Welcome to the Frontier Psychiatrist…. Podcast. It's a podcast with myself, Dr. Owen Muir, as your host, and it's a companion podcast to FrontierPsychiatrist.com, a sassy Substack about health-related things.
This is a conversation between Jazz (Glastra) and me. She is the senior director at Brain Futures, which is a 501c3 not-for-profit. She got to be the interviewer in this one! I’m a big Jazz fan, as a person, in full disclosure. I also enjoy the art form of the same name, but that is a different story.
We are thrilled to have BrainFutures as partners in sponsoring Rapid Acting Mental Health Treatment 2024. It’s in San Fran on the 7th of January! Join us! (that is a ticket link!)
In this conversation, we try to get to a shared understanding of what we actually might mean by mental health, the mental health crisis, and whatnot. This means accepting that other people's minds might not be thinking the same things that we're thinking, and so trying to get to the same understandings is a process that we have to take seriously. We need to build trust, and that's really, at the end of the day, what this conversation is about.
The transcript follows…
Jazz Glastra
I'm Jazz Glastra, and I'm the Senior Director at Brain Futures, which is a nonprofit that advances access to new treatments and technologies in brain health.
Owen Muir, M.D.
I'm Owen Scott Muir. I'm a child, adolescent, and adult psychiatrist by board certification. I identify as an interventional brain medicine doctor because I don't really love... the branding of psychiatry or the expectations. Much of this goes back to me constantly thinking about the role of trust and expectations in any conversation.
Jazz Glastra
What is the difference between a neurological disorder, a psychiatric disorder, and a neuropsychiatric disorder?
Owen Muir, M.D.
In the beginning, there were only humors. And that's a little bit of a joke, but We had neurology as a medical specialty,
Sigmund Freud, whom we think of as a psychiatrist, was a neurologist. Because we didn't have psychiatry as a separate medical discipline, to this day, the American Board of Psychiatry and Neurology is one board, ABPN.
What ends up in what bucket in medicine has a lot of historical ness to it? Neurology used to be all of it? If it was a brain or a nerve, That was neurology, and then Freud came along with an explanatory model for problems people had that didn't involve localizing the lesion,? Neurology took over things where you could point at where it was, and psychiatry took over things where you couldn't point at where it was. If you end up having a thyroid problem, then you go to endocrinology, and you're not managed primarily by psychiatry. The accident of history is nonlocalizable Neurology ended up as psychiatry.
And here I am, talking all the time about fMRI-guided treatment, so I'm getting myself in trouble. One of the people who brought this bridge back was Dr. Nolan Williams, who trained initially as a neurologist. He did neurology first, then got board certified in behavioral neurology, and that not being enough residencies, he did an entire other residency in psychiatry.
And three board certifications in, he's a neurologist and a psychiatrist, and blah blah blah. It ends up being, “Who's got the most practice in their training program with whatever the problem is to own it.” It's an accident of history is the answer.
Jazz Glastra
So, are we in a mental health crisis?
Owen Muir, M.D.
Yes, in that we have no idea what that means, and we feel very crisis-y about it.
Jazz Glastra
I feel crisis-y about it, usually.
Owen Muir, M.D.
What is mental health? I have no idea. It is the worst term because it means nothing. Which is really good for charlatans and hucksters and bad for people who are suffering. I would agree we're in a mental health crisis if, in the same question, you let me say, are we in a mobility crisis?
Yes. When we only fill cars with water that should have taken gas, that's a mobility crisis, and we can have the same response to the mobility crisis of filling up gasoline-powered cars with water as we do to the mental health crisis. I'd say those are similarly crisis y. The cars wouldn't move.
And you could talk about what a problem it was all day long, but the car still wouldn't go because you filled it with water, not gas. That's how I think of the mental health crisis. It's a crisis of misunderstanding; the problem is you don't understand the problem, and then you don't apply the right solutions, and you act like it's a crisis, not an actual understandable and solvable problem.
Jazz Glastra
What do you see as the problem?
Owen Muir, M.D.
If you don't know what a mental illness is, or that there are different ones, and that's important, is there a problem with people who are, for example, dying by completing suicide? Yes. That is one version of looking at the problem.
Is there a problem with people having tremendous suffering? Needlessly throughout their day. Yes. Is there a problem of people being disconnected from each other and hopeless? Yes. Is there a problem of death by drug overdose? Yes. Is there a problem of many people feeling anxious and worried? Yes. Is there a problem? Many people are traumatized and thus have sequelae of that problem.
A lot of different problems. Schizophrenia. Homelessness. Having a poor definition for a problem creates. More problems than accurately understanding?
And so my argument is for starting with understanding and saying okay, if the problem is defined as X, then what? Because the mental health crisis doesn't define anything enough for me to have an answer for you.
Jazz Glastra
You gotta do something!
Owen Muir, M.D.
We have to do something is one of the worst things for anyone who's not a huckster.
If you are a huckster, it's great because just misdirected energy to do something “comma,” anything is a cash grab, and that's awesome.
Jazz Glastra
I think what people probably mean when they say there's a mental health crisis is like the old adage about recessions versus depressions, where a recession is when your neighbor loses their job, and a depression is when you lose your job. When people say there's a mental health crisis, they mean that my immediate family and friends are suffering. People know more people who are struggling or in crisis.
Maybe the question could be, is the incidence of diagnosable mental health conditions rising? Is the incidence of completed suicide rising? Are all these things you listed before, are they getting worse?
Owen Muir, M.D.
Yes, completed suicide is measurable and well-tracked, and definitively, more people are dying by suicide in the United States, at the very least, now than previously. Yes.
Jazz Glastra
What do you think about the term death of despair?
Owen Muir, M.D.
I think it's an attempt at good branding.
It's lumping together—death from overdose, death from suicide, and death from alcohol use disorder. Death from problems associated with psychiatric illness is an attempt to draw a circle around something in a way that.
It is trying to be helpful. I appreciate both attempts to understand and define a problem. Does that definition empirically hold up? Nate Silver doesn't think so. And Nate Silver is good at numbers.
Jazz Glastra
What's the difference between being in remission and being cured? Why don't you ever hear people talking about cures and mental health?
Owen Muir, M.D.
We don't use the word cure because, essentially, the FDA won't let us. I'm a doctor, saying the word cure has a very specific meaning—definition, which is more rigorous than the dictionary definition.
So, the dictionary definition of cure is having “no signs or symptoms of a disease.” I would argue many of the things I do to treat, say, depression, Stanford accelerated intelligent neuromodulation as an example, leads to what could be defined as a cure. However, because of years of hucksterism, We had too many things offered up as cures that weren't.
You end up having to asterisk yourself into incoherence. Could it come back? Yes. I have athlete's foot powder that says it will cure athlete's foot. But that claim was adjudicated by the FDA a long time ago. Meconazole nitrate, a cure. That's a claim on a treatment that they would have to approve. And saying cure makes you sound like a charlatan. Until the FDA agrees with the label that says cure, I'm not going to say cure. Even though people would love that.
Remission is defined as... no signs or symptoms of a disease, which is different from recovery, which I prefer conceptually, which is no signs or symptoms of a disease. And At least one meaningful friendship outside the family and meaningful work or school.
Jazz Glastra
You're getting more into well-being and just whole-person wellness territory there.
Owen Muir, M.D.
I do we need to use that many words to say human? Life anyone would want?
Jazz Glastra
Is that the purview of a psychiatrist or a neuropsychiatrist?
Owen Muir, M.D.
If you imagine the job of a physician stops at no signs or symptoms of a disease no. If you imagine the job of a physician is to help people. optimize full, rich, fulfilling lives and get and stay well, then yes. I tend to be in the latter camp. It's a little bit like trauma surgeons doing advocacy work to reduce gun violence,
they got really good at sewing up bullet holes, but would rather do less of that, thanks. Because there's only so much you can do in the O. R. I trained in Rochester, for med school, where the trauma surgeons were working with the police in the community to set up shot spotter systems and educate youth about gun violence …to reduce the number of bullet holes they'd have to sew up. Trauma surgeons have been thinking about how to do this in the community better than psychiatrists have, by a lot, would be my argument.
Jazz Glastra
I've seen this stat bandied about that something like psychiatry hasn't had a new class of drugs in 30 years or 50 years. And we've been doing all this work and research, but the mortality and morbidity rates. are not coming down in our discipline. So I want to know what you think about why psychiatry has been stuck in this rut for so long…
Owen Muir, M.D.
2023 is a year when new things have come to market. The job of a physician is to understand first and then offer treatment help,
We have an entire medical discipline called Physical Medicine and Rehabilitation, which looks to help people restore their physical functioning. And it's called Physiatry, the actual name of the discipline. Now, Psychiatry. is restoring the function of one's mind and psyche, right? And physiatry helps you move your knee.
Whether it's referring you to a physical therapist, or a psychiatric therapist, or a psychological therapist, or, the right number of walks for you, or a medicine to make the walks easier, I see those as very similar. We have a real dichotomy between functional problems, like problems of how something moves over time, and kind of structural problems.
And it's a lot easier to think your arm is broken, let's fix it, than the way your arm moves is broken, let's fix it. Or the way you think about something is broken, let's fix the movement of your thoughts. such that they function better in your life. And, GI gets this, PM& R is a whole discipline for this, and orthopedic surgery is not the same as physical medicine and rehabilitation, but they both deal with that back pain.
Jazz Glastra
Why has innovation been so hard in behavioral health?
Owen Muir, M.D.
We Changed the term to behavioral health and mental health. Whenever we feel uncomfortable, we come up with a new label for what we're doing. None of them are as good as feeling okay. Do you need behavioral health care? I don't know. Do you want to have a good life?
Oh yeah. Are you freaking out? Definitely, I'd like that to stop. Part of the problem is, again, a lack of definitions. Dan Carlin at Mind Medicine Now would say, We spent 30 years perfecting algorithms to make drugs as safe as water. And we got a generation of compounds with the efficacy profile of water. We were obsessed with errors of commission, like we didn't want to do any harm. It's in the Hippocratic Oath. But we also didn't want to risk helping people. Not too much, anyway. Which is an error of omission. We weren't willing to call a spade and to admit that the suffering we were seeing was unacceptable.
And could you do something about it? We limited ourselves only to things that were not harmful, which excluded many things that might have been helpful. Thus, our vision was narrowed. And so if your expectation is, let's pursue treatments that might get people 50 percent better, you're not going to only look at things that get you a hundred percent better. If your endpoint is remission, and that's all you'll accept, then you spend your time on different stuff. So, we spent our time on half measures because it made sense to do so given the constraints we set for ourselves, which were flawed.
Jazz Glastra
How unusual do you think that focus on remission is in your field?
Very rare. If you don't know it's possible, then why would you do it?
Jazz Glastra
Do you think most of your colleagues don't know what's possible?
I think they know it's possible, but they don't have it, as that's not the expectation. Look, I have drugs to prescribe. I'm a prescriber. I'm going to prescribe them. Those drugs are evidence-based, but to do what? To reduce suffering by 50%. Not studied to eliminate all the symptoms of the much less, heaven forbid, something that could get you even better.
Jazz Glastra
So you and I chatted a little bit this week about the prevention of mental health and substance use disorders, mostly mental health disorders, I think. I'm curious if you could talk about wanting to reduce suffering but not eliminate it.
Owen Muir, M.D.
One of the reasons I worry about Eliminating disorders as someone who's enthusiastic about doing so, there's a reason they had a predisposition to have that problem in the first place.
It is like having a Lamborghini as your car but moving to Colorado. And it won't perform well up the hill in the snow. In the context of living in Denver in the winter, a Lamborghini is a poorly adapted car, and you are a terrible driver. And so if you imagine everyone just rags on you for how well your car performs, ignoring what car it is, then I'm a terrible driver.
It happens to me because I have a Lamborghini, and there's snow, and it's not a good snow car, right? My Subaru friends will rip on me. I'm just better adapted to driving around L.A. That goes, wow, you can sit on the 405 at five miles an hour in style.
It's a context issue. Some people do better in the cold; some people do better in the heat. That's what we're prepared for. Some people do better in high novelty environments. Some people do poorly in low novelty environments. Some people are very careful. Some people are very reckless.
We need a variety of people around. Unfortunately, some of those people are more vulnerable in some contexts. So in a high cocaine environment, people with the predisposition to be more curious and novelty seeking which often shows up as adhd Are more likely to use and get a lot of reward from cocaine and develop a cocaine use disorder if you're Some people are predisposed to have a problem in a context, some people gain more weight from McDonald's and you put them in a high McDonald's environment, they get obese.
Some people are more likely to become depressed when things get bad, and they're more likely to be depressed in a highly depressogenic environment. It's our pre-existing vulnerabilities, which are boons in other contexts. You want some people around who are more curious and look under the rock for the extra thing because they can't help themselves. We evolved together in a tribe, and when you lose track of the fact that we need each other, each of these individual vulnerabilities. Thus, I don't want to think about eliminating people with mental illness.
I do want to eliminate the distress. People have, and sometimes that means environmental modifications. And sometimes, it means acknowledging that this environment is one in which you are maladapted. We need to be able to help you function better in this very difficult environment in which you find yourself.
But there's a classic ad for Valium that I think makes us cringe now but should. And it's a woman in a broom closet. “We can't eliminate her drudgery; we can help the anxiety. Valium,” or some such thing. It's a woman with a rag on her head, and like a bunch of brooms, and it's super sexist.
And it's just ugh. You make, you want to die, and no, stop doing that! Stop, let me, but not everyone has that option. It's about being honest with ourselves. We could eliminate anxiety or make the world a better place so people wouldn't feel trapped. And I don't know that eliminating anxiety is the goal so much as can you, can we help you be untrapped?
Jazz Glastra
We don't need to eliminate people who have a predisposition to anxiety, depression, or schizophrenia, But could we prevent them from having their disorder triggered?
So, I will give you one of the easiest examples of this I can come up with, which is cannabis and schizophrenia. So we have really strong data, mostly from Christoph Carell's work with other people as well, that ultra-high risk for schizophrenia individuals who smoke cannabis are highly more likely to convert to schizophrenia. And so if you wanted to prevent schizophrenia, the easiest thing to do, in quotes around the word easiest, is get young people not to smoke any cannabis. That would prevent a lot of schizophrenia. Good luck with that, by the way.
Jazz Glastra
I think we can have a separate conversation about public health messaging around schizophrenia and cannabis and how effective it could be.
Owen Muir, M.D.
You could prevent schizophrenia by reducing the rates of cannabis use.
Jazz Glastra
I think that would be a nice thing.
—fin—
Thank you for listening to the Frontier Psychiatrist podcast. Leave us five stars on whatever platform you're listening to. It helps discovery and lets other people know that it's a great podcast. I highly recommend sharing it with your friends. If you have enemies to whom you would like to send podcasts, you can do that too.
If you've enjoyed hearing Jazz and I talk, there'll be more of it. , Brain Futures is co-sponsoring an event I'm hosting on January 7th called Rapid Acting Mental Health Treatment 2024. You can get your tickets on Eventbrite. It's in San Francisco, right before the JPM Health Conference. A special shout out to my friend Grady Hannah, the CEO of Nightware, whose idea it was in the first place.
He and other exciting innovators will be there and talking to each other and to you at this reception. (ticket link)