Thursday, 26.11.2020

Thomas A.Ban, editor. Lithium in Psychiatry in Historical Perspective.

 

Reid Finlayson’s comments

A Life on Lithium and Lessons Learned

 

        Tom Ban invited me to contribute  a “comment” to a prospective INHN publication on “Lithium in Historical Perspective” in which I will present my observations/findings and/or life-time personal experience with the substance. I accepted the invitation and in the following I will give an account and reflect on my life prior to and after I was prescribed lithium. I will present my life experience in chronology but bring to attention in advance that after 20 years of treatment with lithium I made an impulsive choice to test my diagnosis of manic depression during a mid-life crisis by reducing my lithium dose. The experiment led to personal acceptance and deeper appreciation of the reciprocal interactions between bipolar illness and substance use disorders. Ultimately, in my work as an addiction psychiatrist, I am grateful to have the opportunity to apply my “inside-out” knowledge and experience in working with patients and colleagues who struggle with similar issues.

Part I – What it was like before lithium

        I was perplexed and still vaguely angry that Easter Sunday morning. Awaking slowly and hazily I remembered having been wrestled to the floor by a sea of faces dressed in white who held me on the floor and injected my buttocks with sedating drugs, against my will. The reality of my plight began to slowly infuse my mind. That morning I came to in a hospital room on the seventh floor of the Clarke Institute of Psychiatry on College Street in downtown Toronto. It was the 14th of April 1974. It was about five months before my 30th birthday and I was a psychiatric resident, both literally and figuratively. It was nine months into my first year of psychiatric residency training, and I had been hospitalized, involuntarily.

        The decision I had made to leave a thriving family medicine practice and begin a four-year training program to become a psychiatrist was complicated. Early in medical school, it was surgery that first appealed to me. I had spent a lot of time in the lab and operating room with Dr. Robert McFarlane, a prominent hand and plastic surgeon at The University of Western Ontario (now Shulick) School of Medicine. He was kind enough to recognize my contribution to a study the he published (1968). The technical surgical skills I was taught allowed me to perform appendectomy and cholecystectomy under close and direct supervision, but I had a tendency to occasionally lose focus briefly during long, difficult procedures. I might need to break scrub for a few minutes rest or have a coffee. I also felt light-headed when I donated blood, so I ruled out training to be a surgeon. Dr. Ramsey Gunton, our much-admired professor, and chair of medicine invited me to specialize in Internal Medicine, but I decided to complete a rotating internship at Toronto Western Hospital in 1970, which at that time was enough to qualify me to be a practitioner of medicine, surgery and midwifery in the province of Ontario. As a third-year medical student, I was 23 when I married Mary. She was the daughter of a doctor with a prosperous general practice who also practiced anesthesia. Our son was born before I graduated and our daughter the following year, just after we had arrived in Owen Sound to begin family medicine practice.

        I established a successful family medicine practice in Owen Sound, Ontario, in a happy and successful partnership with my late friend and colleague, Dr. Ralph Bunston. We met during my internship in Toronto and agreed to practice family medicine together for just three years because we both considered returning to complete more postgraduate education. During those three years, the practice of family medicine seemed routine and didn't challenge me enough. I pursued training as a private plane pilot and was drawn to become Jail Surgeon, providing medical care to the prisoners in the Grey County Jail, and the patients at the local provincial psychiatric hospital. The pathology lectures of Dr. Marvin Smout at Western had been fascinating, as was the sensational career of the Chief Coroner, Dr. Morty Shulman in Toronto, plus I was a fan of the television show Quincy (Jack Klugman in the title role played a medical examiner). So, I volunteered to become the youngest coroner in the province.

        Being a coroner was more challenging than I expected. Tragic child deaths, accidental deaths, murders and suicides which I was called upon to investigate were often very disturbing. My stress was compounded by the responsibility to speak with the bereaved families. In this area my medical training had been woefully deficient, leaving me ill-prepared to cope with the fallout from unexpected deaths and with insufficient training to counsel shocked families.  Psychiatry seemed to offer me an opportunity to increase my knowledge, understanding and to enhance my ability to communicate.

        There were personal considerations too. Another reason I chose psychiatry was to follow in the footsteps of my father. I have always admired my father. He served in the British Royal Navy Volunteer Reserve during World War II and was at sea when I was born in Glasgow in 1944. Father had a difficult time finding work as a doctor in post-war Britain while the National Health Service was being organized. He was persuaded that more opportunities would be available in Canada for our family, so we immigrated to Canada in 1952. My father passed the Medical Council of Canada requirements for licensure while working at the Ontario Hospital School, Orillia, and went on to train in psychiatry at the University of Toronto in the mid-1950s. We moved many times as a family, I had attended eight different schools before my graduation from the University of Western Ontario (Schulich) School of Medicine in 1969. My father the psychiatrist, would sometimes invite troubled colleagues to visit with him in our family home because for them, it avoided the embarrassment of seeing him at the hospital or in his office. As a family doctor, I had been a volunteer participant, available to answer calls for the Ontario Medical Association's physician helpline, for doctors in distress, which was an early precursor to Ontario's Physician Health Program.

        My wife was reluctant for me to leave family medicine to return to postgraduate training after three years. My father-in-law, a prosperous general practice anesthetist, had invited me to join his practice. The University of Toronto immediately offered me a training position, but I was more attracted to the new Department of Psychiatry at McMaster University in Hamilton, where the emphasis at the time was on family therapy. Inviting Mary to come to an interview with the training director was, in retrospect, a sign of my immaturity because Dr. Nahum Spinner sensed her indecision and suggested that I seek some therapy before deciding to start the program. The stress of changing careers was less obvious to me but a Scottish psychoanalyst in Toronto listened patiently and perceived no problems with my proposed career plan and we determined that I was sufficiently interested to accept the position in Hamilton.

        My first training rotation in psychiatry was on an inpatient service at the Hamilton Psychiatric Hospital with Dr. Paul Cakuls, a friendly and supportive teacher. I enjoyed learning with colleagues and also from our patients. Dr. Paul Grof, a brilliant young Czech psychiatrist, worked on an adjacent ward. He was very interested in the new and exciting lithium treatment for manic-depressive illness. At that time, he was researching the various side effects of lithium dose levels, and unaware of my future, I volunteered to be a research subject. I took lithium under carefully monitored experimental conditions for a few weeks, completed questionnaires on its effects and provided samples of blood and urine for the study. Little did I imagine that lithium might become a lifetime medication for me. 

        My first summer in psychiatry residency was a great experience. I worked hard, read and tried new approaches to working with patients. We purchased a home in Hamilton's Westdale area, and the children attended nursery school. It was fun to meet new neighbors and friends. By winter of that year I began to feel depressed. My wife was unhappy with the move, which strained our relationship and my spirits sank further. I returned to the psychoanalyst I had spoken to about my career change and we began psychotherapy. With each visit, my mood seemed to decline further. I remember in one session recalling my family’s departure from Scotland when I was seven-years-old. I cried as I described my aunts, uncles, grandparents and cousins waving us away tearfully on the dock at Millport, singing, “Will ye' no come back again.” Through my tears, I had the perception that my analyst’s eyes welled with a tear. He prescribed an antidepressant for me, protriptyline, and suggested that I begin to take it.

        Although I felt despondent, it was not easy to accept that I might be clinically depressed. I thought of my symptoms, which were poor sleep, decreased appetite with mild weight loss, plus some hopelessness, as the result of events outside myself. Even years later it has been difficult to accept that the changes in mood might originate from within myself.

        Within three days of starting daily protriptyline, I felt excited, confused and restless. The irritability was out of character for me. I had returned to my Scottish analyst and offered him my perception that my tearful reminiscence of leaving Scotland might have affected him, but that, he responded, had not been the case. And I remember thinking (rather grandiosely for my first year of residency training) and making  a note to myself that I was already as capable as any psychoanalyst. It was a passively aggressive expression of my disappointment with him. Later I came to understand that the antidepressant, protriptyline, had precipitated a sudden, severe change in my mood, within several days of starting treatment for depression. Dr. William E Bunney first described this behavioral switch process in 1970 (Bunney, Murphy, Goodwin and Borge), recognizing that a few patients, most often those with manic depression or bipolar illness, can experience sudden changes into excited, confused manic or mixed states with manic levels of energy while taking antidepressant drugs. This is part of the reason for the black box warning for suicide risk on antidepressant medications now.

        By dawn on Good Friday in 1974 I was already awake, and anxious, unsettled and perplexed. I got up early for a walk while deciding to seek help from my program director at McMaster. I arrived at Dr. Nahum Spinner's office unannounced and knocked at his door. He was in the middle of an interview and when we did speak, I don't recall what was said, but he was kind, recognized my distress and arranged for me to accept an injection of haloperidol, a major tranquilizer, and be transported by ambulance to the Clarke Institute of Psychiatry in Toronto. He must have reasoned that it would be wiser to not admit me to one of the Hamilton-area hospitals where I might work again someday. It was quite a different experience, having a psychiatric illness than going to a hospital for surgery. It was also my formal induction into the shame, guilt and stigma of mental illness.

        Easter weekend in the emergency admitting area and later on the ward at the Clarke Institute of Psychiatry was quiet at first. I did not want to be there but was persuaded to stay. Understandably, my wife was very concerned. My father visited the following morning and we spoke briefly together with the clinical director, a colleague of his. I still wanted to leave following our discussion, but a certificate for involuntary committal was completed, which meant I was to be confined in the hospital, against my own will, until a board of review could hear my appeal. I was back on the unit when I learned about it and I wasn't going to have that.  I became agitated, impatient, angry and tried to leave. A sea of faces dressed in white wrestled me to the floor to inject tranquilizers into my buttocks. And I would not, could not, and did not understand that I needed to be there.

        I fantasized my ordeal as being some sort of initiation into becoming a psychiatrist, similar to being initiated into freemasonry or a college fraternity. The ruminative thinking that beset me would often have a religious undercurrent. I was raised in the Presbyterian Church in Scotland. As children in Millport, we had gone to sing hymns at outside services on the sandy beaches accompanied by a portable pedal organ. In Canada, we attended Sunday School each week and sang in the choir. At times of stress, I found comfort in having faith and imagined briefly a career as a minister. But I felt persecuted, righteous and prayed that I wouldn't lose my mind. I can remember lying in bed in the psychiatric unit, in that chemical haze, trying to make sense about what was happening to me. I wondered what God was trying to teach me. It was Easter and I worried that the hospitalization represented personal humiliation and crucifixion. I recall the pathetic fallacy of disappointment and confinement – as if the stone covering my tomb had not been rolled back on that Easter Sunday. The fantasy brought a small measure of comfort temporarily to my confused state.

        My attending doctor at the Clarke was polite, confident, but aloof initially and his resident seemed distant and unengaging. For my part, there was anger when my freedom was restricted and I was furious to be confined and drugged against my will.

        Medications were the foundation for the beginning of my treatment, but I would look for ways to avoid taking them during my initial hospital stay. I was fearful of the potential side effects and because I wanted to avoid being labeled with a mental illness diagnosis. When the nursing staff might be trusting and inattentive around medication times, I would put the pills in my hand, under my tongue or in my cheek, then later discard them in the toilet because I was appalled and questioned the doses prescribed. Much later it occurred to me that the doses might have been increased because they were not having the expected effect!

        The two-week period of commitment in the hospital passed interminably slowly. It was novel to experience being a patient, learning the rituals associated with mealtimes, medications, meetings and spending long hours interacting with other patients. Until I was more able to contain and manage my anger and disappointment about the situation, I was closely monitored by orderlies who were pleasant and sympathetic but unable to negotiate my release. As I began to appear calm and my behavior was more predictable, the difficult adjustment began. It would take years, including many hours in therapy and years of recovery before I was able to more completely accept and even enjoy the harmless “demons” within myself that I was so terrified to face then. The treatment team recommended that I stay on and get more help, but I was afraid to be vulnerable and demanded my immediate release.

        My poor judgment resulted in a second hospitalization that followed quickly on the heels of the first. Just after being released, stressed by the fragments of my life, the implications of what had happened and muddled by drugs, I was uncertain about returning to the psychiatry residency program at McMaster. I confess that I had reduced the prescribed doses of my medications to about 25% of what the doctors recommended for me in the hospital. Under the stress of not knowing what was next, plus my wife's extreme level of concern, I decided shortly after being discharged from the Clarke Institute that things might improve if I were to take the full dose of the medications, just as had been prescribed. 

        Resuming the recommended doses of antipsychotics, I soon became slow, stiff and markedly despondent. My family doctor referred me to Dr. Art Lesser, a psychiatrist who was a family friend and former colleague of my father. I shared my fears about the hospitalization in Toronto and he was the first professional to also listen to my wife's concerns about the situation. He diagnosed clinical depression and recommended that I reduce the high doses of antipsychotic medication and start on the antidepressant amitriptyline (Elavil).

        Amitriptyline had a similar effect upon me as had occurred with protriptyline weeks earlier. Within days I became more fearful, confused, irritable and didn't sleep much. I experienced great, lengthy bursts of high energy. Without an appointment, I walked miles from my home in Hamilton to see Dr. Carl Moore again in Dundas.  He notified Dr. Lesser, who arranged to meet us at my home. They recognized that I was psychotic and arranged to have me admitted to the psychiatric unit at the Joseph Brant Hospital in nearby Burlington. My wife must have been really upset.

        Committed and admitted involuntarily, for the second time within weeks, I became extremely frightened and endeavored to escape. After the first attempt my clothing was removed but I eloped once more and this time made it to the busy highway nearby. I tried to hitchhike but dressed only in an open hospital gown with no shoes, I failed to hitch a ride. A couple of kindly staff caught up and persuaded me to return. They tried to lock me in a seclusion room when we got back to the hospital. My final resistance was to force the door ajar by using the bed on wheels as a battering ram. A sea of faces restrained me again and held me on the floor to administer injectable medicine. Finally, I slept extremely soundly and for a long time when the sedatives and antipsychotic tranquilizers overtook me. I was so sedated I very nearly died, an observant colleague who was there at the time, later informed me. (In retrospect, this may have been due to malignant hyperthermia, a rare reaction to neuroleptic agents whose mechanism is poorly understood to this day.)

        A day later I awoke laying wet and naked on the linoleum floor in an empty room, on my urine-soaked gown and sheets, too unsteady to stand up alone. I was stiff, shaking and breathing with difficulty, nearly all due to side effects from the drugs which were used to sedate me. It was like being born again. Within a day or so and while I was still in the process of awakening Dr. Paul Grof (the principal investigator of the lithium study I had been a subject in) came to visit with me in the hospital. He suggested that my diagnosis could be a variant of manic depression (now called bipolar affective disorder).  It was on his advice that I again started taking lithium carbonate but as a patient this time instead of a research volunteer. It was a great relief to see him again and his opinion made sense to me. He also suggested to my hospital psychiatrist a gradual reduction of the other drugs, major tranquilizers and anti-depressants and sedatives necessary to calm and sedate me. Quickly thereafter my condition improved substantially. I began to behave more rationally within days and to think more clearly. I was able to relate to other people again. I socialized with the other patients on the floor and remember playing guitar and singing Delta Dawn with them alongside the popular recordings of Tanya Tucker and Helen Reddy at that time. Several of the Joseph Brant nursing staff told me with amazement that they had witnessed my radical transformation and saw me transform into a completely different person – a kind and thoughtful young physician – reminiscent of Dr. Jekyll and Mr. Hyde (Stevenson 1886). It would prove to be more difficult for my wife, Mary, to assimilate the extreme fluctuations in my mood.

        Leaving hospital for the second time in as many months, I needed to make decisions about my future. Should I return to psychiatry residency training or look for another career? I was feeling much better, but my wife remained very concerned. I enjoyed being home with the children while I considered whether or not to return to complete my training in psychiatry. My father listened to my ordeal and we discussed the possible options, but, characteristically, he left the decision making to me. I felt I had made the correct choice to train in psychiatry and that I did not wish to start over in another specialty or return to family medicine. If anything, my experience as a patient only heightened my desire to learn more about psychiatry.

        A week or two following my discharge from the Joseph Brant Hospital my wife and our young children visited her parents to discuss my decision. My father-in-law had offered to have me join his family practice as an associate and take it over eventually, but I had decided to complete training in psychiatry, if the program would have me back. The events of that day were to have profound effects on my life and eventually on the course of my career. When we arrived at Mary's family home her father, whom I had never known to use alcohol, had an opened bottle of gin or vodka on the shelf. Not only was he drinking, the Doctor’s speech was slurred, and he was uncharacteristically garrulous and overly affectionate, much more than usual, with our children.

        I was technically off duty on sick leave, but I wanted to talk with him and try to intervene with him and my mother-in-law. His behavior terrified Mary and she insisted that we leave immediately. I have never forgotten that spring day in 1974. Mary and I drove home with our children and as we entered the house, the phone rang with news that Mary's father had been found dead, in his swimming pool beside an empty vial of Demerol and a syringe. I urged Mary that we return to be with her family, but she adamantly refused. His body was quietly buried the following day, but we did return for a memorial service a few days later.

        I returned to my second year in the training program and relations at home improved gradually toward normalization. Life was good once again, feeling stable, balanced, back in better control. I resolved to do my best to master the knowledge and practice of psychiatry and to prepare for the Royal College of Physicians and Surgeons of Canada specialty examinations. After three more years of residency training, I became a qualified psychiatrist. The announcement that I had passed surprised me, not only because I learned of my success a few days earlier than we expected to find out. I became completely overwhelmed by an intense rush of feelings of relief, apprehension and experienced a full-blown attack of panic that day.

        I was invited to join the faculty at McMaster as a Lecturer in the Department of Psychiatry. My clinical duties included managing the Emergency Psychiatric Service at St. Joseph's hospital, under the guidance and leadership of Dr. Giampiero Bartolucci. I continued my personal and professional interest in family therapy with mentorship from Dr. Nathan Epstein and worked in the Human Sexuality education program with Joyce Asquith, MSW, and Dr. John Lamont. I was also a part-time consultant with the Family Medicine Program. Several small grants were awarded and I began to publish one or two papers.

        My wife was less happy with our situation. I had always hoped that she would develop a career interest of her own. She managed a store when our children began school, but it didn't last. I received a small salary increase and we bought a home in nearby Dundas that had a swimming pool. It was a delightful spot for our children, but the marriage continued to strain. Therapy as a couple produced only temporary improvement but I was determined to persist for the children and felt guilt for disappointing her. Our negotiations about nearly every disagreement resulted in questions about the stability of my mood and whether I was compliant with appointments and medication. Reorganizing my life and practice after my episodes of illness and hospitalization had been difficult. Months were required before I was able to return to function at my best. My wife had been severely shaken by what had happened. My behavior, when I was psychotic, must have been terrifying. She tried to be supportive, but Mary grew increasingly wary of any unpredictability and we disagreed about the intensity of my moods. It seemed to me as if she blamed my illness for problems in our marriage.

        After a couple of years, I felt the need to move to a higher paying position and so my wife and I relocated to her hometown in Ontario. For 10 years there, I worked in and eventually led the psychiatric clinic which had been created through the University of Western Ontario by Dr. Gil Heseltine, Chairman of Psychiatry.

        Following my first hospital episodes in 1974, my wife and I had attended sessions of marriage therapy. I later undertook psychoanalytic treatment with Dr. Johann “Hans” Aufreiter (Naiman 2001), three times a week for nearly five years. The dissatisfaction in my marriage continued.  If I did complain, it seemed that my wife distorted it, as if the issues were related to a symptom of my mood disturbance, which was blamed as the cause of the problems. The analytic process slowly allowed me to appreciate myself more fully. Marriage therapy had been unsuccessful, but Mary agreed to attend analytic sessions with Dr. Friedl Aufreiter, the wife of my analyst. After a few months, she decided she had nothing else to discuss and stopped going.

        I was again briefly hospitalized, a third time, for an episode of psychosis, possibly triggered by fiberglass resin fumes. I had been repairing a windsurfer in our garage. Dr. Paul Grof arranged to admit me to Hamilton Psychiatric Hospital for a few days while it resolved.

        As my analysis progressed my practice was flourishing. I participated in medical organizations and became involved in committee work with the Ontario Medical Association, the Association of General Hospital Psychiatric Units and was eventually elected President of the Ontario Psychiatric Association. I was awarded Fellowship in the American Psychiatric Association, in part for my contribution to rural psychiatry in Ontario and participation in the North of Superior Community Mental Health Program. I also commuted to London, Ontario regularly, per my faculty appointment, to lecture and teach students and trainees.

        More than 20 years had elapsed since I had awkwardly arranged to ask the blessing of Mary's parents to marry her, as I began the third year of medical school. Her parents were pleased and supported the marriage, but I could never be entirely sure that being married to me was what Mary wanted for herself. She was much less surprised and upset than were our two children after I found the courage to tell her in 1989 that I was separating and wanted to divorce. More attempts at professional intervention seemed pointless to both of us. I moved into a spare room while we sought legal assistance to separate. Our children were at college. I planned to relocate, away from her hometown and start over.

        I joined the faculty at the University of Ottawa and moved there for three years where I enjoyed working with Drs. Edgardo Perez, John Rassell and Doug Wilkins. It was also an opportunity to re-connect with Dr. Paul Grof, who was terrific support for me again as he worked nearby, at the Royal Ottawa Hospital. I attended several of his therapeutic workshops based on holotropic breathwork, a supervised experience that helped me transcend and integrate some traumatic experiences. I agonized over the decision to commit to a long-distance relationship I hoped might work. Then, in 1993 I accepted a position at Homewood Health Centre in Guelph, Ontario, to be the consultant psychiatrist on the Homewood Alcohol and Drug Service.

        I had always wondered and gradually persuaded myself that my marriage had contributed to my episodes of mental illness. Somehow, 20 years after my first hospitalization, it seemed to me less necessary to continue taking lithium, my mood-stabilizing medication. I thought that I had been stable for years and I was making a fresh start. Besides that, my episodes of severe psychosis had been chemically triggered. I discussed the idea of stopping lithium with my psychiatrist as we had successfully tried taking closely monitored and seasonally appropriate lithium dose reductions. But I did eventually decide on my own to slowly reduce and stop taking lithium. It was a gamble that made sense to me at that time to put my questions about whether my episodes had been situational and substance-induced to the test. It was a self-imposed experiment whose painful lessons I did not foresee. I doubt that I could have chosen a more difficult time to try being without lithium.

        There was an overwhelming degree of stress in my life then, of which I was not aware. Alongside my recent relocation to a brand-new job, plus the stresses of a fledgling relationship, I would have scored at the top of any scale that measured personal stress. Clearly, in hindsight, it was not the time to interrupt my effective mood-stabilizing treatment. At the heart of it, stopping lithium was much like playing Russian roulette. My mood soon began to change from being confidently energetic and expansive to being less energetic, not sleeping well and having ruminative thoughts and indecision. The relationship failed and my feelings of depression intensified. My new psychiatrist prescribed an antidepressant, one of the newer selective serotonin reuptake inhibitor (SSRI) antidepressant medications which are chemically distinct and might have been safer than the older tricyclic agents (protriptyline and amitriptyline) to which I had reacted so badly 20 years earlier. I started taking the prescribed paroxetine (Paxil) but within days symptoms of psychosis necessitated another hospitalization. I was quickly stabilized on risperidone (Risperdal) and started lithium treatment again. I lived with my middle brother’s family for a few weeks until I was able to resume working. The new relationship, that had ended with my hospitalization, rekindled as I stabilized and was returning to work.

        I had first spoken publicly about my illness, during my term as president, at the Annual Meeting of the Ontario Psychiatric Association. About the same time, I also had the stress of testifying at a murder trial and signing off on the final agreement of my contentious divorce proceedings.

        Although I had restarted lithium my mood slipped low and I became more depressed again. My psychiatrist and I felt that another trial of SSRI antidepressant was warranted, but this time with lithium in place. Within a few days of beginning sertraline (Zoloft) it happened again. Confusion and poor sleep quickly led to my fifth admission to a psychiatric unit to be stabilized. I convalesced at the home of my youngest brother and stayed with my parents for several weeks until I was fit to return to my new job at The Homewood, in Guelph, Ontario.

        I was to about to learn a great deal more about the frequent associations and interactions between substance abuse and mental illness working at The Homewood from my supervisor, Dr. Graeme Cunningham and the late Dr. Peter Mezciems (1994), among others. My role was to provide psychiatric consultations and treatment to patients on the unit treating alcohol and substance use disorders. The experience considerably deepened my understanding of the frequent mixture of substance use with mood disorders. Nearly two-thirds of patients with bipolar illness experience substance abuse issues and my own life was about to improve significantly.

        I had previously seen no clear reason to deny myself the comfort of a glass of wine or a beer now and then because I had always considered myself to be a social drinker. I was raised in a family that celebrated the culture of Southwest Scotland and alcohol use was a daily ritual into which my two brothers and I were slowly initiated after our 16th birthdays. My first real opportunity for unlimited alcohol consumption was on a high school trip to Ottawa – I lost count of the amount of beer I had consumed. I discovered, when it was time to go to the bathroom, that I was completely unable to stand up or balance myself. Crawling, hands and knees on the floor to get to the toilet would frighten most people, I think. But I felt only pleasant bemusement, recognizing that the Glasgow slang term “legless” was appropriately descriptive of my condition. More accurately, what I experienced is described as ataxia caused by potentially fatal alcohol poisoning. What I did not appreciate for many more years was that I had a high tolerance for alcohol, likely genetically determined. I sailed through college and medical school occasionally drinking too much on weekends. I would revel in the Westcoast Scottish accent that I had learned to repress on arriving in Canada.

        Working at The Homewood Addiction Division involved teaching patients – among them were many physicians – to stop using alcohol and drugs. Nobody ever seemed to consider me to have any real problems related to my alcohol use, or to be anything more than a social drinker. But I began to notice that my patients at Homewood were being transformed by abstinence and recovery during their treatment on the Addiction Service. Frequently on admission, often arriving there after a crisis, the majority of patients easily met criteria for major depression. But they usually left treatment much brighter, more optimistic and often with restored family relations – without being started on antidepressant medications.

        On July 4th of 1994, I awakened one beautiful morning on Georgian Bay. It was a long summer weekend to celebrate Canada Day – visiting at a friend’s cottage. I awoke that morning with a headache and the feeling that I had fallen asleep before I had stopped partying the night before – and as was my custom, having a few drinks on such occasions.  I was about to take an Aspirin to temper the consequences of my alcohol use, but my conscience replayed the advice I routinely suggested to my patients at my new job. I also recognized that my fuzzy memory might even be a mild blackout. I made a commitment to myself that day to stop drinking forever and it is remains to this day – it was the last time I consumed alcohol.

        In my late teens I had been a sometime cigarette smoker and continuing to consult at the Addictions Unit I began to obsess about the failure to adequately address tobacco in the program. Dr. Graeme Cunningham, the program director and a fellow Scot, was quite open about his addiction recovery in Alcoholics Anonymous and found the courage one day to question my obsession about patients using tobacco. He wondered whether my behavior resembled that of a “dry drunk,” that is being sober, but without benefit of the peaceful serenity that accompanies recovery from alcohol use. It is the same principle, elaborated further by Johann Hari (2015), that the opposite of addiction is not simply abstinence but is the ability to engage in meaningful healthy connections in with other people.

        I promptly began following the same directions that I was proposing daily to my patients at The Homewood and began to attend “90 meetings of Alcoholics Anonymous in 90 days.” As is typical, it seemed important for me to travel to meetings in a nearby town – to avoid the embarrassment of being recognized, at first! I asked the woman who was chairing the first meeting I attended who might sponsor me and was introduced to her husband Eddie, who agreed to be my sponsor in the program. Eddie taught me how to be peaceful and to enjoy living in the present moment, while we worked together on the 12 Steps of the program. We remained close friends until his death.

        Over the seven years at The Homewood I consulted on the assessment team that evaluated physicians, airline pilots and other professionals for substance use and mental health problems. I was also asked to develop and lead a program for patients at risk for compulsive sexual behavior. Men and women in crisis during treatment would occasionally engage in intense relationships with one another that derailed ongoing group therapy and often resulted in discharge and relapses. Although the sexual addiction program demonstrated success (Wan, Finlayson and Rowles 2000), funding for the program could not be continued. Most addiction treatment programs now provide separate therapy groups for each sex to address their intimate, personal issues. Naturally I was disappointed, but it wasn't long before an opportunity arose to work in the United States.

        I have been fortunate to have had excellent psychiatric care over the years. Dr. Paul Grof originally made my diagnosis and started prescribing lithium treatment for me in 1974. Dr. Emmanuel Persad treated me when I lived in Guelph, Ontario. After moving to Nashville in 2001, Dr. Ron Solomon and Dr. Bill Petrie were very helpful and have continued to prescribe lithium for me in subsequent years.

Part II – What things are like now - in recovery, on lithium

        Dr. Peter Martin became a mentor and friend through our common interests in behavioral addictions (Finlayson, Sealy and Martin 2001) and substance use disorders (Martin and Finlayson 2012). We met at addiction research meetings and he invited me to relocate to Vanderbilt University in Nashville. My children were independent adults by that time and the relocation happened much more smoothly in 2001 than in 1983. I was welcomed to the city and immediately felt supported by my fellowship in Alcoholics Anonymous. In fact, when I crossed the border into the United States immigration officers wanted to know all about me and surprisingly asked me informally and politely about my personal status. They explained that I had been issued a type of US visa that is normally reserved “for individuals with an extraordinary ability in the sciences, education, business, or athletics (not including the arts, motion pictures or television industry).”

        Fellowship in Alcoholics Anonymous provided rooms filled with new friends that helped facilitate my relocation to Nashville. My new and current sponsor, Pete, was a terrific resource and guide who also advised me on business matters. With encouragement and support the Vanderbilt Comprehensive Assessment Program was established, grew slowly and has gradually generated a reputation for evaluating troubled physicians from all over the United States and still sometimes from Canada (Finlayson, Dietrich, Neufeld et al. 2013).

        It has been both a humbling privilege and a fulfilling experience over the years to participate in the assessment and treatment of many hundreds of physicians with substance use issues, psychiatric disorders and behavioral problems that potentially interfered with their ability to practice medicine with reasonable care and safety. I have had the privilege of working with the late Dr. David T. Dodd, the late Dr. Roland Gray and Dr. Michael Baron in their roles as medical directors of the Tennessee Medical Foundation. I have also had the opportunity over the years to work in a variety of clinical treatment settings, including The Homewood, The Center for Professional Excellence and Journey Pure – rehabilitation centers with a special focus on recovery for physicians. I teach at Vanderbilt Medical School and supervise post-graduate trainees. In 2014 I completed a degree in Healthcare Management at Vanderbilt Owen School of Management. In recent years I have been appointed medical director for Vanderbilt Work-Life Connections Employee Assistance Program, for Vanderbilt faculty and physicians. I am grateful to have the opportunity to help others and to repay the care and support that was given to me.

        My ex-wife, Mary, died of cancer before I married again in 2006. It seemed to me and without having planned to do so, that I had found peace in my life and career path following my inability to intervene with her father and perhaps prevent his death on that tragic day in May of 1974, those many years before. After being single for 15 years I met a younger Nashville social worker at an agency where we both were practicing.  After checking with her supervisor that it was appropriate, I invited Diana for dinner and learned that she was planning to adopt a Chinese orphan as a single mother. The opportunity to be part of a family appealed to both of us. I surprised Diana with a diamond ring. We traveled with her mother to China in July of 2006 to adopt Olivia and married afterward, to avoid having to alter her adoption application. Olivia has been warmly welcomed into both our families as an American citizen. It has now been 15 delightful years together.

        Life continues, gratefully I remain healthy and still enjoy working at 75 years of age. I follow the recommendations of my doctors and continue taking lithium and other medications as they are prescribed for me. I look forward to July 4th each year, because I still enjoy pretending that the Independence Day fireworks also celebrate my first day of sobriety!

        Psychiatry had begun to change in the early 1970s. The strong influence of psychoanalysis in North America was waning while biological psychiatry, as we now know it, was just beginning. It was a time of psychological and sociological curiosity; interest in the application of family dynamics and family therapy to mental illness was strong. Family therapy might provide new answers for major psychiatric illnesses like depression, schizophrenia and addiction. While working with families can be beneficial, some of the therapeutic zeal of those early days caused family members to feel responsible for symptoms we now believe to have more complex biological, psychological, social and spiritual (how we interact emotionally with others) causation. Also, it is clearer to me now that my interest in family therapy presaged relationship problems that would culminate in separation and divorce. The times and customs of the 1970s and 1980s were different than they are now. Divorce was more frowned upon and unheard of in my family. There was no Oprah show, by which I mean the movement for self-disclosure, self-discovery, self-healing was in the earliest stages.  I downplayed the emphasis on my mental illness and believed it was quiescent if I attended appointments, took my lithium faithfully and forged on with life – like the “good little soldier” I had been encouraged to be as child in post-war Scotland.

        Denial, pride, shame and fear of stigmatization were all part of my reluctance to look within myself at the outset. There is something more intensely personal about disordered thoughts and the anxious feelings which affect one's internal sense of being, in comparison to the more easily explained reactions to external circumstance or due to an illness that has an understandable cause.

        It seems safe to conclude that one's professional status as a physician offers little protection and can sometimes increase the risk from mental disorders. Experience, knowledge and training don't prevent physicians from denying their problems, just as I did, both around alcohol use and the total acceptance of my diagnosis and treatment with lithium. Substance Use Disorders and Bipolar illness are lifelong illnesses that can relapse and significantly interrupt and disrupt life, work and relationships. Fortunately, many helpful forms of treatment and support are now available. Chronic reliance on substances of abuse rarely ends well, especially if used to mask symptoms of trauma or major mental illness.

        My personal experiences as a patient have made me much more tolerant, more empathic and wiser than I might ever have become. Even during the worst times, I continued to hope and considered it possible that my experiences as a patient might prove to be an advantage. I recall being attracted to the early thoughts of R.D. Laing, who saw severe mental illness as a transformational experience.

        As a result of my illness, I can more readily identify and appreciate the hopelessness, fear, shame, grandiosity and other emotional states which occur in my patients. I had considered studying theology in my teenage years, so the coincidence of Easter with my first hospital stay inflamed fantasies of betrayal, crucifixion and despair but not without hope for resurrection or rebirth. Invariably, my colleagues in psychiatry have been sympathetic, they understood and supported me and my struggles with the illness and provided encouragement when I was well.

        I was fortunate to have been raised in a strong family and to have two younger brothers with whom I remain close, many years following the deaths of our parents. Unbeknownst to me at the time, some bipolar illness had been present in our extended family, long before my first episode. One grandmother had several episodes of abnormally elevated mood beginning when she was more than 60 years of age. Tales handed down in the family suggest that others may have had similar difficulties. One of my aunts developed mood swings beginning at the age of 40, another aunt had been treated for recurrent depressions. My family participated in a genetics research study on bipolar illness (Duffy, Alda, Kutcher et al. 2002) at the Royal Ottawa Hospital. Hopefully, such research into diagnosis and treatment will reduce similar suffering for others.

        I had no idea previously that I was using alcohol to feel normal in social settings nor that I would begin to feel so much better by simply not using alcohol, until after I had stopped for a few months. “High-bottom drunks” like me are welcomed in AA, because the only requirement to join is a desire to stop drinking. As I began to focus more upon the similarities between myself and other alcoholics and less upon the differences between us, I began to better understand and appreciate how alcohol use had affected my life, my relationships, and my career. Working the 12 Steps with a sponsor, which means working the AA program – in contrast to just attending meetings – has been a remarkably freeing experience. Based on research in psychotherapy (Patterson 1984) and recent scientific validation of the effectiveness of Alcoholics Anonymous (Kelly JF, Humphreys K, Ferri 2020) plus personal experience, I often recommend the program of AA to my patients as cost-effective psychotherapy.

Some thoughts about lithium

        Along with hydrogen and helium, lithium was one of the three elements produced in large quantities by the Big Bang. Lithium is the least solid chemical element, one of the alkali metals; on the Period Table it has the symbol Li and the atomic number 3. The name lithium comes from the Greek word lithos for stone. It was first used medically in the 2nd century AD by the ancient physician Soranus in Ephesus (Purse 2020), who discovered that the waters in his town, which were alkaline due to high levels of lithium, could be used as a treatment for both mania and depression.  Johan August Arfvedson, a Swedish chemist, isolated lithium in ore from a Swedish iron mine in 1817 and in 1818 elemental lithium was isolated using electrolysis by William Thomas Brande and Sir Humphry. However, it was John Cade, an Australian doctor, who first discovered the role of lithium in controlling bipolar symptoms. Current information on treatment with lithium may be found in the succinct and easily read, clinical guide (Tondo, Alda, Bauer et al. 2019) for lithium use prepared for the International Group for Studies of Lithium. I recommend it as both an excellent review for prescribers and a valuable information source for patients and their families.

        The healing properties of lithium have been extolled for centuries. Bathing in Lithia Springs attracted American pilgrimages to bathe in lithium-rich alkaline waters in Virginia and Georgia – in spas that were recommended by physicians as far away as France to ameliorate symptoms of excessive uric acid and gout. Various carbonated sparkling water solutions of lithium salts included: Buffalo Lithia Water, Londonderry Lithia Water, White Rock Sparkling Water. Early versions of 7Up were promoted and advertised for improving health. Lithium chloride became a popular sodium chloride/table salt substitute for the dietary treatment of heart failure and high blood pressure until its toxicity was recognized Waldron in 1949.

        Lithium occasionally interferes with the functioning of the thyroid gland, which is located at the base of the neck, just above the sternum. My thyroid test results were always fine until an unusual mass on my chest X-ray 10 years ago was biopsied and found to be a goiter growing down into the middle of my chest. It could have been something much more serious. Thyroid cancer cells were found – a common finding in older people – so my thyroid gland was completely removed and I have taken replacement medicine since then.

        Doctors have been concerned about the effects of lithium on the kidneys and on the heart. There is no question that excessive intake may result in permanent renal damage or death. There is evidence that renal complications occur more frequently in the presence of other illnesses like high blood pressure and diabetes which are known to interfere with the normal supply of blood to the kidneys. Careful monitoring of my lithium dosing with periodic blood level checks and regular checkups minimized the risk of these side effects for me but inheriting the good health and longevity of my ancestors undoubtedly played a major role.

        One of the ironies about lithium is that taking too much of it can be fatal. It is crucial that patients are educated about the importance of maintaining adequate hydration and electrolyte balance to avoid possible toxic effects. Taking more than the prescribed dosage is extremely dangerous. I have felt profoundly depressed and at times briefly hopeless, yet never have I entertained thoughts about suicide or planned to end my existence. Lithium is superior to other medicines in preventing suicide. In areas where increased levels of lithium are found in the groundwater, suicide may occur less frequently. The best outcomes result when treatment with lithium is part of a long-term, well-functioning relationship between the doctor, or lithium clinic, and the patient.

        My response to lithium treatment in 1974 was dramatic, but complete acceptance of my diagnosis and the need to continue taking lithium to prevent future episodes, took considerably longer. It was difficult for me to believe that I had a mood disorder and far easier to attribute my symptoms to the antidepressants and untoward external circumstances. I remained in the care of Dr. Paul Grof for many years. He was very supportive, patient and understanding. He negotiated treatment with me, adjusting lithium dose reductions during seasons of low risk, and to boost my mood on long dark Canadian winter nights he suggested light therapy – treatment that is no longer necessary living in the South. He often shared his research ideas, treating me like a colleague. That was a significant boost to my self-confidence, which was always shaken by my psychotic episodes.

        I have remained on lithium prophylaxis continuously since 1993 and am convinced that using alcohol even at social levels contributed to poor sleep and mood instability in my case. Occasionally, I have shared parts of my story in my teaching role and sometimes with patients. Lithium has been like a “silver bullet” in my life but successful psychiatric treatment requires multiple biological, psychological, social and, yes, spiritual (the search for meaning) interventions. Bipolar illness is frequently associated with substance use disorders and with a history of adverse childhood experiences. Dr. Vincent Felitti (2003) and others have suggested that addiction be redefined, based upon his large studies relating adverse events during childhood (ACEs) with many illnesses among the Kaiser Permanente patient population.

        I have not had many side-effect issues and prefer to think of lithium as a mood-stabilizing salt rather than a psychoactive substance. It occurs naturally in the body where it interacts with other chemicals around and within the membranes of our cells. When calibrated to the range of therapeutic concentration it seems to prevent the drastic mood alterations of manic-depressive bipolar disease. It is the single most effective preventive treatment for suicide. Even the presence of lithium in groundwater may reduce rates of suicide.

        Most of us prefer to tolerate and even prefer the expansiveness, mood elevation, energy and the increase in goal-directed activity of hypomania to the dragged down feelings of sadness, low energy and social withdrawal of depressive episodes. For some, the boring sense of near normalcy seems less attractive compared to the grandiose chaos of a manic episode. I have had difficulty persuading several rapidly cycling patients of mine to stop taking the antidepressants which are destabilizing them. The high can be like an addiction. Some patients, on the surface at least, appear to prefer continued chaos over the challenge of accepting life on life's own terms. Facing reality, often necessitates increased levels of care, and considerable support in the early phases as we explore and accept the overwhelming trauma-based fears, guilt and shame, that often rebound when the anesthesia of mood-altering substances, or behaviors ends.

        My ordeals have deepened my understanding of the associations and interplay between alcohol, drugs and psychiatric disorders, and to personally address the issue of stigmatization. I have seen both sides of patient coercion, restraint, isolation. I know what it is like to be without  judgment, reason and emotional control. But I did not lose my mind, my spirit or my soul. Experience has repeatedly taught me that the most powerful enemy is my own fear. But most importantly, I realize that love and understanding are the most powerful treatments available – for without them, nothing else really works.

 

References:

Bunney WE Jr, Murphy DL, Goodwin FK, Borge GF. The Switch Process from Depression to mania: Relationships to Drugs Which Alter Brain Amines. Lancet. 1970; 1(7655):1022-7.

Duffy A, Alda M, Kutcher S, Cavazzoni P, Robertson C, Grof E, Grof P. A prospective study of the offspring of bipolar parents responsive and nonresponsive to lithium treatment. J Clin Psychiatry. 2002; 63(12):1171-8.

Felitti VJ. English version of German article: Felitti VJ. Ursprünge des Suchtverhaltens – Evidenzen aus einer Studie zu belastenden. Kindheitserfahrungen. Praxis der Kinderpsychologie und Kinderpsychiatrie, 2003; 52:547-59.

Finlayson AJR, Sealy J, Martin PR. The Differential Diagnosis of Problematic Hypersexuality. Sexual Addiction & Compulsivity, 2001; 8:241-51.

Finlayson AJR, Dietrich MS, Neufeld R, Roback H, Martin PR. Restoring Professionalism: the physician fitness-for-duty evaluation. Gen Hosp Psychiatry. 2013; 35(6):659–63.

Hari J. Chasing the Scream: The first and last days of the war on drugs. Bloomsbury, London, 2015

Kelly JF, Humphreys K, Ferri M. Alcoholics Anonymous and other 12‐step programs for alcohol use disorder. Cochrane Database Syst Rev. 2020; 3:CD012880.

Martin P, Finlayson AJR. Pharmacopsychosocial Treatment of Opioid Dependence: Harm Reduction, Palliation, or Simply Good Medical Practice? Dusunen Adam: The Journal of Psychiatry and Neurological Sciences. 2012; 25:1-7.

Mezciems PE, Cunningham GM. Treatment of alcoholism. CMAJ. 1994; 150(9):1383–4.

McFarlane RM, Laird JJ, Lamon R, Finlayson AJ, Johnson R. Evaluation of Dextran and DMSO To Prevent Necrosis in Experimental Pedicle Flaps. Plast Reconstr Surg. 1968; 41(1):64-70.

Naiman J. In Memoriam: Johann Aufreiter 1916-2001. Canadian Journal of Psychoanalysis; Montréal, 2001; 9(1): 117-8.

Patterson CH. Empathy, warmth, and genuineness in psychotherapy: A review of reviews. Psychotherapy, 1984; 21(4):431–8.

Purse M. The Discovery and History of Lithium as a Mood Stabilizer. www.verywellmind.com. 2020

Stevenson RL. Strange Case of Dr. Jekyll and Mr. Hyde. Longman. 1886.

Tondo L, Alda M, Bauer, Bergink V, Grof P, Hajek, Lewitka U, Licht RW, Manchia M, Müller‑Oerlinghausen B, Nielsen RE, Selo M, Simhandl C, Baldessarini RJ, International Group for Studies of Lithium (IGSLi). Clinical use of lithium salts: guide for users and prescribers. Int J Bipolar Disord, 2019; 7(1):16.

Waldron AM. Lithium intoxication occurring with the use of a table salt substitute in the low sodium dietary treatment of hypertension and congestive heart failure. Univ Hosp Bull. 1949; 15(2):9.

Wan WM, Finlayson R, Rowles A. Sexual Dependency Treatment Outcome Study. Sexual Addiction & Compulsivity, 2000; 7(3)177-96.

 

October 8, 2020