Psychiatry & Psychotherapy Podcast - The Encouraged Suicide of Conrad Roy by Michelle Carter

Episode Date: October 18, 2022

In this episode, Dr. Corrin Pelini and Dr. Michael Cummings join the podcast to discuss the documentary involving the 2014 case involving Michelle Carter and Conrad Roy, both teenagers at the time in Massachusetts. The state of Massachusetts investigated the suicide of Conrad and filed a charge of involuntary manslaughter against Michelle. We discuss our views on the documentary as well as possible treatments that could have been used. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CME while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds.

All right, welcome back to the podcast. I am joined today with... Dr. Cummings and Dr. Corrin Polini. And Corinne and I have been having a discussion for a couple weeks about a very interesting documentary. Corinne, do you want to kind of open it up a little bit? Yeah, sure. So yeah, I have listened to the podcast for a long time since I was a medical student. Now I'm a PGI-1 in psychiatry.

and I would just like to make a quick disclosure. Anything I say statements made, opinions are representative of myself and not my employer. But anyway, so I heard about this show that came out a couple months ago called The Girl from Plainville. And Elle Fanning, a popular actress was in it. So I figured I would give it a shot, watch the show. And it was all about Michelle Carter and Conrad Roy. and the phenomenon that happened a couple years ago that, you know, hit the national news pretty big, where he died by suicide and she was texting him, saying encouraging things. So I found it fascinating,

and I wanted to get a little bit better of a grip on what happened, not in the potentially sensationalized sense, but, you know, what actually took place, given these are true events that happened. So there's a documentary called I Love You Now Die. I believe it's on HBO Max that I watched that, you know, delved into the events that took place a little bit more, gave a little bit more information about the trial testimonies that were said by witnesses, expert witnesses, and the like. And I had a lot of questions about things that were made or statements that were made and things that were said. So I reached out to Dr. Puter and said, you know, I think this would make a really interesting episode with like productive discussion and and relevant things

in modern psychiatry. So yeah, that's kind of how we got here. Yeah. And just just for anyone else who is thinking about emailing me in a similar way, you did a lot of work summarizing the key points, putting things in quotes that were interesting and really kind of helped it take shape. So I'm going to be calling on you a lot to kind of take us through the story. I ended up watching the documentary this morning at like 4 in the morning and found it really interesting. And I have not seen the full sort of Hulu show after I realized it was going to be 10 hours this morning. I decided to go with the documentary instead. But one of the interesting things that we're going to discuss is the forensic aspects of the case.

And then also the defendant's lawyer hired this psychiatrist, Dr. Peter Briggins, I might be saying that wrong, who is very anti-psychiatry and he made a lot of very sort of strong statements that, you know, as a PGY one, you're like, wait, what a minute? Like, do SSRIs really do that? And so we'll talk about some of the statements he made and kind of where we think the science is most accurately. So, yeah, where do you want to start, Corinne, with this discussion? I mean, I could, I could kind of read over the summary that I sent you in my email that kind of goes over the events that transpired. If you think that would be helpful. I think that would be helpful to get our audience up to speed. Yeah. I have it right here.

So this all started between the defendant, Michelle Carter, and Conrad Roy. He was actually not, you know, his family did not prosecute her. It was actually the state of Massachusetts that did. But he is the victim that was involved. They had a almost entirely virtual relationship. They met on a vacation. my understanding is they met on a vacation and then kept their relationship going through thousands and thousands and thousands of text messages.

I think they only met in person a handful of times, but it became this very intense relationship. And both parties had a history of mental illness. Conrad, I don't want to speak too much on his behalf because I don't know him or his, you know, history personally. We can we can We can sort of say This is what we heard in the documentary

Or this is what supposedly was revealed in the court case You know it was revealed that he had been on Several antidepressants And then he had been had suicide attempts One by acetaminophen That sort of predated Him having this text relationship with Michelle Carter Is that how you would summarize it?

Yes I agree Yeah all of those things took place. He had a psychiatric hospital stay after his intentional overdose on acetaminophen. That all predates Michelle Carter. And then she, my understanding is that she also had a history with an eating disorder. It's unclear exactly what it consisted of. One place that anorexia and others had binge eating disorder.

But she had received treatment for that as well and had been on both fluoxetine and then switched to select. and was on Selexa at the time that these events transpired. And I believe that was the same SSRI that Conrad was on as well. So they had this relationship through text and Conrad confided in Michelle about suicidal thoughts that he had been having. And this went on for months and months and months. And I believe initially she told him how much she loved him and was supportive of him. You know, your family loves you. I love you. Don't do that. But as time-law, went on, the evidence in the text messages showed that she became very supportive of that and made suggestions for him to die by suicide like drinking bleach. You can do all these various things

and was very encouraging of him. And every time that he would say, yeah, I haven't done that yet. Maybe I'll do it tomorrow. She became very upset and was like, no, you need to do this now. And eventually what ended up happening was he got some kind of an engine and put it in the backseat of his truck and sat in his truck with it running to die by carbon monoxide poisoning. And he got out of the truck and called Michelle and was like, I don't know if I can do this. And there's no record of what was said on the phone call, but she did send a text that alleged she told him to get back in the truck. She sent that to a friend of hers. So he did get back in the truck and ultimately ended up dying. Yeah, so let me read the text.

So she sent a text to a friend Sam, and she said, Sam, his death is my fault. Like, honestly, I could have stopped him. I was on the phone with him, and he got out of the car because it was working, and he was scared. And I fucking told him to get back in Sam, end quote. So keep going. Yeah.

Yeah, that text is ultimately. what led to her being convicted of involuntary manslaughter. So the state of Massachusetts, formerly it was the Commonwealth of Massachusetts, looked into this case and ultimately decided to go forward with interviewing Michelle, investigating her involvement in this, and it became this large case that went to court.

And actually, it was not a jury trial. The judge was the ultimate decision maker in terms of the verdict. And she decided to forgo her right to testify. She did not go on the stand. She did not make any statement. She was just present every day. But there were multiple people that did go on the stand, peers of hers, family members of hers and Conrad's. And then as we'll get into, there was an expert witness, Dr. Peter Bregan, that did go on the stand for the defense on why Michelle Carter should not be held liable. for these charges. But ultimately the judge did decide that she was convicted of involuntary manslaughter, and she went to jail for, I believe, 15 months. And she has on a five-year probation. And she's out now. Yeah. Yes. And I guess she had good behavior, which got her out a little bit early. Yes, that's my understanding as well. Yeah. And so interestingly, Peter Briggins did not actually interview her. So he was there to defend her, but never actually interviewed her,

took, you know, did what was necessary to form a diagnosis. Like, officially as a psychiatrist, we can't diagnose someone that we haven't done a history and physical on. Yet it seems like he comes to some diagnostic conclusions based purely on the text messages. And what do you heard about the case? I'd comment on that. The American Psychiatric Association holds it to be unethical to make a diagnosis absent actually examining the individual in question. I'm primarily a psychopharmacologist, but I'm also certified in forensic psychiatry.

And frankly, Dr. Briggins is not reflective of the typical psychiatric expert witness. Although we may be hired by the defense or by the prosecution or appointed by the judge, we're not working for any of those people. Our job is to essentially educate the trier of fact with respect to data relevant to the trial. Dr. Breggins frankly was functioning as what, has termed a hired gun. Yeah, so he's, so he was, he was supporting a narrative that would make her less culpable

of doing this in a clear mind. And so do you want to talk about that, Corin at all, like go through? Sure. Yeah, so I, you know, looked into Dr. Peter Breggen a little bit after just to get an idea of who he was as a psychiatrist, because it seems like he has a lot of contributions to the field. He has a history of being an expert witness in a lot of cases similar to this one, where he testifies on behalf of psychotropic medications, creating a situation where the individual doesn't have intent for their actions and should not be held liable. And what I found is he's

very cautious, I guess, in terms of the use of psychotropic medications. He feels, that they are altering of cognitive function and more ways than one and advises against their use. That's my understanding of his take. I think that's very generous. I would say he's not just cautious. He's like probably one of the most, he has the one of the most negative views on psychiatric medications I've ever heard. But, you know, he has a book and half of the book is like,

here's how every single med is damaging, and then the second half is here's how you detox off the meds. Yeah, I looked into some of these presentations that he's given earlier, and he uses terms like a chemical lobotomy to describe the use of antipsychotics, and he goes into other medications as well. It's interesting. So in this particular case, he calls it an involuntary intoxication. Those are the words he uses to describe what was going on in her. And he says, it's an intoxication, impulsivity, impaired judgment.

She was involuntarily intoxicated. So this is her being on an SSRI, a serotonin reuptake inhibitor. She was taking Prozac and then switched to Calexa. So he describes, like anyone in a hypomanic state, she gets very angry when she gets disrupted.

She texts things like, when are you going to do it? She keeps texting him. She says, text like, yeah, it's less suspicious. You won't think about it much, you know, and you'll get it over with instead of waiting until the night. So she keeps pushing him to do it earlier in the day. So he uses this kind of like argument about her. saying that she was hypomanic, that she was involuntarily intoxicated with this medication.

So that's what we'll be talking about. Dr. Cummings, thoughts on that? There is no evidence that SSRI's cytopram, trade name Selexa, causes an acute intoxication. It does cause adverse effects in some people, can increase gendariness and anxiety during the early stages of treatment. And I sent you an article regarding that.

And it also can, of course, in people with bipolar illness or vulnerable to a bipolar diathesis, increase the rate of cycling, and also cause acute switches into hypomania or mania, as all the antidepressants can. he's using the term involuntary intoxication in a way that is not consistent with its meaning in the legal system. I also sent you a case called Montana v. Egelhoff, which concerns voluntary intoxication. Intoxication from a legal standpoint is essentially an acute response to a medication or substance, that impairs the person's judgment, level of alertness. I think most people are familiar, for example, with acute alcohol intoxication,

acute stimulant intoxication, as in methamphetamine. The SSRIs don't do anything like that. People are still able to function. They're still able to think. They're able to exercise judgment. There's no evidence that they call something similar to an acute intoxication. The FDA did issue a class warning for increased suicidal ideation.

Frankly, they attempted to do that because they wanted people not to give individuals in SSRI and then say, I'll see you in four or six weeks. They wanted a sooner follow-up because, indeed, in treating depression, the neurovegetative signs improve before the mood does, which puts people at increased risk of acting on a still negative mood. So there are cautions with these medications, but they are not neurotoxic. I think Dr. Briggins characterizes them as an insult to the brain and describes them essentially as causing deterioration of the brain.

That stands in stark contrast to a very comprehensive review done by the National Institutes, of mental health published in 2009, that instead finds that, for the most part, psychiatric medications produce neurotrophic and neuroprotective effects. Yeah. So there's studies that show it increases brain-derived neurotropho factor, which is like miracle growth for the brain. You know, like it causes new sprouting of neurons, neurogenesis, in his sort of discussion on this, he talks about how these SSRIs take away all serotonin from the brain. I think he kind of uses extreme words like that. Is that right, Corrin? No, that's frankly, entirely incorrect. He also makes the error of calling the serotonin re-uptake

transporter. The target of the SSRI is a receptor. It isn't. It's a transport pump. And essentially, the effect of the SSRI is to slow that pump so that serotonin remains in the synapse longer than it would otherwise. He correctly describes downregulation of post-synaptic receptors. However, this is down-regulation of receptors that were inappropriately upregulated. So it's a return to homeostasis. The rest of the cascade involves then increase of a number of. of second messengers inside the neurons, which in turn triggers a number of transcription controlling segments of DNA to start producing more cell elements, produce greater growth

factors, as you alluded to. That's hardly a neurotoxic response. And actually, the amount of serotonin available in a synapse increases, it doesn't decrease. Does it long-term decrease, though? Like, is there any reduction? No, it does not. Corny, I know you looked into some research papers on this. What did you find? Yeah, I looked into it, and I will be honest, the literature that I found is kind of all

over the place, very conflicting with each other. So I think what I was looking into was levels of serotonin in the brain upon initiation of an SSRI in the short term and the long term. And I kind of found all sorts of different results. Some studies found that you initially see an increase, but then over time you start to see a decrease and they were measured serotonin levels in tissues and in the hippocampus in various areas. For example, one article by it was in the European. the Journal of Pharmacology said that serotonin levels initially increased, but then three to four weeks later decrease, and the changes may relate to a desensitization of the serotonin 1A auto receptor. That was something that seemed to be pretty widely accepted across the articles that I read.

Can you comment on that a little, Dr. Cumming? Yes. What's being described here, though, is not a pathologic decrease. it is part of the return of serotonin signal to homeostasis over time. That's not a toxic process. The way Dr. Breggins describes it, it's as if the SSRI suddenly depletes the brain of all serotonin. Well, that's simply not true. It initially increases serotonin.

There are post-synaptic and pre-synaptic addicts. that then bring the serotonin signaling back to homeostasis over several weeks. That likely is part and parcel of the recovery process. Okay. Something else that I wanted to mention, and I think this topic in general or what I found in general kind of encompasses how I feel about the research that I found. There was an article talking about how patients with major depressive disorder that have a mutation in tryptophanhydroxylase 2, which is the rate limiting enzyme in serotonin synthesis.

In those in that, with that mutation, had up to an 80% reduction in serotonin synthesis and tissue levels. And it affected their ability to respond to certain SSRI. Specifically, they looked at fluoxetine and peroxitine. So I feel like my opinion on everything that I found is that, you know, you have all these individuals with certain mutations. and you can't generalize these ideas of it's going to deplete serotonin for everybody or, you know, it just seems everything that I heard Dr. Breggen say seemed too generalized to the entire population.

I feel like everyone responds to these medications very differently based on their genetics. So it's kind of hard for him. Yes. Yeah, that's exactly correct. There are people who indeed do not tolerate or do not respond to an SSRI. which is why it's fortunate there are other classes of antidepressant. But that's still a long way from Dr. Breggins characterizing these medications essentially as toxins, especially given the comprehensive data summarized by the National Institute of Mental Health,

which found that on the whole, not only the antidepressants, but the mood stabilizers and the antipsychotics, improve the functioning and anatomical state of neural circuits and in animal studies even are protective in the context of acute brain injury. That certainly does not sound like a toxin. Yeah, and it's like, you know, there's a saying death protest too much, you know? It's like in one TikTok, I watched him go through, every single medication class and all the issues that that happened with each one.

And I could, you know, I've read studies that contradict, and we've done episodes that contradict a lot of the points. Like he says like lithium is like neurotoxic and people on lithium for a super long time. It's like very, very, you know, damaging to your brain. And, you know, we've done episodes on how lithium is actually neurogenerative and people with bipolar who are on it for a long time, it's actually really helpful. Any comments on that, Dr. Cummings? Yeah, as we've talked about, several times, lithium appears to be one of the most

neurotrophic substances out there. And, you know, to back up a bit, I'm certainly not a proponent of saying that everyone should be on psychiatric medications. However, these medications do offer benefits, including neurotrophic benefits, for people with brain diseases. We're still a long way from where we need to be in terms of the effectiveness of medications, but they are, on the whole, very positive for the vast majority of patients. Yeah. Yeah, and I think, you know, he made home make other comments, like people on,

antipsychotics, you know, have higher risk of diabetes, which is like, okay, people on atypical antipsychotics, that's true. But then he'll go on to say, and their brains shrivel up on the antipsychotics and they die 20 years earlier than the average person. Dr. Cummings? Well, that to some extent is true. However, he's ignoring the fact that people with schizophrenia are suffering from essentially a developmental dementia, which is characterized by loss of synapses, loss of neurons. They do die on average about 20 years sooner, but that appears to be from the illness, not from the medications.

He's essentially engaging in blaming the medication for an illness and the effects of that illness, which is a complete mischaracterization. The vast majority of imaging studies illustrate that the brain does undergo atrophy and negative changes during schizophrenia. However, the antipsychotics tend to slow that deterioration of the brain and in some cases actually promote some degree of recovery. I'll be not what we would like to see. So, you know, I think this is a case of trying to blame the medications for everything else.

And, in fact, with respect to this legal case, you know, although this young woman encouraged her boyfriend to commit suicide over months and months and months and months, made multiple suggestions, obviously engaged in planning of ways he could kill himself. Dr. Bregans basically wants to say, well, it was all the pill controlling her. It was making her think these things. Well, that's a bit of nonsense. That's like, oh, the devil made me do it. Right. And I think this idea of involuntary intoxication, like, imagine, you know, you were given a high dose of, like, methamphetamine, and alcohol against your will. And then on those, and PCP,

and on that cocktail of medications, drugs, you went out and committed some crime. Like that would be an involuntary intoxication. Yes. Yeah, the legal terms are voluntary intoxication, which has been found not to be exculpatory based on the legal theory that when you took that first drink, or you use that first hit of drug,

the drug was not yet affecting you, so you made that choice volitionally. Involuntary intoxication results when the person either through lack of knowledge, they didn't know the drug was in the cup of coffee they were having, or through coercion, was forced to be intoxicated against their will, that can be exculpated.

in terms of either diminished capacity or an outright insanity defense, depending on the effect of the substances involved. Right. So it's hard to, like, when you look at her texts, personally, in someone who's manic, it's like, do they have the ability to reason and have conversations? where they're not seen as abnormal, you know? Or if someone is in a true manic episode, would it be more obvious?

Now, I don't want to say whether she was in a manic episode or not, because I've never done the history. But hypothetically, when someone is in a manic episode. Apparently, neither did Dr. Bregans. What do you mean? Well, by his own admission, he never examined this individual, Miss Carter. but he asserts that she was hypomanic, essentially reasoning backward that because she got irritable

when her boyfriend failed to follow her instructions, therefore she was hypomanic. I don't believe that everyone who is irritable suffers from bipolar illness, and I don't believe you can make the diagnosis by that sort of reasoning. Yeah. Yeah, and I think that it's, okay, let's step back and talk a little bit about, like, if someone is under the influence of, let's say, something that lowers their total brain function.

Like, how much does the legal, how much is their legal precedence to be more lenient towards that person? There's a doctrine in the law called diminished capacity, which is, a lesser standard than insanity. In order in most jurisdictions to be found insane, you have to be suffering from a mental disease defect or disorder. That's first requirement. So there has to be something wrong with the way your brain is functioning. And that has to render you unable to know what you were doing. You were strangling somebody, but you thought you were squeezing oranges. Or if you did know what you were doing, you lack the capacity. to know that it was right or wrong.

That's a fairly high bar to reach. Diminished capacity says, okay, you don't have to be that thoroughly mentally unable to function. If you're mentally impaired, however, to the point that you really can't form intent to commit a crime, to bring it back to this case, for example,

one of the reason she was not likely charged with a voluntary manslaughter is to voluntarily kill somebody implies a higher level of intent than if their death results involuntarily. And if you want to raise it even further, in order to be successfully convicted of first degree murder, you have to form malice of forethought, meaning you sat down and thought, I don't like this person. I'm going to plan to kill them. You have to be able to form that intent and be mentally intact enough to make such plans in order to be convicted of first-degree murder. In her case, the legal system said, well, we think there was some form of impairment, and it may have been sufficient to make this involuntary manslaughter rather than something with a greater degree of punishment.

So the law does, now in California, we did away with diminished capacity after the Dan White case and the murderer of Dan White and Mayor Moscone and San Francisco. California has a different variant of that called diminished actuality, which is much more restrictive. The person can't have sort of a general impairment in volitional capacity. They have to have a very specific lack of ability to form intent. I think one of the sort of larger global things that I've seen that relate to this case that I'd be curious, your thoughts on maybe to create a discussion around are, or is the recent change in Canada where now they're allowing for people with mental illness to have like physician-assisted suicide? Any thoughts on that, Dr. Cummings?

It's going to be a very difficult area. Clearly physical illnesses have been a more an easier area to deal with in this. That is, if you have somebody who is mentally intact, but are facing a terminal illness in which they have essentially rational reasons for wanting to end their life sooner. A number of jurisdictions, including California, have basically said, yes, that is a possible area in which a physician could assist them in killing themselves. The difficulty, of course, with somebody suffering from a mental illness who wants, wants physician-assisted suicide, is it is very difficult to know to what extent the mental

illness is impairing their ability to rationally decide that this is their best course of action. Personally, I would have a great deal of reservation about concluding that the person's volitional capacity was adequately intact to make that as a rational decision. I would agree with you there. And I think also this listener who reached out to me about this and was very concerned about this expressed how resources are actually very hard to get sometimes. And so a lot of the treatments that we would now consider for treatment-resistant depression are actually very, very difficult to get.

Like, for example, ketamine treatment or even, T, you know, so it's like if it's both really hard to get the treatments because there may be a lot more people that need it than there's resources to give it. And you have a government that's saying, yes, we agree with physician assisted suicide. And you put those two things together. It can be very, it can seem very dire to people who are not wanting this to move forward. Any thoughts on that? Yes, it is a potentially very dangerous situation in which essentially the, state is saying, well, if treatment's inconvenient, yes, you can go ahead and terminate your life,

and it'll be easier for us because then we don't have to provide the resources. That's a very dangerous position to take. Yeah, I think capacity, you know, when we do like capacity evals, you know, does someone have the capacity to make a decision? if they are depressed can that take away someone's capacity to make a decision at least the way that I understand it is it can

yes yeah it can basically there is a what amounts to a sliding scale in terms of capacity if the decision that's being contemplated has very little potential negative consequence

capacity doesn't have to be very high on the other hand if the person is about to make a decision which could be life-ending then they need very stellar capacity capacity has essentially four elements the person has to be able to receive relevant information i if i give you this it's going to kill you they have to be able to apply that to their own case and then logically deliberate whether that's the right decision. Where the mental illness tends to interfere is in that step. Can the person logically deliberate truly what is best for them if they are feeling depressed and hopeless and the future looks entirely bleak?

The answer in most cases, is probably no, they're not in a mental state to take a neutral view at what would be best for them. Yeah. And I think this comes back to coming back to this case with Conrad Roy, as I kind of saw this documentary and imagined him to be my patient, a patient could have very little hope at times that things would get better, that their future will seem bleak. they will seem like the only out they can possibly have is to commit suicide. I imagined also what that would be like for Michelle Carter to hear that. And to imagine that, yes, okay, I'm going to believe that narrative that the best thing for this guy is to actually die. Like, that's what he really wants.

And unlike having experience working with hundreds of people who have been, in that situation of climbed out and, you know, had lives worth that they loved living afterwards. It's like she didn't have that perspective. And so she kind of just went in with the narrative that actually what is best for him is to help him die. And so if I'm the most empathic, I can possibly be to her and to her situation, it would be to give her that narrative that, like, with her limited understanding as a 17-year-old

girl, she thought that this would be, you know, sort of the solution to his problems, whereas she didn't have perspective. I don't know. Any thoughts on that, Corin? I want to pull you into the conversation here a little bit. Sure. I mean, I have the exact same thought process, you know, if I'm going to really try to put myself in her shoes and understanding where she came from, which really, unless you know

her personally, we'll never know. She didn't testify. She didn't talk to Dr. Preggen, who testified on her behalf. you know, we don't really know what her thoughts were throughout this, but benefit of the doubt, maybe she just felt like, you know, after talking to him for months, his suffering will never improve. And the best way to end his suffering is to allow him to make this decision that he wants to make by dying by suicide.

And then another kind of aspect to go along with that is people describe her as wanting to be there for people, be very helpful. Maybe in her mind she was able to, think this is the way that I can be there for him. I can support his family once this transpires. She was very adamant about that. She was in constant contact with Conrad Roy's mother after he passed. And so maybe it was just something that she could feel fulfilled about, whether she was aware of that or not.

Yeah, it was one of the interesting things about this case that I observed was that but the time he got to the point of committing suicide, she was much less ambivalent about suicide than he was. That is, he was undecided, and at one point obviously got out of the car and was having reservations about going through with committing suicide. Her texts don't appear to reflect any reservations at that point at all. Right.

And she had two, 40, around 45 minute conversations with him at that time. That was what was in the phone record. And we don't have any idea of what transpired during those phone calls, except for when she said that to her friend later that she had encouraged him to get back in the car. And so it seems like she was very, very sure where he still had ambivalence. I like how you put that, Dr. Cummings. Yeah.

And one other piece of this that kind of was interested in me was that at one point he demands of her to never share that he was suicidal. And it was almost like she had this special place of connection with him having this discussion. Like I am, I am, you know, Michelle Carter, the one to bear this sort of special place in his life where he can come to. to me and I will never share it with anyone else. And I think that that was alluring to her. And it kind of describes her throughout the documentary as desiring connection with other people and really struggling to gain connection with other people. And so I see a lot of youth that they gain this connection with other people through illness and through, you know, common mental illness. And sometimes it can be not as helpful because it's like then they focus on it

and focus on it and it's like that's how they're getting this sort of connection whereas they're not focusing on the things that make them unique as people that make them you know the desires for their future the the strengths that they have go ahead corn i know you yeah to add to that um it's i think it's a similar reasoning but it manifested differently she actually in the days before he got in the car and ended up dying she reached out to her friends and said Conrad's gone missing. I haven't heard from him. I'm going to text his mom, see what's going on.

But she was still actively talking to him and encouraging him to guy by suicide throughout those days. And it was very bizarre. And similar to you, Dr. Peter, I think the way that I kind of thought about that was this desire for connection. You know, maybe she knew that it was getting close and it was coming.

And so she reached out to these friends, of hers that, you know, they weren't really good friends. She didn't spend much time with them. She really desired friendship with these people, I should say. And so maybe it was, you know, creating that connection of she's scared so they can be there for her. They went over to her house to support her. She was very appreciative of that. This is all manifested or it all is evident through the text messages. So I think it's the same kind of thing, you know, wanting connections with these people in various ways. So she'll try to create it as much as she can. Yeah, which is at the heart of like a factitious disorder too, you know, where I'm going to create a narrative about myself, about my struggles that allows me to get connection with other people that otherwise I wouldn't be able to get connection with. I think just with my patients who I'm concerned that they get connection and illness, I'll tell them like, look, you can come to see me as long as you want. Like, you can, you don't have to have severe depression to see me.

And sometimes that's like, oh, and with other people, I'll start to just focus more and more on the positive going on in their life. You know, if they have a sport that they're good at. Like, I may spend a lot of time focusing on the positive stuff rather than illness, which maybe allowed them connection with doctors in the past. So I think it's really important as mental health professionals to kind of like gain connection with the real person with their strengths, their goals, their. desires, not just their negative affects. Okay, Dr. Cummings, go ahead. I see you on. Yeah, I agree with that.

I think this is a case of, at least the impression I had from reading her, many of her texts, was that this is a person who desperately wanted to be connected to others, but it was a desire essentially for a pathologic form of connection in which things were based on negativity, bad outcome, rather than anything positive. Yeah. You know, there's multiple sort of text threads that are coming through my mind on like, you know, at one point she was like wanting to name her future kid after him.

And she was like, I'm hoping it's yours, you know? Right? Are you remember that, Corrin? Yeah, I remember. There were so many, you know, confounding statements of, you know, I'm going to help you get to the point where you do this. You die by suicide. But then the next message will be, you know, I want my future children to be yours. It really was so back and forth. Yeah. Or like she would make references to Romeo and Juliet or there was references to the glee character that was dating the guy in real life that ended up committing suicide. So she would text him some quotes that she had the TV character towards the other TV male character that ended up committing suicide. So there were some parallels there that were kind of interesting. Like how much does media or how much just sort of wanting to embody these myths that we watch play into how we kind of have connection, right?

Dr. Cummings, any further thoughts on this? I want to... I think just to come back around to the point that it can be very dangerous for people if their only form of connection with others is based on negative perception and negative wishes, and there does need to be greater emphasis on people pursuing the positive in their lives. I mean, to put it bluntly, life is hard. That's just the nature of life. But I think if people dwell on the negative, it's very easy for people to slip into hopelessness that puts them at risk of greater pathology

and ultimately at greater risk of self-harm. That needs to be countered by more positive involvement. Yeah, that's good. You know, and in some partial programs, they have rules. Like, you can't be friends outside of the partial programs. program. I, you know, having followed patients for a while after partial programs, sometimes see them become friends and then their friendships sometimes explode. Sometimes they last, but, you know, it's like, can you have a friendship outside of illness?

Can you have a friendship looking at the positive as well? I think it's really important. Very important. Dr. Cummys, anything from those other articles that you shared with me, you want to just kind of bring out some of the points that you thought were interesting. I could bring up one article at a time and see what you had to see what you wanted to say about it. There was a review article in bipolar disorders in 2003 called Antidepressants in Bipolar Disorder, The Case for Caution. Yes. Essentially, this article, points to the fact that in bipolar illness, antidepressants are generally not beneficial. In essence, they don't help bipolar depression, but put the person at great risk of increased cycling or switches into hypomania or mania.

There is sometimes an overly reflexive response if someone says, I'm depressed, even if they're bipolar for the psychiatrist to reach for a for an antidepressants. The antidepressants are not effective for bipolar depression for the most part. There are a handful of medications that are, and those include lithium, Lomotrogen, lorazidone, interestingly, Premapixel for anergic bipolar depression,

and quatyapine, or actually it's metabolite, norcotapine. But the classic antidepressants are are frankly dangerous in bipolar illness. And then you also mention the effectiveness of adjunctive antidepressant treatment for bipolar depression. This was the 2007 article in the New England Journal of Medicine. Yeah, this was in some ways this was the seminal article that started people looking at this area. And it published New England Journal of Medicine, so it was a top-tier journal.

this study looked at people who were on either lithium or valproic acid primary mood stabilizers with or without an antidepressant. I think they used buproprion was one and an SSRI was the other arm. The people who were not on an antidepressant actually recovered from their bipolar depression faster than the ones who were taking an antidepressant. Yeah. So this is the case where, you know, physician restraint is so important. It's like we could want to do something. And there may be some options outside of antidepressants,

but once you are sure someone is bipolar, it's pretty much 100% to not consider an antidepressant. Would you agree with that? I would agree with that. People don't appreciate just how dangerous the antidepressants can be for the bipolar. patient, as well as being, as illustrated by the New England Journal article, apparently ineffective at benefiting bipolar depression. And then you also shared an article, and we'll share all these articles in the blog article

that will go with this episode at Psychiatrypodcast.com, and you can get that for free. And this article is called The Neurotrophic and Neuroprotective Effects of Psychotropic Agents. Yes, this is the very large... review compilation put together by the National Institutes of Mental Health, published in 2009, which looked at a vast array of animal data as well as human imaging studies, and basically found that on the whole, antidepressants, mood stabilizers, and antipsychotics are neurotrophic. They promote brain growth and development. or neuroprotective, they tend to limit damage to the brain.

I picked this article specifically as a counterpoint to Dr. Breggen's claim that essentially psychiatric meds are toxins. Yeah, this article only has 206 citations, so you should be able to get through all of those citations within a good afternoon. Just choking. Yeah, it's... it's it's it's that you know when I think about someone who's highly intelligent but then comes to their conclusions maybe prematurely in their life without enough openness to allow for future evidence

to dissuade them of something uh they may only look for the evidence that supports their thought process and giving him the benefit of the doubt you know that it's you know i imagine he meets people occasionally who get after get off of antidepressants and they do better or get off of psych meds and do better. And there are those people out there that are on too many meds, polypharmacy, and need less meds for improved cognitive function. And hopefully this podcast gives you a balanced perspective of like, how do you prescribe in a nuanced way that's not overprescribing or under prescribing?

Yeah, something that he said that was very off-putting to me in one of the his videos was if prescribers knew how dangerous these medications were, they wouldn't prescribe them. And the reason that they don't know is because all of their information is coming from the drug companies, which I think is a very unfair thing to say. I'm clearly very fresh in my career, but all the psychiatrists I've worked with thus far, use evidence-based medicine, we look at the literature, you know, to say that all decisions that are made clinically by psychiatrists are fueled by drug companies' information is pretty out there. Yeah, and specifically, you know, I think all three of us have no conflicts of interest.

We don't accept money directly from drug companies. I don't get paid anymore for prescribing one drug over another drug to any of my patients. Unlike a lot of the sort of homeopaths or naturopaths, it's like they have their own line of, you know, supplements that they get patients to sign up for. and the more patients they can get signed up for their supplement lines, the more money they make. So it's not like we have secondary gain in getting people to take certain medications. Actually, I prefer not to do expensive meds just because insurance companies make it very difficult to get prior oaths. And that's one of my biggest pet peeves. but if I feel they need one of the newer meds,

I will do that for patients, but it's like, it's not really in our, you know, I will say, though, that there are some people who go to a lot of drug rep dinners and may be persuaded to prescribe a newer medication, you know? So I think, you know, Dr. Kempis. Psychiatrists can be vulnerable to the new shiny object effect, the new thing on the block.

I'm always very cautious about that. And frankly, although my primary job is being a psychopharmacology consultant, I spend much more time telling people to taper things off rather than add things. My own bias, my own interest is in getting people to carefully think through medication trials and to design an evidence-based rational approach to their patient's illness. because that gives the patient the best odds of a positive result with the least number of adverse effects. I'm the first person to say there is no medication of any kind that has no negative effects. There just is not such a thing.

But that's why to do medicine carefully and always involves a risk-benefit analysis. Are we going to get more benefit out of this medication than risk? And I think that's essentially the only way to have a balanced, nuanced approach to use of medications. Yeah. I think also that the comment like, well, you only think the way that you think because you're persuaded by this organization and there's money there, right? and therefore I'm going to show you what the evidence really says it's there's like a there's a certain level of like I'm not going to I'm not going to pull out the strongest argument for why these things are good I'm going to pull out like a strawman argument and I'm going to blame your

prescribing the way that you do on ignorance which I don't know this is just not the best way to argue in my mind No, it's a very biased form of argument. But, you know, indeed, one of my criticisms of Dr. Breggen's testimony in this case was he was clearly not giving unbiased, balanced testimony to attempt to assist the trier of fact in interpreting the evidence. He was essentially functioning as a hired gun making and what in my view were. questionable to false assertions. Yep. And, you know, I imagine just like money persuades people maybe to prescribe newer meds,

money can make people or can make some, I don't know who, but, you know, you can make good money doing forensic work if that's how you want to bill your hours, I guess. So maybe there's bias there as well that we should be careful to not enter into us. as physicians. How much does a forensic psychiatrist make per hour, Dr. Cummings usually? Depends on the nature of their practice. The top end forensic psychiatrists, the ones who are really good and actually do very careful, very balanced testimony, they're often earning between $3 and $500 now.

Yeah. Okay. Well, kind of wrapping up our time here, Coran, any other questions that are still lingering in your mind that you want to ask why you have Dr. Cummings and me on here? I guess kind of a comment, kind of a question, you know, trying to put myself in Dr. Breggen's shoes, I think the argument that he was trying to make is that he didn't, he wasn't very forthcoming by saying it so concretely. But he, I think he was trying to say there's potential. that maybe Michelle Carter didn't have major depressive disorder. Maybe she was bipolar. She started on Silexa and that predisposed her to affect of switching and becoming manic, which I can understand that that line of thinking, but I just think that it's totally unsupported by the way that things played out by not interviewing her himself. He didn't see her at the time of these events transpiring. I mean, it just doesn't seem supportive to me. So any further comment? on that. Well, and I would agree with your analysis. It is a plausible hypothesis that she is

vulnerable to a bipolar diathesis, but it's a hypothesis not supported by any sort of information or data. I totally. Which, you know, the whole point of giving evidence in court is to provide data supported evidence that will assist the judge or the jury in understanding the evidence, which is why, frankly, his testimony was not effective. It's up to the trier of fact, in this case, the judge, to decide how much credibility a given witness's testimony should be given. Since she was convicted, obviously his testimony did not carry the day. Yeah, I think if I was trying to make the argument from a more scientific perspective that she could have been hypomanic,

I would have looked at the pattern of texting before and then during this scenario. Like, they never compared, like, you know, they could have shown a graph. Like, look, for two years, she's texting at a rate of, like, one per hour. And now she's texting at a rate of, like, one per two minutes, you know, or like, before she was stating she was sleeping fine, and during this period of time, she's stating she's not sleeping fine. Or, you know,

so kind of going through the, like, during this period of time, she did other impulsive things. Like, what were those other impulsive things? During this time, you know, she said grandiose statements, whereas during the past time, you can see no grandiose statements. So I think if I would have wanted to argue for hypomania or mania, I would have tried to look at the actual criteria and then try to

compare before and after in all the communications that they did have, which I didn't see them doing that, which... No, they did not, and indeed that's exactly the sort of data you would need, is what makes you think this person was bipolar, what criteria of the illness did she meet, what evidence do you have that suggests she met those criteria. And that evidence, frankly, should have included a direct evaluation of her as well as an evaluation of all available past medical records.

He did in his testimony. He said that there was a specific day when going through all the text messages. There was a specific day in which he noticed a change in her behavior and said that's when the involuntary intoxication began. I personally didn't see what he was explaining I thought it was kind of a soft argument. And then in the cross-examination, the prosecuting attorney showed texts prior to that day that showed her still encouraging him to go through with this. So I don't think it was as, you know, it was. It was not a

convincing argument. I agree. Very good. Well, in summary, I hope this was a helpful discussion for people. If you haven't watched the documentary, I recommend it. We'll put a link in the article we'll write to all the articles that we spoke about and court cases, other court cases that might relate. And hopefully this stirred up your curiosity to dig deeper into learning about psychiatry and trying to get beyond our bias and looking at the evidence as closely as we can wherever it takes us. All right, we'll leave it there for today. Okay, thank you guys Thank you, guys.