I’m not seeking it, but people—unconnected people, some of whom aren’t even speaking to me—keep bringing the idea to my attention:

You must write to make your point. To show what you’ve done. To demonstrate what you believe in. To influence the thoughts and behaviors of other people.

I haven’t kept to my previous promise about writing and publishing. Because I’m ambivalent. (From what my confidants have told me, many writers are ambivalent. This doesn’t particularly encourage me.)

There are professional topics that I can expound upon, though my expositions about many psychiatric practices and research are generally oppositional. For example, this month’s American Journal of Psychiatry features an original research article that argues that, in order to treat depression more effectively, one should consider starting two antidepressants instead of just one.

Yes, it is an article arguing in favor of polypharmacy (prescribing more than one medication for one condition). Never mind that there is at least a New York State-wide initiative to try to reduce the polypharmacy already present for antipsychotic medication.

To be honest, I stopped reading the article about two-thirds of the way through because my patience for it evaporated. (The trial was not placebo-controlled. The aurthors argue that they did not have a placebo arm because antidepressant monotherapy is already the standard of care. Never mind that antidepressants may not actually be that much more effective than placebo alone.)

But! To be fair, the authors stated that the reason why they undertook this study was to help alleviate the suffering associated with depression as quickly as possible. If one follows the usual treatment algorithm for treatment of depression, one starts one antidepressant. If that antidepressant fails the patient (versus the patient failing the medication—I hate it when articles state that the patient failed) after a fair trial (six to eight weeks, depending on who you talk to), then the next step is to try another, single antidepressant. If that antidepressant fails, then one can consider adding on another antidepressant as a combination. That means that at least three months have passed and that’s three months of potentially “undue” suffering.

So why not get around those three months and start off with two? This article suggests that starting off with two just might be the Right thing to do.

I readily confess that my bias is against starting medication, let alone two medications at once. (How would we know which medication is “working”? Or is the one causing side effects?) I also readily admit that I value the power of talk therapy and actually discussing whatever might be related to distress.

I do not, at this time, believe that the brain is just soup held in the bowl of the skull. I just don’t believe that adding a pinch of serotonin or tossing in a handful of norepinephrine will somehow make the brain juuuuust right.

But! To be fair, there are biological bases to “mental conditions”. One of the reasons why people got so excited about using penicillin (or malaria) to cure syphilis was because this demonstrated that a pill could actually cure psychiatric problems! (Syphilis can infect the brain in later stages of the disease, which is known as “neurosyphilis”. When people develop neurosyphilis, they can undergo changes in personality and behavior.)

And, really, who am I to express so much confidence that it’s not just about a dash of dopamine here and a sprinkle of glutamate there? Am I the one doing the research? No. I’m just the oppositional person shouting from the sidelines.

And that’s what I think I am doing to myself. Somehow, I’ve got it in my head that the only “meaningful” writing out there is something new, novel, based on research, published in some hoity journal. (At the rate I’m going, I will never get published in any academic journal. Which is not necessarily a bad thing.)

I also assume that other people can say, much more eloquently and with greater concision, whatever ideas I may have. (I’m telling you, another shrink out there has already analyzed the above article and has explained its nuances far better than I ever could.)

Furthermore, I don’t know that I want my writing to solely concentrate on all the things I find frustrating about my profession. That’s a downer and it causes a lot of cognitive dissonance that others can easily discern: “Uh, if you really dislike it that much, why are you still doing it…?”

Because there are things I can do with the knowledge I have—even if it completely contradicts what the journals recommend.

One of the greatest pleasures I have had in my current work setting is stopping medications. Some people—particularly others who feel some sort of responsibility for the patient—often express grand concern about this. After some discussion and agreement, though, we’ve taken down medications… and people are doing just fine. They haven’t “gone crazy”, “flipped out”, or “completely lost it”.

And that’s nice. And it helps people to recognize that they may not actually need pills to feel better, function better, and live the lives they want to lead. That they are resilient and that they have internal strengths they can use when things turn sour.

And that’s really nice.

People have noted that my writing has become more restrained with time. I agree. I find that sad.

I recently finished reading Samuel Shem’s Mount Misery. (Shem is the same guy who wrote House of God. That will mean something to any physician readers out there.) The novel traces the life of the hero, Dr. Roy Basch, as he goes through his first year of his psychiatry residency. Like House of God, the plot and themes of the story are hilarious, heartbreaking, horrifying, hyperbolic, and not really that far from the truth.

(I will say that I, too, thought the book ran a little long, but I still enjoyed the book immensely.)

One of the main themes that runs through the book is the loss of humanity that can accompany psychiatric training. Sometimes—often?—it’s hard to be human. You forget to be human.

I forget to be human.

I do not mean to place the blame entirely on my psychiatric training. That’s not fair. However, there are moments when I wonder what the heck I’m doing and how I would ever come to the conclusion that “I should say these meaningless words and keep my facial expression flat because, you know, what the patient needs right now is some lack of humanity.”

And writing here pulls me in both directions. On the one hand, sharing ideas and stories here helps stoke my humanity. It helps me develop empathy, which, I think, people appreciate. People want to connect. I don’t have the citation handy, but research on psychotherapy has shown, on a fairly consistent basis, that the type of psychotherapy someone “does” isn’t the healing component of therapy (or, in this case, meeting with patients). What is healing is the level of engagement and rapport.

That means being human.

On the other hand, we can’t run on emotions all the time. We developed big brains with big frontal lobes that can reason. These capacities are for us to use. And writing does help me step out of myself and consider what I have said and done. It’s like internal quality control.

Help me create and develop a writing niche. I think that’s my request.