Interviewed by Mark Gold, MD
FEATURED ADDICTION EXPERT:
David Baron, MS.Ed, DO
Professor at Western University School Of Medicine, and formerly USC Professor
Can you share your own personal story of training for the Olympics and resilience?
Resilience can be broadly described as the ability to bounce back (recover) from adversity and stress. Often thought to be a measure of toughness in the world of sports, it is actually a bio-psycho-social mediated response. Ongoing research into clinical conditions like PTSD and Stress Disorders, are demonstrating the important role of genomics and epigenetics in understanding not only the stress response, but resilience. Athletes at every level of competition must learn to deal with adversity in order to succeed. In my over 50 years of competing, coaching, and treating athletes at every level of competition, I am confident the rewards, and general sense of control (if I work hard and stay focused I can succeed) associated with being an athlete play a key role in resilience. Being a member of an Olympic team is unique for any elite athlete. For most, this is the ultimate, once in a lifetime accomplishment. Just making the team, and having the opportunity to represent your country, exceeds all prior successes. The pomp and circumstance surrounding the Olympic Games is unequaled in competitive sport. The Olympics have transcended the world of sport, and have become a marquee sociocultural global event. The 1972 Munich Games changed the Olympics forever. For the athletes, this was not the story anyone ever dreamed of during a lifetime of training, but one we will never forget. Like all of the Games, good and bad, it changes one’s life perspective forever.
What drugs are used by athletes for performance enhancement? Do they work? What are the risks?
Doping in sports, or the use of performance-enhancing or masking agents to gain an unfair competitive advantage, is literally as old as organized sport. It has been traced back to the original Olympic Games in Athens. The story of modern doping in the U.S. dates back to the late 1930s in York, PA. It is a fascinating story, initiated by the desire to keep pace with other countries heavily involved in state supported doping programs. The primary focus was on anabolic steroids, intended to improve strength and power. Since then, doping has expanded to include agents to mask the detection of steroids, along with drugs intended to increase stamina, focus, and speed up recovery from injury and intense training. When I began working as an Olympic Doping Control officer in the early 1980s, the list of banned substances was relatively short. Over the years, the list of banned agents has exploded, and no longer fits on a laminated business card, as it originally did. Even the method of testing has morphed beyond urine collection of in-competition testing of the winners, to a focus on no-advanced notification, out of competition testing protocols.
The most frightening “advance” in doping has been experimentation of gene doping (literally altering the human genome to increase athletic performance).
All forms of doping have some side-effects. The nature of these unintended health consequences varies with the drug, and importantly, the dose. This has made it challenging to study the actually effects of doping. The high doses, and “stacking” employed by athletes doping is well beyond the comfort zone of any IRB, especially in healthy subjects. Cheaters use doses well beyond what has ever been tested, or used, in standard clinical care. Despite this limitation, clinical researchers such as Skip Pope, one of the godfathers in the field, have demonstrated both short tem and long term negative consequences resulting from doping. In the case of gene doping the outcome could be death.
In response to your question of do they work, the answer is a qualified “yes”. Doping athletes can increase their strength and endurance, and ability to recover quicker, but not without a price. In the recent past, the pressure to dope in order to be competitive was intense. Numerous Olympic athletes have shared with me the sentiment that “if you ain’t cheatin, you ain’t tryin”. This was particularly true in cycling. I have seen a change in doping practices. Steroids are much less common (as they are relatively easily detected), and doping to achieve greater endurance and quicker recovery (or extend an athletic career) are more prevalent than merely achieving greater strength. Unfortunately, doping is still a major concern in elite sports (as witnessed by the recent IOC ban on virtually the entire Soviet team), but the face of doping has evolved.
For the interested reader, an excellent review of this topic can be found in Performance-Enhancing Medications and Drugs of Abuse, edited by Mark Gold, MD, published by Haworth Press in 2007.
What is the biggest change you have seen in Psychiatry in diagnosis over your distinguished career?
By way of full disclosure, I am a third generation psychiatrist, so I have literally grown up in the field. The biggest change I have seen is a broader, more biopsychosocial approach to diagnosis. For many years, diagnosis was rooted more in theory than in a thoughtful consideration of multiple factors. As neuroimaging and neurogenetics continue to develop, it will be interesting to see how the diagnosis of psychopathology will evolve. The NIMH push to evolve to RDOC has had an impact, and at the least, sparked important debate on the most effective diagnostic schema. The DSM system, around since the 1960s, continues to evolve, but not without its share of controversy. The very public debates which have resulted in this less than positive news coverage have, in my opinion, not helped our field. Critics have even claimed it is merely a way for the APA to make a great deal of money by publishing a new version every decade or so. This is unfair and uninformed criticism. The effort put into producing a fair and unbiased living document by many of the finest psychiatrists in the country, without pharma influence, is noteworthy. I believe this debate has in fact added to the core prejudice of mental illness by the uninformed and uneducated.
What is the biggest change you have seen in psychiatric treatment of depression over your distinguished career?
Prior to the early 1970s, depression was treated primarily with psychotherapy. As antidepressant medications were developed, treatment shifted to a more pharmacotherapy based treatment. Current treatment emphasizes a more comprehensive approach, utilizing nonpharmacologic interventions combined with appropriate use of antidepressant medications. Advances in neuromodulation, rTMS, and ECT (still one of the safest and most effective treatments for severe major depression) continue to add additional tools to the clinician’s toolbox. In addition to new treatment interventions, the role of sleep, diet, exercise and stress management continue to play a prominent role in effective treatment. The expanding theories of the etiology of depression to include the role of the inflammosome will no doubt offer additional treatment options. An important factor to consider is that there is no one form of depression. Like cancer, the type of depression may require a more personalized approach to care. The acceptance of this concept will likely result in the biggest change to the treatment of depression. In my experience, all the approved treatments work, just not in everyone. The art and science of treating this chronic disease requires a knowledge of the many interventions available along with an understanding of the uniquely personal issues which initiated and contribute to the disease process.
What are the biggest advances in the use of exercise as an adjunct to treatment of addictions?
I have been interested in the role of exercise in treating depression and addiction since high school. My father ran a methadone maintenance program for Philadelphia over 50 years ago. It was that early exposure with addicts that initiated my interest in the biology of happiness, not depression, and the role exercise could play. As brain science has advanced since the 1990s, our understanding of the biology of enjoyable exercise on brain physiology has clearly demonstrated this is not merely a placebo response. I do not feel it is going out on a limb to recommend an appropriate, enjoyable exercise program for every patient struggling with addiction.
How do you balance the health and exercise needs of patients with anorexia, bulimia, or binge eating disorders? Is exercise essential in bulimia and BED? Which type of exercise? What are the health limitations and concerns?
The treatment of eating disorders is challenging, requiring an integrated BPS approach to care. I believe exercise plays a role in all forms of ED, but requires close supervision and monitoring by experienced clinicians. I have treated patients with anorexia with over-exercise being a key symptom of their illness. The key issue is to have a thoughtful exercise intervention be an integrated component of treatment, monitored closely by an experienced MH professional with expertise in the treatment of ED.
Can you help us understand ADHD and treatment and also why successful treatment with psychostimulants reduces rather than increases drug abuse-addiction risks?
Contrary to the false belief that ADHD was created by pharma to sell psychostimulants, the condition was first described in 1870, and first reported in the modern medical literature in 1902 (well before the 1st stimulant was marketed). Without question, ADHD is a brain disease, hallmarked by core symptoms of hyperactivity, impulsivity, distractibility, and impairment in executive functioning. It has been established that untreated ADHD increases the risk of drug abuse, and the stimulants are schedule 2 drugs with an abuse liability. However, work by Wilens and many others has demonstrated that appropriately treated ADHD lowers the risk to what is observed in non ADHD controls. Blum and others have articulated the role of dopamine in Reward Deficiency Syndrome and ADHD. Although dopamine homeostasis is the key factor, the role of dopamine modulation achieved with the stimulants helps explain their therapeutic effect.
Many people have put themselves on gluten free diets. Is this logical? Who needs such a diet?
I take a more conservative approach when it comes to diet and dietary restrictions. If someone has a proven food allergy, by all means, restrict or eliminate exposure to the offending foods. However, I get concerned when overly restrictive diets are recommended. It sometimes feels “fad like” when it comes to some of the reported new diets. Short of documented food allergy, I believe a well balanced diet with adequate daily hydration is optimal for most patients. Moderation is a key factor, and frequently lost in fad diets. When asked my recommendation, I usually suggest a Mediterranean based approach to an overall healthy eating strategy (not a diet–nobody likes them).
Certainly, drugs like methamphetamine are at the top of the list, but chronic use of substances like alcohol and yes, marijuana have demonstrated a potential negative impact. There is no doubt there are genetic vulnerabilities effecting long term negative consequences. As a clinician and clinical researcher, I am concerned over the impact legalization of marijuana will have, not unlike what has been seen in alcohol misuse. We know a percentage of marijuana users will experience psychotic symptoms with initial or escalating use, we just don’t know who is at risk yet. This is an important area for future clinical population based research.
What role in depression can exercise play? Diet? Psychotherapy? Medications?
All play an important role in developing a personalized (precision) treatment strategy. As mentioned earlier, there is not ”a” depression. Effective treatment must begin with an understanding of the patient, not merely focusing on symptoms. I firmly believe an enjoyable exercise program should be considered for every patient with depression, along with some form of psychotherapy. A focus on achieving a healthy lifestyle, including a well balanced diet, adequate restful sleep, stress management, and seeking happiness on a daily basis is key. Medications play an important role for the moderately to severely depressed patient, but should always be one piece of a larger treatment puzzle. Maintaining optimal physical health should also be a critical element in treating depression. Mental health and physical health should be considered as essential to each other. Achieving a balance to life, or homeostasis, is the key to good health.