Introduction to Psychiatry

Intro Video on my Practice

This is my Substack for my private practice clinic, where I share educational information.

Intro Video:

Transcription:

The first rule of psychiatry is that you have to have a patient.

With that in mind. I'm Dr. Bradley Brown, and this is my introduction video for my private practice clinic here in Berkeley. I was a philosophy major who went to medical school to kind of study the science of the mind in the context of psychiatry.

My practice here is kind of based on two fundamental clinical ideas: The first is that in medication management, most psychiatrists are both too timid regarding the escalation, either of a particular medication or down a medication algorithm, and they're not properly weighing the risks and benefits to the patient. It's a principal agent problem.

My second concern is that as psychotherapists, some (not all, but some) of the core ideas of our therapeutic culture are theoretically flawed, and this makes them counterproductive, or at least less productive than they could be.

I'm going to include some medication algorithms below this video. Let me explain some aspects of my medication approach to start with.

Nowadays pretty much everyone in modern medicine would claim to be evidence based, but whenever I use that term what I mean is that I don't really trust textbooks or professional association guidelines. I'm more interested in reading the primary literature and drawing my own conclusions from this primary literature.

Now, in 80% of cases, this doesn't really make a difference. It's not like everyone's been wrong all of the time about everything. But there are a few things that I'm going to point out, in my notes, based on the order of controversy.

Here's a good starting example: Melatonin is a very common sleep aid. You can buy it over the counter. It's commonly dosed between three to ten milligrams. The actual most effective dose is probably like 300 to 500 micrograms. That's about a 10th of how it's commonly used.

The issue is that some scientists at MIT, I think back in the 90s (I'm speaking extemporaneously) actually had a patent for the evidence based effective doses of melatonin, because melatonin is part of your body's natural circadian rhythm. So you want to have a dose that mimics the body thinking it's getting later in the day.

But unfortunately, really high doses weren't patentable because there was no evidence. You can't patent a natural hormone. You can only patent a certain dose for a certain purpose. So these high doses of melatonin became really marketable. And frankly, it was kind of a failure of evidence based psychiatry that we didn't clarify that for people, because I don't think there's anyone who actually knows the literature who would doubt that melatonin is best dosed at what's sometimes called physiologic dosing, which is in the microgram range instead of in the milligram range (or at the most 1 MG).

Speaking of sleep medicine actually reminds me that I once had this issue where I was yelled at by this sleep medicine doctor about the fact that he was board certified and had a fellowship and all this, because we were consulting together on a patient, and I said they were probably a rapid Ambien metabolizer. It was like the Ambien just wasn't hitting them.

Ambien is a common hypnotic. The weird thing was he was so confident there was no such thing as a rapid metabolizer, and it's true there's no specific genotype for this, but if you just look at the data, like, look at the original FDA studies for a particular dose of Ambien, I think it was in 50 healthy volunteers. The range (I forget the actual number) was essentially quadrupled, like it was between 100 to 400 micrograms or whatever measure they were using.

Whatever numbers were used, when you actually measure the serum levels of Ambien at either five or ten milligrams, there was a massive range difference in these healthy volunteers. But because there's no exact textbook warning about rapid metabolism, this fellowship trained sleep medicine doctor was frankly kind of clueless about this and offering what I thought was some bad clinical advice.

Another area that I think it's worth pointing out here, so you get a sense of my treatment approach is another common medication used for probably too many purposes: gabapentin or Neurotin.

People often waste their time with small dosing adjustments of like 100 milligrams here, 100 milligrams there. “I went from 300 and now I take 400, I used to take 800, now I take 900.” But the weird thing is, if you look at the actual original studies, (and this isn't obscure; this is on the FDA label) there's a ceiling effect to absorbing gabapentin. So going from 900 to 1200, which you think would be like a 25% increase, is actually less than a 10% effective increase. So when you take massive doses orally, there's just diminishing returns in terms of the absorption.

So I think at lower doses, you're absorbing about 60%. About two thirds. And once you get into the really high dosing range, you're absorbing less than a third. So you might have to triple it to double the effective levels depending on exactly what you're looking at.

Once again, you can verify what I'm telling you about these things with a Google search. Just type in FDA access data for any given medication.

I'm kind of in a weird spot here because I don't want to toot my own horn too much, but, I mean, this is an area where some doctors are really kind of falling short in psychopharmacology. The thing I really want to point out, and this is probably the second most controversial thing I'll say is alprazolam or Xanax is a really helpful antidepressant for a lot of people, and this was pretty well established back in the 1980s.

The problem with psychiatry is that it's so cyclical in terms of what's popular or what's acceptable. We have all this excitement now about medications like Ozempic, which is fine for weight loss, but traditionally we probably had better results from combining an amphetamine with a barbiturate. There are medications like Dexamyl that really helped nearly eliminate obesity as a societal problem back in the 1960s (smoking probably helped, too).

But now we're going back to weight loss drugs because we have a new medication class. My point here is that when it comes to treatment resistant depression, people are talking a lot about psilocybin and LSD and everything now, and everything old is new again, which is fine. It's something that we can get into.

But Alprazolam or Xanax, they actually studied the doses of ten milligrams a day, and it's a really good antidepressant. And the Cochrane Review agrees with me on this. People dose it too low. There are weird myths about its half life. Its half life is about 16 hours [in the elderly, which are typically the population worried about]. It's not particularly short acting.

It's also unique among the benzos. It's a triazolobenzodiazepine, which only one other medication is. (It's only used for anesthesia, because that one, triazolam, truly is short acting, like on the order of less than an hour.) So Xanax is good. If I have to summarize it. Now, before I go into the second part of my introduction, le me say something. Living in the Berkeley area, the Bay Area, one of my favorite types of patients is the high functioning autistic person, like a software engineer, scientist, or grad student.

These are high functioning people who have complex neuroses and are neurodivergent in some way. Probably my favorite population to deal with. And what I'm about to say is going to alienate some of them. But I think it's important to show that I'm an honest broker and that I've done the reading on a lot of these topics in psychiatry. By far the most controversial area of modern psychiatry, if we go by what's in the popular imagination or in politics, would be the treatment of gender dysphoria, especially the kind that emerges in adolescence or later. I understand that some states are banning this, and others, like my own California, might be passing laws to make it not exactly mandatory, but maybe kind of considered abuse to withhold it.

So what we're talking about here is using primarily hormones, sometimes surgeries, to treat gender dysphoria by making the body match the desired gender or the desired sex.

There's really only a few dozen papers relevant to this, and I frankly doubt that any of these therapies have a meaningful mental health benefit. Saying that is not to disrespect, like, transgender people or patients as a subculture. I just think being trans is similar to being Mormon or being a vegan or even joining the Marines or something. It's a subcultural group. If you'll benefit from perceiving themselves to be part of a community, or from actually being part of a community.

But being a part of a community means you often have a hard time accepting that your practices aren't as beneficial as you would like them to be. I've had to argue with some pastors that baptism or other Christian rituals won't really cure alcoholism. And I once had an Iranian father who had this idea that a proper Islamic circumcision would help his son's bipolar disorder. Because they were immigrants, they didn't have, like, the proper Islamic circumcision that I think you typically have in Iran. But anyway, these things like baptism, spiritual experiences, and our rituals have their place, but people who are involved in these communities tend to overstate the benefits.

With that in mind, I'm going to briefly discuss the research on gender dysphoria here, because this isn't something that people commonly talk about unless they're kind of proponents or advocates of it. So in modern populations, especially teenage populations, the primary research in this field was done by a group of Dutch researchers about ten years ago.

Now, the problem is that they measure gender dysphoria at one point with the birth sex based questionnaire. So in a male to female case: are you distressed by your penis? by your beard? Your jawline or masculine kind of traits? Then later, after being on feminizing hormones for a certain period of time, they gauged the benefit by asking the female questions: are you distressed by long hair? breasts? your hips and waist and other feminine traits?

That's just a methodological flaw. It doesn't establish a benefit. And my concern is with real cases of gender dysphoria, not so much in cases of people who are trans kind of by choice or kind of as a lifestyle decision, for lack of a better term. I’m concerned with who really has true gender dysphoria. They're actually distressed. It's actually comparable to anorexia or something. Their body is a huge problem for them.

The Dutch method doesn't really work because you can't establish a benefit to feminizing hormones if you're not asking about the masculine traits. Right? So even the original research in this area was too deeply flawed to draw many conclusions from.

My real concern here, and I've seen this clinically, is that cases of gender dysphoria, whenever you're still identifying as your birth sex, you might be distressed by one or two things. Consider a female to male case. This person might be disturbed by their breasts. But once you start identifying as male and maybe have your breasts removed, you've traded one problem for several, because then you're worried about your hands, your height, your voice, your waist, or feminine body proportions.

It's not about “passing” per se, but that the body dysmorphia has moved from what you didn't like about your birth gender to what is now incongruent with the desired gender. So I think by affirming the idea that gender transition treats gender dysphoria, that's almost certainly a mistake. It's probably the biggest thing I disagree with most modern psychiatrists about, although there's a great deal more controversy than you would think just by judging from the people who speak out publicly.

I don't want to focus on this too much. I'm just trying to demonstrate, whether you're interested in this topic or not, that I'm a close reader and honest broker of psychiatric studies. So there have only been two papers within the past few years that really tried to meaningfully address the outcomes of treating gender dysphoria this way in modern adolescents.

Both of them were written up as though they were positive, but they really weren't. In one of the studies, the actual group treated with hormones didn't show any actual benefit. It [the study] looked at the course of the questionnaires for anxiety and depression. The reason they were able to argue there was benefit is because the untreated group, which wasn't randomized but I believe it was because the parents wouldn't consent, or the patients were unsure about taking the medications.

So it wasn't a randomized study. But the untreated group, they had a massive dropout rate. They were comparing, like 80 to 100 patients to 80 to 100 patients. But by the end of the study, there were literally only five people left in the gender dysphoria-but-not-treated-with-hormones group.

And of course, those five teenagers did have poor mental health outcomes. But what's the most common reason why someone would start going to a gender clinic and then stop going entirely? Well, I mean, what happens in these cases is that the gender dysphoria resolves, which is consistent with a lot of the historical studies, which I'm going to do a brief aside for those familiar with this topic.

I know that a lot of the modern researchers on gender dysphoria like to argue the old studies don't apply to modern populations, because the old studies included primarily effeminate boys, to use their terminology, and didn't require the patients to actually identify as the opposite sex. But it's a persistent problem in psychiatry that we change our our diagnostic criteria and then try to throw out old studies.

So the old studies show that feminine boys have only a very small percentage to actually grow up to be adults who have gender dysphoria and might desire to take feminine hormones or somehow transition to living as a woman.

And modern gender clinicians, and I've actually argued with them about this, they say that those studies don't really apply because they didn't require the effeminate boys to identify as the opposite sex. But whenever somebody identifies as the opposite sex, it doesn't come out of nowhere. If you're in the 1970s, the effeminate boy would never think of identifying as transgender. It wasn't on the cultural milieu. Whereas now I've seen autistic teenage girls who think they “might be boys,” to use their terminology, because of a few discrepancies regarding gender stereotypes. They like insects and fires and want to do science and not wear dresses. So the idea that we can throw out the old studies because they didn't include an identification “as trans” just ignores the broader sociocultural context.

My concern is that modern affirmative treatment locks these patients into an identity that might not last and which is largely counter therapeutic. So my point with that first study is there's no benefit in the hormonally treated group and the only way that you can argue one way or another is they researchers are making unwarranted assumptions about, like, the 75 kids who dropped out of what was essentially the talk therapy group.

And then in a more recent study, I think, from January of this year, there was no control group and it was written up to be generically positive, but they didn't find any benefit in the male to female cases. There was a small benefit in the female to male cases, but the problem is not only was it a small effect size, but for one thing testosterone has a direct benefit on mental health. This doesn't mean it's a meaningful treatment. Just generally taking any kind of anabolic steroid, especially if you're low on it or you're naturally low as a woman, is going to make you at least temporarily feel better. The other thing is, without a talk therapy control group, we can't really attribute the benefits to the gender specific treatment.

We would expect a group of depressed teenagers to feel somewhat better after a year of some kind of a therapy. So once you subtract that away, I don't think there's any clinically meaningful benefit left. That's enough about that topic, really, for this video, but it is my “proof of concept” that, although some of my colleagues will disagree with me, that I'm willing to read the primary literature on these topics.

And it's important because [it is] one thing a lot of people misread. I've had gender distressed teens in the ER who are worried about the idea of permanently changing their bodies, because of course they would be, but they tell me less than 1% of people will regret this. And my colleagues reinforce that idea, but that's at best really misleading because most of these studies have, like, a large dropout rate.

So it's not that 100 people were treated and 99 were happy with it. It's the 100 were treated and then only 70 people out of the hundred returned and maybe one or two of them expressed some level of regret. So you could say it's 1%, but it's 30% loss to follow up, which I think is concerning given the broader cultural context.

Another problem with some of these studies is that they only sample people who currently identify as transgender, which is — that's more than a mild methodological flaw or limitation — consider if I were a CEO of a drug company and I sent out a survey for people who are on my drug (that's the inclusion criteria here: people currently taking Caplyta or whatever drug). And I asked them how satisfied they were with the drug, and then I published those results without making my inclusion criteria clear.

That would be a major ethical scandal. It might even be criminal if I had a financial conflict of interest, because, of course, people who are unhappy would no longer be taking the drug. Some of these transgender surveys, like the one from 2015, only included people who identified as trans, you can't really capture data about any kind of regret rate.

So that's the state of the field.

Let me move on to psychotherapy here. It probably won't surprise you to hear that I find some aspects of our culture to be counter therapeutic. Let me do this by telling you a story.

Let me tell you a story.

A few months ago, I was in court for a psychiatric hospitalization hearing. Whenever someone needs to be forcibly hospitalized against their will for a psychiatric reason or receive medications without their consent, there is, of course, a legal process. And it usually involves the treating psychiatrist testifying before a magistrate or a judge. I was at this kind of a hearing.

It was for an unfortunate schizophrenic man who had a delusion about infection, about a skin condition. He was essentially drowning himself in public or at least giving himself hypothermia and trying to dive into some of these natural bodies of water because he had an outright delusion about what was actually happening with his body. He also believed that his eyes and parts of his brain and other organs had been replaced by, I think, what he called a fungus, when actually he just had a mild, like, normal dermatitis from some of the hygienic problems of living in a tent.

During this hearing, I realized I was losing the judge because the judge saw that he had a real skin condition. “How can you say he's delusional whenever it seems more like an alternative medicine thing, right?” He wants to bathe in natural waters as kind of an alternative treatment for this dermatitis. The judge wasn't really grasping how dangerous this was or the hypothermic condition that first brought this patient to the ER.

So he could, I think, tell by my hesitation that I had two options there. I could either really candidly and honestly explain why I thought that this patient was delusional despite having a skin condition, which I was actually in a position to do because the judge couldn't examine the patient himself.

Or I could say that basically there was no skin condition, that essentially this didn't really happen. I could say “To the extent the patient has a skin problem, it's entirely delusional.” And only one of those answers, I realized, was going to convince the judge. I think the judge could realize this, or he realized that we weren't seeing eye to eye and that he was nevertheless kind of at my mercy regarding my presentation of the medical facts.

So he tells me to remember that it's not my responsibility: that the outcome of this hearing isn't my responsibility, that I just have a duty to tell the truth. Now, that might sound like a really mundane thing for him to say, but I think it reflects an aspect of our culture that's counter therapeutic and just plain isn't right. How can one adult tell another adult that they are not responsible for the foreseeable outcomes of their actions?

It doesn't actually make sense. I mean, I hate to invoke the Nazis or something, but I think it's helpful to have that context. You think that one adult can tell another “oh, what's happening isn't your responsibility”? Because there was this really unfortunate young man with a major mental health condition who is probably going to kill himself by drowning or hypothermia, and I have the power to stop it. But there's a bureaucratic obstacle in my way, and the enforcer of this bureaucracy is telling me that the patient's life isn't my responsibility. I'm absolutely responsible for everything that I do. There's no human who can tell you that you're not responsible for the foreseeable outcomes of your actions. That's just not thing.

So I did tell the judge the truth, and the patient did leave the hospital, because I value my integrity more than I value this patient's life.

And I have to be willing in my mind's eye to think about his mother and his parents and the people who love him. And if he dies, I have to be able to tell them that my integrity was more valuable than your son's life. And it might surprise you to hear me say that.

Why would I say it? But it's inevitable. Unless you're telling me that you would outright lie to a judge in this situation, you believe the same thing. There's no such thing as not being responsible for the foreseeable outcome of what you do.

It's just kind of a collective delusion that we have. A lot of the great French and German writers of this century have talked about this. Of course, living through the Holocaust and the Second World War definitely influenced their thinking. But it's like the old story told about a young man during World War II who goes to his professor and says, “I'm the last caregiver for my mother. My two older brothers have died in the war. I want to fight for France, and I want to fight the Nazis. I think the Nazis are a world historical evil. But my mother can't walk. She can't feed herself. I'm her full time caregiver. What can I do when I love my mother enough to care for her? But I also hate the Nazis enough that I want to fight them. I love my country and my freedom enough that I want to fight for them.”

And the answer here is that the young man is wrong. He is simply deluding himself. He's lying to himself. And he has to confront the truth that only one of two things can be true.

He either loves his mother enough to care for her, or he loves his values, his country, whatever you want to call it, enough to go fight for it. Life is a series of trade offs. There's simply no way around it. And there is that saying of Sartre: “There is no genius beyond the work. There is no love without works…” That last part may have been from Sorin Kierkegaard, but there is no alternative. This is a hard thing to hear, but you are your life. You are what you do. I cannot tell the family of this young Schizophrenic man that I valued his life enough to lie for him. I have my own values. My own integrity. And if a man has to die for it, that was a choice that I made.

I could have chosen otherwise, and I didn't. But we have to acknowledge that we're constantly making these trade offs and there is no fantastical world where I can say that I valued both things. What we do is who we are; we are our lives. We are what we do. This has been a hard problem. It's not an easy thing to face, but it's something that we have to acknowledge.

Irvin Yalom, who is a famous existential psychotherapist at Stanford, says there were four fundamental existential topics that have to be addressed in therapy, but people are often afraid of doing it. They are death, meaninglessness responsibility, and isolation. Or the last one, sometimes called abandonment in the literature, is just the idea that you have your own subjective mind that no one else can really penetrate. You can't really know what it's like to be someone else. What did Wittgenstein say? The lion could speak, but you wouldn't understand him. So we're all radically isolated in a way such that that no one else can ever really know what it's like to be us.

I don't do long form existential psychotherapies. I don't have time for it yet. I'm trying to do like a mixed medication management practice. But definitely these these topics play a role here.

The final point is, when it comes to psychotherapy, isn't just these bigger existential issues. The quality of behavioral therapy requires fundamentally that we humble ourselves about our epistemic state (that is how we know what we think that we know).

Neuroscience tells us that our minds don't perceive things as they are. We're constantly putting a gloss on the world. We are constantly interpreting things through our previous knowledge and part of cognitive behavioral therapy is learning to challenge our assumptions on these points, because we might think that we know how people act, we might think that we know how people are or what's happening to us, but we're all distorting the truth and jumping to conclusions that aren't really true. And I have one example here I want to share as a final point. If you have any kind of Christian background at all you may have heard — I'm sure you're familiar with the idea that Jesus told parables. Let me ask you this before I go any further. Why did Jesus tell parables? What's your understanding of that? If you've ever read the Bible either as a religious text or just as world literature, what's your understanding of why Jesus often spoke in parables?

You've probably read the stories many times. But despite that, because you came to the stories with certain assumptions, you probably got the answer wrong. So the reason Jesus told parables, which is what he directly tells us (there are multiple accounts, but let me pull it up right here): The disciples ask him why he spoke in parables, and he says to his disciples, “to you it was given to know the mysteries of the kingdom of God, but not to them” (that is, not to the crowd). “I spoke in parables so that seeing they may see and not perceive. Hearing they may hear and not understand.”

So wait a minute. He didn't tell parables to explain complex concepts. He told parables to obscure his meaning, literally the exact opposite of the stereotypical Sunday school explanation. He spoke in parables as he did not want the crowd to understand him. And the reason I bring that up is just because, for those who have read these as stories, our preconception is so strong that we glossed over the direct, obvious meaning of the text. Someone who had never heard of Jesus before and read the story would have a better understanding than, frankly, more than half of the clergy who read the text. Because their preconceptions are so strong they don't see what's there black and white in the text.

And that applies to many aspects of our lives, that we have such strong assumptions that they distort the reality. If you're going to prove this to yourself, look at a moving clock. It’s a really common optical illusion where the brain knows that most small objects do not in fact move in like a circular fashion. So the first second appears much longer to you. And it appears longer because even though the brain, even though the eyes see the movement of the hand, the brain says, “no, stop.” My assumption is that objects do not move in that manner, and it [the brain] actually prevents you from perceiving it. So proper therapy has to be Socratic. We have to question our core beliefs. And if you find yourself leaving a therapy session feeling better about yourself, it's kind of like a workout. I have to question how much good it actually did you. It really only counts when it hurts. I'm going to stop talking.

I opened this with a quote. I want to close it with another quote from one of my mentors. One of my best psychotherapy mentors was frankly a very old man who himself had studied under Anna Freud. So only two degrees of separation separate me from Sigmund Freud there.

But he said the person who is talking the most is the patient. And that's a descriptive rule. It's not a prescriptive one. Meaning it's not that the patient should talk more; it's that if you ever find yourself talking more than the patient, then I'm afraid that you are the patient in that context.