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Sometimes when a patient asks for a ‘change in meds’ I look at their chart, thick as a brick, and wonder what on earth to do given all we have done already. I tell the patient to hold on until I do a chart review. This usually involves a weekend afternoon when I reread the chart from beginning to present. As I do this I draw onto a single piece of paper a timeline of what meds were done and what happened, looking for patterns and ‘forks in the road’ where we tried “A” instead of “B”. It’s tedious work but it always gest me to see the forest for the trees and what is the logical next step. It never fails to come up with ideas. I place the paper in the ‘chart review’ folder. I pull them out when a patient with one has an appointment to add to it when changes are made.

I have another folder. When a long time patient with a chart review stops coming in I take the paper out of the ‘active’ folder and put it in the ‘inactive’ one. Sometimes patients disappear for years only to return and I move theirs back into the ‘active’ folder. However the majority of the inactive folder stay there. Some I know why: they have moved away or have died. The majority I don’t know why they didn’t return.

Whenever I open the inactive folder to place or retrieve a review I see the all names of the ones therein and remember them. Of the ones who have died there is no point in holding onto their reviews; they ain’t coming back. However I don’t throw them away. It is like a cemetery that I visit and see their grave stones.

The active patients know I have a chart review but the ones in the inactive file (dead or otherwise) do not. It doesn’t do the deceased any good that I still think about them from time to time. It does me some good I suppose. One of the premises of Jungian psychology is any encounter of the analyst with an analysand causes both to alter. I’ve learned and grown from these interactions. Sometimes I’ve suffered for it. I never know how much (if any) I effected them and their psyches. Some patients have been very trying if not hurtful to me but there were lessons learned and the suffering therefore has some meaning. I feel honored I was part of their lives, even if only for a little while.

In another drawer it a third folder, an older ‘patient cemetery’ of some patients I had back in the 90s when I had a pokey private practice in Chicago. Who knows what happened to them. I know the outcome of one of them: he killed himself. Afterwards his family tried to sue me. I hold onto this one’s chart review somewhat out of a sense of regret of what I could have done. His spirit lives on this way to remind me what I may have done wrong (if anything).

Every once in a while I think to throw out the chart review of the deceased and the ones I know are not coming back. But I hold onto them.

Most of us won’t be remembered past a few generations; it is nice to know someone remembers us for a little while.

God gave us fingers–Ma says, “Use your fork.”
God gave us voices–Ma says, “Don’t scream.”
Ma says eat broccoli, cereal and carrots.
But God gave us tasteys for maple ice cream.

One of the main ‘chief complaints’ I hear from patients isn’t depression or anxiety or mood swings, it is low motivation. People remonstrate they have no motivation to do something they know they should or want to do. Related to low motivation is the complain of ‘lacking willpower’. This means they have a modicum of motivation to do something but aren’t doing it. This usually is about being more virtuous: eating better; exercising; quitting a bad habit like smoking or eating nasty chips. The lack of motivation is often felt to be from depression while the lack of willpower is supposedly coming from a ‘failure of character’.

When low motivation is happening, the first task is to find any context: is it part of a depression or a hormonal problem or a physical matter?. If so, treat the condition and hopefully the low motivation improves.

The ‘lack of willpower’ requires more education than treatment. Patients often hope I will give them some sort of ‘pep pill’ to create motivation to clean that closet or do their taxes or assist them to stop eating late at night or buying things they don’t really need. Alas, medications don’t work for this, much to everyone’s disappointment.

These patients don’t like insight – they know eating right or exercise and paying bills are ‘good’. They sometimes joke their intellect is at war (and losing) to something else – and they aren’t wrong. We are animals; all (?) living entities have evolved to avoid pain and go for the goodies like high-caloric foods. Humans developed higher functions like reason and insight and the ability to accessorize but Mother Nature forgot to erase the more primitive drives still programmed in the lower parts of the brain.*

I educate their avoidance of a messy house or taxes is understandable. We are wired to avoid doing things dreary, tedious and painful (like my men). On the flip side, we are wired to for the high-calorie crunchies. It’s not our fault we no longer are out in the wilderness eating as much as we can when something substantive comes our way. There were no bags of nasty chips or barrels of ice cream on the African savannah. I thought of this the other day when I foolishly looked into the candy dish in the home office. Patience above! Therein were some gummi bears. A minute ago I wasn’t thinking of such nor was I peckish. Seeing these lovelies set off several autonomic nerve systems that all sang out hallelujah! and zip the sweeties were gone, eaten with relish – even as my upper brain shouted out should statements of shame. Oh the horror.

So, what to do about the conflict between the upper and lower parts of our noggins? Being a Jungian I like to use archetypal images. “Shadow” energy should not be denied or exorcised; to do the former bites you in the butt and to try the later is not going to work. You are both St. Gallus and The Bear. The bear in you always goes for the sweets and runs away (or hibernates) to avoid work or pain. It is up to your saintly part to put up impediments so the bear in your doesn’t have easy access to the sweets. For example, the candy bowl in my office was ‘right there” and had no barriers for me getting at them. About a month ago, they were in the freezer, underneath brown parcels of frozen meat. If I had a hankering for candy I would have to get up and go to the freezer, remove the parcels, take out the candy, and let them thaw. These steps are enough for Gallus to win and the bear (who is lazy) not to. It was foolish of me to have moved them.**

Another impediment is NOT TO HAVE IT IN THE HOUSE IN THE FIRST PLACE. If I buy bags of nasty chips or boxes of crackers, dammit they are going to get eaten, St. Gallus can go jump in the lake. At Uncle Albertsons he, not the bear, makes the grocery list. Time sucking apps are eliminated from the phone, or put into files in the back with extra passwords making them hard to get to and open – or eliminated from the phone all together. Vanity sometimes is useful to get things done. I told Someone I want to weigh myself every Wednesday and please ask me each week did I do so. If I had a spending problem I would ask him to hold onto the credit cards and give me so much money per week (or day) and no more. I also have an app “Way of Life” that lights up a cheerful green for each day record I do my stretches, floss, and read something. It puts up a bloody red light and a nasty sound when I don’t. While this isn’t 100%, these goals are sure better than when I wasn’t recording them.

Those are about thwarting immediate pleasures; what about attending to tasks tedious or painful? I have mentioned these before. First we acknowledge people avoid doing something because it’s boring or painful or of no immediate consequence. Don’t look at the forest but at the first tree before you. The goal of ‘do my taxes’ or ‘clean out the office” should be broken down into a small, short step done daily (preferably at the same time) for 5 minutes. If you find ‘the ball is rolling’ keep going. Doing something is better than doing nothing. Get someone to assist or hold you accountable. We are more likely to do something if there is a direct quickly associated consequence. Not cleaning the room means only the room remains so and you feel bad. Not cleaning the room -and having your spouse post it on Facebook or donates a dollar to the Ron DeSantis for president fundraiser is something else.

I point out Bear Tamer/Bear dichotomy feels like Bear is in charge and unbeatable but he is not. St. Gallus wins in the end when we give him assistance. Motivation and so-called will power – or lack there of – are out of the equation irrelevant to doing the task at hand.

*Mostly in the brain stem, near the parts that keep us breathing and the heart beating, to show you how ingrained longing for food is.

**I don’t remember doing this. I must have unconsciously acted out or put them in the bowl to thaw and happily forgot I did so.

I’ve been feeling happy a lot lately. As is my wont I wonder ‘why’ or what is contributing to this. It’s mostly coming from feeling content in life. I like my work; I am enjoying my exercise programme. I am in frequent contact with chums.* I have something to look forward to. Overall there isn’t any thing terribly the matter in my life. Happiness is seldom a sense of fireworks and jubilations. Rather it is a soft warm quiet emotion like that of a cat sleeping in a sunbeam. It’s easily missed or misinterpreted as ‘just life happening, only realized after it goes Yet if you got in the way-back machine and traveled to that moment and asked your former self ‘are you happy?” more likely than not he/she would say ‘what do you mean? Can’t you see I’m busy doing things?”.

My patients on the whole are suspicious of happiness. If they feel good and things are going well ehey don’t believe it to be true, or if they do, they see it as temporary. “I am waiting for the shoe to drop” is often said. That is true viz. some obstacle or problem will come along. However, few say in a bad state “I am waiting for the shoe to pick up”. Happiness feels ephemeral while down feels ‘real’ or permanent’.

Funny therefore how often folks have a sense of happiness as the result of some action, like a trophy or piece of cheese at the end of a maze. This is called ‘The promised land” phenomena. When they retire they will be happy. When they quit that job/ditch that relationship/win the lottery etc. then they will live happily ever after. Three guesses how well that works.

Happiness is both a sense of contentment and an overall umbrella state of being. My life has a lot of problems and shortcomings yet I am happy in general. My symbol for happiness isn’t The Buddha surrounded by demons, serene and unresponsive. Rather it is an inflatable punch’em clown who gets swatted, falls over and gets up, over and over. I would rather not have the house repairs and expensive dental work but life’s good anyway. Or good enough.

The clause in the constitution ‘the pursuit of happiness’ is both comforting and frustrating as it doesn’t say what happiness. On the whole we’ve been snoockered to believe money/power/status = happiness when the data supports having warm relationships is what most matters.**

I think it was Kurt Vonnegut who was asked at a party thrown by a celebrity how did he feel the host earned more money in a week than he would in a year. Mr. V. replied he had something the host didn’t have, and that is a sense of having enough. He was happy while the host had unending hunger to have more.

I wrote this one in the morning prior to my work day beginning. By day’s end I will be tired and probably a bit grumpy and frustrated as well. All the same, I will still feel happiness. The shoe will drop but with its punch I will fall over and get up. Like Mr. Vonnegut I have enough.

*The exception is blogger-buddies. I am woefully behind in my blog-reads. This does not make me feel happy. However I plan to put aside all other recreations tonight and catch up.

**That, and a nice cup of tea.

Mistress Maddie (the dear!) wondered the other day why people (meaning patients) don’t come back to me. MM is better than The Muses (and dressed better too) to get me thinking. This entry won’t be particularly entertaining to the average Spo-fan but it’s good exercise for me to write out my thoughts.

Being a scientist at heart, I want data to hypothesize why folks don’t return, and I haven’t any, worse luck! I don’t know the percentage of patience who are seen once for an evaluation and don’t return. Established patients drop out of treatment all the time as all and I don’t know why either. Very few if any of them tell me or the office ‘why I ain’t coming back”. Some businesses send out surveys to clients hoping to get such information. The Boss and The Overlords aren’t curious enough to look into these matters – that or they are busy enough as it is handling the ones who keep coming. I know there are some nasty reviews online about me – all doctors have some – but these aren’t enough apparently to keep away new patients. There is no lack of customers; I don’t lack for business. If one drops out there are two or three looking to come in.

I believe the majority of folks who don’t return do so from of simple economics – they can’t afford it. Their insurance changes or other matters take precedence. In some ways Psychiatry is a ‘luxury’ specialty. If you can only afford only one, the dentist or the shrink, the former wins hands down. There is also the ongoing belief depression/anxiety are things one can do on their own, pull yourself up by your boot straps why don’t you.

Another factor is people move away. About once a month a patient announces they are moving out of state and this is farewell. Before video and telephone appointments became available, a move across town was enough to change doctors, especially if you have driving anxiety.

When I am aware of someone having dropped out without explanation of course I wonder if I did something wrong. It’s human nature to project into a black box worse-case scenarios and personal short-comings. Both are probably not true or not much of a factor.

In Medicine there is something called ‘goodness of click’ where you ‘gel’ or not with your doctor. The physician before you may be brilliant but if they don’t feel ‘right’ you aren’t going to stick around. Sometimes patients of the female persuasion I sense transfer onto me their trauma emotions upon seeing a male and this is too upsetting. In the men folk (the straight ones) they sometimes pick up I am not (the red high heel shoe-shaped door stop keeps giving me away) and they don’t feel comfortable with a queer shrink or won’t work with me out of moral indignation.*

Another factor is along the line of ‘getting more than you bargained for”. Sometimes folks come in with a superficial complaint such as insomnia and in the evaluation process all sorts of stuff comes up like trauma, drug/alcohol factors, or subconscious issues now revealed. Working on the real problems and not patching the symptom, is too much for some; they get scared and run off. Sometimes these types return in time when they feel more ready. For them I leave the porch light on.

After thirty years of shrinking heads I don’t fool myself I have things down right. If I am doing something wrong that turns folks away I would like to know so I can better myself. This sort of data just isn’t available to me. My intuition tells me I am not doing anything grossly wrong other than failing to dress up to contemporary professional standards.**

Jungians have a sort-of cosmic approach the patients who need me will come, and the ones who go and return do so when they are ready. Thems unhappy with me find someone else. So I don’t worry about the ones who don’t return. I work with the ones who are there. Considering my full dance card it’s good as it is.

*While I won’t discuss politics with patients on occasion patients perceive I am a tree-hugging-save-the whales liberal and they won’t return for that reason. These sorts are rare cases, for right-leaning types seldom if ever seek out mental health care. They either don’t believe in mental illness or see it as a moral deficit they ought to fix themselves. If they can’t they commit suicide using the guns they all have. Death before admitting frailty.

**At least in the eyes of the The APA Secret Police. On the whole patients like my Spo-shirts and The Bosses not once have told me to put on dress shirt/tie and trousers for appearance sake. There is some value in ‘dressing the part’ to convey authority but this has never been my style.

At work I see a lot of folks with ADD ( Attention Deficit Disorder). There seems to be a rise of cases. It is not clear if this is due to a heightened awareness that thems with such are seeking help with it (good) vs. something in society is creating more of ADD (bad). I should write about ADD someday. What I am focusing on here (pun intended) is attention in general.

Thems in my field define attention as

“The ability to actively process specific information in the environment while tuning out other details.”

This serves nicely.

Folks worry a lot about their attention span, mostly not having a long enough one. This is relative of course and often correlated to what they want to do. Focusing on one thing vs. eight things is different. Have we become less attentive? Lots of ink has been spilled on the subject. I propose as a species we are not overall less attentive but we’ve shaped our environment to strain our attention spans. We’ve filled our lives with all sorts of things many of them specifically designed to draw our attention to them.

We’ve also snoockered ourselves into the fallacy we can multi-task and we ought to. It’s sort of a perverse merit badge to claim how many things one can do at the same time. We are aghast at the notion of doing A then B then C rather than trying to do ABC at the same time.

I am as guilty as anyone wanting to do many things at once. While walking the dog I listen to podcasts and I am often texting. At work I am renewing scripts and writing notes while doing language lessons or reading blogs. The joke’s on us: studies show again and again we do we aren’t doing five things well but half-baked five things.

No wonder why we aren’t focused. We want our brains to do something it doesn’t like doing. This leads to the emotion of feeling overwhelmed. When we are try to think and do too many things at once brains get cranky and make us feel overwhelmed hoping we will freeze up to prevent us running around doing half-baked actions.*

We need to let go of the rubbish notion doing one thing at a time is NOT a shortcoming or a failure but the right way to do things. We must continually keep conscious keeping those gosh-darn attention grabbing devices out of reach (and out of mind) to not tax our attention.

Finally, when patients complain about having a poor attention span I ask what is attention for? If we feel we don’t have enough or are paying too much attention to our phones/social media etc, what ought we being attentive to? There are the things we must at the moment like work, but there are other arguably more important things, whatever they may be.

I remember from child psychiatry a common complaint from parents about a child is ‘he’s doing that for attention”. Now. what’s so bad about wanting attention? I can think of no better thing give someone viz. your attention. On the flip side, nothing feels as good as someone is paying attention and listening to you.. Think how annoying it is to be talking to someone only to sense they are looking at their phone. In my line of work nothing is more positive as ‘my doctor listened to me and paid attention to what I was saying” often more valuable than actual ‘help’. If our attention spans seem strained we would be a lot better if we paid less attention to Twitter and more to the person next to us.

*I tell my patients (and myself) whenever you feel overwhelmed, stop, recognize it is happening, take a few deep slow breaths, and get ABCD out onto paper as A – B – C – D. Do them one at a time.

I wrote a lovely entry (if I do say myself) but it got lost in a computer freeze. When this occurs, one can either start writing it again or do what I did and decide the gods (or the demi-gods) were not having it. Instead of Attic wit and profundities you get boring old office stuff. Spo

Work is like a ghost town that both offices see little if any action. The therapists and such are either taking time off or working from home I suspect the former. Unlike Urs Truly who is on salary the therapists are paid as they work. Most of the counselors are married with spouses who have full time jobs, so it is not vital for them to work full time. Regardless of the reason(s) the halls are quiet and most of the time I work with my door open as no one is around.

Some offices decorate for Christmas time often using nice and tasteful decorations. Where I work if there are any decorations it is sort of do-it-yourself as as what few people are around are not inclined. When I have a moment tomorrow I plan to hang a few plastic bulbs in the plastic plants in the hallway. ho ho ho

It seems both offices are up for grabs. The MESA office I was told would likely sold given its bad neighbors who park their van lengthwise across four parking spaces and they make the air in the system smell like a Cheech and Chong comedy sketch. I thought the PHX office was secure until the other day out of nowhere a group came by what seemed to be someone showing potential buyers the space and what it was like/what could be done to accommodate their needs. My office door was open at the time so they sort of peeked in but no one told me who they were (or asked permission). It implies the PHX office is also up for sale. In their defense The Overlords are under no obligation to keep their thralls abreast of the business transactions. The sale of both offices conjures up notions the entire place may shut down in 2023 but that’s pure worse-case speculation on top of little to no data.

From a mental health point of view, Christmas should be banned like asbestos for the public good. While it’s a hard time for many curiously my work load goes down some. People are too busy to have appointments and what money they have is goes to travel and gifts, which is understandable. I hear about the tales after the fact in January.*

In contrast to appointments I get a lot of anxious telephone calls about getting prescriptions done prior to 1 January when insurance and coverage change. There are also the anxious tearful calls from a few folks finding out their 2023 insurance doesn’t cover seeing me anymore and what’s to be done? *

That’s about all the notes from the office for now. Tune in tomorrow to see if the gods (or the demi-gods) mess with my entries some more.

*With the availability of video and telephone appointments taking time to drive to the office is less of an impediment and there are less cancelations and no-shows now.

**Answer: they go elsewhere or the pay out of pocket to see me. I don’t have the numbers to support this but my intuition tells me many stay and pay rather than start up with a new shrink. In a way I am touched.

Since change is the rule and continually happening you would think we would be at ease it. We see it coming yet we usually react with anxiety and trepidation. Our brains run amok change will cause more change which will cause us to change which will annihilate our world as we know it. We also whitewash the past as something good, static, and preferable to this god-awful now. The nostalgia for times not true worsens at Christmas when we compare Christmas ‘now’ to Christmas ‘once upon a time”

I am no better at this. As I age I see the youngsters going to hell in a handbasket with their TikTok and lack of social skills and inability to write. Oh the horror. But then I check myself and I think back when I was a boy and my grandparents felt the same emotions about my generation with their crazy calculators and maleficent microwave ovens and nobody learning Latin. We were going to turn into idiots who won’t be able to add two and two. “You won’t have a calculator on you at all times you know!” Grandmother Spo said.* My maternal grandmother bemoaned microwaves will ruin cooking and young wives won’t be able to make a meal.

I recently had an elderly patient grumble about kids not learning cursive. I secretly agreed with her but instead asked her how many words can you type in a minute. Her grandchildren can and they work in jobs that demand typing skills. No one is asking them to write memos by hand in cursive while she is tapping at keyboards using two fingers.**

Trouble is we are wired to see new and unfamiliar things as a threat. Novelties are sinister substitutes for old things and not add-on/niche inventions. Yet this seldom happens. Margarine didn’t make the diary industry go out of business. No one ‘cooks’ in the microwave; we use them for thawing and heating things which is blessedly faster than wrapping leftovers in foil to warm up in an oven (remember doing that?) There are a lot of examples. Apparently ancient Greeks deplored books to memorized verse. Radio, then TV, then AOL (remember that?), and now TikTok will turn youth’s minds into mindless gunge. You see the pattern.

I recently heard a lecture on this topic and the speaker pointed out when confronted with anything not status quo we go through four stages

Panic. First you panic. This is understandable so don’t feel bad when it happens. Then (hopefully) it dies down as curiosity kicks in and the mind remembers having been here/done this before and this too will sort out somehow.

Adaptation. We are very good at this. Recently at work I got a new king-size-titanic-unsinkable-Molly-Brown new computer with a screen as wide as a boat. It takes up the whole desk and blocks my view of the patients. I can’t figure out where everything is on the new device. But I am learning. I will soon move the desk around to accommodate things.

The new norm. Most Spo-fans are old enough to remember the barbaric dark times before the internet, before microwaves, before cellphones, and instant communication. I don’t think most of us would really want to return to these times. Which leads us to…..

Wouldn’t have it any other way. As I type this I am taking a pause from writing notes in the electronic health records which includes prescriptions sent directly to the drug stores. I would not want to return to handwritten notes (in cursive) and prescriptions, yet when they were first introduced everyone in Medicine lost their minds with suspicion and jeremiad rants Medicine would fall apart.

As soon as the new things settle into the ‘wouldn’t have it any other way’ and things are status quo Dame Change turns The Wheel of Time around and something else will arises to induce panic and threat and the cycle repeats.

*Jokes on you Grandma, I do, it’s called a cellphone.

**She didn’t much appreciate this.

“I am half inclined to think we are all ghosts…it is not only what we have inherited from our fathers and mothers that exists again in us, but all sorts of old dead ideas and all kinds of old dead beliefs and things of that kind. They are not actually alive in us; but there they are dormant all the same, and we can never be rid of them. Whenever I take up a newspaper and read it, I fancy I see ghosts creeping between the lines. There must be ghosts all over the world. They must be as countless as the grains of the sands, it seems to me. And we are so miserably afraid of the light, all of us.” – Ibsen (from his play “Ghosts’)

Sometimes when one of us proposes we do something different than the usual way it is reclined along the following dialogue:

“I got an idea, rather than going to Kobalt on Friday as we always do, let’s try going to Bar-1”

“No thanks”

“Why not?

“It is custom” (translation: I don’t want to change what we usually do).

This expression is a tongue-in-cheek reference taken from a book (I forget which one) about a man visiting a country in which he encounters a lot of questionable if not downright dysfunctional attitudes and actions. When he asks ‘why’ or suggests alternative ways of doing and thinking he is told over and over the way things are done are done as ‘it is custom’. No one is willing to think outside the box let along alter the status quo.

“It is custom” is one of mankind’s greatest impediments.* Most of the time we are so enmeshed in cultural norms we don’t question them. It is sort of like a fish being asked how’s the water and it thinks what is water?” A lot of my professional and personal life is getting folks/ myself to recognize what they are immersed in isn’t an absolute truth nor is it unchangeable.

Speaking of my own culture (America), a lot of misery and disease here derives from it. If a person fails it is their own damned fault. Public shootings cannot be stopped. Health care is not a public service. Many in the land are beginning to question these so-called truisms. They either try to alter things and are met with the resistance of thems in charge who are all too ready to say ‘it is custom’ or they devolve into dropping out of society. The rise of depression/anxiety in the land (especially in children and adolescents) is correlated with the consequences of ‘it is custom’ thinking. They are immersed like fish in the foul waters and do not thrive. Society addresses problems with pat answers and band-aids and the usual point-the-finger-at ‘them’ who are the scapegoats.

I don’t know have answers to fix things, but I can do my part by constantly challenging ‘it is custom’ beliefs whenever I sense one. Given our negative bias towards things we tend to think ‘it is custom’ ways cannot be altered. This is not so. When enough folks do what was considered written in stone can change. Let us hope so.

I wrote this on a Monday morning before the work week began. I will challenge patients with depression and anxiety to look at the context and their surroundings for contributions to their symptoms. “It is custom” can questioned at home/at work/in the nation and maybe make a difference.

*Other impediments include our tendency to split folks into ‘us vs. them’, to obtain more than is necessary, and build strip malls.

Psychedelics are the talk of the town these days. Plenty of patients are coming in to their appointments having heard of them or read something on line that they are the new miracle cure for whatever ails them. I wish I had a shilling* for every time there is a new and exciting treatment that gets into the public press before the details are sorted through only in time for the promising pill to fall flat. Medicine Road is paved with disappointing discards. This is especially so in psychiatry. I’ve heard all sorts of supplements and such patients hope will be something to help them when other things failed. Alas, Babylon! these are usually are a bust, worse luck. Remember Saint John’s Wort and SAMe? Once upon a time patients were agog about both. In time these two supplements turned out to be duds. It wasn’t that they didn’t ‘work’ but SJW isn’t regulated (or covered) and it only helps in mild cases of depression and it doesn’t like to play with other medications especially birth control pills. Oh the horror. SAMe, at least in The States, in an expensive supplement that by the time the patient gets to the dose that shows promise they are shelling out of pocket hundreds of dollars per month for something that was fair at best. It’s a disappointment.

Which brings us to the newest rising star: psychedelics. Once upon a time LSD, ‘magic mushrooms’, and the like showed genuine medicinal potential. Then the hippies and party boys got hold of them and the straight-laced types were horrified and thems in charge made these drugs illegal no-nos with reportedly no medicinal value. Now we know more about how they work in the brain so they are rising from pariah status towards possible treatments for depression and PTSD.

For thems curious how they work, read on; for thems not interested, skip over this next paragraph why dontcha.

Psychedelics work by interacting with certain neurotransmitter receptor sites in the brain that the conventional medicines don’t. Glutamate and some subtypes of serotonin neurons are the main ones activated. These creates connections not easily done otherwise. Think of airplane hubs and connections. You are in San Diego and you want to go to North Dakota, but there are no direct flights. You have to go to Houston then to Chicago then catch a flight to Bismarck. Psychedelics allow all city hubs to connect directly to the others, allowing connections years of conventional counseling often are needed. In this near-numinous removal of impediments one can do therapy work that otherwise is very difficult or too emotional to do. Another metaphor is finally getting the right-shaped key to open doors to hallways in the brain the usual keys could not open. Groovy.

Trying to sort through the rubbish for genuine worth is a challenge. Research is working on the science of ‘how much’ and in what form and context might these substances actually work and not cause harm. For thems who have never done psychedelics there is the possibility of a ‘bad trip’ and thems doing these drugs often do so with a ‘guide’ nearby to help them in the newly dissociated state of being. These are not to be done likely; do not try this at home. I suspect if/when they become bona fide FDA-approved treatments their use will not be a simple prescription ‘take this daily’ pill but done in a supervised setting with a counselor/supervisor. That will require time and effort on the part of the patient, and this demand may make this a ‘rich man’s drug’ as not many folks will be able to afford taking a few hours off from life/work 2-3x a week to trip in a psychiatrist’s office. **

There is a lot of potential with psychedelics in psychiatry. I hope society doesn’t spoil it the way we did withcannabis. Cannabis has probable treatment benefits, but society voted to make it legal before there were proper tests done on it, so now it is the wild west in terms of amounts/dosages, mixtures etc. Pharmacies don’t distribute these things but merchants who are keen on selling things for profit. When a patient asks my advice on ‘medicinal marijuana’ I tell them it is buyer beware as I can’t tell them ‘how much and how often’ and even if I could there is no guarantee they will find it as nothing is regulated for purity. Now in public domain, no one is going to do the costly research needed to find evidence-based data. For all I know cannabis is mostly placebo effect.*** Thems who try it swear it works, but they were excited to try it in the first place. That sort of set up nearly always works. Oh to have a double-blind study! This won’t happen.

I am excited to someday have psychedelic-based treatments for my patients. What I have now to offer often doesn’t work well or is intolerable. New means of treatment are always welcomed. However I won’t count my chickens. I want to see proper data no rubbish that assure me and my patients psychedelic Rx really works and how to use it and what dangers/drawbacks it could have in the long run. Until then I tell my patients to wait – and don’t do this on your own. For one thing it is still illegal and I hate seeing people deluded by shysters out of their money and hope for miracles that aren’t there.

*This bet amount is based on the pre-15 February 1971 money system. Overall a headache system but more interesting really.

**Presently ketamine indicated for the treatment of depression. This involves going to a certified center 2-3x a week to start with where they administer this psychedelic sprayed up the nose and then you have to be watched for psychoses/dissociation for an hour so. There must be a designated driver to take you to/from your appointments. I tell my patient referred for ketamine to think of it like kidney dialysis in time and effort. Few folks have the time and driver for this sort of thing. Stinko.

***Think of it for a moment. I have heard cannabis lauded as treating almost everything. What drug actually does this? I smell a rat when someone is trying to sell me something that is a panacea of all ills.

I finally threw out my ponderous collection of “The green journal”, which is the official journal of the American Psychiatric Association. It has a dark verdant cover like that of a pine tree. It is the psychiatric equivalent to JAMA or The Lancet or The New England Journal of Medicine.* After I receive and read one I put it on a shelf at work at work to use as reference, but mostly for decorating. Patients see and associate them with knowledge. Truth be told I never open them and after quickly after skimming one ita contents are forgotten. The articles are very complicated, difficult to read, and most important hardly ever applicable to patient care. Here’s an example:

Aberrant developmental patterns of gamma-band response and long-range communication disruption in youths with 22q11.2 deletion syndrome.

Another factor about these journals is they become quickly obsolete. Articles become outdated after a few years.

I feel sheepish throwing them out. Thirty years of Medicine has ingrained in me a large ‘should statement’ about the importance of journals. This is what one does to stay abreast of the news and be a good physician. The dirty secret is medical journals are obsolete and a case of the Emperor’s new clothes. If I need something I go online. I get my news and updates from apps, lectures, and audio-lectures. Reading ten-page journal articles – who has time for that? I bet in any lecture hall if you got folks to be honest nearly everyone would raise his or her hand to confessing they don’t read them either.

There are so many journals. Urs Truly subscribes to a half dozen, and the ones I read are the ‘fun ones’ that are short, practical, and easy to digest – like my men. I skim through the JAMA headlines at bed time to get the ‘gist’ of what’s happening in Medicine In General and other what’s happening in other specialties, knowing I don’t need to know the latest is surgery or pulmonology or the newest protocol how to work up hematuria.**

Some of this is being ‘old man’ thinking. It feels like sticking with LPs or CDs when it isn’t how things are done anymore. However most of my reluctance is letting go of ancient lofty ‘should statement” to admit I don’t read journals and that’s OK, I am not a bad doctor for doing so.

With this relief I have to figure out what to put on the newly emptied shelves at the office. Once upon a time medical textbooks served similar signals of study and sagacity. Medical textbooks are even less read nowadays than medical journals.*** Perhaps I will fill up space with rocks and tasteful art pieces. No books or journals in the office may be off-setting to the oldsters but the young ones won’t care. And there is less clutter, which pleases me very much.

*All very lofty and prestigious journals indeed. If you get your paper published in any of these you are a on the “A” list of Medicine.

**Blood in the urine.

***About five years ago or more I bought the 22nd edition of Cecil Textbook of Medicine, traditionally the Bible of Internal Medicine. I cannot recall the last time I opened it. It sits next to the PDR which I believe they stopped publishing after decades, not unlike the Telephone Book.

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March 2023

Spo-Reflections 2006-2018