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."
But Dr House never had Alexander Hamilton to contend with. We're talking about a man who crossed the Delaware with Washington, co-authored the Federalist Papers, and who, as the nation's first Secretary of the Treasury, came up with a brilliant solution for consolidating the state and national debts, which set the scene for unprecedented prosperity and growth.
Without Hamilton, the new nation would have come apart at the seams in its first ten years of existence and Balkanized into 10 or 15 minor coastal entities constantly bickering with one another, easy prey for the European super powers.
Hamilton graduated from Columbia a year ahead of schedule, and taught himself economics during lulls in the action in the Revolutionary War. In a side-by-side comparison with Thomas Jefferson, the nation's third President would probably come across as the dullard.
This is a guy who, if he were alive today, could teach himself quantum mechanics in six weeks, string theory in four, and have us out of Iraq tomorrow. Okay, I'm exaggerating. Two days to get us out of Iraq, one day for universal health care.
Psychiatry is kid stuff to Hamilton. Five minutes in the waiting room with his MacBook and already he is on the short list for the Nobel Prize in Medicine.
"Here's what we're going to do," Hamilton instructs his psychiatrist in a voice that lets everyone within two time zones know who's in charge. "Since these recommended doses are totally irrelevant to my situation, and since you have absolutely no evidence base to guide you, and since I know my own brain better than you do, I respectfully suggest that you start me on half the recommended minimum dose."
Pregnant pause. "And can you tell me where I can pick up a good pill-splitter?"
Disclaimer: This is a hypothetical conversation. Yes, you may want to challenge your psychiatrist to prescribe lower than recommended doses, but many of us may need to stay on high doses for the rest of our lives.
Also keep in mind, we are all unique. There are no right or wrong answers, only informed and uninformed ones.
"And another thing," Hamilton goes on to say, cueing up a published meta-analysis on his MacBook,. "drop-out rates."
According to the meta-analysis, the drop-out rates for bipolar patients on antipsychotics and mood stabilizers over the long term - 12 to 18 months - range from (get this) sixty to one hundred percent. Long-term studies involve patients who have been stabilized during a short-term trial (typically four weeks), then kept on the same dose range of meds.
Despite these appalling drop-out rates, psychiatrists persist in using the same dose ranges for long-term bipolar patients - patients who are stable but not necessarily feeling well, though definitely not manic - as on their emergency room patients.
Do you find something wrong with this picture? So does Alexander Hamilton. He lays it on the line to his psychiatrist in no uncertain terms: "Listen," he lectures. "I think these patients are trying to tell us something. We don't want our wings clipped. You may say that we are not compliant, but I say that you should be listening to us."
So what do you think? Should psychiatrists be listening to their patients?
Congratulations. You just aced this exam.
The above is based on conversations I had with John Gartner PhD of Johns Hopkins, author of "The Hypomanic Edge." It formed part of my second talk that I gave at the DBSA conference in early August in Orlando.