Take Five

It's natural to wonder what role psychiatric medications should have in the treatment of mental disorders. I have, of course, thought about this for years and have come to the conclusion that our medications don't treat diagnoses nearly as much as they do dimensions of functioning. What I mean by this is that for any given diagnosis there are a cluster of symptoms associated with that diagnosis. Depression for example is characterized by sleep problems, low mood, often anxiety, and almost always a decrease in a pleasurable response to things that ought be fun. The consequence of this is we often find ourselves recommending a blend of medicines as the treatment. There are exceptions: schizophrenia and ADD for example are conditions where one can see striking improvement with a single medicine, but in the majority of instances patients end up taking more than one medication to treat the different aspects of functioning that are clustered around what we would call a diagnosis.

So what are the aspects of functioning that medications are most helpful with? Let's take five: sleep, energy, mood, anxiety, concentration and clarity of thinking. While we humans are incredibly diverse in terms of our style and talents, we all share the need for a sense of wellbeing in the five dimensions listed above. We can view these five as dimensions which when blended together with different weight characterize many diagnoses. Regardless, each of these dimensions is essential for a sense of well-being.

Quality sleep is restorative for the brain and is closely linked to our circadian rhythms. Sleep is essential to daytime health, mental as well as physical.

Energy is a very useful concept. Positive energy is what gives us the spark and motivation to compete in life. Negative energy on the other hand is associated with agitation, decreased sleep, and sometimes anxiety. Too much energy is associated with states like mania, while too little often accompanies depression.

Mood is fundamental to the attitude with which we approach life. A person with a bright mood experiences optimism, and is engaged with the world. Mood relates to energy because much of our energy comes from perceiving the world around us vividly. When our mood is depressed our senses our dulled. A normal mood on the other hand promotes us taking in external experiences in an inspiring way.

Finally, clarity of thinking is not only related to severe conditions such as psychosis, but it is also represented in far subtler and more common conditions such as ADD. Difficulties with cognition is often under appreciated in people who are depressed.

Managing medications is largely a function of asking in advance, what do we want the medicine to do, and then making sure we achieve that result with minimum doses and absence of side effects. Choosing a medication involves balancing an awareness of diagnosis, the latter helping us narrow our options to what medications are likely to be helpful, and also paying attention to the five dimensions of functioning to further help us fine tune our choices.

Now to the image at the header of this article. The Dave Brubeck quartet was a jazz ensemble known for stepping outside the conventional use of rhythm in jazz. 'Take Five' is one of their more famous albums. On the one hand the group distinguished themselves with their signature beats, stepping outside the box of conventional jazz rhythms, but on the other hand their music, at least to me, was a bit boring and less passionate than what I normally associate with jazz. Thus there was a duality to the band, a duality that is similar to looking at human behavior from the perspective of the five dimensions we have outlined; attributes that we all share as humans are crucial, but it is the unique blend of these attributes from one person to the next that is interesting.

Thus psychopharmacology, to use an athletic metaphor, is somewhat like the restorative work a sports trainer does with an athlete, important but not as wondrous as seeing the athlete's talent displayed on the playing field. Improving dimensions of functioning with medicines should not be underestimated, but neither should they be vaunted as a be and end all. In a majority of cases people will benefit from a productive experience in counseling where a person's natural talents can be optimized.