Psychiatric Career and Life-Long Learning: A Conversation with Emily Deans

Emily Deans, MD, is a psychiatrist in private practice. She graduated from UT Southwestern Medical School in 2000, followed by a residency and chief resident position at Harvard Longwood in 2004. She was a clinical instructor in psychiatry at Harvard Medical School for 17 years before stepping down in 2021. She is interested in the impact of nutrition on mood and the intersection of immunology and psychiatry, leading many talks and workshops at the American Psychiatric Association (APA) annual meetings, as well as in Canada, New Zealand, and the UK. She has blogs exploring food, mood, evolution, and health at “Evolutionary Psychiatry” at Psychology Today and Substack.

I’ve followed Dr. Deans’s work online for several years now, and although we may not always see eye to eye, I admire the no-nonsense, clinically-pragmatic attitude she brings to discussions about psychiatry. She also strikes me as someone who exemplifies the spirit of lifelong learning, which, in my opinion, is a particularly important virtue for psychiatric clinicians. In this Q&A we talk about her intellectual development as a psychiatrist and her thoughts on various debates about the profession.

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Aftab: Your medical and psychiatric training was around the turn of the millennium. There was a lot going on in the psychiatric profession at that time. What's your perception of the state of psychiatry in the late 1990s and early 2000s, and the changes you've observed subsequently over the course of your career?

Deans: There were a lot of things about the end of the 90s that were just exciting in general (I graduated medical school in 2000). A new century coming. The song “Right Here Right Now” by Jesus Jones is such a great insight into what a lot of people were feeling in the US. The Cold War was over, we had highly effective anti-retroviral medications for AIDS, and most of the infectious diseases that killed us in the 19th and early 20th centuries had been vanquished with vaccines and water treatment. The 90s were designated the “Decade of the Brain” by President Bush senior. Stephen Stahl started his Neuroscience Education Institute and there was the idea that you could tune the neurotransmitters with a tweak here and a push there and take care of resistant depression and psychosis and all the problems that plagued psychiatry for over a century. Granted, I was a very young psychiatrist at the time to buy a little bit into these ideas... psychotherapy as a discipline was still in a war between the psychodynamic vs cognitive behavioral frameworks, but it felt a little like it was coming all together.

At the same time, though, managed care was deep into defunding psychiatry, and psychiatric units were closing right and left. I was at Harvard Longwood and a newspaper article came out saying our major training hospital unit was closing and we would have to train somewhere else when I was still an intern. They closed two of three inpatient units at the main hospital, but not surprisingly, extra psychiatric help is always needed, and we didn't run out of places to train. 9/11 happened when I was on emergency psych coverage as a second year resident, and that pretty much doused all of our cultural optimism for a while. In the early 2000s a lot of data and news coverage came out telling us what the wise and more experienced psychiatrists already knew... “Big Pharma” had smothered studies about how SSRIs etc. were ineffective and promoted the studies that they worked. Maybe Stephen Stahl calling a certain medication combination “California Rocket Fuel” wasn’t as exciting as it seemed (and don't get me wrong, I think he’s a great educator infected by the optimism we had back then). We didn't have precise, calibrated instruments to cure depression, anxiety, and psychosis; we had therapy and some chisels and sledgehammers. Were there psychiatric pharma miracles that developed during my training and early attending life? Absolutely. Second generation antipsychotics for depression kept so many people out of the hospital. I did my detox training before Suboxone, we had a 5-day methadone taper then you go home; it was horrible, 95% failure rate, and it was basically a miracle when Suboxone came out. I got my X waiver right away when it came out.

I don't know how much of this was just me gaining real life experience over those early years and getting wiser vs. being oversold on some things by Pharma and whatever Big Psychology is. Therapy is always an interesting comparison because everyone in the business knows people made much, much worse by the wrong therapy or the wrong therapist, but therapy trials don't typically report side effects like med trials do. Also, some people just really aren’t what we call “psychologically-minded” — between you and me, I might be one of those people — I did some therapy with training and I resented it (lol). I am probably just very defensive, but I also have undiagnosed autism in my family so that may be an aspect of it. The best therapy training we had was Leah McCullough’s Short Term Psychodynamic Psychotherapy… She took hundreds of psychotherapy sessions and a bunch of graduate students watching videos and rated what techniques were used vs people getting better. There were limitations, no psychosis, no substance abuse, etc. But with the typical neurotic patient, I still use these techniques every day.

Aftab: Something I'm really interested in talking to you about is the nature of life-long learning as a psychiatrist. How has that played out in your case, and what shape has it taken?

Deans: The promise of psychiatric meds and neurotransmitter tuning falling flat on its face, plus the limitations of psychodynamic and behavioral therapy, left me pretty jaded when I was a young psychiatrist, so I looked for other things. A lot of my colleagues did psychotherapy fellowships, and there is a deep academic tradition there that I respect a great deal but never quite fit me. An obvious direction was alternative medicine, whether it’s yoga, nutrition, or sleep. I read a lot of the lay person books and followed up on the references and found out the books were completely misinterpreting or overinterpreting the references. I decided I could only do this exploration myself and started a blog; this was in 2009, coinciding with the birth of my second child. I had a part time nanny for the first one and the baby was a very good napper, so I had a lot of time to dive in and write as I learned about nutrition and evolution of the brain and all sorts of interesting things (this ended up being the Evolutionary Psychiatry blog at Psychology Today). This is even more true now than it was back then, but there are a million convincing people out there willing to take your money and tell you what you want to hear and that they have the answers. But if you push that all aside there are super interesting aspects of whole foods/non-processed diets and ketogenic diets that intersect with mental health. When you write about these things you also meet the most interesting people and you go to great conferences. If you are interested in psychiatry nutrition you must go to ISNPR. 

Aftab: You've have had a private practice for many years, you've also maintained an academic connection. What sort of cultural differences have you observed when it comes to how psychiatry is practiced in these contexts?

Deans: I have been in group or private practice since 2004. I taught intro to psychiatric practice and interviewing at Harvard Medical School from 2004-2021. Harvard doesn't really hand out assistant professorships so I was technically a Clinical Instructor that whole time, unpaid. I didn't see too many cultural differences between my practice and the academic practice (because we were really teaching very basic interviewing) until recently, when there was a lot of focus on pronouns in the introduction to a patient and some other fairly new cultural changes at the medical school. And in a select population of students and pretty online people I think it's a great way to engage a person and make them feel included and heard. In a general population, you are talking about subjecting people to a grammar pop quiz right off the bat with “what are your preferred pronouns?” (What is a pronoun I haven't thought about that in 20 years? My upper right abdomen is killing me? What are they asking me? I don't know)… I think a much better open and inclusive question is “how would you prefer I address you?” I really don't want to sound like Jeffrey Flier or some of the rigid academics bemoaning freedom of speech and wokeness, it’s really just a recognition that most people don't live online that sometimes young and feisty and well-meaning medical students don't get. When the pandemic came and some personal illness happened, I dropped my academic association and stopped teaching. To be really honest, it wasn't as much fun since students turned in their write-ups online. For so many years, I got a pile of papers I marked up with my red pen and handed back the next week. Once it became online it was a race to address the students turning in their write-ups the morning of our next class and it was expected I had it marked up before class. I sound so crusty! I'm really not. I think the young Harvard students are absolutely amazing and they will change the world.  

Aftab: You've had an interest in nutritional psychiatry, and this is also something you incorporate in your psychiatric work. What does it look like in practice? 

Deans: It really depends on the patient. If they have an interest, we work together on reducing processed foods and maximizing brain foods (seafood, multiple nutrients, omega 3s, zinc, B12, whole foods, reducing processed foods) but on a one to one basis it usually involves simple things like teaching people how to steam vegetables or what are the best seafoods that are easy and not gross. It's so individual. The great thing about being a psychiatrist is that you see patients more often than most other clinicians so we can really work overtime on this if someone is interested.

Aftab: Do you ever meet psychiatric colleagues who are dismissive of your focus on nutritional approaches?

Deans: Psychiatric? Not really? Every year we did a Food and Mood presentation at the APA (5 or 6 years in a row, I can't remember) we had a huge room, people sitting in the aisles, and a crowd going out the door. It’s more of a general medicine skeptical distrust because studies of different nutrients have failed and failed again. Remember vitamin E and dementia? But we learn and study this all wrong… nutritional psychiatry is about recognizing which patients are at high risk of nutritional deficiencies and not ignoring the symptoms of iron deficiency or B12 or B6 deficiency, and knowing the most important brain nutrients (iron, zinc, Omega 3s, creatine, choline, phospholipids, magnesium, B12, B6, folate) and when someone is likely to be deficient. Vegans, elderly people with limited ability to chew and restricted food budgets, post gastric bypass, eating disorders, women with fibroids and lots of bleeding, ulcerative colitis or Crohn’s, celiac, etc. Be suspicious for weakness, shortness of breath on stairs, neuropathy, constipation, restless legs, sores at the corners of the mouth, brain fog, insomnia. Eating and food are big parts of people's lives and cultures and asking about it and knowing what they think about food and slowly steering those who might need some changes to more home cooking and more diversity of eating is easy and has nothing to do with being a dietician and knowing all the percentages and calories they have to know.

Deans: Nutritional psychiatry is about recognizing which patients are at high risk of nutritional deficiencies and not ignoring the symptoms of iron deficiency or B12 or B6 deficiency, and knowing the most important brain nutrients (iron, zinc, Omega 3s, creatine, choline, phospholipids, magnesium, B12, B6, folate) and when someone is likely to be deficient.

Aftab: You have an active online presence. Have you experienced any challenges navigating social media as a psychiatrist?

Deans: I have a few rules I live by. One is that even if I am super pissed off I need to be empathetic. Don't punch down. Never talk about patients (with some very generic unrecognizable educational exceptions explicitly stating this). I also never really wanted to be anonymous because I didn't want any temptations to break one of those rules. If you live with integrity, you are empathetic, you keep the secrets you are pledged to keep, and you are smart then social media is fine and a good way to share med-ed. 

Aftab: Why do you think so many people are angry at psychiatry? This is one of the things that I didn't have much of a visceral appreciation of before I became active on twitter.

Deans: I think this is a basic human evolutionary fear of things they don't understand. Back in the day, all illnesses had people consulting the tribal shaman, who typically lived a little separate from the tribe and wore weird hair or clothes or whatever, and when people discharged their illness, the shaman could take it and expunge it separately from everyone. In time most illnesses became explained and consigned to normal science and doctors, but mental illness was still weird and separate, and if something like tertiary syphilis became explained, it got carved out of psychiatry and relegated to normal medicine. Psychosis is scary. Depression is scary. Psychiatrists are the shamans manifesting the scary consequences of these illnesses. In some ways, this fear and separation from mainstream medicine is helpful, we have more privacy, we have more time. In some ways, you will always be an enemy because psychosis and mania and depression are scary, and we are the living manifestations of that. Also, we are failures sometimes, and people need a scapegoat. A cultural scapegoat is behind the online hate. I just block the provocateurs; I don't have time or interest in it, though I appreciate people like yourself who write up the philosophy of it.

Aftab: What are your thoughts about people who are angry at psychiatry because they’ve had traumatic experiences with psychiatric care (often involuntary), or they’ve have severe/permanent medication adverse effects, such as PSSD or complicated withdrawal, and they’ve felt abandoned by the healthcare system, and have no way to express that frustration other than their online interactions with psychiatrists? I struggle with that. When interactions become hopelessly negative, setting boundaries and disengaging becomes necessary, and I do that as well, but I feel the moral weight of this suffering that I have no meaningful way of diffusing. We are cogs in a machine — this maddening, bureaucratic, indifferent, inefficient healthcare system that we have — and I keep wondering about the responsibility I have to the people whose lives are trampled by the system, a system I am a part of. Do you ever struggle with such things?

Aftab: We are cogs in a machine — this maddening, bureaucratic, indifferent, inefficient healthcare system that we have — and I keep wondering about the responsibility I have to the people whose lives are trampled by the system, a system I am a part of.

Deans: I don't struggle with it. I'm a pragmatist and stoic at heart, and I can only do what I can do, my struggles would not help. I do my best with my own patients to bend over backwards to work with their families to keep them out of the hospital if I can. I hate the current system and how underfunded and backwards inpatient care can be, but I didn't create it. I'm not really in a position to make it better, and I’m not online to accept the hate and disappointment for everyone in the world who had a bad experience. I’m also not in agreement with the total no-conscripted treatment and no ECT folks at all. ECT saves lives with dangerously suicidal, catatonic, and psychotic depressed patients every day. I also have been in the position of being a psychiatrist to patients who I know well when they aren’t psychotic who would not want to be wandering around psychotic for months at a time, spending their money, ruining their lives and relationships and jobs, who would prefer being taken to the hospital and medicated, but the laws and system don't allow us to adhere to the wishes of the patient when they are well (which is the universal ethical stance). I have empathy for universal suffering, but I don't think accepting online bullying will help. If they are abusive I just block.

Aftab: What’s your assessment of the popular controversy around the efficacy of antidepressants? In particular, what do you make of the fact that some of the staunchest critics of antidepressants are academics (some of them psychiatrists) who claim to be upholding rigorous standards of “evidence-based medicine.”

Deans: I think I will default to the high-end academic argument about this, which is… antidepressants work but not as much as we want them to. We discussed some of the history before but any psychiatrist in my position nowadays is working with refractory depression. It goes without saying that the normal antidepressants aren’t working, or they would never see me. My whole job is to ask enough nosy questions to make sure I’m not missing some medical or nutritional or secondary psychiatric medicine miracle the first treaters missed. I’m never the first treater anymore. I’ve seen all the antidepressants fail, but once you get on the right track things go so well.  

Aftab: My motivation behind the question, which didn’t come across very clearly, was to probe your thinking on the dissonance between how clinicians think about efficacy and how certain skeptically oriented researchers think about it. In critical discussions of efficacy, there is often a focus on the magnitude of separation from placebo in RCTs, and the skeptics will say that the degree of separation is marginal or insignificant. It’s a pretty standard arguments for antidepressants at this point, but it also applies, for example, to second generation antipsychotics in the treatment of depression whose separation from placebo in phase 3 trials is pretty underwhelming. Yet, you’ve found them very valuable in your clinical practice, as have many others. Ketamine is a hot topic right now. A large number of people with depression have been treated in ketamine clinics for years, and some people have had great success with it. Yet, if you look at the scientific community, people will say that the trials have methodological problems, there are conflicts of interests, and that based on separation from placebo over several weeks, it is still not clear if ketamine offers anything more than dramatic expectancy effects, in combination with its transient psychoactive effects, in the treatment of depression. I find it dizzying that a treatment can be widely used and found to be valuable by clinicians and patients — and may even be FDA approved and recommended by practice guidelines — yet for researchers to be unpersuaded by the results of available clinical trials. Our casual reliance on characterizing treatments as “evidence-based” seems to gloss over the complexities of reconciling standards of evidence that are good enough for clinical practice, good enough to justify clinical use, vs standards of evidence that are sufficiently rigorous to convince scientific critics.

Deans: When I was in training the newest thing was the Texas antidepressant algorithm. But whenever I looked at my actual patients they didn't quite fit. One did great with an SSRI but side effects made it untenable, but another SSRI worked great. One was really bipolar. One had a tough situation with their boss. And as much as I believe in experience and pattern recognition and psychotherapy for personality disorders you never forget that severely personality disordered patient who caused a stir with the staff and the office manager who turned completely around with a simple med change (this is uncommon compared to the personality disorders who come to you on eight meds and you consider it a success to taper it to three or four). The problem is that clinical depression is an end product caused by a lot of psychological and physical and polygenic and medical problems, and any particular intervention alone (therapy, meds, or anything else) is likely to have a high failure rate. Education about this is important for patients and practitioners. I really try to keep everything in mind, not ignoring vitamin and mineral deficiencies, remembering reactions to other meds. In my experience, catatonia and psychotic depression still need antipsychotics and/or ECT while the severe dysfunction of personality disorders and suicidality seems to work better shunted to the ketamine clinics. Milder cases seem to do well with lithium. Mixed bipolar disorders you start to recognize in the springtime as a pacing, irritable, agitated depressed mood and it responds really well to temporary depakote. Is some of this placebo generated by a transference to my long years of caring for a person and knowing them well? Probably. That's okay though, if they get better. So far as the critics… I don’t treat anyone who doesn't choose to come see me, usually after years of struggling and seeing other people. I try to use as few meds as possible and I'm always open to deprescribing, carefully.

Aftab: Any advice for early career psychiatrists? 

Deans: If the 1990s were the decade of the brain, the 2020s are even more exciting. Nothing is simple, but the brain isn't simple, so that’s not unexpected. Think not just about social and economic aspects of psychiatry, but also nutrition and exercise and all the boring things. You don't need to be a Registered Dietician to recommend good nutrition, you just need to help people recognize poor nutrition and open their horizons to new foods and not miss out on major nutrients with vegan or carnivore diets or whatever people are doing.

Aftab: Thank you!

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