#404 ‒ Mental health beyond neurotransmitters: the role of hormones in psychiatry, why symptom reduction isn’t enough, and the future of psychedelic therapies | Linus Abrams, M.D.

Linus’s passion for understanding his patients and going beyond traditional psychiatry [A: 2:45, V: 00:11];

• Linus has a very unique perspective on the integration of all of the traditional tools and insights of psychiatry, along with those of endocrinology

Is that a relatively recent fascination for you? 

• Yes
• He has been in practice for almost 35 years
• He was in a bit of a rut; he was enjoying his practice, but felt that he wasn’t learning as much as he wanted to learn
• There are a number of factors that drove him in this direction
• But the pivot is quite recent, and he is still learning about endocrinology
  • It’s been a recently evolving trend, but he’s thought about it deeply

During the first 30 years of your practice, (A) what did you love, what gave you satisfaction, and (B) and what did you question or feel was insufficient to help  your patients? 

• Linus sees himself as a kind of humanistic, existential-oriented psychiatrist who happens to be practicing psychopharmacology as a way to make a living and having an expertise in bipolar spectrum disorders
• But he found that psychopharmacology was perceived ambivalently, for the most part
  • Even in very successful cases from an objective point of view in terms of symptom reduction
  • That the patient felt it was undesirable, even if they had a spectacular reduction in symptoms
• And it led him to think about what was contributing to that

“What I finally decided was the organizing principle was that psychiatry aims at reduction of symptoms, but not restoration of the full human experience that makes life most worthwhile.”‒ Linus Abrams 

If you were at a dinner with 9 other psychiatrists, would they share that view as well? Is that a largely uncommonly held view amongst your peers? 

• Probably not, but Linus doesn’t go around asking that question
• It is an important question
• He would say that his peers would agree that there’s an unusual amount of struggle, even in cases where there’s a dramatic improvement
  • Where people come with horrible levels of suffering, and a psychopharmacologic intervention results in a dramatic reduction of that suffering
  • That it’s often still a struggle to encourage a patient to continue with an ongoing regimen when it’s needed
  • And there are certain conditions that require chronic treatment—bipolar disorder is chief among them

Linus doesn’t want to undersell psychopharmacology 

• He feels blessed to have had such a wonderful career and experience of psychiatry
• He loves the field of psychiatry, and he doesn’t mean to criticize psychiatry per se

This is more about adding an additional lens of perspective than detracting anything in any way from psychiatry, because psychiatry is a remarkable field 

To the question of what’s been fulfilling 

• He was lucky to have made the choice to become a psychiatrist and take advantage of the wonderful opportunities to get to know human beings on a deeper level
  • That’s been probably the most fulfilling aspect of his career—to really get to know people in depth who are remarkable human beings
• And that’s what inspired him to go into psychiatry in the first place
  • Because understanding the patient is always greater than his ability (or any provider’s ability) to understand them
  • Because the nature of a human being is so unique and remarkable

It’s progressive layers of insight and progressive attempts to understand and reinterpret our misinterpretations 

One of the things about psychiatry that is quite unique to medicine is the lack of measurable biomarkers or objective findings that could be measured on imaging 

• When you think through presumably the spectrum of conditions that a psychiatrist would be treating, from anxiety to depression to hypomania, bipolar disorder, all of these things, there’s nothing that’s going to show up on a CT scan or an MRI of the brain that makes that diagnosis
• There isn’t a blood-based biomarker that’s going to say, “Oh, this person has high ferritin, or, low this or low that.”
• Peter points out that Linus said something a moment ago that rings very important
  • Even though he used the term psychopharmacologist several times
  • Implying that the main tool he uses is a pharmacologic tool
  •  The human story piece of it is the diagnosis 

Peter thinks Linus has to have a very good hypothesis based on his subjective interaction with the patient 

• Yes and no
• First, he does a lot of psychotherapy too
• He’s one of those rare people (in a self-directed way) who chose a residency program at Harvard that trained both psychotherapy and psychopharmacology
• And he did that quite intentionally because he wanted to have a lot of cases where he was doing both as opposed to dividing and partitioning a patient’s care
  • Because that led to his curiosity and the psychotherapeutic aspect of it
• Peter knows from other friends who have done psychiatry residencies at Harvard, that Harvard is unique in that it still preserves that legacy of…
  • Harvard is a very heterogeneous institution, and it really depends on which particular hospital, which training program, because there are a number of different training programs (even within psychiatry)

Getting to the other aspects of Peter’s question, diagnosis and psychopharmacology don’t always go that hand in hand 

• One would think that they would, but not necessarily

There’s a certain art of psychopharmacology that’s somewhat intuitive and somewhat evidence-based 

• Linus finds that part interesting
• And all the information that one gets from a trial of a psychotropic medication is useful information
  • It isn’t categorical—this is a good drug for this or a bad drug
• But an adverse response gives us potentially actionable information going forward and should be part of the record permanently to advise any future physician about how to best help that individual

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