Clinical examples of restoration
Rather than try to explicate the concept of restoration, it may be more useful to illustrate it with several examples from my clinical work with mood disorder patients. I have a score of men in whom bipolar illness was diagnosed in their 20s; who were hospitalized repeatedly; and who had multiple suicide attempts, legal troubles, and failed marriages stemming from inadequate treatment and nonadherence. Once these patients were able to work through the obstacles of finding competent care and their own internal barriers to accepting the diagnosis of a chronic disorder and consequent need for lifelong medication, their lives gradually but steadily transformed.
Most of these men are now not only symptom-free but disorder-free. Many of them work full- or part-time, and those who are retired or on a pension are volunteering, traveling, and raising children and grandchildren. They are phenomenally stable on modest but therapeutic levels of lithium(Drug information on lithium), valproate(Drug information on valproate), and perhaps small doses of adjunctive benzodiazepinesand atypical antipsychotics. I see them 2 or 3 times a year for checkups and I can seldom find even mild swings of the mood pendulum.
Most of these patients have painful memories of their active illness, yet other than having to take pills with the prosaic daily rituals of breakfast and sleep, their Axis I diagnosis has little effect on their lives, self-images, plans, or dreams. They will all readily admit that they may be in a different place socially and economically than they would have been had they not had bipolar disorder; but most are at peace with their genetic legacy and enjoy their quality of life.
To a patient, they attribute their stability and fulfillment (restoration, if you will) to their mood stabilizers. The only intense emotional reactions I have seen from these patients is when they are afraid that their trusted medication regimens might be altered. As one patient told me at his initial visit, I always am anxious about seeing a new doctor because I am afraid they will feel they have to change my medicines to prove themselves. I know what has kept me out of the hospital and I don’t want to fix what is not broken.
A coalition of interventions
At this point, many readers may be rightly wondering if I am a biological reductionist. Far from it: the benefits of neurogenesis are only possible if patients commit to the messages in the bottle, and only psychosocial therapies can foster and sustain such a commitment. It is psychotherapy that enables patients to integrate their illness into their identity and reconcile the losses and traumas it has wrought. It is psychoeducation and case management that teach patients and families early on about the signs of relapse and the triggers of episodes and how to manage side effects; it is supportive employment and consumer groups that help patients develop lifestyles and relationships that enable them to integrate into the community, overcome stigma, and follow the path to recovery.
This coalition of interventions is what Noordsy and colleagues,11 in a pioneering paper on redefining the goals of antipsychotic treatment, call recovery-oriented psychopharmacology. Rather than widening the mind/brain split, restoration offers a synthesizing consilience of Luhrmans’ dialectic characterizing a profession divided and divisive over the use of psychopharmacology and psychotherapy.12 This synthesis is a spiritual one, not in a theological sense, but in a transcendent sense. Restoration is more than the sum of any parts of symptom remission or return to functioning or even recovery of original homeostasis. Restoration is a process of growth and healing from neuron to mind to soul or spirit that is holistic in nature and iterative in process and that encompasses the healing of damage from cell to self.
For years, psychiatrists have had a fortress mentality, and have been on the defensive against substance use, noncompliance, and the recurrent nature of affective illness. Our victories of Hamilton Depression Rating Scale response and remission with residual symptoms often seemed Pyrrhic and transient until the next relapse. We watched in frustration and shame while too many patients spiraled into disability payments, group homes, and revolving- door admissions; too few achieved mere remission.
The reality of recovery and the realistic hope of restoration transform psychiatry into what Kupfer,13 in a different context, deemed the mission of therapeutics. This mission involves a vigorous dedication to early diagnosis and intervention of serious mental illness; aggressive treatment with all the neurogenic therapeutic modalities, including psychotherapy, of every patient with an affective disorder; and the professional commitment to an ethic that we will accept nothing less than recovery and ultimately restoration for each patient.
These are the strengths of the mission. Are there limitations? Of course, as with any vision it is a long translational road from bench to examining room; there are enormous economic and policy problems to resolve if we are to have adequate funding for such an ambitious project; psychiatric education will need to undergo a minor revolution if medical students and residents are to embrace the new activist and activated face of psychiatry; and ethical questions regarding the place of pharmaceutical companies, primary prevention, and outpatient commitment must be resolved. We really have no choice, though, except to go forward—because once we found that BDNF could reverse the effects of forced swimming, and treatments already in our possession could generate new neurons, morally, everything has changed.
Dr Geppert is chief of consultation-liaison psychiatry and chief ethics consultant at New Mexico Veterans Affairs Health Care System in Albuquerque. She is also assistant professor in the department of psychiatry and associate director of religious studies at the University of New Mexico in Albuquerque.