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For more information, contact:

Duncan McEwen, MD

3308 Durham-Chapel Hill Boulevard, Suite 131
Durham, NC 27707
Telephone: (919) 810-3536

Pushing Psychiatry Towards Balance

“Two things come to mind, when I consider the word ‘balance’ as it relates to mental health,” says Durham psychiatrist Dr. Duncan McEwen. “Balance—as it applies to the patient; and balance as it applies to psychiatry.

Dr. McEwen hails from Boston,
but attended Duke University
as an undergraduate and
then attended Tulane Medical School. He completed his psychiatric residency at
the University of North
Carolina in 1986, and has
been practicing in the
Triangle area ever since.
Over the years he has
 worked in both the
private and public
sectors with a special
interest in treating
mood disorders, substance
abuse, and ADD, and is
certified by the American
Society of Addiction Medicine

“For each of us, achieving ‘balance’ in our lives is not a matter of avoiding symptoms, rather it’s about handling those symptoms with poise—viewing problems as a challenge rather than an affront. In fact, it would be more accurate to talk about balancing. It’s really an active state, not a static condition. Life often throws hurdles at us.

“As I work with patients to help them develop these ‘balancing’ skills,” he continues, “I am increasingly convinced of the importance of balance in psychiatric practice. Patients aren’t just a collection of symptoms—they’re human beings, with stories that are often more important than their symptoms. Treatment should recognize and address all the factors influencing the patient—biological, social, and developmental. Practicing from this multiple perspective is what I mean by ‘balanced’ psychiatry.

Health&Healing: How do you practice “balanced psychiatry”?

Dr. McEwen: Any treatment approach should take into account the multiple factors influencing a patient’s health. But it’s more than that. I would argue that we need to integrate those same components—biological, psychological, and sociological—in our treatment methods.

Going back to the influence of Freud, early psychiatric treatment was essentially a psychological model; we simply didn’t have biological tools to help people. Beginning in the ’70s and ’80s, with the development of psychotropic medications—such as Prozac—treatment moved to a biological, medical model; so much so that psychiatry almost forgot its humanistic roots. And while that’s not entirely true,it reflects a too-common imbalance in psychiatric practice.

In my early training, we used to talk about a bio-psycho-social model of mental health—emphasizing biological, psychological, and sociological components. Each component matters. And, today, I see an exciting trend toward just such a balanced approach. A good example of this is ketamine—the novel, rapid-acting antidepressant.

H&H: How does ketamine factor in?

Dr. McEwen: Ketamine is an exciting—and, I think, very promising—new tool for the treatment of depression. It’s a small molecule that’s been used as a light anesthetic for years. It’s a very safe drug and can be dosed in a way that the patient maintains consciousness. Used in low doses, it doesn’t anesthetize a patient but makes them more open to psychological treatments. And, at the same time, works on the biological level as a rapid-acting antidepressant.

That’s the balance I referred to: a medication that works on both the biological (antidepressant) and psychological (opening up) levels.

H&H: How do you use ketamine in your practice?

Dr. McEwen: Medication is a very important tool in my practice—but certainly not the only one. It’s most helpful when medications enable the patient to engage with a counselor. But until you can get the patient’s attention directed outward, you’ll make little progress with counseling. That’s often where medications come in. And ketamine—because it works on both the psychological and physical levels—is especially effective.

I’ll give you an example that illustrates this approach. I remember, years ago, listening to one of my professors treat a patient with anxiety, where the kid had agoraphobia that made it hard for him to sit in classes. And so the doctor said to the patient, “You’re in class, you’re listening to your inside. Why don’t you just focus on the teacher?”

As it turns out this simple statement is very profound. Recent studies on brain function have shown that when you “listen to the teacher,” you are activating your attentional networks which in turn suppresses the default mode network.

H&H: What do you mean by these different brain networks?

Dr. McEwen: These are terms that stem from exciting studies coming from functional MRI—a technique that came of age in the early 2000s—that allows us to understand how areas of the brain connect in different emotional and cognitive states.

The “default mode network” is a network of interacting brain regions that seems to correlate with self-preoccupation. If you’re in pain and preoccupied with that pain, the default mode network is active. But when you’re distracted, attentional networks quiet down the default mode network by activating other areas of the brain. Thus, your subjective level of distress decreases, simply by finding a way not to let internal unpleasant signals capture you.

And that takes us back to ketamine: what ketamine does is transfer the balance in a patient’s mind—making them less self-preoccupied with pain, and more centered in the world around them.

Typically, I’ll prescribe ketamine twice a week for three or four sessions until there’s a sense of robustly lifting out of the depression. Then we’ll get the patient back into counseling and watch how things are going. We’re very careful to individualize the therapy to each patient’s experience, however, as people are different.

Ketamine treatment is a gentle experience and interesting at the same time. I saw a patient who was suffering from physical pain, who described her ketamine experience as: “It feels like the pain is outside my head, no longer inside.” And, when I asked if that was helpful, she responded: “Yes; I feel detached from it in a constructive way.” So, I advised her to take that “experience of detachment” back to her counselor and explore it.