Through the Times With Ronald Pies, M.D.

Psychiatric Times

November 2005

Vol. XXII

Issue 13

Psychiatric Times' columnist Ronald Pies, M.D., is a physician committed to encephiatrics ("brain healing"), a poet with a compassionate heart and a philosopher with a zeal for exploring fundamental issues of life.

A native of Batavia, N.Y., Pies was educated at Cornell University and then continued his studies at the State University of New York Upstate Medical Center in Syracuse, where he received his M.D. degree and completed his residency in psychiatry.

"I had the sense from the very beginning that psychiatry was the specialty within medicine that would allow me the greatest breadth and depth in terms of my general interests," Pies told Psychiatric Times.

Several of his professors at Upstate Medical Center (now University), including Eugene Kaplan, M.D., Robert Daly, M.D., Richard Phillips, M.D., and Ellen Cook Jacobsen, M.D., helped him see that that psychiatry "allows one to create a synthesis of sorts, bringing in everything from biology to poetry to art," said Pies, who is now clinical professor of psychiatry at the Tufts University School of Medicine. Pies was also formerly a lecturer on psychiatry at Harvard Medical School.

Indirectly, Pies said, the residency program stimulated his interest in psychopharmacology.

"We had a very fine program and really excellent teachers, but it was focused much more on psychodynamic psychiatry, including object relations theory, and less so on psychopharmacology," he said.

Pies wanted more, so he and a resident colleague started a monthly newsletter discussing psychopharmacology.

Much of Pies' subsequent career has included psychopharmacology. He wrote the Handbook of Essential Psychopharmacology (2005, 1998; American Psychiatric Association), and he authored the Handbook of Geriatric Psychopharmacology (2002; American Psychiatric Publishing, Inc.) with Sandra A. Jacobson, M.D., and David J. Greenblatt, M.D. He has been director of psychopharmacology and research at Bay Cove Mental Health Center in Massachusetts; staff psychiatrist and director of psychopharmacology at Harry Solomon Mental Health Center in Massachusetts; and chair of the Psychopharmacology Interest Group for the Massachusetts Psychiatric Society.

For more than a decade, Pies operated a private psychopharmacology consultation service where he "saw some very sick individuals," most of whom were not getting better even under psychiatric care. "It certainly taught me a great deal about very refractory cases," he said. Those refractory cases and others taught him much about the humanity of the patients he treats.

"My patients have taught me how generous people who are suffering can be and how strong people are. That may seem surprising, because these were often very severely impaired folks, people with psychotic-level disorders and so on," he said.

"What I remember most about some of the patients I saw early in my career was their generosity and kindness, particularly when I would make mistakes, and, of course, we all do. Sometimes, a patient would almost be in the position of comforting me by saying 'There, there doctor, it is OK that the medication really didn't help me. I'll get through this.'"

Despite his expertise in psychopharmacology, Pies doesn't consider himself a psychopharmacologist.

"I consider myself a general adult psychiatrist who has always had--and this goes back to college--a very strong interest in the biological functions that underlie thinking and feeling," he explained. "Even as a freshman and sophomore at Cornell ... I was very interested in neurotransmitters, how the brain works and how that fits in with broader ideas about the mind, which, I think, leads one almost naturally to have an interest in how medications can work for mood disorders and other psychiatric conditions."

Asked about the direction of psychopharmacology, Pies said he found it fascinating that some of the medications being used and tested work not so much by increasing neurotransmitters but by actually improving neuronal growth and development. He disagrees with those who criticize medication use as being "cosmetic" by covering up patients' root problems.

"Although that is sometimes the case in poorly conducted treatment, it turns out that these medications are having profound and very fundamental effects at the level of the gene," he said.

Lithium (Eskalith, Lithobid) and other psychotherapeutic medications, he explained, increase levels of nerve growth factor: "You can actually demonstrate the brain becoming more massive or heavier with the use of some of these mood stabilizers and perhaps antidepressants and antipsychotics as well. So, it is not specifically a given agent that I find so promising as this aspect of their mechanism of action. There is a lot of potential for developing new agents along the lines of neuroprotection and improved neuronal function."

On the controversial issue of prescribing antidepressants for children, Pies said, "In general, antidepressants, if used appropriately and for the right indications, do much more good than harm, and I believe that is true in both children and adults."

With regard to suicidality, Pies said, "The jury is still out." He has seen the warnings from the U.S. Food and Drug Administration and acknowledges there is a puzzling finding of about a 2% difference in terms of suicidal thoughts and behavior between the children taking placebo and those taking the antidepressants. But, he said, it is difficult to know what that percentage difference really tells us.

"Those figures are not based on actual suicides, but rather on suicidal thoughts and behavior. Sometimes, something like a child banging his head on a table was included in some studies as an indication of suicidality," he said. "We need to interpret those figures cautiously."

Pies suggested that some of the children who become agitated and possibly suicidal after receiving antidepressants may actually be children who have undiagnosed bipolar disorder.

"If you give an antidepressant without a mood stabilizer to someone with unsuspected bipolar disorder, some of them can get quite agitated and enter a so-called mixed episode, in which they can become suicidal," he said.

Within the first week or so of a child or adult taking a psychotropic medication, Pies recommended that the patient's clinician do a very careful assessment, looking for akathisia, agitation and signs of a mixed state.

Suicide rates in specific age groups actually may be declining, Pies suggested.

"If you look at the epidemiologic data over the last 10 or 15 years from a number of different countries, it looks as if suicide rates have been declining in those populations above the age of 15," he said. "This decline coincides with the use of [selective serotonin reuptake inhibitors]. So, I really think the evidence [about suicidality] is inconclusive."

Future of Psychiatry

For many years, Pies has pondered the future of psychiatry. Two years ago, he won first prize from the Irwin Foundation for his essay on the future of psychiatry, "Why Psychiatry and Neurology Cannot Simply Merge," which subsequently appeared in the Journal of Neuropsychiatry and Clinical Neuroscience (2005;17[3]:304-309). In the editorial, he explained that while psychiatry and neurology share a common substrate, the human brain, they differ in their discourses (complexes of credentials, protocols, jargon, and a specialized knowledge that defines theory and practice within the human sciences).

Neurology is fundamentally a discourse of neuroanatomical and neurophysiological relationships, he said, while psychiatry, notwithstanding its burgeoning interest in neuroscience, remains grounded in human subjectivity and existential concerns.

"Psychiatry needs to redefine itself as a medical specialty, and that is a real challenge," Pies told PT.

"Psychiatry's future, if we are to have a future as a medical specialty," he said, "will involve our creating a field, a new language and a new level of discourse." Pies proposes to call this new field encephiatrics. The term is derived from the Greek roots enkephalos (brain) and iatros (healer).

"What that means really is that we become of healers of the brain. This idea of healing the brain is based on the notion that the brain is the final common arbiter of all of the input it receives, whether biological or social or psychological or spiritual. The way psychiatry will define itself is as the medical specialty that provides optimal healing for patients with brain dysfunction," Pies said. "I see that as occurring through a mastery of not only psychopharmacology, but also of all those approaches to human suffering that we have learned as healers over these many centuries."

Included in encephiatrics would be talk therapies and even literary approaches, such as poetry therapy, according to Pies.

"I believe there are many ways of influencing the brain for the good. The brain is a kind of funnel that takes in all of these different stimuli. I see psychiatry as moving into that very comprehensive and all-inconclusive direction. There is a risk of becoming distracted by all of these opportunities to change the brain function. [But] I believe we can surmount that and become a truly comprehensive, brain-healing discipline."

Many Interests, Many Talents

Multitalented, Pies has many varied interests. He has conducted research, taught, written journal articles and literary works, and served on editorial boards. A long-time member of PT's editorial board, Pies received the publication's Lifetime Achievement Award in 1996. While he is well known for the "Clinical Puzzles" and "Psychiatric Medicine" columns that have been published for years in PT, Pies' first submission to the publication was a short story. In 1985, he saw an ad requesting contributions, nonfiction or fiction, for the newly created publication.

"The very first piece that I sent in to John Schwartz, M.D., was a short story, "Hyman Gleeber Buys a Friend." The story was based on a teaching in the Talmud, which has been a great source of inspiration and interest to me," Pies said. "To my surprise, since PT was ostensibly a psychiatric newspaper, John liked the story and it was published. That launched my fiction career, and to that extent, I owe John a lot."

Pies has a rich literary and philosophical life. In 2004, he wrote Zimmerman's Tefillin, a collection of short stories (PublishAmerica). His poems, such as "Spellcheck for a Malformed Fetus," "Congestive Heart Failure," "Return to Brooklyn" and "The Golden Years" have appeared in JAMA. He also has published poetry in numerous literary journals and anthologies and has written on the therapeutic uses of poetry and the nature of poetic language. Last year, a collection of his poems, Creeping Thyme, was published (Brandylane Publishers, Inc.).

"Robert Frost defined poetry as a 'momentary stay against confusion.' In that sense, it may be broadly therapeutic for me. I see it as a way of delving into language in such a fashion that it creates a small piece of order in a chaotic universe," Pies said, adding that writing poetry is "part of the broader artistic impulse to seek out and create beauty and order."

In 2000, Pies the philosopher wrote The Ethics of the Sages: An Interfaith Commentary on Pirkei Avot (Jason Aronson Publishers, Inc.).

"Even though I don't consider myself observant in the Jewish faith, I have had a very strong emotional bond to Jewish philosophy, literature and ethical teachings for many years," he said.

In Ethics of the Sages, Pies compares precepts contained in Pirkei Avot, the only tractate of the Talmud that deals exclusively with moral and ethical lessons, with similar precepts from the world's other major spiritual traditions. Additionally, he demonstrates the relationship of Pirkei Avot and other spiritual teachings to concepts found in modern psychotherapy literature.

Pirkei Avot, he said, contains an immense number of psychologically rich observations and truths.

"There is a maxim in Pirkei Avot that says 'Who is rich? He who is happy with his lot.' This notion that we can be rich or happy by appreciating what we actually have I think is a very important psychological truth," Pies said.

Unfortunately, psychiatric patients and some psychiatrists as well, he said, tend to dwell on the things that they don't have and become fixated on those.

Currently, Pies is working on a book, called Everything Has Two Handles.

"That title is taken from a Stoic teaching. The notion is that everything that happens to us, good or bad, can be seen in two ways, or, as it were, picked up in two ways. You can pick it up in a way that leaves you feeling miserable, sad and hopeless, or you can pick it up by the handle that allows you to view it in a positive and creative way," Pies said.

The melding of Judaic, Stoic and some Eastern traditions is of great interest to Pies as a psychiatrist, because he believes the spiritual traditions that he draws upon are focused on helping individuals put aside some of their unnecessary suffering.

Pies also has written a novella based on the life of Moshe ben Maimon (Maimonides), a medieval physician-philosopher. For Pies, Maimonides should be a guiding star for psychiatrists. Maimonides, he explained, believed, "The physician does not cure a disease, he cures a diseased person."