Risk/reward and dopamine

Here is an e-mail I sent recently to Chris’s psychiatrist, Dr. Stern. I based my concerns about the continued use of the meds on the dampening of dopamine levels to suppress anger and anxiety while simultaneously suppressing the risk/reward incentive.

Dear Dr. Stern,

The concerns I expressed about the medication suppressing the risk/reward incentive I think is very real. While Chris seems very stable in many ways, he lacks an enthusiasm and a willingness to stretch himself. I am puzzled why he is content to continue to audit one course at a time at university, rather than jump in for credit. Ian and I have not been pushing him in any way, just the opposite. We are letting things go along at the pace he wants to set. But, he is 26 now, and time is moving on. Leading a fuller life requires being willing to take some risks.

I don’t want Chris to become a perpetual patient and that is a risk that is very real the longer he continues with the medication. Already, because of the Serdolect (a drug I never wanted him to take), he has to check in with his family doctor to have ECGs. This is keeping him a patient by adding new medical visits to his schedule. In one week recently he had two appointments with you, one with Dr. XXX, and one with Dr. YYY for the ECG. I am all in favor of the work you are doing with him and twice a week is fine as long as you feel that greater progress is being made, but I am not at all in favor of adding medical complexity of more doctors and unnecessary medical tests.

Dr. XXX is connected with a program that I wanted to extract Chris from because the program failed to deal with the root cause of psychosis, offering instead a biochemical view of mental illness that didn’t help Chris for the two years that he was enrolled in the program. I feel that our wanting to meet with Dr. XXX and her chief threatens the program’s established view of mental illness as biochemical. This view is rapidly becoming out-of-date due to many recent published articles and books that question the efficacy of medications to treat mental illness and that look once again at mental illness as a logical reaction to pain.

I am sharing my concerns with you because I think you share to some degree the points I am raising. I do not have confidence that Dr. XXX and her boss feel to the extent you do that there is a time limit to medication. I hope they prove me wrong. I have been thinking, but have not mentioned to Ian, if we could eventually trade Dr. XXX for a private psychiatrist to monitor the meds (and work with you to reduce/eliminate them when the time comes). I know that you don’t want to be side-tracked by focusing on meds when you see Chris, and you like the idea of a second person to handle the meds. A private psychiatrist would be more open to working with the desires of the patient, instead of imposing the thinking of the institution on the patient. I have never met Dr. XXX, but know the program she is involved with.

These are my concerns which I thought I should share with you before we meet with Dr. XXX in the near future.

Best regards,

Rossa Forbes

Existential concerns

Chris will soon be released from the hospital after three months. I am concerned that we will be right back to the situation that prompted his hospitalization in the first place. He knows that he needs to get out, he is bored out of his mind, and yet he is not looking like he can blend in with quote unquote “normal people”. He arrived home for the week-end on Saturday morning, attended to his e-mails and fixed a few computer problems. He talked to me very thoughtfully on Saturday evening. Sunday was a different story. We invited him to join us for a lecture and lunch. We went for a walk on the grounds of the lecture hall before lunch. He was in existential despair. He didn’t want to spend his day with “old people”. I can’t fault him there. He said he didn’t know what was real anymore – was I real? Was this scenery real? Was the day going to end and the sun go down? He claimed he didn’t know. I asked him if he wanted to resume his Alexander Technique lessons when he came home. “No, I have learned everything I need to know”, he answered.

The hospital fussed with his medication, introducing a second antipsychotic over my objections. I maintain that despite the elaborate, weird behavior that got Chris committed, his problem cannot be fixed with medication. It is looking likely that I am correct. The doctor is not satisfied with the addition of the second antipsychotic, noting that Chris seemed overall better just after they introduced it in a low dose. So, now they are tapering it back but not discontinuing it. Discontinuing it would be admitting they were wrong. Nobody, not my husband, not the hospital psychiatrist, not Chris’s regular psychiatrist nor anybody having seen Chris in his pre-committal state, understands my objection to the medication. It is they who just “don’t get it”. Chris has problems that persist whether he is on medication or not.

What I think has taken the edge off the situation while Chris has been hospitalized is not the medication but the fact that Chris got away from us, from living in claustrophobically close quarters every day and being treated like the two year old he was becoming. The doctors acknowledge this reality, but medicate anyway. When I object to the fact that this latest med was the fifth antipsychotic Chris has been on, and shouldn’t we conclude that antipsychotics don’t work for Chris, the clear message I receive in return in that it is foolhardy not to use antipsychotics as one treatment modality. My husband is almost threatening to divorce me if I undermine in any way Chris’s staying on medication. He reminds me of the lead-up to the hospitalization. Yes, I am painfully aware of all that but I also know that Chris has exhibited extremely weird behaviour while on medication, beginning with his first antipsychotic. His mind is more powerful than any drug or vitamin. Until he resolves his existential problems, we will continue to weather the storm.