Ordinarily Well: The Case for Antidepressants

11

Interlude

Transitions

IN MEDICAL SCHOOL and then in residency at Yale, I had two interests, psychotherapy and community psychiatry. I worked with wayward youth, parolees, and indigent legal defendants. I ran groups for the gravely mentally ill, made home visits in inner-city neighborhoods, and staffed public clinics.

I might have continued in this vein except that I had begun dating a woman—Alan’s friend Rachel, whom I would marry—who lived in Maryland. To join her, I agreed to an increased workload in New Haven in exchange for permission to spend my final six months in the federal government, in Rockville. A Yale professor there ran an office that brought model programs to mental health centers nationally. When that effort fell to budget cuts, I was sent to the agency that oversaw the NIMH and its sister institutes.

My boss was Gerry Klerman.

In the early months, I worked with Charles Krauthammer, then just out of his own psychiatry residency. Followers of Charlie’s unsparing conservative political commentary will be amused to learn that he left to become a speechwriter for Walter Mondale in Jimmy Carter’s losing reelection campaign. At that point, I ran the Division of Science of the Alcohol, Drug Abuse, and Mental Health Administration, largely because I constituted the whole of its remaining professional staff.

I had an extensive portfolio that included, from my prior life, research on illness and social disadvantage. My main job was to consult with experts and then brief Gerry for presentations to Congress and the White House. He was a large, quick man, and much of our contact was on the move, as in Aaron Sorkin television shows—The West WingThe Newsroom—that feature assistants at their masters’ heels. Once I’d prepped Gerry, he’d fill his speech with examples I had not provided and arrive at conclusions more sophisticated than those I had proposed.

Under his tutelage, I studied treatment-outcome research. Our focus was proposed legislation, originating in the Senate, that demanded controlled trials in mental health care, with an emphasis on psychotherapy. If therapy failed, federal programs would not pay for it. If therapy passed muster, psychologists would gain new practice privileges under Medicare. Gerry was pressuring psychotherapists: randomize until it hurts.

Gerry had standing because he and his future wife, Myrna Weissman, had conducted the first substantial trial of psychotherapy for depression. The research utilized a simplified version of psychoanalysis called interpersonal psychotherapy, or IPT. The treatment’s elements were specified in manuals, used for training via brief instructional courses.

Gerry and Myrna tested IPT’s ability, alone and in conjunction with the tricyclic Elavil, to prevent relapse in patients who had recovered from a recent episode of depression. On its own, Elavil outperformed IPT. (In another trial, of depression treatment, the two did equally well.) Surprisingly, combined treatment, psychotherapy plus Elavil, was no more protective than Elavil alone. This result was early evidence that mental health interventions are not always “additive.” If each of two treatments gives a benefit, the two together may not give a larger benefit.

The main impact of these trials was to show that psychotherapy could be tested, like any medical intervention. This conclusion encountered resistance. The setup—manuals, quick training—outraged many psychotherapists.

I was one. How many hours had I spent attending seminars and undergoing supervision in the effort to master particular psychotherapies? That’s before mentioning reading, my personal analysis, and time spent in patient care—followed always by self-criticism. Was I present, imaginative, spontaneous, kindly, empathetic, and clear? Psychotherapy was an aspiration or destination. And now we were testing its worth via brief treatments conducted in accordance with mechanical guidelines.

Consistently, the outcome trials showed efficacy, but each time they did, I thought, It might have been otherwise.

Gerry dismissed these concerns as naïve. The government and other payers would demand that treatments prove their worth, and rightly so.

In 1980, with Gerry’s encouragement, the NIMH established a Psychosocial Treatments Research Branch under Morris Parloff, an expert in outcome trials. (Like my father, he’d been one of the “Ritchie Boys,” German speakers with a scientific bent who served in American military intelligence in World War II.) Morrie was urbane, with a wry manner. In group settings, he generally held back. If the discussion veered in a direction he found unhelpful, when called upon, he would venture, “I feel like I’ve said too little already.” I worked with him on research policy.

Morrie estimated that there were 250 schools of psychotherapy. Each variant might have a dozen targets—schizophrenia, alcoholism, and so on. You might want to look at those treatments for those targets in, say, a half-dozen patient groups—adolescents, the medically ill, and more. If so, evaluating each combination of treatment, disease, and patient type once would require eighteen thousand clinical trials—and then replication. The government was having trouble finding funding for a single substantial trial.

But Gerry was set on outcome testing, and in the area he had pioneered, depression treatment. The great activity, in the two and a half years I worked in government, was preparing for a large-scale psychotherapy trial. Not on his watch, but shortly after, Gerry’s vision carried the day. The research would also set standards for the testing of medication—and play a role in the antidepressant controversy years later.

Meanwhile, I was accumulating experience treating depression. Doctors in federal posts were granted time to teach and practice. I joined the faculty at George Washington University—but where might patients come from?

An elderly psychoanalyst had been weakened by a chronic and now terminal illness. He was looking for young doctors to take on his remaining patients and try treating them with medication. A professor at GW recommended me. I visited the analyst in his large brick house near Rock Creek Park.

The visit was an assessment: Was I up to the task? There was another agenda. Among the remaining patients was Stephan. In adolescence, he had been delicate, living in an abusive setting. The analyst, call him Dominic, and his wife rescued Stephan, taking him into their home and acting as foster parents. Perhaps because this arrangement demanded secrecy, Stephan had never been referred for consultation.

Stephan was timid and solitary, a career administrator in the federal bureaucracy. Throughout adulthood, he had been pessimistic, scrupulous, cautious, and glum. As Dominic became frail, Stephan had slipped into “double depression,” an acute episode superimposed on a chronic state. Double depression was just being discussed in the field, and antidepressants were thought to help. I did not hesitate in prescribing a tricyclic.

The depressive episode resolved quickly, a pattern that was new to Stephan, and he noted that he was less liable to downturns in mood.

Stabilization proved important. Dominic died. Under Ronald Reagan, government workers faced a “reduction in force”—firings. Stephan assumed more varied duties and reported to a different boss. Ordinarily, upheaval at this level caused Stephan to experience mild paranoia, as if organizational restructuring contained threats intentionally directed at him.

The medication sustained more benign views. Stephan understood what he had been told repeatedly, that crises constitute chances to nudge staff forward. He had what he said was a new thought: “I deserve a good life.”

For Stephan, so attached to Dominic, I represented entropy: the dissolution of shared memories and assumptions. I was of a cooler temperament than Dominic and likelier, prescribing aside, to throw Stephan on his own resources. The medicine, not I, proved to be Dominic’s replacement. It seemed that antidepressants could act that way, as transitional companionship—in this case, at a level that allowed Stephan to begin socializing, if cautiously, with peers from his workplace.

In my clinical practice, the experience of being Roland Kuhn played out over a decade. Repeatedly, I encountered patients who responded to medication as they never had to remedies they trusted more.

With Gerry, I read endlessly about outcome testing based on rating scales. But, as Jonathan Cole had taught, it was clinical care that demonstrated what drugs offered. An antidepressant might free a patient to accept change. I stored that result in my library of potential medication effects.

As for my own development, I had moved from studenthood, with its constant supervision, into private practice. Evenings, I went to an empty office, and people came to me. I was hooked, by the autonomy, the responsibility, and the privilege.



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