Back in the early 1980s, in the waning days of the Old Psychiatry, when I was training to become a psychiatrist, you had to make a decision early on--which camp were you in? Did you 'believe in' psychotherapy? Or did you 'believe in' medication? Those young MDs who chose therapy were soon applying to analytic institutes, on their way to becoming psychoanalysts...and those who chose biological psychiatry pulled out their prescription pads, and began writing scripts for lithium, haloperidol, and imipramine. The psychotherapy folks often didn't 'believe' that medicine worked; the psychopharmacologists scoffed at the talking cure.
It seems a million years ago! Today, despite all of Marcia Angell's complaints about SSRIs, we have a lot more and better choices of safe, effective meds to treat depression and anxiety. And despite naysayers of all ilks, we now have innumerable studies that show the effectiveness of various psychotherapies to treat such disorders. We psychiatrists (not to mention psychologists, social workers, and other clinicians) generally try our best to make our practices evidence-based. As many others have observed, the old Cartesian dualism is dead.
The limitations of the Old Psychiatry are now obvious. For one thing, combined treatment is often better than medicine or therapy alone. Beyond that, having a more integrated view just plain leads to good care. The old psychoanalysts often practiced a 'brainless' psychiatry; and the old psychopharmacologists often practiced a 'mindless' psychiatry. Today, all practitioners try to integrate an understanding of mind and brain.
But there's one key area in which the old adversaries did see eye to eye. In the old days, it was always amusing to hear the medication specialists take potshots at the analysts in our hospital's Grand Rounds conferences, or to hear the analysts 'interpret' the psychopharmacologists' unresolved issues. But, in general, whether the psychiatry they practiced was mindless or brainless, nearly all of their practices were 'bodiless.' For the most part, the concern of all mental health practitioners back then focused only on those portions of the body above the neck.
How things have changed! In the past decade or so, many different lines of research have demonstrated that physical health has a profound effect on the brain, and in turn that health of the brain has a profound impact on the course of psychiatric disorders. As a result, one of the key principles of the New Neuropsychiatry, as I describe in my book Heal Your Brain, is that brain health is an essential component of the care of depression and anxiety disorders--as well as virtually every other psychiatric disorder.
A concrete example of the change: when I was a resident, every psychiatric office came equipped with ashtrays, often emblazoned with the hospital's logo. Whether talking about symptoms or free-associating their fantasies, the patient would often be puffing away at a cigarette--and the therapist would be taking a drag from a cigarette too! Hospitals and clinics generally reeked of tobacco.
Now, of course, cigarettes have been banished from psychiatric hospitals and other health facilities. And we have learned that medical problems such as obesity, high blood pressure, diabetes, and other illnesses, make the course of depression and anxiety disorders worse. Such physical illnesses injure the brain, and thereby decrease the number of brain cells, the number of brain cell connections, and the growth of new brain cells. If you want your cognitive functions to remain intact into old age, it's crucial to keep such illnesses under control. Beyond that, as I describe in Heal Your Brain, it is becoming clear that mood and anxiety disorders are generally disorders of the brain and mind and body. The chronic high-stress state of depression has an impact through the pituitary and adrenal glands on all of the body, including the heart, lungs, and intestinal tract, as well as on the immune system.
Perhaps most interesting, new research shows that the body plays a key role in maintaining positive health of the brain. Most notably, physical exercise enhances 'neurotrophic factors' which are proteins that enhance the health of neurons, including Brain-Derived Neurotrophic Factor, or BDNF. Numerous studies in animals and humans show that exercise can be an important component of recovery from depression--and not just because it makes you 'feel good' but because it increases the levels of these neurotrophic factors, which in turn improve the brain's health.
Which brings me to "Paolo O.", a patient whose care I describe in Heal Your Brain. A 38-year-old unemployed film executive, he presented for treatment with severe and treatment-resistant depression, which had not budged despite the fact that he was taking 8 different medications per day! Paolo had chronic anxiety, agitation, insomnia, and indigestion, not to mention a total loss of pleasure in all daily activities, and had become more and more preoccupied with suicide in recent months. His treatment plan (inspired by the 6 principles of the New Neuropsychiatry), included a simplified medication regiment and cognitive-behavioral therapy, but most crucially, a regimen of breathing and relaxation exercises, and regular physical exercise. Unable to jog because of a bum leg, Paolo became a dedicated swimmer in the local pool, putting in a mile or two of laps three or four times a week. It was amazing over time to see how Paolo's depression resolved, how he retrained his 'fear response systems'--and how he actually became calm and relaxed as he became more physically fit. Not to mention, that for the first time in many years he felt 'happy.'
So in summary, the New Neuropsychiatry has rediscovered the body. We have discovered how crucial physical health is for recovery from what we used to call 'disorders of the mind'--but what we now realize are 'disorders of the mind, the brain and the body.'
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