Excerpt From The New York Times January 23, 2001 CASES A No-Drug Approach to Wellness By ANNA FELS, M.D. -------------------------------------------------------------------------------- Related Articles Psychology Home Health Home Forum Join a Discussion on Mental Health and Treatment -------------------------------------------------------------------------------- When I first met Mr. J. in my office he looked terrible anxious, exhausted, demoralized. He had stopped going to work several days earlier and was mostly staying in bed. After taking his history, I recommended psychotherapy and medication for his depression. But he would not consider taking medication. He wanted to deal with his depression, he said, "without depending on drugs." Perhaps because I had been an internist for several years before becoming a psychiatrist, I was baffled by his response. In medicine the situation had been exactly the reverse. There was huge pressure to hand out prescriptions for every cough and sniffle, even when it made no real sense. "Do something to make me feel better, now," was the unspoken mandate. When a patient left my office empty-handed, it was often with a palpable sense of disappointment. But in my psychiatric practice, I soon came to realize, Mr. J. was far from alone in his outright rejection of psychotropic medications. In fact, he was fairly typical. Yet like many of my patients, he seemed almost dangerously accepting of the psychological side effects of drugs given for physical ailments. In his case, he was on an anti-hypertensive medicine that affected his sexuality and possibly even contributed to his mood disorder. He also reported the frequent use of two psychoactive substances with known toxicity: alcohol and cigarettes. So what was the issue here? It seemed illogical and to a psychiatrist that's always a sign that there's something of interest going on. On his next visit, knowing that Mr. J. was increasingly convinced that I was missing something important, I asked him to explain his feelings about medication. After considering for a moment, he gave me a response that I was to hear, in various versions, over the following years: "I want to understand what is happening to me so that I can change. I don't believe in using chemicals to alter my mind. I don't want a `happy drug.' " What took me by surprise was the strength of Mr. J's conviction that understanding his depression would necessarily lead to its resolution. Contained within his statement was a brief for the power of the conscious mind. It began to dawn on me that by suggesting medication I had inadvertently challenged one of my patient's and the larger culture's most deeply held beliefs, the notion that our consciousness is the central organizing and shaping force of our minds. Awareness and understanding, according to this theory, form the fulcrum by which we can move our mental world. As I reflected further, I realized to my confusion that the same concept forms the cornerstone of my own profession. For Mr. J. and many other patients, taking the antidepressant was tantamount to ceding the supremacy of consciousness in controlling who we are and what we do. Hidden in my apparently harmless suggestion was a subversive new notion of the self. It removed consciousness from the dominant center of the brain to merely one among many mental constellations. If Copernicus had removed us from the center of our solar system and Darwin from the apex of the natural world, this was the final indignity. By proposing medication I was suggesting that we were not even the masters within our own minds. From my dusty medical school memories of neuroanatomy, I resurrected a picture of the peripheral area of the brain where consciousness is thought to reside. It suddenly seemed like a small outpost. Distant from the most central, ancient portions of the brain, it was simply one among many distinct areas, each with its own biologic mandate and potential for dysfunction. Like Jupiter's moons, which circle in their own trajectories while still being held within the gravitational pull of the Sun, the various areas of the brain perform their separate functions. How could we assess the power and reach of rational thought within such a system? But even as I had these thoughts I was looking across to Mr. J.'s thoughtful face. He was mulling over his ideas on medication, but seemed cheered by our discussion and became more animated. We moved on to discuss the problems that he had been having with his aging parents, and by the end of the session, we decided that he would see me for psychotherapy. Over time Mr. J. 's depression resolved without medication as most depressions eventually will. But when his symptoms returned again after only nine months, he reluctantly agreed to a trial of antidepressants. Four weeks later, when he was feeling better, I asked Mr. J. to try to describe what he felt like on medication. "I guess I feel like myself," he said, then laughingly added, "Whatever that means." --------------------------------------------------------------------------------