Ken Duckworth, M.D.: How Do You Move Beyond Blue?

Dr. Duckworth won the award for Clinical Excellence from the Massachusetts Psychiatric Society as well as teaching awards from Boston University, for his work at Harvard Medical School, and from the American Psychiatric Association. He was also a recipient of the Ken and Rona Purdy Award for his work to combat stigma.

Currently an Assistant Professor at Harvard University Medical School, Dr. Duckworth is also a board member of the American Association of Community Psychiatrists. He has served as a school consultant for a decade, has had an active private practice, and currently does community mental health work with Vinfen Corporation in Boston as their Medical Director.

But what was TRULY amazing about the guy is this: I could understand him!!!!

Here he is … Dr. Ken Duckworth.

What do think the biggest misconceptions are about mental illness?

Well, there are many mental illnesses. We’re in a big barnyard there. But I think there is more pessimism regarding treatment than is warranted. If you look at many aspects of treatment outcomes of persons with most psychiatric illnesses, a synonym for mental illnesses—anxiety disorders, OCD, bipolar disorder, even schizophrenia—a lot of people do well over time. And I think one of the misconceptions of the field is that these illnesses are invariably chronic and therefore untreatable.

Another misconception is association of violence and mental illness. While it is true that a subset of persons with psychiatric illnesses are violent, the percentage is very small. And most of them are associated with substance abuse problems, which are not being treated.

Also, we do not know how our treatments work. This unsettles people. We have all these theoretical models. This is the way medicine was shortly after penicillin was delivered. People knew that it worked, but they couldn’t say know how. I think it will be very elegant once we have neuroscience mapped out, and we can say exactly how medicines work. That’s an Achilles heel of the field. Because people want to know exactly how medication works.

You say that the treatment outcomes of persons with mental disorders are favorable, in general. I’ve read statistics that say 80 percent of people respond to treatment. And about 20 percent don’t. Those people are treatment-resistant. Is that correct?

We are lumping together a lot of different conditions here, so I think we need to be thoughtful. But it is true that not everyone responds to even our best interventions.

Many of my readers, I believe, are treatment resistance. They’ve been on tons of medications and nothing seems to work. There is a real desperation in some of their messages. What, as a blogger, can I tell them?

If you look at the STAR*D study, I think the message there is to keep on trying new medicines, and you are likely to hit one over time that works. Is it arduous? Of course. Is it unpleasant? You bet. Is it unfortunate that we don’t have the kind genetic mapping that can say how you are going to respond to a certain medication? Yes.

The other thing I recommend people to do is to get an independent consult with an expert. For example, in Boston, I can tell you who the treatment-resistant depression guru is. He will get more creative with medications and try some that other doctors didn’t consider.

I would advise people generally to go to the local academic medical center. Go to the depression center. Most academic medical centers do have such capacity.

The other thing I encourage people to do is to re-double up on their non-pharmacological efforts. So Tom Cruise and I have almost nothing in common on how we see mental health conditions. However, he does encourage people to exercise. Aerobically exercise: that’s his answer to everything. And if you look at it, there is some data that shows it does help persons with mild to moderate depression. Now can aerobic exercise help people with treatment-resistance, severe depression? Never alone. And I mean NEVER alone.

But what I have found that someone who has been severely depressed for years is that they can become despairing, which is a human, natural response, and they forget about the comprehensive nature of the approaches that probably helped them in the past to combat the illness.

For example, I’ll sit down with a patient and go over not just the medicines, but the other strategies that can help. None of this is a magic bullet phenomenon. Very few interventions in mental health are solely medication driven. It’s almost always psychotherapy plus meds, vocational rehab plus meds, a thoughtful, creative, strength-based approach plus a med.

Could you address the connection between alcoholism, bipolar, and suicidal tendencies?

I cannot say that we’ve identified a neurochemical smoking gun. That would be an exaggeration of our capacitiy on the biological side, but I will say that these things travel together quite commonly. This is a relatively classic association of bipolar disorder, substance abuse, and suicide. In fact these conditions run in my own personal family. But not always in the same person.

I will just say that in my experience there is a common association between mood disorders and alcoholism.

The piece on suicide is an interesting problem. Suicide does run in families. Is this a biochemical phenomenon? There are some theories that there are biochemical changes in people's serotonin levels before they commit suicide. There is some reason to believe that serotonin is the biochemical contributor to suicide.

However, I’ll also say that just as divorce runs in families or another phenomenon runs in families, when suicide runs in a family, another way to think about it is psychologically—that people now have that in their lexicon, in their repertoire, of choices they can make when they’re desperate. So for the socially taboo act, if someone in the family has done it, it can give the person a little bit more permission to do it when they feel desperate.

So when people say that suicide is the most selfish act, what would you say to that?

My experience with people who are suicidal in the context of a mood disorder is that they’ve actually lost sight of the other people in their lives. They are so self-troubled that they haven’t been able to connect to the other people in their lives. The other people in their lives are, of course, very hurt by their act. Very hurt.

That goes along with the concept of being connected to alcoholism, because isolation is so much part of alcoholism.

That’s right, and there is no question that mental illnesses and alcoholism put together is a very bad combination, a very high risk combination.

One of the things that I’ve observed in working with this dual-diagnosis population—usually substance abuse and some form of mental illness, in this case bipolar disorder—is that it’s difficult because the cultures of treatment are so different.

In the substance abuse culture, the person is generally viewed as the agent of the problem, and they are held accountable and have consequences for their relapses. In the mental illness culture, the person is often viewed not as the agent of the problem, but as the victim of their illness. We tend to hold people a little less accountable for bio-chemical processes.

So if a person has schizophrenia and is hearing voices, people tend to be a little more paternalistic, they tend to be leaning forward a little more in their interventions.

Now what I have experienced, when the person has both substance abuse and a mental illness, people don’t know how much to do for the person, and how much to have them be accountable, and to have them learn from their mistakes because in this case, when you have both together, the mistakes could easily be lethal.

You can see this dichotomy. And when I work with families dealing with both conditions, my heart really goes out to them because in the AA world, and in the substance abuse culture, they are encouraged to have the person hit bottom and be accountable, but that’s not the case in the mental health world.

A question for my Beyond Blue readers: Do you want me to type out the rest of the interview? If you'd benefit from it, I don't mind.