Psychology Today Blogs - Mood Swings

The psychology of ambition

Dr. Nassir Ghaemi — Thu, 21 Aug 2008 21:40:28 -0700

Whenever I visit Walden Pond, I think of the beautiful eulogy that Ralph Waldo Emerson gave upon the passing of Henry David Thoreau. After much praise, Emerson allowed space for some criticism, so uncommon when speaking of the recently deceased; he faulted Thoreau for not trying to do more with his potential: "Had his genius been only contemplative, he had been fitted to his life, but with his energy and practical ability he seemed born for great enterprise and for command; and I so much regret the loss of his rare powers of action, that I cannot help counting it a fault in him that he had no ambition. Wanting this, instead of engineering for all America, he was the captain of a huckleberry-party. Pounding beans is good to the end of empires one of these days; but if, at the end of years, it is still only beans?"

Emerson's eulogy is echoed in his aphorism that you must aim a bit above if you will hit the mark. This healthy ambition, we might say, is needed in young and able persons; more of us achieve less because we fail to try than fail to achieve because we try too hard.

Let's call this Emerson's thesis.

There is another approach to ambition, one I cull from the thoughts of a little-known psychiatrist Elvin Semrad, who once said: "You can achieve whatever you want, as long as you are willing to pay the price." Do you want to be president of the United States? Pay the price: If you put the effort of every living moment into reaching that goal, your chances may not be negligible. (See Clinton, W. J.) Do you want to be a famous writer? Spend every second learning how to write, working on writing, meeting other writers and publishers and agents. Do that for decades on end, and, it is not unlikely that you will become quite the writer. Now let us suppose you also want to take a few vacations, or get married, or have children, or bowl on Sundays....There is the price. What will you need to give up to reach your dream.

I have always had dreams and ambitions; I suppose most blog writers for Psychology Today do also, otherwise they would not make the effort to please and entertain and inform as they do. Most of us, probably, would not mind becoming best-selling authors or some such, taking the fame and the funds that follow. But what price are we willing to pay? In my twenties, I never comprehended the attachments to family that I saw in my father and in so many others whose achievements, though often notable, had never reached the mark of their original ambition. I fancied myself different: I would reach for the gold, not settle for bronze.

Now with the children, I see things differently. Recently my five year old son fell hard off a bike and opened up his chin; thankfully he was not hurt more, but it could have been otherwise. It got me thinking: Suppose Mephistopheles made me an offer - all the fame and fortune I could want, in return for my left arm, or my right arm, or my leg, or a child.... A decade ago, since it was all abstract, I'd think about it; now, I would turn him down on all counts, and count my blessings as I settled at night, beer in hand, to watch famous people on television.

At some point, all ambition has its price. When the price paid exceeds the merits of the prize, then ambition becomes hubris, and the seeker becomes lost. That is when, as Williams James said, ambition becomes nothing but sacrifice to the bitch-goddess Success. Perhaps that is also when Thoreau's example might stand up well, when the simple blessings of living are most deserving of gratitude, and when the youth becomes transformed into a man.

Amphetamines without tears

Dr. Nassir Ghaemi — Sat, 05 Jul 2008 17:50:36 -0700

"You sound like Tom Cruise" a child psychiatrist told me after a lecture. I wished he had said that I looked like Tom Cruise, but oh well.... Since then, I've continued to talk to medical audiences, and with my patients, about what I think are some underappreciated risks with amphetamine stimulants. As a new blog writer, I knew I could not avoid writing about this topic too though I hoped to delay the moment. It didn't take long.

In my last blog post, discussing the pharmaceutical industry and psychiatry, I intimated some concerns about the safety of amphetamines and the concept of ADHD. In ensuing comments, readers requested elaboration. I do so with hesitation, because I expect it will be almost impossible to say anything on this topic without offending someone or without being misunderstood. But since the academic career has its heroic obligations (credit: William James), here goes: (Final caution: I'm sure I'll need more posts to present this fully, so for now I'll focus on amphetamines, later on the ADHD concept)

Recent studies indicate that prescription drugs are the most commonly abused agents in the world. Among such agents are amphetamine stimulants. Since amphetamines do not have a medical withdrawal syndrome, nor fatal overdose risk, many physicians feel comfortable prescribing them (mainly for their primary indication of attention deficit hyperactivity disorder (ADHD) in children and adults). Outside of somewhat disreputable lay circles, the wisdom and safety of these developments are little questioned within medical settings. Yet it may be that amphetamine stimulants are being overprescribed and contribute to the epidemic of prescription drug abuse. It may further be the case that this prescription is especially harmful in children and young adults due to long-term neurobiological deterioration, a slow process which may be overlooked in lieu of the absence of short-term safety risks.

In about a year of lecturing to medical audiences on this topic, I am surprised that they are surprised when informed of the rather extensive animal research literature demonstrating long-term neurobiological risks of amphetamine stimulants. Although the extension of animal data (primarily rats) to humans is not always valid, the potential relevance of such data is widely accepted. Especially if exposed in adolescence or early adulthood, young rodents experience a pattern of neurobiological harm that is consistent with other drugs of abuse (like cocaine) and inconsistent with non-controlled substance prescription psychotropic drugs (like antidepressants or lithium or antipsychotics). This pattern includes the following: decreased functioning of dopaminergic pathways in adulthood, decreased hippocampal size with notable atrophy in long-term follow-up, and increased corticosteroid response to stress. (Translation into English: In rats, amphetamines cause neurons to become smaller and sometimes die, making certain parts of the brain that involve memory smaller. Thus, paradoxically, drugs given for cognitive problems can cause cognitive problems.) Lithium, in contrast, increases hippocampal size over time, decreases long-term depressive and anxiety behaviors, and normalizes the exaggerated corticosteroid response to stress seen in animal models of depression. (Translation: Lithium, which most people view negatively, keeps the brain alive longer and prevents neurons from dying. Another paradox: A drug that is seen as toxic in fact may improve cognition over time). There are not, in contrast, safety studies with five years or longer follow-up that demonstrate that such evidence of neurobiological harm is absent in humans given amphetamines. It is also interesting that in rat models, early exposure to amphetamines leads to increased depressive and anxiety behaviors in adulthood; the commonly discussed "comorbidity" of ADHD with mood and anxiety disorders could perhaps be reconsidered as possible stimulant-induced worsening of mood or anxiety symptoms.

That is my concern. (I published some references in a recent review paper in the journal Current Psychiatry, June 2007 issue, here. If I have missed relevant research studies that counter what I describe above, I would be glad to know of them.) Here are some of the printable responses I have heard: 1. "You cannot conclude from rat studies that these drugs hurt humans." True. But we draw such conclusions with many other drugs; in fact, such effects have led to other drugs never making it to the US market (due to rejection by FDA). In contrast, antidepressants have beneficial effects in rat brain studies, which many have touted in support of their use. (Their benefits in primates and humans is much less established). 2. "These effects may exist in animals, but they are far outweighed by the clinical benefits shown in human studies." This may be somewhat true in childhood ADHD, but even those studies are mainly short-term; whether the long-term benefits of amphetamines outweigh their long-term risks has not been shown because these kinds of neurobiological studies have not been conducted in humans with long-term exposure. Further, other non-amphetatamine drugs (like bupropion), which have no animal evidence of neurobiological harm, have been shown to have benefits in childhood ADHD. Lastly, the efficacy literature of amphetamines in adult ADHD, with which the possibility of harm might be outweighed, is much more limited than in children. 3. "Ritalin (methylphenidate) and its cognates (Adderall etc) is not an amphetamine and thus should not have these risks." Wrong. These studies were conducted with methylphenidate and show it to have similar risks to other amphetamines. (Standard pharmacy texts class it as "amphetamine-like").

I do not conclude that every child should come off ritalin, nor that Scientology has it right, nor that Tom Cruise should write a textbook of psychiatry. I do think that our profession has tended to ignore some biological realities. George Orwell once said that truth becomes untruth if uttered by your enemy: we need to stop suspecting all who critique amphetamines or ADHD simply because some may do so irresponsibly. I also think that this whole class of controlled substance has been too "grandfathered": if drugs with these effects in animal studies were proposed today, they would be highly unlikely to make it to the marketplace. Instead, since doctors have been using amphetamines since the 1930s - they are the earliest psychotropic drugs of the modern era (called "mood stabilizers" back then) - we are comfortable with them, despite their weaknesses. In my view, we should be more cautious in using these agents, trying non-drug interventions for ADHD first, and then using amphetamines mainly short-term. Even if amphetamines were as effective as many claim, these long-term safety concerns cannot be dismissed without further study. And for those who would rather keep using them until they are proven harmful, some lessons in medical history may help, showing how that kind of attitude has led to major debacles in the past (the best example is bleeding or leeching, used for about two millennia; more recently, one could cite thalidomide; or even more recently, though with more caveats too, estrogenic hormone replacement therapy). One cannot presume drugs are safe; one should presume they are harmful until their safety is proven. In the meantime, the history of medicine suggests caution as the wisest course.

Witch Hunt?

Dr. Nassir Ghaemi — Mon, 16 Jun 2008 14:27:13 -0700

Another mainstream article makes the press about corrupt doctors taking pharmaceutical industry money. The June 8 New York Times (http://www.nytimes.com/2008/06/08/us/08conflict.html?_r=1&scp=2&sq=Biederman&st=nyt&oref=slogin) reported on a US Senate investigation into poor disclosure of millions of dollars in income provided by pharmaceutical companies to Harvard child psychiatry researchers at Massachusetts General Hospital (MGH). Like Dr. Peter Kramer ("In Practice" blog http://blogs.psychologytoday.com/blog/in-practice/200806/drug-research-and-financial-bias), I too have carefully followed the work of the MGH research group, both for their research on childhood bipolar disorder (with which I agree in large part) and their research on ADHD in adults (with with I disagree in general). Regarding treatment, my own experience and research has tended to be opposite to theirs: I have found amphetamine stimulants (especially methylphenidate) and antipsychotics to be less effective and more harmful than they have reported. Has their optimism about medications been biased by their profits? Perhaps; perhaps not. There are plenty of profits to go around, and just as much can be made these days bashing medications as marketing them.

Consider this new genre of books: Overdosed America: The broken promise of American medicine; Comfortably Numb: How psychiatry is medicating a nation; The loss of sadness: How psychiatry transformed normal sadness into disorder; The medicalization of society: On the transformation of human conditions into treatable disorders; Against happiness: In praise of melancholy; Overtreated: Why too much medicine is making us sicker and poorer; Selling sickness: How the world's biggest pharmaceutical companies are turning us all into patients; The truth about the drug companies: How they deceive us and what to do about it.

Okay. We get it.

I see no books defending the pharmaceutical industry, or the principles of capitalism, for that matter. Not that I would argue for such tomes, but the sheer number and vigor of this current trend suggests we pause a moment. Let me preface my comments by saying that I agree with the gist of many of these critiques: The pharmaceutical industry can, and has, overmarketed drugs and reaped excessive profits for some marginally effective or questionably safe medications. And, academic medicine can be, and has been, complicit in some of these practices. This needs to change.

However, I wonder whether we will get the change we need from a one-sided, adversarial approach. Further, the logic behind the specific focus on the pharmaceutical industry is not entirely obvious to me.

Is the problem profits per se? If so, we are left with this dilemma: we like capitalism in principle, but we dislike it in practice - or at least in medical practice. Maybe that's the answer: perhaps medicine should not have a profit motive; it should be cleansed from any capitalist basis. So....socialized medicine? Like Canada?

No, that seems too radical. But why pick on the pharmaceutical industry, and let other forms of profit go? How about the profits generated for authors and the book industry from all those books? Is there a conflict of interest there? Or how about the profits in the private practice of medicine? If research doctors are corrupt because they are making millions of dollars from their links to the pharmaceutical industry, how is that different from those private practice doctors in Beacon Hill, and Park Avenue, and indeed on Main Street, making millions of dollars in their practice of medicine for money? Should we join our British cousins? Let doctors get salaries from the government - let us remove all exchange of fees, and turn medicine into a purely non-profit craft.

I personally would not fear such an outcome, and some critics of the pharmaceutical industry - like Physicians for a National Health Program - have proposed it. Such honesty would be refreshing, in fact. Let all the researchers give up their consulting fees; and let all the private practice doctors give up their clinical fees.

But we seem too liberated for such a solution. We should, some critics seem to say, stop some people from making profits, while letting others proceed.

The illogic of this critique suggests we need to approach this problem with less moralizing, and more pragmatism. What exactly is the problem that concerns us?

Here I have to add a second preface: My further comments stem from my own experience as a psychopharmacology researcher, one who has done research funded by pharmaceutical companies, and who has received income from speaking fees for those companies. Further, I know the specific persons mentioned in the NY Times article personally, having been their colleague for a time at Massachusetts General Hospital and in Harvard. Perhaps this personal background introduces some bias, but it may also allow me some insights:

The problem of money and academics is complex. On the one hand, the public and our profession supports research; we are told research is a good thing. On the other hand, the federal government (the NIMH) provides very little money for research (at least in clinical psychiatry). Thus if funds from the pharmaceutical industry are not used, we will have less research. Perhaps we are willing to accept this result; but we need to be clear that it would follow. Further, hospitals and universities encourage research because they earn money from it, whether it is NIMH funded or pharmaceutical industry funded. If we stop such research, hospitals and universities would have more economic problems; again, perhaps we will accept this, but we need to know it could happen. Reality: the average academic researcher makes about 1/3 less income than the average non-academic physician. The extra income made by lecturing for pharmaceutical companies usually brings academic incomes to the norm of most doctors; usually academics do not get rich, they simply join their peers, with such income. If such extra funds are stopped, we will incentivize fewer doctors to become researchers. Many will continue to do so, due to their scientific commitment to knowledge, but some may not be able to do so for financial reasons; perhaps we can accept this, but this too can be a result of cutting the connection between the pharmaceutical industry and research.

The problem of conflict of interest is even more complex: One book says we should just follow the money. I suppose Karl Marx would agree. He has a point, but if matters were this simple, Leningrad would now be the capital of the free world. I have found that it is generally a bad idea to try to infer others' intentions. Humans do things for many reasons, most of which are opaque to us; the driving force is sometimes money, sometimes prestige, fear, lust, insecurity. It is hard to tell why people do what they do. If I had to guess which motivation matters most, I would say prestige rather than money. In any case, it is not straightforward to infer bias based on receiving income from the pharmaceutical industry. Why are not such inferences made in all those books-for-profit written in critique of the pharmaceutical industry?

There is corruption: some academics have made excessive profits and have been biased in their research and teaching. Some pharmaceutical companies have done likewise. There is a need to clean up this relationship. But I believe we should turn to the substance of what is at issue, rather than inferring motivations or judging others' ethics. Let us look at the actual research that is being done, critique the stands that academics take, and apply valid scientific standards to claims that are made. And let us set up and enforce policies that keep academic-pharmaceutical industry relations within reasonable bounds, while at the same time providing more government funds for research.

I will write much more about this topic; it is too large and too hot to handle briefly. But for now let me end with a personal conversation I recently had with a prominent psychiatric researcher who also has been the target of media criticism for his pharmaceutical ties; he dismissed it all as a "witch hunt." I think he was in the wrong on a number of matters and that he overhyped certain medications. I have published my critiques of those specific issues of substance and I have lectured and taught about them widely. So I do not agree with him. But, humans have many faults, and being judgmental is one of them. This is not just a witch hunt, but it can easily degenerate into one.

Relax: You're not bipolar

Dr. Nassir Ghaemi — Fri, 23 May 2008 19:00:37 -0700

I have not known National Public Radio (NPR) to closely follow the annual meetings of the American Psychiatric Association (APA). Maybe I just missed it, but I haven't noticed Carl Kasell roaming around the 15 conventions I've attended. Hence my surprise to hear a report on May 6, 2008 entitled "Study: Doctors overdiagnosing bipolar disorder." The interviewer described a study presented at the recent APA annual meeting by Brown University psychiatric researchers in which about 50% of patients diagnosed with bipolar disorder by community psychiatrists, upon careful re-examination by research psychiatrists, were deemed to fail to meet DSM-IV definitions of bipolar disorder. Hence, bipolar disorder is overdiagnosed.

This seems straightforward and worthy of reportage; after all, one can then blame the pharmaceutical industry for hyping up this diagnosis, as with so many others, to sell their harmful poisons, creating profits for Wall Street, irrespective of the weight gain, diabetes, and other side effects suffered on Main Street. So went the reporting - albeit with some equal time given later in the piece to researchers on bipolar disorder who cautioned that the illness is difficult to diagnose, and that many patients are also underdiagnosed as having other conditions.
I had the opportunity to see the study described in the piece months before the APA, at another research conference, and I gave the researchers the feedback I am about to write here. It could be I am wrong; or it could be that criticism is hard to hear. Either way, I will risk repeating my view, since I think there is a major scientific mistake here.

What is wrong with the Brown study? It seems like straightforward overdiagnosis. Well, it may represent misdiagnosis, but whether it is overdiagnosis needs to be shown in another way. Overdiagnosis means that it is made more than others: where is the control group which is underdiagnosed, and mistakenly labeled bipolar, by contrast? There was none.

Perhaps more importantly - and this is the critique I made directly to the researchers, to no apparent avail - the study mistook reliability and validity, two terms that need definition. Reliability means (in this case) that two doctors call an illness (say, bipolar disorder) the same thing; what they call it may be right or wrong (their definitions may or may not be right) but at least they agree on what to call it (their definitions). Validity is about whether their definitions are right or not.

This study assessed reliability - to what extent doctors agree - not validity - how frequently clinicians are wrong.

Put another way: This study shows that when people are called bipolar, they do not have it half the time. (The same applies for all psychiatric conditions, see below). But many other studies show that when people actually have bipolar disorder, they are not diagnosed with it about half the time.

This is the problem, then: There is disagreement about diagnosis of bipolar disorder, but it still remains underdiagnosed, not overdiagnosed.

Now the explanation:

Reliability studies start with a group of diagnoses, which may or may not be correct, as with the Brown study. This group of patients was seen as bipolar by clinicians. Then researchers (or a second group of clinicians) reassess the same patients with what is our current gold standard (a research diagnostic interview with DSM-IV criteria). They disagreed about 50% of the time. That looks bad. But the claim that it represents overdiagnosis of bipolar disorder runs aground on the fact that such data also exist with similar results when the initial diagnosis by clinicians is unipolar depression, or schizophrenia, or alcoholism, or obsessive compulsive disorder, or (for that matter) congestive heart failure. In the real world clinical practice of psychiatry (and much of medicine), doctors frequently disagree. Reliability of clinical diagnoses for any psychiatric diagnosis is rarely more than 50%. In one large community-base study (the Epidemiologic Catchment Area study, ECA), reliability of psychiatric diagnoses ranged from 5-35%. Thus, all diagnoses are overdiagnosed!

But that conclusion is mistaken too. To claim the wrong diagnosis (whether over or under), we must claim validity. We must know whether or not the diagnosis is valid, before we can tell whether it is being over or underdiagnosed. We need to start with valid diagnoses of bipolar disorder, and then assess past clinician's diagnoses to see whether they were right - not the other way around, as was done in the Brown study (and indeed in most studies claiming overdiagnosis).

Here is proof of underdiagnosis: a validly diagnosed bipolar sample would have been diagnosed, in part, as having other conditions by past clinicians. Here is proof of overdiagnosis: a validly diagnosed bipolar sample would have been diagnosed, almost always, as having bipolar disorder by past clinicians, and validly diagnosed other conditions (like schizophrenia or unipolar depression) would have been diagnosed, in part, as having bipolar disorder by past clinicians.

That is the way to do it: yet no such study has ever been done that shows overdiagnosis of bipolar disorder. In contrast, a few such studies have been conducted and shown underdiagnosis of bipolar disorder, and overdiagnosis of schizophrenia, unipolar depression, or ADHD. In those studies, only about 40% of persons with bipolar disorder receive that diagnosis despite repeated manic episodes. They are misdiagnosed with the other conditions, receive the wrong medications (antidepressants, stimulants, or antipsychotics instead of mood stabilizers), and lead miserable lives for, on average, a decade, seeing over 3 psychiatrists, before they get correctly diagnosed.

Doctors may call conditions bipolar that are not bipolar, just as they call conditions congestive heart failure that are not congestive heart failure (unreliability), but they also consistently and demonstrably fail to diagnose bipolar disorder when it exists, while diagnosing other conditions (like depression or ADHD) not only in those who have them but in those who have bipolar disorder (underdiagnosis).

My experience supports the scientific literature just described: I've seen about a thousand such patients in the last decade, and I've seen their lives turn around when they get off the wrong drugs and get on the right ones.

This aversion towards bipolar disorder is a matter of some cultural interest. It is an historical fact, worthy of note, that bipolar disorder has generally not been commonly diagnosed. It was first described 150 years ago by French and later German psychiatry (especially Emil Kraepelin, pictured), much as it is now. (NB: There were no functional pharmaceutical companies in that era).

But for much of the 20th century, the most commonly diagnosed mental disorder, by far, was schizophrenia. In the 1950s, for instance, when the first antidepressants were developed, the pharmaceutical industry was relatively uninterested, because schizophrenia was believed to be far more prevalent. A half century of interest in depression has followed - and continues: depression received increasing attention, and a slew of medications were developed and marketed for it.

Bipolar disorder remained an orphan, with a single generic drug - lithium - that was hardly marketed and infrequently used. Until the last decade, other mood stabilizers were not proven or marketed, and now that some attention is being given to them, academics and skeptical clinicians raise concerns. The fact remains, though, that despite being at least as common as schizophrenia (probably more), and perhaps one-third as common as depression, research funds for, and scientific studies about, bipolar disorder represent one-fifth or less of what is spent on, or published in, either schizophrenia or unipolar depression. Perhaps four drugs now qualify as mood stabilizers, compared to more than three times as many antipsychotics or antidepressants respectively. There are about twenty research centers on bipolar disorder in American universities, versus hundreds for schizophrenia or depression separately. The pharmaceutical industry begins research on many drugs in animal models of depression or psychosis, but hardly ever mania; thus drugs are rarely specifically developed for bipolar disorder.

Too much attention would seem to be the last problem with bipolar disorder.

Rather, there seems to be a cultural resistance to the whole concept, whereas depression or even schizophrenia seem to have been more palatable to researchers, clinicians and the public. Also, perhaps the claim of overdiagnosis itself is attractive: people generally want to be told they are less ill, rather than more. And attacks on the pharmaceutical industry, though often valid, easily follow in what seems to have become a sudorific sport.

To sum up: Unreliability, yes (like most psychiatric illnesses); overdiagnosis, no (unlike many other psychiatric illnesses) - a century and a half later, and still counting.

The torch is passing, but to whom?

Dr. Nassir Ghaemi — Wed, 21 May 2008 18:28:08 -0700

In my late twenties, when I was a psychiatry resident with little time to spare, I volunteered to canvass my Cambridge, Massachusetts neighborhood for Ted Kennedy's 1994 re-election campaign. He had no primary opposition, but he needed enough signatures to be put on the ballot. I thought I could make a small contribution, and an easy one: after all, who in Cambridge would refuse to sign a form so Kennedy's name could be on the ballot? A lot of folks, to my surprise - especially older, somewhat crotchety, ethnic gentlemen in North Cambridge. Despite this being Tip O'Neill country, many of these mostly Irish-American men were socially conservative; Kennedy, to them, was anathema. As they spouted about Chappaquidick and asked me how much I was paid while slamming the door, I received a political education: If even Ted Kennedy could become unpopular among his own people, then nothing of value could be achieved in politics without risking unpopularity. (After the balloting, I received a thank you letter from the Senator, musing on his early door-to-door experience campaigning for his brother.)

For a number of years afterward, I attended the yearly birthday celebrations for President Kennedy at the John F. Kennedy School of Government at Harvard, held in May. Ted would always be a key speaker; JFK Jr. also spoke and often presided, and one year I sat just behind him. I suppose I partly went to be close to their celebrity, but I also went because I thought they mattered. I had some personal evidence to support this belief: My father had been active in Iranian politics in the 1950s and 60s, a social democrat out of place in a conservative monarchy. In the brief years of the Kennedy administration, he and others like him could finally breathe: in the Middle East, the name Kennedy meant democracy respected, not benignly neglected.

Ted was the least likely to have succeeded. His eldest brother Joe - bright, handsome, ambitious - was to be the one; his WWII death passed the torch to the sickly and playful John, later tragedy sent it to melancholic Robert. The youngest, out of sight in the Senate, was a supportive cast figure. In the end, he turned out to be the star, achieving more than all the rest, through his patient and painful work in that least appreciated of our three (theoretically) co-equal branches of government.

He did not seem to have the fire for the presidential role, his protean campaign against a sitting Democratic president doomed to fail, his timing terrible; the fallout from that loss persists (Jimmy Carter complained as recently as last month about Kennedy's refusal to shake his hand in the 1980 convention), but it was for the best. The Senate was Ted Kennedy's term-unlimited kingdom; why give it up to be a time-limited citizen-president?

Though the standard image of him is the fusty liberal, there is something in him that spurns the mainstream; his early endorsement of Barack Obama, rather than the Clinton establishment, suggests a deep contrarian streak. Or perhaps he has been at the center of power long enough to know that those at the center generally do not deserve it.

Now diagnosed with terminal illness, he will, hopefully, live a good while longer, but his mortality is upon him - and us. My grandfather went through the same illness a year ago; his brain tumor held him at the edge of death for about 6 months. I spent 2 weeks of it with him, day after day, thinking about his life, wondering about his death, meeting his friends who came, one by one, to say goodbye. All in all, it is probably more helpful to survivors, though more emotionally trying for the dying, to grieve slowly and over time.

We are never ready to let go, though, even when someone has lived a full life. There is always more to learn, more benefit to be had, and, for us in middle age, more comfort in the continued presence of our parents. Ted Kennedy has well-known flaws, long the target of right-wing rhetoric, yet grief is palpable, and more will be felt, because he is our final connection to that generation of his family, and their peers, who have led us ever since World War II; seven decades of leadership cannot be easily replaced.

Will the next generation - the younger Kennedys, the Obamas, and others, neither "tempered by war", nor "disciplined by a hard and bitter peace" - be up to the task of leadership? One feels the midlife tug of crisis - the passing of the old, the rising of the young, the burden of the present. As one surveys this scene (along with the recent deaths of Arthur Schlesinger Jr., John Kenneth Galbraith, and William Buckley), it is hard to suppress the hunch that the best of us are going, and the lesser ones who remain have much work to do. Perhaps Ted Kennedy's example can give us some hope: sometimes when little is expected, much is accomplished.