Getting Past the “Shotgun” Approach to Treating Mental Illness

We treat depression by trying different drugs until we find one that works—a highly imprecise approach to treating the most sophisticated of organs, the brain.

Alexia had been in-and-out of intensive psychiatric therapy for nearly two decades by the time we met. She suffered from bipolar disorder, which meant that she cycled between explosions of boundless energy and black holes of suicidal despair. Despair brought her to our unit.

Her long chart chronicled how previous psychiatrists had emptied the armory: antidepressants, antipsychotics, anticonvulsants, mood stabilizers, group and intensive inpatient therapy, psychotherapy, dialectic and cognitive behavioral therapy. Nothing had a lasting effect.

What struck me was the shotgun approach: try everything. Her medications spanned the molecular gamut: some stopped the disposal of the neurotransmitter serotonin, allowing more to be present in the brain; some focused on norepinephrine; others blocked the action of dopamine; yet others had an unknown target but had proven helpful to some patients. The imprecise approach to treating this most sophisticated of organs, the brain, seemed odd.

I was a third year medical student at the time and was asked to speak with her, design a treatment plan, and present it to the team later in the day.

We met in a small room with Ikea furniture. Alexia wore a loose black t-shirt and grey sweat pants with faded pink hospital socks—the ones with traction padding. I was stiff with naiveté. She seemed entirely limp. She moved and spoke slowly, as if each whisper betrayed some tragic secret.

She shared a story consistent with what I’d read in her chart. She hadn’t been affected by the profound forgetfulness characteristic of severe depression. To my surprise, beneath her cloud of depression, she was sharp and lucid and witty.  An intelligent woman who enjoyed literature. She painted.

It was clear she suffered deeply. Her pain, torment incarnate. But beyond literary descriptors, what was going on in her brain and how could we treat it was unclear.