Dr. Vassilis Koliatsos is the first Stulman Scholar in Clinical Neuropsychiatry at Sheppard Pratt Hospital. Right now, he is gazing out the window of his office and wondering why young doctors no longer seem to discuss interesting cases. He quickly concludes the obvious: they are too busy. They see a whirlwind of patients coming and going, and they expend their energies writing endless notes in the form of justifications for continued stay and documentation of treatments. The leisure to ponder pathology has long given way to urgency. And case conferences, once a hallowed tradition in medicine, have largely disappeared in large part due to HIPAA mandates over privacy. Dr. Koliatsos has other concerns. As one having both psychiatric and neurological training, he laments what he describes as an increasing “pseudoneurological” view of mental illness whereby CAT and PET scan findings become the sanctified hallmarks of illness. This is well and good, Dr. Koliatsos remarks, if there exists a patient who, say, begins mumbling obscenities after bruising his orbitofrontal cortex in a skateboard accident. But many neuropsychiatric conditions have no crisp etiology and the treatments of them require devotion and time instead of tests and drugs. Nowhere is this more evident than in the dementias found among the larger number of people living longer. Using the generous $1.2 million dollar grant from the Leonard and Helen R. Stulman Charitable Foundation, Dr. Koliatsos plans to teach doctors about the social rehabilitation of geriatric patients with neuropsychiatric illness. The grant will also fund programs to work with the chronic apathy syndromes seen in schizophrenia or traumatic brain injured patients. This work relies more on a patient’s aptitudes and mood than on the site of his lesion; while imaging techniques may reveal the cortical locus of symptoms, such findings seduce the clinician with a false sense of diagnostic completion. The needed treatments are far more mundane.
Dr. Koliatsos finds a certain reductionism to pervade modern psychiatry. Using PET scans, many syndromes can be associated with, say, increased activity in Brodman’s area of the brain including depression, grief, and even romantic disappointment. But what are we to make of this? Surely, brain structure mediates behavior but the matter is far from simple. And the nonspecific nature of brain function is highlighted by findings that both drugs and simple learning can produce structural changes at a synaptic level. Thus therapy can be as powerful as medication, something that should make us humble. Dr. Koliatsos simultaneously respects evidence-based treatments and is wary of them. The current emphasis on evidence has a certain danger to it, he says, and that risk is one of dehumanization. Not everything can be measured. Relationships between people are powerful elements of healing. Basic exercise can do more for a body than any number of somatic interventions. But current culture worships the quantifiable and pays only for what it can objectively see.
Dr. Koliatsos has been interested in the protective function of neuropeptides, he has served on National Institute of Aging committees to study biomarkers of aging and on FDA panels, and received two prestigious investigatorship awards from the National Institute on Aging and the National Institute of Neurological Disorders and Stroke. He is very active in competitive, RO1-funded research on fundamental mechanisms of neural injury and repair. Yet he still admires the discipline of psychoanalysis. He is quick to point out, however, that psychoanalysis can be every bit as parochial as new brain imaging techniques. Instead of hyperactive or hypoactive brain spots, psychoanalysis seeks to explain anything and everything with constructs of the unconscious. The trick is to respect the brain and the mind. In fact, Dr. Koliatsos plans to implement “mind-brain” fellowships for doctors in which cognitive and behavioral treatment strategies are devised for such diseases as frontal lobe injuries and impulse control disorders.
Dr. Koliatsos has not forgotten the soul. He wishes to evoke in clinicians a sense of wonder and respect. Instead of producing health care service providers who work fast and cheap and are thus endorsed by managed care, he wants to reward craftsmen and artists who cherish medical practice. In a sense, he wishes to turn back the clock to an era when the healer was respected for his wisdom, not just for the numbers he churned out. Time is particularly valuable. Time has become eroded, and doctors have so little of it in their professional lives. The Stulman grant is structured so that the time of participating clinicians will be financially protected so that they can work with chronically ill patients and devise new treatments. Dr. Koliatsos hopes in time to train a generation of clinicians with psychosocial instincts and talents to broadly manage longstanding disease. What is required here is an attention to detail and landscape, a comprehension of the hard science and the softer outcomes. And there is a mission of rekindling awe in those who seek to cure others. One is reminded of a quote by the 16th century physicist and astronomer Galileo who, after devoting his life to the precision of celestial bodies, remarked, “The Sun, with all the planets revolving around it, and depending upon it, can still ripen a clump of grapes as though it had nothing else in the Universe to do.”
Dr. Vassilis Koliatsos is director of Sheppard Pratt’s Neuropsychiatry Program. He can be reached at 410-938-4826 or e-mail firstname.lastname@example.org.