Alex Hamilton Talks to His Psychiatrist

Imagine you're Alexander Hamilton. The man on the ten-dollar bill. You're a Founding Father, perhaps the most influential Founding Father of them all.

You're brilliant, you're creative, you're a war hero. You are a chick magnet. But you're also something of a loose cannon and a bit of a hot-head. And there's this insufferable pain in the butt named Aaron Burr. You need to teach him a lesson.

Now let's switch hats and imagine you're Hamilton's psychiatrist. How do you treat him?

Do you medicate his hypomania out of him? This guy is up virtually all the time. He's capable of doing something crazy, such as stop a bullet with a vital organ.

Or do you do nothing? This guy is a spectacular achiever, after all. Why fix what ain't broken?

Another thing to consider: How long do you seriously think someone like Hamilton will stay on his meds if he starts feeling like a fat stupid zombie eunuch instead of a chick magnet Founding Father?

So here you are, Alexander Hamilton, talking to your psychiatrist. "Look, Doc," you say. "I'm feeling a bit stressed. I feel like that pitcher in Bull Durham, you know, the one with the 100 MPH fastball who keeps beaning the mascot." (Please forgive the double anachronism.) "Anyway, I need you to slow me down just a little bit so I have control, but not so I pitch at 50 MPH."

Do you trust your psychiatrist in this situation?

Suppose I told you that there are ZERO clinical trials involving treating patients with hypomania? And suppose the psychiatrist recommends to you a mood stabilizer in the standard dose range.

You're Alexander Hamilton, remember. You're not about to just walk out the door with a prescription. "Look, Doc," you say, "how about we sit down and read the drug labeling together?"

Your psychiatrist, of course, is trying to hustle you out the door. Why won't he just take his meds and shut up? he is thinking. But an enlightened psychiatrist will welcome the opportunity to keep the dialogue going. At last, a smart patient I can work with, she thinks. She knows that "expert patients" who take the trouble to learn about their illness and actively manage it do a lot better than patients who simply take their meds and wait for something to happen.

Do continue, she gestures.

Hamilton now has the package insert unfolded like a road map. "Look," he says, pointing to some small-print boilerplate. "These recommended doses are all based on treating mania in the short term. These are your 911 cases, people who are bouncing off the walls and ceiling. The people you can't talk to. Look, I'm sitting in a chair. We're talking."

But even enlightened psychiatrists have an arrogant streak. "So what do you suggest we do?" she queries, sounding a bit too much like Hugh Laurie in "House."