Treating the Mind
August 1, 2018 | By Kimberly Uslin
Omar Manejwala, MD (A93) is an international expert and speaker in the fields of addiction and mental health. He is the author of Craving: Why We Can’t Seem to Get Enough and currently serves as the senior vice president and chief medical officer of Catasys. He is a recipient of the 2018 Award of Merit from the St. John’s College Alumni Association.
What led you to pursue a career in mental health?
When I was at St. John’s, I was torn between studying musicology and medicine. I had been inspired by Bill Pastille and Andre Barbera, who introduced me to musicology as a field of study, and had even met with Carl Schacter at Mannes College of Music for entry into their master’s program. After significant soul searching and a lengthy lunch conversation with Mr. Barbera, I decided to enter medicine with a plan to study surgery, possibly neurosurgery.
During medical school, I experienced a transformative event while rounding on post-surgical patients. I had done two sub-internships in neurosurgery and a research project on the gamma knife, and was already registered in the neurosurgical match (a process where students are matched to residencies). Early one morning, when I was mostly alone examining patients who were comatose, I became aware that I was more attracted to the idea of being a surgeon than the work itself. I realized it was the mind and brain’s function that fascinated me most. Later that morning, I met with the department chair, whose wife was a psychiatrist, and he suggested I discuss it with the dean of student affairs—himself a psychiatrist. Although it was a bit late to be considering a residency change, he helped me with the process of getting another sub-internship—this time in psychiatry.
I still remember the first sentence of my application essay to psychiatric residency: “Madness demands investigation.” I recalled asking questions about insanity when I was exploring the Great Books at St. John’s as well. In the very first book we read, the Iliad, Agamemnon blames his behavior at one point on “madness, blinding ruin.” My favorite composer Franz Schubert, whom I discovered at St. John’s, also struggled with mental illness—which was evident in my all-time favorite composition of his, Winterreise, which is really a story of a winter’s journey into insanity. So the idea of mental illness itself wasn’t new to me. What I discovered was that I wasn’t going to be comfortable or satisfied leaving this phenomenon unexplored. I had to follow this thread.
Why addiction particularly?
I had no intention of practicing addiction medicine; in fact, I avoided it. My experience working in emergency rooms was with people who seemed to be manipulating me and the system to either get drugs or “three hots and a cot." I didn’t understand the illness and how it affects decisions, memory, emotions, and judgment.
Then my best friend at St. John’s died a decade after we graduated. This had a profound impact on me—more than I can convey here. I felt responsible, like I didn’t do nearly enough, and we had fallen out of touch for a few years, which I thought was entirely my fault. At the same time, we had a shortage of addiction doctors where I was living in Charlotte. People had always referred cases to me, but after my friend died, I stopped referring them elsewhere. I started seeing them and their families, and I started listening.
What don’t people know about addiction?
Well, really several things. First, addiction is a treatable condition. Medically, it is considered a disease, and newer thinking suggests it has aspects of a learning disorder. Addiction affects memory, emotions, decision making—really all aspects of how we think, learn and feel. This is evident when we study the brains of people with addiction. There are structural and functional changes in areas of the brain, whether [from] alcoholism or even addictions with no “substance” involved, like gambling addiction. The treatments we use are about as effective as treatments for other chronic conditions like diabetes, COPD, and heart disease. But unlike [people] with those conditions, most people with addiction will not receive care—and for the few that do, most care is short term or “acute” rather than chronic. This leads me to the second point—that addiction is the most stigmatized condition in the world. That stigma is killing people. Imagine if we treated diabetes by saying “we’ll admit you if you are about to die, but we won’t give you insulin after you leave, nutritional counseling or any other support—you are on your own.” And yet, this is, by and large, how we treat addiction. The recent opioid epidemic underscores this, with over 30,000 people dying every year from overdoses. And most people don’t realize that alcohol still kills three times as many as the opioids—nearly 90,000 deaths a year.
We also need to address poverty, isolation, trauma, food insecurity—all the so-called “social determinants” of addiction. Many—but not all—people with addiction also have another mental illness and those need to be treated as well. Long-term support that addresses all the drivers of addiction is needed—biological, psychological, social, and even spiritual. I believe that addiction treatment should be the path of least resistance, not the result of most coercion. When getting help is easier than getting high, things will change.
In what ways did St. John’s prepare you for your career?
It's really difficult to summarize all the ways that my education at St. John’s has helped me. But at its core, the Program is about inquiry—how to approach first questions and those that follow, and about how to connect seemingly unrelated ideas in ways that open up new lines of inquiry. I don’t think in terms of careers. I’ve always viewed work as how we solve problems in the world, and from that lens, I can’t imagine better preparation than St. John’s.
Do you think the St. John's legacy will live on in your family?
At the rate they are going, my boys Adam (7) and Amir (5) may be budding Johnnies. They sure ask more questions than I ever did!