35
It is a big problem. And you articulated it really, really well. Every time we change our minds, it’s almost always based on facts and experiences. And my favorite mind changing moments are the ones when my false idols have been shattered. I love that. To kind of know that this was sort of wrong, and it turns out to be wrong. That’s not as good a learning experience. A better learning experience for me is to have these cherished beliefs about whatever the case might be. And then being shown the evidence that is so profound, and so convincing, that I not only changed my mind by changing my mind, I’ve made my life better and the lives of people who are around me. Let’s use mindfulness as an example of Will. So, if you are listening to my accent, this is not an authentic Texas accent. I don’t know if I fooled you and fooled everybody listening to me. I may live in Texas, but I have lived here for 32 years. I’m originally From India, now many Westerners think India is the land of great mindfulness and great religions. And everybody is, you know, meditating 14 hours a day. And that’s simply not true. So, I grew up in a place in a time in an era where rejecting everything that was Eastern was automatically right. That’s what I grew up in. And that’s one of the reasons why I came to the state because at that time in the mid-80s, states were very much into individualism, self-sensuality, right? I found that very attractive, until I got older. And I started facing my own challenges and then went into my early 40s. I did encounter meditation and mindfulness for the first time, and then I became just like you very encouraged by it actually went and got formal training. By Zindel Segal, the gentleman who started the whole MBCT movement, we started in MBCT, entire endeavor here, I practice meditation now on a near daily basis. And I am stunned, absolutely stunned by how wrong I was. And I love that. And I love that not because I enjoy being wrong so much, but there’s more value sometimes to being challenged in yourself. But if we can just pursue that conversation a little bit further, I also made another mistake of thinking of mindfulness as a psychological technique. It is not, it is such a strong combination of psychological, biological and wellness. It’s a three in one. And therefore, these false dichotomies we sometimes draw between traditional medicine, complementary medicine are, to some degree not quite accurate, the placebo response to medications is real. And the biological response to physical exercise and socialization is real. Right? So yeah, I think we are all in need of loosening our own belief systems in a healthy way. And as you said earlier, talking to each other and listening to each other, so we can all benefit.
Keith Kurlander 17:19
Yeah, thanks Rakesh. I think that’s so aligned with how we teach in our institute. You know, we’re teaching an integrative model that’s really about transcending and including, and I think that’s challenging. It’s very hard when there’s so much polarization, like you were both talking about and more like, let’s just get the best from all worlds. Why rule anything out, right? It’s like, we have so many tools now available to us; more tools than we’ve ever had on this planet. And we might as well get the best of all of them, and know how to use them wisely, and when to use them, what’s appropriate. And I guess that brings me to the next inquiry here with you, which is let’s say, there’s the therapist who’s thinking of referring a patient to psychiatrists for medication, or let’s say it’s a psychiatrist, and all they’re really used to is prescribing medication, but they’re like, what else do I do? Do you have sort of a series of questions you’re asking yourself to know if medication is a good fit for the type of person’s presentation that’s in front of you, or whether you would really encourage them to slow down in considering medication? Do you have any questions that you’re wanting to get answered to work with that?
Dr. Rakesh Jain 18:32
I do. And I suspect they’re extremely aligned with how you folks approach your patients. And your client says, Well, there are some disorders where the case is closed. So, if I have someone where I’m absolutely convinced this is their first break psychosis, from schizophrenia, the case is closed, we’re going for medication. So now I will put all my emotional energies and all my persuasive powers, in an appropriate fashion, to convince the patient and their system, their family, that medications are central and needed immediately. But that’s the easy one. Let’s pick a completely different scenario where it is far more complicated: Autism. In autism, it lives on such a spectrum. Right? And an individual is not just on a spectrum, they are on a spectrum that changes month to month. So, I have had scenarios where I’ve had to pursue completely opposite tracks where you start with medications, you get things so much better for the individual and their family system where medications are not only not needed anymore, they actually become independent to progress. And I’ll give you a real-life example of that in just a second or two. But there are other examples. And I’ll give you a live example of right now. I work with a Baptist preacher from South Texas who had been sober from alcohol for I think about 30 years, between 25 and 30 years, and suffered from horrendous depression, depression like, oh, gosh, humans are not to be facing, and yet he hadn’t come to see me. He came to see me only because he could not simply control his suicidal ideations. He was convinced he was going to end up taking his own life. Even with him, because he was so opposed to medications, I was willing to wait four weeks. Because I had, in some ways no choice, and I knew that he was not going to agree to it. And we tried CBT with him and other modalities, they simply failed. We gave him medications, and I’m going to tell you, four weeks later, he came back to see me. I talked to him every single day. But four weeks later, he came back to see me and he did this, “30 years of suffering and all I had to do was take this little yellow pill”. And I followed him for 10 years. And then he moved on elsewhere. So, I’ve lost touch with him. But by the same token, I’m giving you a completely different example that only complicates the answer I’m giving you. I’ve had patients who had panic disorder, who I overtreated and kept them on their benzodiazepines and SSRIs. I now know that they no longer need it to the point that they can now no longer come off them without going back into profound panic attacks. So what questions am I asking? This is what I’m asking them and myself. What is the disorder? What is the severity? What is the family history? What are the patient’s preferences? Preferences really of course matter. And then finally, pragmatically, where am I willing to concede to the patient’s wishes, and where I simply won’t. If the situation absolutely demands no medications, or a patient has a recent challenge because of addictions, and they’re asking for the Xanax, again, I’ll hold the line and say no, and vice versa. But other than that, it’s a complex set of issues I interact with before I pull the trigger on medications. Does that answer your question to some degree?
Keith Kurlander 22:36
Yeah, it answers my question. And I think another way we could kind of go down this rabbit hole and different sort of rabbit holes would be, let’s talk about depression. You know, depression, just looking at the trajectory of people with clinically significant depression over the last number of decades and where we’re headed, it kind of feels like in 50 years from now, more than half the world’s going to be depressed, potentially. I mean, there’s a lot of depression. And of course, we see a lot of treatment resistant depression, or medications are failing. And I’m curious, when we kind of drill into depression, how do you think about medicating people who are on the spectrum of depression, obviously, we have all the way over to one spectrum of the full-blown psychotic depression, and then we have you know, more of like, intermittent depressions and things like that. So, I’m just curious, like, how are you even framing now the conversation for yourself for medication with depression?
Dr. Rakesh Jain 23:32
Mm hmm. So besides being an MD, I also have a master’s degree in Public Health. And the reason why I bring that up is because I obtained my Master’s in Public Health in 1987 where the American risk of having depression was about 8.7%. And today, in 2020, the risk is now closer to 21% than it is to 20%. What the heck happened to us? We got wealthier every single year. Our life expectancy went up. We launched 25 plus psychiatric medications, including 10 antidepressants, and this is what we have to show. So, even though you were kind enough not to point it out, I am going to point it out. With most psychiatric disorders, psychiatry has been a dismal failure actually. We’ve not been good. Traditional psychiatry has fought valiantly. It’s not that we’re lazy. But it’s not worked out. I think and I’m coming back to answer your question. It may well be because we took too much of a biological angle to treating it. And when I say biological, I mean medication biological, there are many other biological interventions. That includes meditation, I actually think meditation is a biologic, psychological and spiritual intervention. We did that. And as a result, not only do we suffer, look, I also get to interact a lot with my colleagues from all over the world. I just did a training seminar for my physician colleagues in Thailand, where they’re reporting an explosion of major depression because they have adopted our models. When I say our, I really do mean the American, I don’t mean the Western world. I do think American psychiatry is probably more infatuated with pharmacology than perhaps any other country I know of. As a result, the approach that you folks have taken at your institute is actually a very good one, which is a holistic approach, a curative approach rather than a symptom-controlled approach. I resonate with that very loudly. And of course, the time horizons for recovery should be a lifetime, meaning you do not kind of Oh, call it a three-month episode, and then kind of say you’re in remission, I’m done with my job, I’m out of here. You don’t need me anymore. But a true lifelong approach to curing it, if you will permit me I do want to maybe not disagree with you but just because it’s mild, truly does not mean that it is not going to be exquisitely and positively sensitive to medications. Some of my most chronically ill low-grade depressed patients actually have done so well with psychopharmacology despite 10 years of every known diet. And every known vegan diet and gluten-free diet and high dose IV vitamin D sixes and oxygen therapy, and you know, all kinds of wonderful things that really do work for people. But for them, if $4 for a 30-day prescription medication evaporates their depression, so there we go. So, see how challenging this is, is it not?
Dr. Will Van Derveer 27:14
I’m really enjoying getting a peek into the complexity of your thinking process Rakesh and your willingness to hold the Jungian of opposites really in their thinking. And it reminds me of when I was a medical student and picking a career, which specialty should you go into, and they gave us a questionnaire and one of the questions was, how comfortable are you with uncertainty? And if you said very, then they put you in psychiatry. If you are not very comfortable, I recommend you go into surgery or something different, I guess. But there are two pieces here I want to further explore with you. So, the first one I want to bookmark which is, I think a big part of what we’re talking about today is the appropriate use of medications at the right dose and for the right length of time. So, I want to come back to that. But because you mentioned coming out of your background growing up in India, and kind of the prevailing environment of rejecting Eastern perspectives, and your encounter with American society and this focus on the self. I’m very curious, I’ve been reading Carl Jung recently and this concept of the ego being healthy when it’s in connection with this bigger capital S self or this divine self, to you, in your movement growing older and maybe being less connected in with a young man’s point of view about self, do you feel that there’s something about American culture that needs? I guess what’s coming up for me is this sense that we have that the ego is the crown, or the sort of pinnacle of Western development, let’s say for a human being, but it seems like a recipe for depression for us to sort of crown the ego as Okay, I’ve got a functional ego and therefore I should be happy or I should be fulfilled. It seems like there’s something more that people need. What’s your view about this relationship about the self?
Dr. Rakesh Jain 29:15
You and I are brothers from different mothers is what I say despite our backgrounds. We are very unified. I totally agree with you. My mood and my wellness are incredibly influenced whether I know by my nodes of connection. So, will I know you now, right? I know you, Keith. Therefore, your mood, positive or negative, affects me. We actually know how much it affects me. We know that from the Framingham Heart study where they look not just at the heart markers, but actually wellness and disease transmission from people to people who are not genetically related. So, Will, I really hope you are doing well. Because if you are 9% of your wellness will actually rub off on me. Now, here’s the interesting thing, your friend, who I’ve never met before ever, ever, ever. That person’s happiness or sadness has a 5% effect on my sadness or my wellness. And by the way, that’s two nodes. The third node, meaning that friend, whose friend you have never met before, either, that also indirectly affects me. And these flows both ways. So, to support your point, I do think as human beings, the societal wellness, which we have just abdicated, it became, you’re so right. I came to America because I found everything American to be. And I still do. I love this country. I’m here by choice. I just think it’s such a fantastic country. But there’s so many things we do well, but there are a few things we don’t do well. We did abdicate this very large part of who we are: our psyche, our soul, and our brain. Right now, when I’m looking at you, I am spending a shocking amount of energy looking at your face. But that’s not me. That’s what my brain is. I am designed to read your face. I am designed to read every expression you’ve got, even micro expressions, good, bad, neutral, whatever the case is. I’m a social creature, whether I want to be or not, I am. We did advocate that. But the other thing we abdicated was genuine spirituality, not religion, which is, of course, a different thing. And I’ve only discovered in the last couple of decades, and at least for me, that journey was heavily influenced by my psychedelic use, that really has influenced my growth. You talked about Jungian philosophy. I read it because I was required to read it. Because I’m a psychiatrist, you have to read all that and be able to pass exams, but I didn’t quite understand when he talked about the connection with nature and connection with the self-greater than you, what it means, and when that is well developed, what a positive influence that has on you for a long time. I hear you. And I am resonating loudly with you that recovery from depression, the small “d” depression, which I do think is different from the big “D” depression does require going back to our ancient selves, because our ancient selves had a set of skills that we let go of once we landed in this industrialized nation model, and no country does industrialized nation better or worse than we do here in the United States.
Dr. Will Van Derveer 32:50
Yeah, I mean, I totally agree with you that this is the two sides of the coin of the beauty of the American system and the tragedy, at the same time. I’d like to come back to this issue of how long and how high of the dose and our mutual friend Chuck Raison mentioned recently that you had an interest, I think he said that you had familiarity and interest in this concept that’s become a part of the conversation recently in psychiatry about the risk of Tardive dysphoria. And when you spoke recently, just a few minutes ago about your patient with panic attacks, and I wondered if you were alluding to the person who has a hard time coming off the SSRI, and how does that factor into changes that you’ve made over the years in the way in your prescribing habits?
Dr. Rakesh Jain 33:44
Yeah, maybe we should define Tardive dysphoria for our listeners, because it’s still, even though it’s being talked about now for 15 years. It’s a still a relatively nascent concept in our field, isn’t it? So, dysphoria forces sadness, Tardive would be late arriving. And the concept is very, very much like tardive dyskinesia, which is, you often get the opposite of what you are seeking, and opposite of what you originally got, just by staying on intervention for a long time. And there’s a lot of parallels with multiple other fields. For example, oncology. In oncology, if you treat a child who’s 10 years old, for acute leukemia, good for you because you now have a 95% chance of helping the child out but without meaning to, you really have increased the risk of them developing leukemia type disorder in the 50s and 60s. Just because you had to apply the treatment to save the person’s life to this concept of Tardive re arrival later re arrival of the disorder is actually not new to medicine. We have seen that for a long, long time with multiple disorders, including obviously tardive dyskinesia, Tardive dysphoria is a very interesting and a pretty worrisome potential complication of long-term antidepressant therapy. Clearly not in the majority of people, it is important, we’re not end up scaring any lay or professional audience members. But we also need to advise them that this is a concept that may become of some importance where just because you’ve been on antidepressants for a while, your brain and when I say brain, I think I should perhaps narrow it down a bit. The neurons and the receptors that really are the currency, really the tools that the brain uses to communicate with each other, may configure themselves in such a way that not only do you no longer respond to antidepressants, you may be depressed because of the antidepressants. You might as well go ahead and challenge me now. What is the biologic evidence, show me hard evidence, and I don’t have it. It does not yet exist. There are however, sadly, a lot of tantalizing clues and worries, and maybe in 10 to 15% of people Tardive dysphoria will occur. So, what do we do with it? Right. So, this may be a good time to rethink and be more cautious about who to offer medications to pull to perhaps gently push towards looking in other directions, at least for the time being. And then who should continue beyond a certain length of time, be it six months be the year to potentially decrease the risk of Tardive dysphoria, while at the same time making sure a patient who does need long term treatment isn’t denied what potentially could be a lifesaving treatment.
Dr. Will Van Derveer 37:07
Again, we’re very aligned here Rakesh. And I just want to reiterate the point that you made that when medication works for a person, it can be absolutely lifesaving and essential and necessary in the long term for some people. And we certainly don’t want to discourage anyone who needs that, or cause them to even doubt or feel second thoughts or for sure, any sense of shame of meeting that ongoing support, everyone needs ongoing support of a wide variety of different flavors and forms. What we’re talking about is this concern that in a minority of people, there may be long term consequences that we previously didn’t understand well enough and still don’t understand adequately to make sweeping recommendations. But we do want people to be aware about this emerging figure coming forward out of the fog of ignorance, and through the shining the light of experience onto this, this figure coming forward, that appears to be something like crossing a threshold where now the depression in this case, may actually be more of a result of the treatment, as opposed to the treatment being the curative effect of condition first place.
Dr. Rakesh Jain 38:22
Which is, yeah, yes. Will you forgive me for stepping on your words there?
Dr. Will Van Derveer 38:27
Not at all, please.
Dr. Rakesh Jain 38:30
Yeah. Which is why we should come to a few agreements. The agreement is I don’t know anybody who suffers from any psychiatric condition, who would not benefit from more than biological interventions? Right? So why don’t we while there are so many unknowns in the field, and there are complexities in the field, there’s one thing we can agree to not based on our belief system, but based on our belief system, and the evidence at hand, no one but no one, whether they’re psychotically depressed, or, quote, unquote, mildly depressed, should avoid taking full advantage of the full array of complementary holistic and wellness techniques. We agree. Right in doing so, by doing so you’re decreasing your dependence on any one modality of treatment, which is in our stack investment, would you invest everything in just one single stock? It’s a highly risky maneuver, you might really succeed but Oh, why did that fail, see, and then it’s a problem. So, we do agree on some things, but look, if you get a fracture, have your leg, the orthopedists will put a cast on you. And that’s a good thing. But the orthopedist is going to be very quick to take it off the moment it is safe to do so why? Why not just leave it on for another six months? What’s the big deal? And the reason for that is leaving a cast on when you don’t need it actually weakens the very cause that you’re trying to fix. The very bones trying to heal, you have now made yourself weaker by doing something longer than you need it to. with depression, just like the bone in my femur, maybe three months, but in my hand, maybe six weeks what why can’t depression also be the same thing valuable in terms of meat? What do you say to that, Will?
Dr. Will Van Derveer 40:24
1,000% agreement, that’s all I can say. Absolutely. In fact, it’s funny because when I talk about my brother from another mother, I use the very same analogy of the orthopedist and the cast and in my clinic with my patients.
Dr. Rakesh Jain 40:40
A great analogy is good. Yeah, did not know you did that. The very fact that, especially as different from psychiatrists, orthopedics has in its own way. And they’d probably learned it 200 years ago, because they had castes back then, well, we only got our castes. psychopharmacology was born in 1952. So, we are a very young specialty, we’re just learning. But as we are learning, I’m so glad in your podcast, you’re highlighting that there is not a one direction response to our interventions. But there are some things that really do have one direction, I have never, ever heard someone being directly harmed. Because they lead a well-balanced lifestyle, I just never have never, you would have thought this man is 58 years old, maybe he’s by now at least met somebody who was harmed by doing that. So maybe there are some unifying principles in life that are true for everybody. So, we live with certainties, which is very good, which by the way, are solid in ancient and wonderful. And these uncertainties, we will navigate that with the consultation with our patients, but also with a very open mind and a heart.
Dr. Will Van Derveer 42:06
Right, and I think dynamic that we haven’t named yet, but it’s so clear and so present here, which is accounting for the risks when we inform our patients about the choice of whether to do a lifestyle intervention or medication. And I remember reading that back in the 1800s, there was a big schism between naturopathic doctors and physicians around the treatment, I think it was a treatment for malaria, where we, as the MDS, were giving people Mercury, intravenous Mercury, and more than half of the people died. But the ones who didn’t die were cured. But the naturopaths had a much less toxic treatment where people, way more people died from the original disease. But basically, no one died from the intervention. And so, patients were getting in line for the natural pass, because they didn’t, at any rate, they didn’t want to be killed by treatment, they would rather die from the disease than the treatment. And so there was this movement that happened to sort of dominate the medicine where the AMA is, and don’t have all the details in front of my mind. But we came in with these riskier and more dangerous, let’s say treatments that provided more benefit for the people who got benefit, but they were more risks of harm. And I think part of the popularity of alternative medicine and complementary techniques is along these lines is that a person faces less efficacy in many cases, or very weak evidence for the treatment in cam versus say, you know, a double-blind placebo could you know phase three FDA data for medication. But there’s a perception that you’re going to also get less side effects, or you have fewer negative experiences from cam. And so, there’s this interesting balance that I think as practitioners we have to hold off first do no harm, but also do enough to actually impact the person. Right? So that’s how I feel about it. So, I think about it.
Dr. Rakesh Jain 44:23
You are wiser than your yours. You really are. Yeah, that’s exactly it, that constant tension between Is it enough? What is the price for it? Is it not enough? And what is the price tag to that is one that we constantly have to hold in our heads and it’s not easy. It’s just not an easy decision for us. But imagine how difficult it is for patients, they actually have to live with the consequences of their decisions. It’s interesting you brought up the 18th century experience, I read a book that was incredibly illuminating, called Lincoln’s melancholy. If you ever get a chance, and you are free during this pandemic, to spend a couple of days reading a great book about American psychiatry, read Lincoln’s melancholy, he attempted suicide four times in his life, a very serious suicide attempt, I believe the first or second one was at 19. And he got treated by the leading psychiatrist of that time rush, and the treatment was led, and mercury and arsenic and a few other things. But Lincoln got horribly, horribly sick from it. And I think he got sick enough that by the sixth day, he said, I’m cured. Leave me alone, I’m leaving treatment. Let’s go back to that. But look, what else so they did for people who had depression that we don’t do now. We don’t do as well, they used a bio psychosocial model. They really did. They really do. They use what we call alternatives today, they call essential. That’s why I have such a problem with calling it complementary or alternative. And because complementary means it complements something that is essential. And it’s the other way around. It’s not complimentary. It’s essential, it’s baseline, it’s foundational to being a human being. And why do we call it alternative? Because alternative means, Oh, you didn’t find that on amazon prime, here’s an alternative. It’s about equal to the same thing. And that’s simply not true. All the things we talked about, you talked about mindfulness. But if we go further, if we talk about homeopathy, for example, if we talk about wellness interventions, for example, even sleep, hygiene, social activity enhancement in a focused way on these other things, those are not complementary. Those are not alternatives. Those are the foundational things. So, I do think of Western medicine, which I actually believe has great power. And I’ll defend it. And I’ll defend it, because I do believe it has a major, major role. But if we started thinking of it as an add on, and not the centrality of the intervention, as an intervention to offer when other things aren’t enough, Oh, my gosh, I think we’ll not only end up harming fewer people, we probably will end up helping more people, both in the short and the long run.
Keith Kurlander 47:35
I think we might have our terms flipped in terms of what’s comfortable, complementary and alternative to sustaining life. And thriving. Yeah, this is kind of, I want to share a personal, short, personal kind of anecdote here, which is that psychiatric medications have been very essential to my own healing process. I recommend psychiatric medication still to people regularly, in certain cases. And as long as I’ve been on psychiatric medications, I’ve had a wean off almost the same amount of time, we’re talking like 6 7 8 years on 6 7 8 years weaning off. So, what I’ve discovered, and I’m one person, and I hold that when I talk about these things, but there’s this whole concept of are you having symptom recurrence, when you’re coming off your vacations. And with some medications, there’s a very direct conversation about rebound when there’s passive build fast tolerance, like benzodiazepines and things. But I’ve seen not only myself, but a lot of people I’ve worked with where I think it’s very hard to tell the difference between a true symptoms recurrence versus having rebounds on medications that we don’t normally talk about as having rebound. And, and I’ve tried medications in almost all the classes. And I’ve seen I believe, rebound in all the classes, you know, where you would use, let’s say, antipsychotic for sleep, that you wouldn’t assume would have the same type of rebound as a benzodiazepine. But then you stop and you can’t sleep for three nights at all. And so, to me, this brings up you know, the conversation of if it’s so hard to get off of these medicines for some people, because of having a pendulum in the brain of some sort. Well, now what did we do? How do we talk about this with people, you know, 10 years ago, no psychiatrist ever once mentioned anything about this to me, ever, it was just like no these meds there’s no rebound here? There’s nothing like you’re coming off of these and you have new symptoms like you’re having a recurrence of your issue. So, I’m just curious about your thoughts on this.
Dr. Rakesh Jain 49:52
yeah, yeah. So, remember, we’re trying to find some very common grounds that apply to everybody. So, here’s one more very common ground, we can apply to you, Keith, to me, to Will, to everybody who’s listening, and every patient who’s ever taken a psychiatric medication, take this to the bank, what I’m about to say. Every medication has a rebound. Addiction is not the same thing as rebound. Lithium has one of the strongest rebounds known to mankind and has no addiction potential. And if the biological reasons for it, and I see that you wear glasses, I don’t wear them now, mainly because I had LASIK eye surgery. But you know what’s interesting? If I had my glasses on all day, and I took them off, my vision was bad. But it was worse, because I had my glasses on all day than it typically is, if I don’t have them on for four or five hours, and that’s a rebound. That’s rebound vision, neurons rebound, no matter what the medication is, when you remove it abruptly and abruptly is in psychiatry defined very differently, Keith. We have sadly mistaken half-life of the medication for the rebound duration. I have not seen benzodiazepine withdrawal. The last two years, I have seen SSRI which is quote-unquote, non-addicting rebound last six months to a year, I’ve seen lithium rebounds that you can still hear the reverberations of, three to six months after you stopped taking it. So, psychiatry did not know about it. But now and I’m leading this, I’ll take credit for it. I mean, it’s okay to take credit for it when it’s appropriate. So, I’ll take credit for it. I this year, conducted the first de-prescribing seminar for psychiatrists to the best of my knowledge ever conducted. And the reason why I did it is because what you’re just describing is true. And prescribers are simply unaware of it. And it’s very difficult to caution a patient about something that you don’t even know is an issue. Now, am I so smart to have figured it out? Heck no, the only reason why I am completely cognizant of the challenges with withdrawal and rebound, let’s call them slightly different things because they are but they’re both very challenging is because it took about 20 years of hundreds of patients telling me you are missing the boat man. You are just not being accurate. So, I went in, I looked at the literature, we conducted some of our own research anyway. Yeah, yes, yes. Individuals are suffering because the human brain just doesn’t like sudden changes. So, what am I now with my practice with it? Same place where I was, if I do start a medication, I want to be cautious in terms of Is it right? If it is right, the least effective dose, the fewest, but I have several patients who are on nine or 12 psychiatric drugs, call me a bad psychiatrist if you want to. But I don’t believe that is the situation they simply need. But each one of them I’m costing them, every medication we have can have a rebound. It’s a potential challenge. Please know I’ll walk the walk with you. We will do it carefully and safely. Did I answer your question? I’m very much hoping your own psychiatry team in time becomes aware of maybe because of our conversation today. Maybe because of some of the writings that exist in the field. That de-prescribing is probably as important as prescribing and actually requires a greatest set of skills than just prescribing a medication.
Keith Kurlander 53:59
I mean, yes, you definitely answered my question. And why would I agree as a patient in psychiatry that de-prescribing skills seem to be much more complex than prescribing skills, because you have to be very patient as a provider with it very, very patient. Whereas prescribing the ramp up as much quicker.
Dr. Rakesh Jain 54:27
You said it beautifully and prescribing there’s some heterogeneity. Like Prozac someone on 20, but ultimately, I’m sort of going someplace but de-prescribing, oh my goodness, you create a route for that particular individual and you should be I’m talking to me the prescriber, you should be willing to change your route and keep just yesterday, I and my research partner recorded a presentation. Now this, I gotta tell you, this is going to be torture for whoever listens to us a six-hour psychotherapy presentation, thank god broken into three components. It’s an update on psychopharmacology for the non-prescribers that we will show at a pretty large bi Annual Meeting called evolution. But I spend a lot of time talking to non-prescribers about the importance of learning about de-prescribing, because de-prescribing isn’t just the prescriber and the patient, it is the prescriber, the patient, the therapist and the family. We all have to collaborate to help them come off it with minimum and hopefully zero challenges.
Keith Kurlander 55:48
Yeah, thank you for your contribution there. And also, for paying attention over the course of your career to recognize and challenge what you were told, so that you can dig deeper to find out some answers. And I am aware of the time so we could talk for a long time. This is really fun. But so, I want to wrap up here with you. So, we end with the same question to every guest. And the question is, if you had a billboard that had a paragraph on it that every human would see once in their lifetime, what’s the one thing you would want them to know?
Dr. Rakesh Jain 56:43
I’ve never been asked that question and I love it. Oh my god, okay, sure, sure. I am more than happy to tell you what I have learned in 58 years of living in two continents, and more importantly, living in two continents up here. It has been remarkable to live in two very different continents of thinking just one way and then being able to change it. Perhaps what I would say to people is this. Instead of asking yourself what’s wrong with yourself, you might as well ask yourself, what’s right with yourself. Most of us are very blessed to have more rights with ourselves than what is wrong with us. Appreciate that your brain will often lead you astray by perhaps making you ruminate and worry. But if you focus as much on wellness, and being a holistic individual, with a well-developed spiritual life, a well-developed social life and a well-developed life filled with purpose. That’s a well lived life. And should the slings and arrows arrive? Don’t avoid seeking professional help of any kind. It is not only Okay, you are honoring your mind and your body and spirit by seeking help so you can be back on your track to asking yourself every day. What is right with me?
Dr. Will Van Derveer 58:01
Keith Kurlander 58:03
Thanks so much for being on the show, Rakesh.
Dr. Rakesh Jain 58:06
Thank you both for doing this. You don’t have to do this. But you’re doing this out of caring for your colleagues and your patients. And I admire that. I really do. So well done, gentlemen and keep at it, okay?
Dr. Will Van Derveer 58:27
Wow, what a far ranging and deep conversation with Dr. Rakesh Jain. We could go on for hours exploring different aspects of psychiatry, what’s working, what’s not working, how emerging evidence is shaping clinical practice. Such a delight to explore with someone who is so thoughtful and so heartfelt as a psychiatrist. I hope you enjoyed this episode as much as we did. We look forward to connecting with you again on the next episode of the higher practice podcast where we explore what it takes to achieve optimal mental health.