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Saturday, May 4, 2013

Bounded to Boundless

Boundaries and borders: the implication is that what’s on this side of the border is different than what’s
on the other side.” Without borders” is the basic premise of unity. Demolish borders, and different
becomes the same. That is when one finds oneself boundless.

Not everything that is different (than you) is threatening, but granted, everything that is threatening
is very different than you. Make it the same and the threat disappears. That is the most basic motive
behind building empires. The more you expand your borders the less threatening the world is.

Yet, the world is infinite. The problem with expansion through “borders inflation” is that in an infinite,
boundless world, regardless of how much you expand, there is still an infinite that remains to be

Absolute expansion cannot be accomplished through any quantifiable expansion.

What is required is a qualitative change. From bound to unbound to boundless.

© Copyright Adrian Preda, M.D.

Friday, May 3, 2013

The Image Trap

Having an image! Realize: it is an IMAGE, i.e. it is NOT YOU.

Image consultants. An image obsessed culture.

Pretty easy to get caught in this scheme which distances one from oneself.

Now, why be surprised when people no longer know who they are?

© Copyright Adrian Preda, M.D.

Monday, February 4, 2013

Aha Stories

There are some therapists who use therapeutic or inspirational stories as part of their therapy process. Sort of “a-chicken-soup-for-the-soul-adapted-for-the-therapy-hour” if you will. As we all have our own preferred colors and hues and the way we let our brush strike the canvas is as unique as one's own fingerprints I prefer to let the patient tell his own story. .

But then there are the times when a patient chooses to share a story that is not his own but for some reason he found enlightening. Such rara avis: a story found inspirational not by someone else but by the patient himself.

And today I was told one of these stories. Here it is:

Once upon the time there was a country where there was a very rich man who owned all the land in that country as far as one can see and a very poor man who owned nothing. Each man had a son.

When his son was almost ready to be a man, the rich man took him up the top of the tallest mountain in the country. 

And he said: “Son, look. One day everything you see will be yours.”

When his son was almost ready to be a man, the poor man took him up the top of the tallest mountain in the country. 

And he said: “Son, look.”

For some reason it was this story - from the many stories that my patient has heard or read - which brought that rush of insight, a true Aha moment.

What I learned from this story is how a simple message could hide layers after layers of meaning.

My analysis follows but reader be aware. Reading further is my breaking the above koan-like story apart. So please take a moment, read the story again, savor it, stay with it, draw, if you need to, your own conclusions and only then, if you still feel like it, come back to read my take on it. The risk is that if you will jump to reading my take on it before letting it sink you might see the magic of the story fading away.

There are many ways to present mindfulness. There are many stories alluding to the power of presence, complete awareness, or entire books for that matter about the Power of Now. At the same time there are stories galore about the inherently distracting and as such destructing power of focusing on external gratification. Whole religions have been built on the foundation of what St. Augustin sees as re-ligare, re-uniting the distracted mind with the unmovable side of things (internal and external).

Two and a half millennia ago Heraclitus noted that "everything flows, nothing stands still" to which a number of traditional religions and philosophers offered the solution that the way to wisdom and peace of mind is to see and accept things as they are in the moment. While everything changes from moment to moment, nothing changes in the moment, litt. inside the moment.

Not to mention the inherently distracting nature of material riches, forms without content, and of course Voltaire's "Le mieux est l'ennemi du bien”. Aspiring to possess "everything you see" is not only the enemy of the good but a sure solution for the end of mental equanimity.

How so many things can be conveyed in the space of a 110 words story is in part what makes it magical, a true Aha story.

Many people have their own Aha stories. Stories that others might think strange or maybe in poor taste or made up or simply boring. Fairy tales or real life or may be just so stories.

I hope to hear back from you with any such stories. For a story to qualify as an Aha story it needs to have passed the test of an Aha moment. A moment of a sudden flush of understanding or insight following the reading, hearing or at times maybe remembering of a story one has heard a long time ago. And then yes, of course, it needs to be short. Less of a thunderstorm, more like a lightning. Short for enlightening, right? 

I hope you will share your Aha stories here as comments - if of reasonable length. Or, as always, you can email me your comments or, in this case, stories

Here is my promise: your Aha stories enhanced with my "psych" notations will be introduced to a worldwide audience through this blog. I will dedicate each story a full blog entry as long as the sender will share what about the story resulted in an Aha moment.

Looking forward to our Aha's.

© Copyright Adrian Preda, M.D.

Saturday, December 29, 2012

The Antidepressant Wars, a Sequel: How the Media Distort Findings and Do Harm to Patients

Reposting of my December 26, 2012 PLoS guest blog on Mind the Brain.

Central to the perspective I present in this blog post is my work supervising psychiatric residents and medical students at a university-based psychiatry clinic where our patient population includes a good number of adults suffering from mild to moderate depression.

In 2010, the publication by JAMA of a single-study challenged and upended a major assumption that had guided clinical work like ours for over three decades (Barrett 2001; Qaseem 2008). This was the widely covered meta-analysis of antidepressant (AD) trials conducted by Fournier and colleagues(2010), which drew the far reaching conclusion that ADs show significant response in very severely depressed patients, but are not more effective than taking a placebo  in less severe cases.

Fournier was not the first study that took aim at the foundation of treatment guidelines for depression, which in essence recommend treating depression with antidepressants. In 2008 Kirsch et al. meta-analysis of clinical trial data submitted to the Food and Drug Administration ended with a rather strongly worded conclusion:
“Drug–placebo differences in antidepressant efficacy increase as a function of baseline severity, but are relatively small even for severely depressed patients” (emphasis added). (Kirsch et al., 2008)

After reading their findings a neutral conclusion for Kirsch et al. would be that

ADs are statistically better than placebo
Response correlates with patients’ severity of symptoms.

Not an earth shattering conclusion by any means as both results were already common knowledge for anyone who started prescribing ADs since 2002, the date when Kahn et al. published their 45 studies based meta-analysis of FDA submitted AD trial data. Their conclusion?

“The magnitude of symptom reduction was significantly related to [..] initial depression […] scores; the higher the […] initial […] score, the larger the change.” (Kahn et al. 2002)

Therefore, one can look at the Kirsch (2008) study findings as a replication of earlier findings, a continuation of a line of knowledge that has already been established. Which is most times the way scientific knowledge expands. Given this, one would be hard pressed to understand how a study that essentially replicated prior positive findings would become the poster child for the anti-antidepressant movement that followed. But that is exactly what happened.

Interestingly, Kahn et al. (2002) was not cited by Kirsch et al. (2008), in itself a remarkable oversight considering the similarities between the two studies. But I found even more troubling that instead of conservatively explaining their findings and providing as much of a neutral and tentative explanation as possible — the validated scientific communication tradition —  Kirsch et al. appeared to formulate their conclusion from a position of commitment to an anti-antidepressant view:

“The relationship between initial severity and antidepressant efficacy is attributable to decreased responsiveness to placebo [even] among very severely depressed patients, rather than to increased responsiveness to medication.” (Kirsch et al., 2008)

And that strongly worded conclusion made the Kirsch study an almost overnight media hit. Front-page newspaper and radio coverage followed, criticism was dismissed (Horder 2011).

To this date, the Kirsch study remains one of the most popular papers on the PLoS Medicine website, as reflected in the following metrics: 282,219 views, 631 citations, 300 academic bookmarks, and 404 social share (data as of December 20th, 2012).  A number of critical commentaries followed.  Some directly criticized Kirsch et al. (2008) for methodology or overstated conclusions (Kelly, 2008; Khan and Khan, 2008; McAllister-Williams, 2008a, 2008b; Moller, 2008; Nutt and Malizia 2008; Parker, 2009; Turner and Rosenthal, 2008). More interestingly, a few who decided to re-analyze Kirsch’s data found they could not replicate Kirsch et al. pessimistic view on AD’s efficacy (Fountoulakis , 2011; Horder et al., 2011). For unclear reasons these subsequent reports aimed at reestablishing the ADs respectability got much less media attention than Kirsch’s 2008 original.

“Déjà vu All Over Again”

In this context when Fournier at al. came along in 2010 I thought I had a déjà vu. Not as much in terms of the study’s conclusions but rather in terms of the emotional intensity and dramatic flavor with which it was greeted by the mass media. I first heard about it on NPR, and this surprised me as I usually get the studies I am interested in before the media does.

Over the next couple of days headlines such as these appeared in print and online media around the world:

The NY Times: “Popular Drugs May Help Only Severe Depression”(Carey B, 2010)

From the LA Times: “Antidepressant medications probably provide little or no benefit to people with mild or moderate depression” (Roan S, 2010)

Immediately following this media hoopla, I found that my students – a new generation who have not been part of the Kirsch antidepressants wars – began to routinely question the wisdom of continuing or starting antidepressant treatment for our patients suffering from mild or moderate depression.

And it did not take long for our patients themselves to express their doubts about the efficacy of antidepressants — even for severe depression.

I was troubled at the time by the unquestioning coverage of Fournier et al which inferred that this single study was in fact “settled science” on the subject of antidepressants when it was not; and by the inattention given (in either the professional literature or popular press) to either the complexities or long history of debate (as discussed above) or at least the serious flaws in the study’s methodology – as I’ve summarized below.

Two years later I’m equally concerned about the lack of media coverage given to a 2012 publication, also by JAMA, of a study by Gibbons and colleagues (2012) which, history aside, refutes Fournier’s claim that antidepressants are not more effective than placebo for mild to moderate depression. Similar to Fournier et al. (2010) Gibbons et al.’s (2012) findings are based on individual patient data and include longitudinal measurement which makes its conclusions a strong counterpoint to those of Fournier et al. (2010).

Among the points I now make to my students when questions arise about antidepressant efficacy as a result of the meta-analysis conducted by Fournier et al, are the following:

The individual patient-level data approach used by Fournier et al represented an improvement over standard meta-analyses; however their results were based on only 6 studies that met their criteria from more than 200 relevant studies. Reducing 2164 citations to 6 is hardly representative, especially when the 6 analyzed studies represent only two medications: paroxetine and imipramine, the latter not recommended for first line treatment of depressive disorders. Furthermore, of the 6 studies, 5 specifically excluded with very mild depression making the authors’ conclusions about lack of separation of ADs from placebo for mild depression weak.

Exclusion Criteria Raise Major Questions

The strength of a meta-analysis is based on applying a solid statistical approach to all studies meeting a set of relevant inclusion/exclusion criteria, and in this case it appeared that the authors excluded too many relevant studies.  Specifically, 228 studies were excluded based upon their exclusionary “placebo washout lead-in” requirement (a requirement that all study participants get a placebo to start with and only those who do not respond to the placebo continue in the study). The placebo washout/lead-in represents a common historical design used in antidepressant trials with the intent of excluding patients who do not demonstrate symptom stability thus are not likely to benefit from a truly effective AD. Fournier et al. (2010) acknowledge that “it is not clear that placebo washouts actually enhance the statistical power of antidepressant medication/placebo comparisons” nevertheless they proposed that in order to evaluate the rates of “true placebo response” one should exclude all studies using a placebo wash-out/ lead-in design.

While it is true that a placebo washout might limit accurate estimates of placebo-response and might not improve the probability of an AD being more effective that a placebo, this design for studies of depression would not affect the validity of an active AD – placebo separation, were one to be found. The exclusion of washout studies was especially problematic precisely because this represents acommon design for AD clinical trials, meaning that numerous relevant studies will be excluded. In other words Fournier et al. imposed a seemingly arbitrary (i.e. not evidence based) exclusionary criterion that effectively filtered out themajority of the relevant studies. This is a very bright red flag and potential source of bias, which greatly limits the validity of the authors’ conclusions.  Assuming these easily excluded studies were otherwise methodologically sound, the number of study investigators contacted would have increased from 23 to 251; and likely significantly more than 6 would have contributed to the final analysis.

Considering the potentially grave implications of either mental health providers or patients accepting the headlines generated by widespread publication of these results at face value, the study’s  methodological weaknesses  –which were not treated in any depth by comments accepted for publication by JAMA – warrant further critical review.

Overlooked and Highly Relevant Research

Likely because it received dramatically less coverage, far fewer of my students are aware of the 2012 study by Gibbons et al (2012) who, after reviewing 43 fluoxetine and venlafaxine trials, concluded that, contrary to the Fournier at al. (2010) findings, these two antidepressants are in fact efficacious for major depressive disorder in all age groups, regardless of the depression severity at baseline.

As noted, Gibbons et al. (2012), as Fournier et al. (2010), also used patient-level data – making the point against Fournier el al. even more significant. In addition, if you compare Gibbons et al. (2012) final set of 43 studies with a meta-analysis population of 4303 patients in the fluoxetine trials and 4882 patients in the venlafaxine trials (in total more 9000 patients) to the Fournier et al. (2010) final set of 6 studies (3 paroxetine and 3 imipramine trials) with a total of 718 patients, Gibbons et al. (2012) significantly larger number of studies makes for a more believable conclusion.

Both studies are limited in that they focused on only 2 ADs: paroxetine and imipramine for Fournier et al. (2010) versus fluoxetine and venlafaxine for Gibbons et al. (2012). At the same time Gibbons et al. (2012) used an all-inclusive set of studies, whereas,  as noted above, the Fournier et al. (2010) study used a highly selective group of studies. There are also important differences in data analytic methods that could explain the differences in results. For example, Gibbons et al. (2012) defined severity differently than Fournier et al. (2010).

To expert eyes, the main effects for the drug versus placebo differences can be actually seen as similar in the two data sets. And that is the very reason for engaging in this debate.

Which study is more convincing?

The Gibbons study reminds us that it is our duty as physicians and society at large to carefully screen and aggressively treat depression, including with medications if so recommended. The Fournier study makes us aware that there might be more to the story of AD response than a straightforward active ingredient effect.

We can all speculate about why the Gibbons study received so much less media coverage than did Fournier and colleagues.

The Sequel

In the antidepressant wars, we have seen the pendulum’s full swing from the early nineties when Elisabeth Wurtzel’s “Prozac Nation” was thrilled to be “Listening to Prozac” with Peter Kramer, and into the early millennium years when Healy’s tongue in cheek advice was to “Let Them Eat Prozac”. By the time Carl Elloit’s “Prozac as a Way of Life” hit the stands in 2003, some thought we were at the end of an era.  But ADs came back strong, only to engender renewed debate and, as argued above, uneven and thus inaccurate media coverage in the current decade.

Unintended Consequences of an Unevenly Covered Debate

As my esteemed colleague Michael Thase adeptly put it to me, “There is no ‘last word’ in the science of this debate.” He is undoubtedly correct. And, as a physician, I find relief in the fact that we continue to question engrained assumption and are reluctant to accept there is such a thing as a last word or simple explanation when it comes to complex issues. Depression, with its multidimensional tentacles equally anchored in nature and nurture will never be a good subject for simple explanations.

But, again, as a physician I am very concerned about major unintended consequences of uneven coverage of the competing major findings discussed above. Specifically, I fear that clinically depressed members of the public at large will refuse a likely efficacious treatment option.  And while all may be well if that depressed patient makes the informed alternative choice of starting treatment with cognitive behavioral therapy (CBT), a validated form of therapy for depression that compares well with SSRIs for mild or moderate depression, all is certainly NOT well if the patient’s decision not to accept treatment with antidepressants is based primarily on media delivered misinformation.

Given the stigma against acknowledging or treating a mental illness with a psychotropic medication, the media saturation given to one study only worsens an already difficult situation for many patients who fear the personal and social consequences of admitting their illness and seeking treatment.

In closing: my hope is that members of the media who cover this debate will realize that “first do no harm” is not only the duty of physicians; it is also the responsibility of anyone trusted with giving health information to the public at large.

Acknowledgements: I would like to thank Lawrence Faziola and Steven Potkin for critically discussing Fournier et al. and Michael Thase for his critical read of the draft to this article.


Barrett JE, Williams JW Jr, Oxman TE; et al. (2001) Treatment of dysthymia and minor depression in primary care: a randomized trial in patients aged 18 to 59 years. J Fam Pract. 50(5):405-412.

Carey B (2010) Popular Drugs May Help Only Severe Depression. New York Times, January 5, 2010

Fournier JC, DeRubeis RJ, Hollon SD; et al. (2010) Antidepressant Drug Effects and Depression Severity A Patient-Level Meta-analysis. JAMA303(1):47-53.

Fountoulakis KN, Möller HJ (2011) Efficacy of antidepressants: a re-analysis and re-interpretation of the Kirsch data. Int J Neuropsychopharmacol. 14(3):405-12. Epub 2010 Aug 27.

Gibbons RD, Hur K, Brown CH, Davis JM, Mann JJ (2012) Benefits from antidepressants: synthesis of 6-week patient-level outcomes from double-blind placebo-controlled randomized trials of fluoxetine and venlafaxine.Arch Gen Psychiatry 69(6):572-9.

Horder J, Matthews P, Waldmann R. (2011) Placebo, prozac and PLoS: significant lessons for psychopharmacology. J Psychopharmacol. 25(10):1277-88.Epub 2010 Jun 22.

Kelly BD (2008) Do new-generation antidepressants work?. Ir Med J 101: 155–155.

Khan A, Leventhal RM, Khan SR, Brown WA (2002) Severity of depression and response to antidepressants and placebo: an analysis of the Food and Drug Administration database. J Clin Psychopharmacol 22: 40–45.

Khan A, Khan S (2008) Placebo response in depression: a perspective for clinical practice. Psychopharmacol Bull 41: 91–98.

Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT (2008) Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med 5: e45–e45.

McAllister-Williams RH (2008a) Do antidepressants work? A commentary on ‘Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration’ by Kirsch et al. Evid Based Ment Health 11: 66–68.

McAllister-Williams RH (2008b) Misinterpretation of randomized trial evidence: Do antidepressants work?. Br J Hosp Med (Lond) 69: 246–247.

Moller HJ (2001) Methodological aspects in the assessment of severity of depression by the Hamilton Depression Scale. Eur Arch Psychiatry Clin Neurosci 251(suppl 2): II13–20.

Moller HJ (2008) Isn’t the efficacy of antidepressants clinically relevant? A critical comment on the results of the metaanalysis by Kirsch et al. 2008. Eur Arch Psychiatry Clin Neurosci 258: 451–455.

Nutt DJ, Malizia A (2008) Why does the world have such a ‘down’ on antidepressants?. J Psychopharmacol 22: 223–226.

Qaseem A, Snow V, Denberg TD, Forciea MA; et al. (2008) Clinical Efficacy Assessment Subcommittee of American College of Physicians. Using second-generation antidepressants to treat depressive disorders: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 149(10):725-33.

Parker G (2009) Antidepressants on trial: how valid is the evidence?. Br J Psychiatry 19: 1–3. Web of Science

Turner EH, Rosenthal R (2008) Efficacy of antidepressants. Br Med J 336: 516–517.

Roan S (2010) Study finds medication of little help to patients with mild, moderate depression. Los Angeles Times. January 06, 2010.

Thursday, December 27, 2012

The Antidepressants Wars and the Uncertainty of Depression

My recent PLoS guest post generated a lot of interest.

Here are a few follow-up thoughts jotted down in the aftermath of the comments I've been getting  on the post.

It is abundantly clear that depression is not an easy topic to handle.

First, there are those who claim that mental illness does not exist. Period.

Secondly, there are those who concede that some mental illness might exist but contend that depression, especially the so-called garden-variety (meaning mild to moderate depression) does not exist as “it is all in your head” and you only need to will yourself out of it.

Thirdly, there are those who concede that depression might exist but argue that the way we make our diagnosis is all messed up as we keep changing a set of “subjective” diagnostic criteria.

Fourthly, there are those who accept the diagnosis but debate the way our research has chosen its animal models or neuro-molecular targets.

Lastly, there are those who don’t care what the reason is, but became invested in demonstrating that approved treatments are effectively ineffective, or at least, no better than placebo.

Sum it up and chance is that if you are a patient with depression you will end up fairly confused. To make matter worse, chance is that if you are a busy doctor (not only a psychiatrist but also a primary care doc, as primary care doctors treat the vast majority of the depressed population) you are going to be almost as confused. The news are non-informative or even misleading when it comes to the topic of depression, and the research literature is too many times too complex to be understood by straightforward clinicians.

So, here we are, with a problem in search of a solution.

A complex problem, a true biopsychosocial Hydra, depression cannot be tacked with simple solutions. I believe this realization of complexity is the first step in successfully fighting it.

By accepting the complexity of the depression construct all the above perspectives can change from being plainly wrong to being, each one, partially true. Similar to the famed blind men disagreeing on what on elephant was for as long as they kept their findings separated instead of summing them up, a “together” perspective will allow us to not only better define depression but attack it on multiple fronts.

There is no end of fight in sight if biology will hold to its guns against psychology which in turn will hold to its guns against biology etc. only a catch-22 that will hurt those suffering.

Instead, working toward a model where the nature-nurture relationship is truly bidirectional (as when we understand how inherited genes express preferentially in different epigenetic contexts) is the path to follow if we are to see the light at the end of the tunnel.

© Copyright Adrian Preda, M.D.

Newtown Connecticut: Reflections on Sorrow

Originally posted on December 17th on my PsychologyToday Psychiatrist at Large blog:

On Thursday, April 19, 2007 following the Virginia Tech shooting on my Psychiatrist at Large blog I wrote a post titled "From Columbine to Virginia Tech".

I wanted to believe that was the last time I would write about children killing and getting killed in this day and age in this country. Unfortunately it was not. I have no words to express the sadness I felt when I learned about the Connecticut tragedy.

I cannot put myself in those Newtown families' shoes, as I feel like I could lose my mind. There is anger and disappointment, not directed at anyone specifically but rather at all of us – a society in which we somehow created a space and a state of mind where such tragedies are becoming a common place.

A place, where in this time of sorrow, we seem to be choosing time and again to disrespect private mourning and instead give thumbs up and high audience ratings to media that pry most intrusively into people's sorrow with its pointed lenses, sharp cameras, and unstoppable journalists. A time when our main reaction to tragedy is voyeurism.

Newtown now follows in the steps of a number of traumatized communities. As a small community facing such massive trauma, Newtown will struggle to recover. It’s hard enough to make sense of arbitrary chaos that hits out of the blue, to repair the broken trust and to heal the wounded hearts. Let's not make it any harder by further assaulting it with our microphones and bright lights. 

Let's allow Newtown its privacy, let it bury its dead and heal its bleeding hearts in peace and quiet.

In this time of sorrow, it is so much more disturbing to see that what I wrote five years ago is as true today as it was then. Time is supposed to not only heal, but teach. Hopefully, five years from now, this will only be a sad memory, and will no longer ring as true as today.

 What follows is 2007 text with changes indicated in parentheses.

 Here is a disturbing timeline of school killings in America:

• [December 2012: The son of a teacher kills his mother and then walks into her school where he kills 20 children (ages 6-7) and six adults.]

• April 2007: A student goes on the rampage at the campus of Virginia Tech killing 32 people before killing himself.

• October 2006: A 32-year-old gunman goes on the rampage at an Amish school in Pennsylvania, shooting dead at least three girls before killing himself.

• September 2006: A gunman in Colorado shoots and fatally wounds a teenage schoolgirl, and then kills himself.

• September 2006: A teenager kills the head-teacher of a school in Cazenovia, Wisconsin.

• November 2005: A student in Tennessee shoots dead an assistant principal and wounds two other administrators.

• March 2005: A schoolboy in Minnesota kills nine, and then shoots himself.

• May 2004: Four people are injured in a shooting at a school in Maryland.

• April 2003: A teenager shoots dead a head-teacher at a Pennsylvania school, and then kills himself.

• January 2002: A student who had been dismissed from the Appalachian School of Law in Grundy, Virginia, kills the dean, a professor and a student, and wounds three others.

• March 2001: A pupil kills two students after opening fire at a school in California

• February 2000: A classmate shoots dead a six-year-old girl in Michigan.

• November 1999: A 13-year-old girl is shot dead by a classmate in New Mexico.

• May 1999: Six are injured by a student in a shoot-out in Georgia.

• April 1999: Two teenagers shoot dead 12 students and a teacher before killing themselves at Columbine School in Colorado.

What are we to make out of this? Clearly, we are no longer looking at isolated events. These are not events we can file away as “accidents”, before turning over and falling asleep. We are looking at a pattern. A horrific pattern of children killing children in schools. Children, a symbol of life before anything else, killing? And where? At school. I’m not sure what frightens me more. Is it that children kill children? Or is it that schools are now places where one can kill and be killed? School is supposed to evoke feelings of safety and joy and respect; instead it is being redefined as the new human jungle – as unsafe and run down as a drug- and crime-infested neighborhood. When above all, a school is supposed to be both a sacred and safe place for our children. How can one teach and how can one learn when one worries about one’s safety?

My fear is that school violence will condemn our children to perpetual inadequacy and fear. My fear is that our scared and scarred children will grow into fearful adults who think violence is normal and to kill and be killed is a fact of life. This is one frightening prospect.

What are we to do? The easy answer is to do whatever it takes to establish safety. But how do we define safety? Where is the problem coming from? Does establishing safety mean beefed up barbwire fences, metal detectors, around-the-clock security guards carrying assault weapons and bullet proof jackets marching down the schools hallways? Or does it mean an open school, without isolating fences, where students are connected to each other, respectful of their teachers and excited to learn?

As a psychiatrist, I know that fear begets fear and violence begets violence. More of the same begets sameness. When I see violence I first look for the violence that preceded it.

In my book understanding is at the root of healing. As more of the same begets sameness, I also know that violently curbing violence, as appealing as that might be on the short run, will certainly bring not less, but more violence in the future.

I believe that the way to peace is through peace, and only understanding can mend misunderstanding.

What is preceding our school violence? Is it just an accident that our beloved America makes it part of the American way to be a captive audience for a media fatally invested in juicy, violent subjects, and ending with the much less publicized fact that the US is possibly the only country that has been almost continuously at war for more than a century?

Can it be related to the fact that our society values individualism above all?

Our heroes are outcasts and pioneers settling on the far border, creating places for themselves in the midst of nowhere as far as possible from any other humans.

Should we then be surprised when centuries later our suburban generations feel isolated and disconnected? When our cities are spreading out instead of coming together and distance rather than closeness is a common trait of the American urban landscape, should we really be surprised if people feel lonely even in a middle of a crowd, and alienated from not only the others but from themselves? And if that is so, what is it left?

The way of a reservoir dog, of a natural-born killer, always ready to kill the common Bill, in an impeccably told pulp fiction: and that is, sadly enough, our daily bread!

© Copyright Adrian Preda, M.D.

Monday, August 13, 2012

to Charge ahead Relentless to Cross that Finish Line

to you 
fellow Olympians
we say

this rare
in this day and age
opportunity to witness 

explain this to me

in the 400 relay
 I cheered 
for a man with artificial legs rather than for my home team  
Or do you know that I got misty eyes 
when I learnt about women 
for the first time 
in the history of a country 
with countrymen mad at a woman bravery

My wife pointed to me 
that I would choose to rewind some
to see a flawless performance leading to gold
perfection matters

but then I would rewind
time and again
time and again
to see an athlete 
fall or fault

how cruel she said
you like to see them down

No I said
I like to see them fly

stand up
with Fiery eyes 
pursed lips 
clenched jaws
gushing blood out of open wounds
time and again
time and again
to Charge ahead
to Cross that Finish Line

to give a heartfelt hug 
to say
"well done" 
and mean it
to those
who took away
your children's chance to chant
the Medal song

spine shattered
spirit unbroken
still  bowing graciously
like sunshine in the rain

smiling with eyes
full of tears 
of pain

not for a medal 
but just
to cross that finish line

to you 
Olympian Gods
descended upon us
once in four years
I bow

I raise my cup


© Copyright Adrian Preda, M.D.