Monday, March 31, 2008

My Three Shrinks Podcast 44: Guest J. Raymond Depaulo MD

[43] . . . [44] . . . [45] . . . [All]

We are pleased to have the head of Johns Hopkins Psychiatry, Dr. J. Raymond DePaulo, joining us here to talk about diagnoses, labels, and the ethics of using drugs to enhance one's cognitive skills (a fascinating discussion).

Dr. DePaulo joins us on the next podcast as well (#45) to talk about treatment-resistant depression, bipolar disorder, favorite quotes, and words we don't like. That should be up by April 6.

March 30, 2008: #44 Guest Dr. Ray DePaulo

Topics include:

  • NYT: The Ethics of Artificial Brain Enhancement, by Benedict Carey. On using cognitive enhancers, like Adderall, Vyvanse, and Provigil, to perform better. The article quotes NIDA's Nora Volkow, who wrote, "Even though stimulants and other cognitive enhancers are intended for legitimate clinical use, history predicts that greater availability will lead to an increase in diversion, misuse and abuse." Dr. DePaulo addresses the treatment of symptoms (eg, inattention in pilots) vs diagnoses, on the bases of functional impairment and subsequent consequences. Be sure to listen to the part around 24 minutes, where we discuss the ethics of a hypothetical drug that increases IQ by 30 points.

  • Diagnosis in Psychiatry. Also some comments on ADHD vs Bipolar diagnosis, which led into an interesting discussion about the nature of diagnosing psychiatric "syndromes" in the absence of a definitive diagnostic aid, like a blood test or brain scan.
    Other references and topics mentioned by Dr DePaulo: Kraepelin. // Quote from Paul McHugh: "A good clinician in Psychiatry is someone who makes prudent decisions based on insufficient information." // Judy Rapoport's 1978 study of stimulants in normal kids. // The history of "ADHD" and "minimal brain dysfunction". // Labels and diagnoses. // William Styron // Kraepelin's Manic-Depressive Insanity.

  • Prison Health Care. Clink compares correctional psychiatry capabilities with those in free society and wonders why care can be provided in jails and prisons yet we are the only country still without some sort of national health care.

  • JAMA: Loss of Serendipity in Psychopharmacology, by Donald Klein. Article in the March 5 issue of JAMA. "This Commentary on the psychopharmacological revolution focuses on 2 mysteries: fostering medication discovery and finding out how they work."

Dr. DePaulo's most recent book is Understanding Depression.

There are three audiences for this authoritative book: people who think they m
ay be depressed, those whose condition has already been diagnosed and are in treatment, and those who are concerned about someone who is either in treatment or probably needs to be.

Credit: At the end is a few seconds of "Manic Monday" by The Bangles [iTunes, Amazon].

Find show notes with links at: The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom).

This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from
Thank you for listening.


DrivingMissMolly said...

I only listened to a few minutes of the last two podcasts, so I opened this one up with trepidation, but I really enjoyed it. I love, love, love Dr. DePaulo. Actually, a long time ago I thought Ray was Roy!

Anyway, what a sweet faced nice guy he seems to be! And, of course, smart. I rememebr my earliest psychiatrist as intimidating and foreboding so I always am attracted to a friendly, open expression in a mental health provider!

I have recently been diagnosed with Bipolar II and was super pissed off at my doc. I accused him of bestowing yet *another* trashcan diagnosis on me, the other being Borderline Personality Disorder.

Now that I have read up a bit on Bipolar II I can see where my psychiatrist is coming from. I've cried with relief because I think I've had a "mixed-state" before but had no idea what it was. I have been reading about the idea of a spectrum of bipolarity rather that the use of the designations I and II.

Anyway, on the use of drugs to "enhance cognitive skills," I was in grad school when I had my last "breakdown." I only completed one semester and with excellent grades and positive responses from my professors. It breaks my heart that I am no longer in grad school due to my mentall illnes(es) including inability to concentrate, racing thoughts, anxiety....

I want to go back to school so BADLY! I don't even need cognitive enhancement! I know I am smart enough, I just need a handle on these emotional and psychological issues.

Five years of therapy didn't seem to help so I quit.

Well, I'll wrap this up by saying that I really enjoyed hearing Dr. DePaulo speak as well as the Shrink Rappers.

...but can you get Dr. Peter Breggin!?!

Just kidding,


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Noni Mausa said...

I enjoyed this edition quite a lot, with a couple of reservations:

-- you discussed number of Americans in prison. It's now over 1% of adults, people over 18. This works out to over 700 prisoners per 100,000. By contrast, most nations have roughly 90 - 120 per 100,000. Not only is the US the largest, but they lead by a very large margin. The BBC has some numbers here:

Second, one of you (Dinah?) said that a woman (let's call her "W") came in with a highly organized file folder on the topic of Adult ADHD, which W claimed she had. She pooh-poohed the idea that W could have had ADHD, chiefly because of the piles of files, but also because of W's many activities.

Please note that attention in ADHD is typified by comprehensive difficulties with directing attention, but with some limited areas of hyperfocus on topics which have caught their attention.

What better focus of hyperfocus but the topic of ADHD, upon the revelation that a life of falling short, beginning but never finishing projects, being routinely told you have great potential, if only... might actually have an explanation besides being lazy and unmotivated.

What are the best current numbers for ADHD? About 4% to 9% of children, depending on the study, with roughly 60% persisting at levels disruptive to a normal life into adulthood.


April said...

I agree with Noni--I was kind of annoyed when you talked about telling the woman she didn't have ADHD. (Maybe because I was diagnosed with it and it made sense to me although I'd never considered it before the diagnosis. Anyway...) I appear to be functional (as you mentioned there has to be functional impairment), but nearly all of the signs/symptoms applied to me when I read the checklists. And also the idea that many women are underdiagnosed since ADHD makes us think of unruly little boys.

Subsequently I started taking Concerta while going to school and I did notice a difference, but I also learned that I am more right-brained in terms of learning so I added those skills to the mix and I don't take Concerta regularly anymore. Anyway, that's my 2 cents.

Aqua said...

This podcast could not have come at a more perfect time. I have TRD and have worked with my pdoc for 6.5 to try to find medication that will help me. He is of the school that does not believe a diagnosis is the end all and be all of everything. Very early on in my treatment it became obvious I have severe cycles in my mood states. Another pdoc diagnosed me as BPII, my pdoc says no I have Chronic Major Depression with bipolar like cycling. He believes I have a hyperthymic my normal personality is really high. Really, who cares what my diagnosis is, all I want is to feel better. were talking about fearing using stimulants. If you want proof that they are incredibly helpful to some people review my blog for the past three weeks. I am exactly who I used to be; intensely creative, love being alive, action oriented, bubbly, passionate, playful, social, better self esteem, sleeping for the first time in years, having energy for the first time in years...the list could go on. The result has been my completing 4 paintings, and starting two others, in the last 3 weeks (I've only ever painted one picture before), over the period of two days I have developed a workshop for the Art Clubhouse I volunteer for (part of my job before I became sick was developing curriculums and Lesson plans), I am thinking clearly for the first time since I became sick 6.5 years ago. I feel like my cognitive ability is much improved...basically the dexedrine dragged me out of severe depression I was feeling up to the time I added it to my mix.

It all began when my pdoc added Dexedrine to my mix of 600 mg Tegretol/night, 30 mg Prozac/day, and 10-20mg Valium/night.

(The valium is for Prozac induced side effects...clicking, tapping my teeth and incessant snippets of 4-8 bars of music repeating over and over in my head...the music is gone now, but the teeth tapping remains, but is better after I take valium.)

Anyways, I have no idea if I will remain myself for an extended time because of this mixture, but I do know that as soon as I began taking 10mg Dexedrine twice a day I have my life back.

Roy said...

Aqua, stimulants and other dopamine agonists (bromocriptine, pergolide, pramipexole, etc) are sometimes used as augmentation strategies for TRD. I used to use these a lot in my private practice and only had problems with the drugs inducing mania or hypomania a couple times, so I felt the benefit was worth the risk (as did most of my pts). Other risks include hypotension, psychosis, headaches, and movement disorders.