A doctor can treat a patient using either of two approaches: a “magic wand” approach or a “long hard road” approach.
Say you’re sick with a bacterial infection. Bacteria have taken over your body. The infection is so severe that your organs are failing. Your blood pressure is falling. You’re delirious, nearly dead. Then a doctor injects you with a chemical -- an antibiotic -- and you live to see another day. Administering an antibiotic to treat a bacterial infection is an example of a “magic wand” approach. Now, when I say “magic wand” I don’t mean to imply that a doctor waves an actual magic wand to make the infection disappear, but bringing you back from the brink of death with a finely dosed solution squirted into your veins is pretty magical when you stop and think about it. So when I say “magic wand” approach, that’s the sense I’m going for.
The “magic wand” approach uses a chemical substance, otherwise known as a drug, to treat a health problem quickly. Inhaled anesthesia works in seconds, as fast as an actual magic wand, but most drugs take longer to exert their effects. It depends on how the drug molecules are delivered. If the drug is swallowed, it may be thirty minutes or longer before it starts working. And some drugs can take days or weeks to reach therapeutic levels, but even days and weeks are short amounts of time when you step back and see the big picture. Drugs act rather quickly.
The “magic wand” approach to the treatment of a health problem can come in other forms besides medications. A scalpel is a “magic wand” approach. Think of how miraculous surgery is. A doctor cuts you open, slices out your appendix, sews you back up again, and you retain no memory whatsoever of the entire operation. That’s pretty magical. Implantable medical devices -- a pacemaker, a deep-brain stimulator -- are other examples. The “magic wand” approach is when the wonders of technology and marvels of modern medicine are used to treat a health problem in a short amount of time.
Contrast this to what happens when you’ve had a stroke, and you’ve lost the use of your arm. To get your strength back, you have to work at it. You have to work hard. There’s no magic wand to wave over the arm to make it better. There’s no pill you can swallow, no injection you can receive, no surgery you can undergo to make your arm strong again. It must be exercised back to health. This is an example of the “long hard road” approach. There’s absolutely nothing magical about it. Progress can be agonizingly slow. Simply put, the more you move your arm, the better your arm becomes. It’s a lot of hard work to exercise a paralyzed arm back to function. You have to do it over and over and over. Recovery happens in many thin layers. It can take months or even years. So, whereas a “magic wand” approach acts rather quickly, a “long hard road” approach takes a lot of time.
Apart from the difference in the length of time required to achieve their results, there’s another difference between the two approaches. During a “magic wand” treatment -- a drug, a surgery -- the patient is rather passive. The most you’re asked to do is swallow a pill or show up at the right time and place for the surgery. The “magic wand” does the rest. During a “long hard road” treatment -- physical therapy, exercise -- the patient must take an active role in the process. If you don’t, you won’t make any progress. If you just lie back and wait for a “magic wand” to make you better, you’ll wait in vain. Nothing will happen.
Say you’re overweight. A physical exercise regimen might be an effective treatment. This would be an example of a “long hard road” approach to weight loss. This approach stands in contrast to a “magic wand” approach, one which uses, for example, a medication to induce weight loss. Talk therapy, behavior modification, diet modification and long-term changes of habit are other examples of a “long hard road” approach to weight loss.
To recap, there are two approaches to the treatment of health problems: the “magic wand” approach and the “long hard road” approach. The “magic wand” approach is when a doctor gives a fast-acting treatment to a patient. The “long hard road” approach takes more time to achieve results, and the patient is required to take a more active role in the process. The approach has to be tailored to the particular health problem under consideration. Some health problems respond to a “magic wand” approach. Some health problems respond to a “long hard road” approach. It depends on what’s being treated.
In reality, many, if not most, health conditions are best treated using a combination of both approaches. Consider the treatment of obesity. A gastric bypass can surgically reduce the volume of the stomach to achieve weight loss, but anyone who has had a gastric bypass will tell you that unless this “magic wand” approach is combined with a “long hard road” approach -- a change in eating habits, an exercise program -- the effects of the surgical procedure will be short-lived. The patient must take on two roles, one for each approach. In the “magic wand” approach, the patient is rather passive. You just lie on a table and the surgery is done to you. In the “long hard road” approach, the patient must take on a more active role. You have to alter your eating habits. You have to exercise. Both approaches are necessary.
Now that I’ve described the difference between the two approaches, we’re ready to talk about the treatment of emotion. Anxiety, irritability and depression are extremely common after a brain injury. Not only are people worried about having to adjust to a new life, and are anxious and depressed about that, but their brains have been bruised, sometimes permanently, resulting directly in emotional symptoms. A person may have never had a down day in his life before the injury, but now he’s so depressed he can’t function. He’s irritable and easily frustrated. He may have been as cool as a cucumber before his brain injury, but now he’s so anxious he can’t sit still.
A doctor could use a “magic wand” approach -- an anti-depressant -- or a “long hard road” approach, such as talk therapy or counseling. Which one works better? Studies have shown that a combined approach works best, especially for severe cases. An anti-depressant in concert with therapy is more effective than either approach alone. In other words, both a “magic wand” approach and a “long hard road” approach. Physical exercise, proper diet and good sleep hygiene are also crucial elements of managing mood symptoms, but these “long hard road” approaches aren’t usually given the same emphasis during office visits with a doctor, and very commonly patients go without any “long hard road” recommendations at all, relying on the “magic wand” of medication alone to provide them with a cure.
But for many people with depression, a pure “magic wand” approach doesn’t work at all. A very large study recently reported in the Journal of the American Medical Association (1) showed that for many people taking anti-depressants for cases of mild to moderate depression, the drugs have no helpful effect. In other words, doctors are prescribing “magic wand” treatments for conditions that don’t respond to “magic wand” treatments. Not everything responds to medications, right? It’s an important fact to remember.
If you will recall the patient I mentioned earlier who was struggling to exercise his paralyzed limb back to health after a stroke. No amount of medication was going to make his arm stronger. Rehabilitation of a paralyzed limb demands a “long hard road” approach. A doctor can wave his “magic wand” all he wants. It won’t do any good. For millions of people being treated with anti-depressants today, this is exactly what’s happening. Doctors merely give the illusion of active treatment. There’s a lot of “magic wand” waving, but not a lot of results.
And not for nothing. Medications are expensive. And they have side effects. I once treated a woman who was admitted to our program with a diagnosis of dementia. She was being considered for long-term placement in a nursing home after failing to function at home independently. She’d been seeing a doctor for memory loss, and was being prescribed a medication for dementia. When her memory loss worsened, she was prescribed a second medication. When it worsened further, more medication was added. As she became increasingly incapacitated, her family and her doctor blamed the worsening dementia. But after reviewing her files I suspected that much of her confusion may have been due to the side effects of medications. When I discontinued her medications, her memory cleared, and she returned home to live an independent and productive life. Her “dementia” had been the result of a misguided approach to the treatment of her condition, causing more problems than it solved. “Magic wands” can be harmful.
The side effects of anti-depressants are perhaps more subtle, but they can be equally counterproductive. SSRIs, for example, aren't harmful in the sense that there's a very low likelihood you'll have a fatal reaction to them, but they're harmful in the sense that they frequently cause side effects which can go unrecognized or, especially in a person with a brain injury, which can be mistaken for a symptom of the brain injury. And a person with an injured brain is more sensitive to side effects, compounding the whole problem further. I've treated many patients with agitation. Not uncommonly my treatment was to simply discontinue the SSRI, and the agitation subsided.
Don’t get me wrong. Anti-depressants can be god-sends, particularly for people with severe depression, but also for people with milder forms. When they work, they really work, and it’s truly like witnessing a small miracle. But many times, medications do nothing more than a sugar pill would. Or they can be downright counterproductive. And a medication-only approach might overlook more helpful treatments. I prescribe a lot of medication. They can be extremely helpful. But I decline to prescribe medication or discontinue medication just as frequently. It's important to be judicious.
Frankly, in many ways, the practice of medicine has become more and more about “magic wand” approaches. It’s easy for a doctor to prescribe medications and feel like he’s doing something when he isn’t. Doctor visits are brief, not much time for traveling down the long hard road, and many practitioners who prescribe anti-depressants today are primary care physicians or family doctors with limited experience in the treatment of psychiatric conditions. In fact, between 1996 and 2007, the percentage of prescriptions for anti-depressants written by non-psychiatrists more than doubled (2). Non-psychiatrist physicians are less likely to be familiar with -- or recommend -- talk therapy, behavioral modification and other “long hard road” approaches.
And even when a doctor does recommend a "long hard road" approach, often the patient doesn't go through with it. It’s not called the "long hard road" approach for nothing. It’s hard, and it takes a long time. So doctors wave their “magic wands” and pretend that they’re working when they’re not. They can wave them all they want. They can prescribe medications all day long. Sometimes there’s just no bunny under that hat.
Say you’re sick with a bacterial infection. Bacteria have taken over your body. The infection is so severe that your organs are failing. Your blood pressure is falling. You’re delirious, nearly dead. Then a doctor injects you with a chemical -- an antibiotic -- and you live to see another day. Administering an antibiotic to treat a bacterial infection is an example of a “magic wand” approach. Now, when I say “magic wand” I don’t mean to imply that a doctor waves an actual magic wand to make the infection disappear, but bringing you back from the brink of death with a finely dosed solution squirted into your veins is pretty magical when you stop and think about it. So when I say “magic wand” approach, that’s the sense I’m going for.
The “magic wand” approach uses a chemical substance, otherwise known as a drug, to treat a health problem quickly. Inhaled anesthesia works in seconds, as fast as an actual magic wand, but most drugs take longer to exert their effects. It depends on how the drug molecules are delivered. If the drug is swallowed, it may be thirty minutes or longer before it starts working. And some drugs can take days or weeks to reach therapeutic levels, but even days and weeks are short amounts of time when you step back and see the big picture. Drugs act rather quickly.
The “magic wand” approach to the treatment of a health problem can come in other forms besides medications. A scalpel is a “magic wand” approach. Think of how miraculous surgery is. A doctor cuts you open, slices out your appendix, sews you back up again, and you retain no memory whatsoever of the entire operation. That’s pretty magical. Implantable medical devices -- a pacemaker, a deep-brain stimulator -- are other examples. The “magic wand” approach is when the wonders of technology and marvels of modern medicine are used to treat a health problem in a short amount of time.
Contrast this to what happens when you’ve had a stroke, and you’ve lost the use of your arm. To get your strength back, you have to work at it. You have to work hard. There’s no magic wand to wave over the arm to make it better. There’s no pill you can swallow, no injection you can receive, no surgery you can undergo to make your arm strong again. It must be exercised back to health. This is an example of the “long hard road” approach. There’s absolutely nothing magical about it. Progress can be agonizingly slow. Simply put, the more you move your arm, the better your arm becomes. It’s a lot of hard work to exercise a paralyzed arm back to function. You have to do it over and over and over. Recovery happens in many thin layers. It can take months or even years. So, whereas a “magic wand” approach acts rather quickly, a “long hard road” approach takes a lot of time.
Apart from the difference in the length of time required to achieve their results, there’s another difference between the two approaches. During a “magic wand” treatment -- a drug, a surgery -- the patient is rather passive. The most you’re asked to do is swallow a pill or show up at the right time and place for the surgery. The “magic wand” does the rest. During a “long hard road” treatment -- physical therapy, exercise -- the patient must take an active role in the process. If you don’t, you won’t make any progress. If you just lie back and wait for a “magic wand” to make you better, you’ll wait in vain. Nothing will happen.
Say you’re overweight. A physical exercise regimen might be an effective treatment. This would be an example of a “long hard road” approach to weight loss. This approach stands in contrast to a “magic wand” approach, one which uses, for example, a medication to induce weight loss. Talk therapy, behavior modification, diet modification and long-term changes of habit are other examples of a “long hard road” approach to weight loss.
To recap, there are two approaches to the treatment of health problems: the “magic wand” approach and the “long hard road” approach. The “magic wand” approach is when a doctor gives a fast-acting treatment to a patient. The “long hard road” approach takes more time to achieve results, and the patient is required to take a more active role in the process. The approach has to be tailored to the particular health problem under consideration. Some health problems respond to a “magic wand” approach. Some health problems respond to a “long hard road” approach. It depends on what’s being treated.
In reality, many, if not most, health conditions are best treated using a combination of both approaches. Consider the treatment of obesity. A gastric bypass can surgically reduce the volume of the stomach to achieve weight loss, but anyone who has had a gastric bypass will tell you that unless this “magic wand” approach is combined with a “long hard road” approach -- a change in eating habits, an exercise program -- the effects of the surgical procedure will be short-lived. The patient must take on two roles, one for each approach. In the “magic wand” approach, the patient is rather passive. You just lie on a table and the surgery is done to you. In the “long hard road” approach, the patient must take on a more active role. You have to alter your eating habits. You have to exercise. Both approaches are necessary.
Now that I’ve described the difference between the two approaches, we’re ready to talk about the treatment of emotion. Anxiety, irritability and depression are extremely common after a brain injury. Not only are people worried about having to adjust to a new life, and are anxious and depressed about that, but their brains have been bruised, sometimes permanently, resulting directly in emotional symptoms. A person may have never had a down day in his life before the injury, but now he’s so depressed he can’t function. He’s irritable and easily frustrated. He may have been as cool as a cucumber before his brain injury, but now he’s so anxious he can’t sit still.
A doctor could use a “magic wand” approach -- an anti-depressant -- or a “long hard road” approach, such as talk therapy or counseling. Which one works better? Studies have shown that a combined approach works best, especially for severe cases. An anti-depressant in concert with therapy is more effective than either approach alone. In other words, both a “magic wand” approach and a “long hard road” approach. Physical exercise, proper diet and good sleep hygiene are also crucial elements of managing mood symptoms, but these “long hard road” approaches aren’t usually given the same emphasis during office visits with a doctor, and very commonly patients go without any “long hard road” recommendations at all, relying on the “magic wand” of medication alone to provide them with a cure.
But for many people with depression, a pure “magic wand” approach doesn’t work at all. A very large study recently reported in the Journal of the American Medical Association (1) showed that for many people taking anti-depressants for cases of mild to moderate depression, the drugs have no helpful effect. In other words, doctors are prescribing “magic wand” treatments for conditions that don’t respond to “magic wand” treatments. Not everything responds to medications, right? It’s an important fact to remember.
If you will recall the patient I mentioned earlier who was struggling to exercise his paralyzed limb back to health after a stroke. No amount of medication was going to make his arm stronger. Rehabilitation of a paralyzed limb demands a “long hard road” approach. A doctor can wave his “magic wand” all he wants. It won’t do any good. For millions of people being treated with anti-depressants today, this is exactly what’s happening. Doctors merely give the illusion of active treatment. There’s a lot of “magic wand” waving, but not a lot of results.
And not for nothing. Medications are expensive. And they have side effects. I once treated a woman who was admitted to our program with a diagnosis of dementia. She was being considered for long-term placement in a nursing home after failing to function at home independently. She’d been seeing a doctor for memory loss, and was being prescribed a medication for dementia. When her memory loss worsened, she was prescribed a second medication. When it worsened further, more medication was added. As she became increasingly incapacitated, her family and her doctor blamed the worsening dementia. But after reviewing her files I suspected that much of her confusion may have been due to the side effects of medications. When I discontinued her medications, her memory cleared, and she returned home to live an independent and productive life. Her “dementia” had been the result of a misguided approach to the treatment of her condition, causing more problems than it solved. “Magic wands” can be harmful.
The side effects of anti-depressants are perhaps more subtle, but they can be equally counterproductive. SSRIs, for example, aren't harmful in the sense that there's a very low likelihood you'll have a fatal reaction to them, but they're harmful in the sense that they frequently cause side effects which can go unrecognized or, especially in a person with a brain injury, which can be mistaken for a symptom of the brain injury. And a person with an injured brain is more sensitive to side effects, compounding the whole problem further. I've treated many patients with agitation. Not uncommonly my treatment was to simply discontinue the SSRI, and the agitation subsided.
Don’t get me wrong. Anti-depressants can be god-sends, particularly for people with severe depression, but also for people with milder forms. When they work, they really work, and it’s truly like witnessing a small miracle. But many times, medications do nothing more than a sugar pill would. Or they can be downright counterproductive. And a medication-only approach might overlook more helpful treatments. I prescribe a lot of medication. They can be extremely helpful. But I decline to prescribe medication or discontinue medication just as frequently. It's important to be judicious.
Frankly, in many ways, the practice of medicine has become more and more about “magic wand” approaches. It’s easy for a doctor to prescribe medications and feel like he’s doing something when he isn’t. Doctor visits are brief, not much time for traveling down the long hard road, and many practitioners who prescribe anti-depressants today are primary care physicians or family doctors with limited experience in the treatment of psychiatric conditions. In fact, between 1996 and 2007, the percentage of prescriptions for anti-depressants written by non-psychiatrists more than doubled (2). Non-psychiatrist physicians are less likely to be familiar with -- or recommend -- talk therapy, behavioral modification and other “long hard road” approaches.
And even when a doctor does recommend a "long hard road" approach, often the patient doesn't go through with it. It’s not called the "long hard road" approach for nothing. It’s hard, and it takes a long time. So doctors wave their “magic wands” and pretend that they’re working when they’re not. They can wave them all they want. They can prescribe medications all day long. Sometimes there’s just no bunny under that hat.
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