Do you see patients who have no motivation to do anything? Michael Posternak has a novel strategy for working with this depressive symptom during the medication visit in this special tribute to the late psychiatrist.

Published On: 07/31/2023

Duration: 23 minutes, 07 seconds

Transcript:

CHRIS AIKEN: This month, we lost a true brother in the Carlat family. Michael Posternak was a frequent contributor to the journal, and he passed unexpectedly on July 3 2023. He worked up until the very end, turning in his final piece on binge eating disorder a few days before he died. He leaves behind two children, a loving extended family, and a private practice filled with patients whose lives were changed by his work.

Mike began his career in academics, working alongside Mark Zimmerman at Brown University School of Medicine. I knew of his work back then, because even from that Ivory Tower he was producing papers that were relevant to everyday practice. He was the first to show that antidepressants begin to separate from placebo by week 2 – not after 4 weeks like conventional wisdom would have us believe. Later, when the maker of Trintellix tried to use this feat to claim they had a faster onset, Mike brought them down a notch. 

One paper he published in 2005 was unforgettable. The title was pure Posternak, “Why isn't bupropion the most frequently prescribed antidepressant?” Not the kind of title we’re used to seeing in an academic time like the Journal of Clinical Psychiatry. But Michael had a passionate voice, and a keen eye for where psychiatry was doing a disservice to their patients, in this case by using SSRIs first line - medications that caused apathy, sexual dysfunction, sleep problems, weight gain, and a terrible withdrawal syndrome instead of bupropion which caused none of these. Why? He suspected it was marketing, and the myth that serotonin calmed anxiety while bupropion did the opposite. This, he showed us in that paper, was a misunderstanding, the type that comes about when we mistake “anxiety disorders” with anxiety as a symptom, conflating those concepts by their linguistic similarity even though they have little scientific overlap.

SSRIs do treat anxiety disorders – which, perhaps, are better titled phobic disorders – and bupropion does not. But when it comes to the more common kind of anxiety we see in everyday practice – anxiety as a feature of depression – nowadays called the anxious distress specifier – bupropion works just as well as the SSRIs, based on several large head-to-head trials. Mike uncovered other misunderstandings about bupropion – that it causes seizures, insomnia, and triggers anxiety – all of this is true, but it does so just as often as the SSRIs, and unlike the SSRIs it improves sleep quality.

His paper changed my practice, and was the basis of my first podcast – one I did for Psychiatric Times. But Mike and I did not always agree, and that’s something I’ll miss about him. 

Shortly before I became editor he wrote a Carlat piece advocating for more liberal use of benzodiazepines in psychiatry. I took the counter point, as I thought we were entering more dangerous times with the benzo-opioid interaction becoming more widespread. We debated late into the night, but it made us both better doctors, and I often assigned him pieces where I knew he would take a different view, and it added balance to the journal. He wrote our first pieces on Spravato, esketamine, where he favored the rapid-acting antidepressant. He wrote on adult-onset ADHD; he covered the cognitive benefits of Trintellix, and most recently Trichotillomania and a piece this summer where he argued that combining two antidepressants rarely – if ever – works better than one. 

Mike was no ordinary doctor – in fact he started out as a behavioral technician in psychiatric hospitals, and that grounding in the patient experience is something he brings to the podcast you’re about to hear. We recorded it in November 2020, and it’s one of my favorites. Mike takes a problem we see every day – depressed patients who have no motivation to do anything – and comes up with a solution that speaks to the paradoxical web of self-defeat that is depression. He knew the illness well, and his wisdom changed my practice.  

KELLIE NEWSOME: Where do you start when patients have no motivation to do anything? Michael Posternak has an answer in this first installment of our winter series on combining medication with psychotherapy.

CHRIS AIKEN: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report.

KELLE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

In this month’s Carlat Report we feature an interview with Donna Sudak, a psychiatrist and psychotherapist who has written a book on how to integrate CBT into the med visit. The interview really lit up our editorial board, and after reading it they’ve all been sharing ideas for how to do this kind of work. Michael Posternak thought of one that has changed my practice. He doesn’t try to get patients to do more, but to do less. Here’s what he said….

[Dr. Posternak Audio]

CHRIS AIKEN: Michael’s idea – to accomplish just one thing a day but to do it consistently – is well suited to the psychology of depression, and to the way the brain works. The brain needs positive experiences to get out of depression, but the brain doesn’t care if you climb a mountain or clean out a desk drawer – there’s only so much dopamine that can fire in there. What matters is doing something consistently, and that’s what is missing in depression. They get started on a project, and then get overwhelmed with thoughts and ruminations – “I’ll never finish this, I have so much more to do, It’s not even worth it anyway” and give up. When it comes to treating depression, better to clean out one drawer in your kitchen each day consistently then to climb a mountain once a month.

KELLIE NEWSOME: Yes Michael’s idea really helps patients stay focused on the consistency, and he’s trying to boost up the reward by having them spend more time appreciating their success. People with depression are quick to move away from that. You know, patients will often come in bent on telling me about how awful everything is and how much of a failure they are, and I’ll try to turn that around and ask, “I get that, now tell me the other side, what’s one thing you accomplished this week, one thing that went well for you?” If they do think of something, they’ll quickly dismiss it. They’ll talk about their success as if they had no role in it, like it was just something that happened to them rather than something they accomplished. And they’ll discount their accomplishments with the old “yes, but;” as in “The plumbing broke in my bathroom, and I got it fixed but it was just a disaster and it ruined my whole week.” 

CHRIS AIKEN: That sounds like a certain thought style we see in depression – rumination. It’s a cycle of negative thinking that never gets anywhere. It often plays out like an argument – the depressed patient will try to cheer themselves up by focusing on something positive, then they’ll discount it with “yes, but;” and it just goes back and forth. The endless, unproductive cycle of rumination is demoralizing – it’s depressing in itself. There’s a version of CBT for rumination that Edward Watkins developed that uses this kind of behavioral activation to help patients break out of the cycle of ruminative thoughts. 

KELLIE NEWSOME: Yes we interviewed Dr. Waktins in our June 2018 issue – it has a lot of good tips for working with depression. 

CHRIS AIKEN: One cause of rumination is perfectionistic, compulsive tendencies and the kind of all-or-nothing thinking that goes along with that. Bear with me a minute, because I’m going to describe a patient who is the opposite of your prototypical depressed patient. This is someone who does too much, rather than too little, but the solution is the same and it brings us back to Dr. Posternak’s idea. You see, one cause of rumination is trying to do more than you can. You’ll see this in patients with compulsive, perfectionistic tendencies. They spend their entire lives trying to multitask and squeeze more into an hour than they are capable of doing. They drive themselves like a harsh coach, and the inner dialogue is constantly critical – oh why didn’t you do more?!? It’s 2 o’clock and you’ve accomplished so little. If you hadn’t of gotten so caught up in that useless youtube video you’d have that presentation for work finished by now.”

KELLIE NEWSOME: It’s like that expression, “There’s always room for one more,” but it gets turned on you. You spend your whole life thinking you could have accomplished more than you did.

CHRIS AIKEN: Yes, and Dr. Watkin’s theory is that this constant stream of negativity builds up into a full depression. So to turn things around in these patients, he has them practice the art of doing one thing at a time, and actually scheduling more time to complete things than they need, so they can enjoy the ride and get it done.

KELLIE NEWSOME: I’ll bet that’s not easy. A lot of these patients are tied to the workhorse of trying to do more than they can. It’s like an addiction.

CHRIS AIKEN: Yes you have to rearrange the goal posts for these patients. The goal here is to treat the depression, not work 8 days a week.

KELLIE NEWSOME: This is interesting because it suggests that it’s not just what patients do that matters, but how they experience it. So you’re saying that someone could be active, accomplishing things all the time, and it could still be a set up for depression if their over-arching experience of all that activity is negative.

CHRIS AIKEN: Yes. That’s why some people argue that behavioral activation is not a purely behavioral therapy. You’re not just trying to get patients to do more – you’re trying to change their experience of it so they can reconnect with what is rewarding in their daily life. That’s what Dr. Posternak is doing here. He’s knows it’s not about a numbers game, like “OK now you’ve succeeded at 1 thing, let’s move on to 2, and then 3.” He’s not just trying to fill up a calendar with activity scheduling. He’s trying to help people change the experience of what they do.

KELLIE NEWSOME: You know, I’ve found this kind of behavioral activation works particularly well when patients start transcranial magnetic stimulation, TMS. You see, TMS is a big investment of time and money. It can cost $1-2,000 just in copays, and the patient has to drive in to the office 5 days a week to get it. So when patients take it on, they have a lot at stake, and here’s what I tell them. “There’s evidence that TMS works better if you do something active before each session. So go out and walk in the woods for an hour before you get the treatment. And, like Michael said, we have to settle on a time and place for that walk. Normally, it’s hard to get patients to do that kind of thing, but there’s a lot at stake when they are starting TMS. I mean, when they’re investing all that time and money into it, they have a little more motivation to make sure that it works.

CHRIS AIKEN: You know there’s more truth to what you saying than you might imagine.

KELLIE NEWSOME: What do you mean?

CHRIS AIKEN: Well, of course patients are going to get more out of their treatment – whether it’s antidepressant medication or TMS – if they combine it with behavioral activation. But there is also research showing that TMS works better when patients are experiencing positive thoughts, rather than negative ones, while the magnetic is running. 

KELLIE NEWSOME: Wow that sounds interesting – I mean we know this about the oldest psychotropic medication in the book – alcohol. Alcohol has different effects on mood, depending on whether you’re alone or with people, happy or sad, when you drink. So why not TMS. 

CHRIS AIKEN: We’ll get into that TMS research more at a later time. But now it’s time for the word of the day….

KELLIE NEWSOME: Wait that’s my line. And now for the word of the day… Delirium mussitans

CHRIS AIKEN: Mussitans is the Latin word for muttering, and Delirium mussitans is a severe form of delirium where the patient mutters with repetitive, slurred, non-sensical speech. It’s also called “muttering delirium.” Movements are reduced to tossing and turning, trembling, and muscle twitches. Like any delirium, it is typically caused by medical illness, and it’s often described as part of Typhoid fever, where it’s sometimes called the typhoid state. Here patients pick at their bedclothes and at imaginary objects. In Shakepeare’s Henry the Fifth a tavern hostess describes Falstaff’s last moments before he died, and how he babbled, fumbled with his sheets, and played with imaginary flowers with his fingers….. it’s an apt description of delirium mussitans:

“He parted even just between twelve and one, even at the turning o' the tide: for after I saw him fumble with the sheets and play with flowers and smile upon his fingers' ends, I knew there was but one way; for his nose was as sharp as a pen, and a' babbled of green fields.”

Thank you to Anna Jane Rogers for her reading from Henry the Fifth

Click on the link in the episode notes to earn CME for this podcast. There’s only two questions, and we think you can get them. Here’s the first one:

1. TRUE or FALSE In Dr. Posternak’s view, patients are more likely to stick with behavioral assignments when they are accountable to someone else, as long as that person is not the psychiatrist. Using the psychiatrist to hold patients accountable fosters dependency and distorts the therapeutic relationship.

CHRIS AIKEN: We close not with a study of the day, but with another loss. Sinéad O'Connor died at the age of 56. The cause of her death is still unknown, but so is force that drove her life. Sinéad broke boundaries at every step, and she was dismissed as having mental illness with every boundary she broke. But if refusing to conform to the hair style of your assigned gender is mental illness; we have a long way to go. If calling out the Pope on Saturday Night Live for covering up child sexual abuse is mental illness; we have a long way to go. If refusing to sing the national anthem because you disagree with the war in the Middle East is mental illness; we have a long way to go.

 Sinéad did seek psychiatric help throughout her life, and was variously diagnosed with bipolar II, complex PTSD, and hormonal dysregulation, all diagnoses that she variously agreed with and variously refuted. But – as we’ll learn in an upcoming episode - it’s not the patient that fails when our diagnosis or treatment doesn’t fit– it is us. Thank you Michael, and thank you Sinéad, for bringing us a little further along in our journey; we still have a long way to go.

KELLIE NEWSOME: Next week we pick up again with updates from the international bipolar conference, where we run into Robert Post, former chief of the National Institutes of Mental Health, and learn which are his top 3 meds for bipolar disorder. Got questions? Got ideas? Write us at asktheeditor@thecarlatreport.com, and thank you for being part of the Carlat family.

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The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.