Education Medicine Observations Systems

Everything Changes, Nothing Changes.

The Mutter Museum Instagram account recently posted this photo:


“Thorazine” is the trade name for chlorpromazine. It is considered the medication that ushered in the “psychopharmacological revolution”, thus allowing some patients to leave psychiatric institutions. (You can read the interesting history of chlorpromazine here. Spoiler alert: It was designed for use in surgery, not psychiatry.)

Chlorpromazine is often touted as the first medication that could reduce symptoms of schizophrenia. Other FDA-approved “psychiatric” uses of chlorpromazine[1. Other FDA-approved uses of chlorpromazine that are unrelated to psychiatry include acute intermittent porphyria; intractable hiccoughs; nausea and vomiting; and tetanus, “adjunct”.] include:

  • Apprehension, presurgical
  • Bipolar disorder, manic episode
  • Problem behavior, severe

I don’t know the context of the ad (who was the intended audience: physicians? patients? husbands?). One wonders why the ad features a woman and puts greater emphasis on “emotional stress”. A hefty dose of chlorpromazine will result in “prompt” sedation that will give someone—perhaps not the patient—”sustained relief” for several hours.

Did physicians in that era tell patients that the original use of this medication was for schizophrenia? Or did physicians focus primarily on the tranquilizing effects of chlorpromazine for those individuals who had more neurotic, not psychotic, symptoms?

Everything changes, nothing changes. Quetiapine (tradename: Seroquel) was also developed for the treatment of schizophrenia. Now, its uses include:

(1) add-on treatment to an antidepressant for patients with major depressive disorder (MDD) who did not have an adequate response to antidepressant therapy; (2) acute depressive episodes in bipolar disorder; (3) acute manic or mixed episodes in bipolar disorder alone or with lithium or divalproex; (4) long-term treatment of bipolar disorder with lithium or divalproex; and (5) schizophrenia.

The header for the page (what shows up on the browser tab) doesn’t even list the drug’s name. It says only “bipolar disorder medication”.

If you search for “Abilify” (generic name: aripiprazole) on Google, the brief summary that shows up under the first link says:

Official pharmaceutical site for this antipsychotic medication indicated for the treatment of schizophrenia.

However, when you actually go to the official website, the listed uses include:

Use as an add-on treatment for adults with depression when an antidepressant alone is not enough
Treatment of manic or mixed episodes associated with bipolar I disorder in adults and in pediatric patients 10 to 17 years of age
Treatment of schizophrenia in adults and in adolescents 13 to 17 years of age
Treatment of irritability associated with autistic disorder in pediatric patients 6 to 17 years of age

Asenapine (trade name: Saphris) also has approval to treat both schizophrenia and bipolar disorder. Should we be surprised if paliperidone (trade name: Invega[2. Does it mean anything that, of the five photos on the landing page for paliperidone, only one of them features white males?]) and iloperidone (trade name: Fanapt) soon also receive FDA approval to treat conditions other than schizophrenia?

This is why skepticism is indicated—nay, essential—whenever people exclaim with confidence that “we” understand the biology of psychiatric conditions. We live in an era where cancer drugs can be designed to interact with specific receptors because scientists have located and studied those specific receptors. That specificity does not exist in psychiatry. If it did, one drug class would treat one condition, not four.

While I am probably more reluctant than the “average” psychiatrist to prescribe medications, I believe that, for some people with significant psychiatric conditions, medications can offer great benefit. First, however, do no harm.

It is frustrating when many in the field of psychiatry insist that the serotonin hypothesis is true when, in fact, it is just a hypothesis that is probably false. Also frustrating are the multiple forces that insist that medications are the primary and sole forms of treatment for psychiatric conditions. What about exercise? Therapy? Diet? Social support?

If medications alone could successfully treat these conditions, wouldn’t the pharmaceutical companies have saved us all by now?

Education Observations Reflection

A Review of Inside Out by Pixar.

Like others, I saw the Pixar film Inside Out and I, too, recommend it. Drs. Keltner and Ekman[1. Paul Ekman is the guy who studies the expressions of emotions on faces and their universality.], the psychologists who provided consultation to Pixar about the film, were incisive about the point of the story:

“Inside Out” offers a new approach to sadness. Its central insight: Embrace sadness, let it unfold, engage patiently with a preteen’s emotional struggles. Sadness will clarify what has been lost (childhood) and move the family toward what is to be gained: the foundations of new identities, for children and parents alike.

The film demonstrated in colorful and delightful ways how emotions interact with each other; how memories are created, moved, and stored (the marble imagery was both beautiful and fun); and how emotions, thoughts, and behaviors can interact with each other. Parents may wish to bring tissue; all the adults around me (and me, too) audibly cried at least once during the movie.

If you haven’t seen the film yet, please note that the rest of this post has spoilers in it. You have been warned.

Some other observations of the film:

Like others, I didn’t like how Sadness was portrayed in the film. I do not protest that she was the color blue; I do wish she wasn’t portrayed as lumpy, lazy, and lethargic. (At several points in the film, Joy literally drags Sadness around.) While sadness can make us feel listless and inert, sadness often motivates us to take action. Sadness is ultimately redeemed in the film: The family becomes and feel more connected because of the introspection and action Sadness fosters. However, I don’t think Sadness should have been thrown under the bus in the first place.

It is also noteworthy that Sadness is portrayed as female. One wonders if Sadness would have been portrayed as lumpy, lazy, and lethargic if the character were male. Is this social commentary on the perceived “moodiness” of women?[2. Just to be clear, I do not equate “moodiness” to “depression”. Others sometimes do.]

Of course, sometimes a cigar is just a cigar.

The “leader” of the emotions in the mother’s head is Sadness (looking sharp in a business suit, no less!). This choice may have been a foreshadowing device: The mother demonstrates skillful parenting in the film, which hints at the organizing power of sadness. This again suggests that sadness has value and helps us connect with others in meaningful ways, as parents or not.

The film uses the model that thoughts occur as a consequence of emotions. Emotions come “first”. Champions of cognitive therapy[3. Related: Cognitive behavioral therapy may be losing its effectiveness over time. One complaint many people have had about CBT is that the process can feel invalidating: “So… you’re just saying that I think the ‘wrong’ things. If I only thought the ‘right’ things, then I wouldn’t feel this way. So you’re saying it’s all my fault. Thanks a lot, jerk.”] would disagree with this: They would argue that thoughts always precede emotions, even when we have no idea why we feel the way we do.

This is one of many hypotheses about our internal experiences. Other models concur with the film’s assertions that emotions have primacy; our behaviors and thoughts can be consequences of what we feel. I believe that they are ultimately all related and each can have primacy, depending on the circumstances.[4. This isn’t entirely related to the primacy of thoughts, but someone, who I now can’t remember, said something pithy like, “Who are you between your thoughts?”]

There are delightful visual puns in the movie. One that I thought could use elaboration was the “train of thought”. The train in the film didn’t serve much purpose other than as a literal means of transportation for the emotions. Pursuing more meaning in the train may have derailed the film, so I understand why the train of thought was left as a train. It, however, might have been an opportunity to explicitly describe the interactions between thoughts, emotions, and behaviors.

I do recommend the film to adults and children alike. It offers a refreshing counterpoint to the messages we usually get from society about sadness (e.g., feeling sad means that there’s something wrong with you; you should try to avoid feeling sad as much as possible; etc.). When we embrace those emotions we often want to avoid, we learn more about ourselves, what steps we can take next, and the value of our internal lives. Pixar does an excellent job of teaching us these lessons in a fun and colorful way.

Lessons Observations Reflection

Truths from Glacier National Park.

This is St. Mary Lake from Glacier National Park in Montana:


My time in the great outdoors reminded me of these truths that I often forget:

The world is much bigger than any of us. Those mountains have existed for much longer than we have and will continue to do so long after we are gone. While it is true that even mountains will one day disintegrate (… and glaciers will melt and inland seas will evaporate…), they will persist much longer than any of us.

What a way to put our problems and worries into perspective!

When we die (a detail we all neglect to remember), none of this stuff will matter. We shouldn’t get too attached to what we do or what the outcomes are. Those mountains, glaciers, lakes, and forests were doing their thing long before we were born… and they will continue to do so after we die. We are lucky to be here to experience all this stuff, but, in the grand scheme of the universe, we are mere blips in time.

Life is ephemeral, so appreciate The Moments while you can. We’re those people who are out on the trails before 7am. The morning light only shines for a few minutes, so you must appreciate the soft glow it casts across the sky, mountains, and valleys when it happens. You also know that you can’t stay on top of the mountain and look at the spectacular vista forever. And you realize—maybe with some sadness—that the camera cannot capture the colors, textures, width, and energy of the scene.

So you appreciate it for what it is… and then you let go of it because you must. There’s a lesson in there about gratitude and grace.

People take care of things. People who venture into the great outdoors are all there for the same reason: We want to see the grandeur and beauty of nature. And these people come from all over: They have different hair, eye, and skin colors.[1. To be clear, though, the vast majority of people we saw while hiking were white people. This is not a new observation. While no one at Glacier asked me if I can speak English, people at other national parks have. White People Love Hiking. Minorities Don’t. Here’s Why.] They speak in different accents, languages, and dialects. They dress in different styles and carry different accoutrements. They nonetheless make eye contact and greet you. They warn you about potentially dangerous wildlife up ahead. They take care of things for you: They don’t pick the wildflowers so you can see them. They pick up their trash so you don’t have to. They stay on the trail to prevent further erosion of the earth.

People can do ugly and violent things. People can also do beautiful and kind things, and not just in national parks.

The world is a beautiful place. Much of the world’s beauty arises from imperfection. Mountains are jagged, lakes are non-uniform shades of blue, glaciers have irregular borders and rough surfaces, trees are bent and twisted in strange ways, boulders are shattered into coarse rocks, and clouds have different textures as they stretch across the sky.

Nature is non-uniform, random, and imperfect—and therein lies its grandeur. Is it the same with us? In society we want “perfection”, whatever that is, but the very nature that we find so beautiful and breathtaking is all imperfect.

May you soon have the opportunity to remember those truths that you know you forget.