Saturday, March 10, 2018

The NEJM Depressed and Recovered Surgeon Commentary

In the March 1, 2018 edition of the New England Journal of Medicine is the story of a surgeon and told by that surgeon about lifelong depression and severe depression that required both involuntary treatment and electroconvulsive therapy.  The essay has been widely hailed on Twitter and elsewhere as a story that illustrates the problems in medicine as well as problems when physicians develop mental illnesses and need treatment.

The first few paragraphs are written in an interesting style reminiscent of one of my all time favorite books Zen and the Art or Motorcycle Maintenance (ZAMM) by Robert M. Pirsig.  In that book. Pirsig details a very personal and spiritual journey on a motorcycle trip across the northern USA from Minnesota to California.  He describes his journey through life at that point including his academic failures and accomplishments.  He talks about the relationships with the people on the trip including his son, another couple, and the friends they are scheduled to meet along the way.  He explores Eastern and Western philosophy and discusses personal difficulties that he has had along the way, including a psychiatric admission to a hospital and a series of electroconvulsive therapy (ECT) that left him delirious, confused, and obliterated a previous alter ego - Phaedrus. Much of his discussion focuses on threads he recalls about Phaedrus and the problems he encountered.

I started reading this book when I was in the Peace Corps in about 1976.  I say started because if you are like me and many other people - this book had a profound effect on you and you kept reading it.  I was reading it a decade before I finally became a psychiatrist.  I was discussing it with enthusiastic fellow Peace Corps volunteers - very energetic and bright people.  Like a lot of people, I look back on that as a very exciting part of my life.   I really don't have any regrets and don't miss those days.  I can still recall them with a great deal of excitement.  When people ask me what I got out of the Peace Corps - I always tell them that meeting and relating to the people I was with was the best part of the experience.  ZAAM  was part of that for me and it still is.

My first read through the book was chilling when I read the passage about ECT:

"He (Phaedrus) was dead. Destroyed by order of the court, enforced by transmission of high-voltage alternating current through the lobes of his brain. Approximately 800 mills of amperage at durations of 0.5 to 1.5 seconds had been applied on twenty-eight consecutive occasions in a process known technologically as "Annihilation ECS." A whole personality had been liquidated without a trace in a technologically faultless act that has defined our relationship ever since.  I have never met him. Never will."

Reading about it later confirmed that Pirsig had been hospitalized and treated with ECT.  He was misdiagnosed with schizophrenia and eventually diagnosed with depression.  He apparently had more than one course of ECT.  I thought about Pirsig's description of ECT in ZAAM.  The ECT would have happened about a decade before he wrote the book.  In many biographic pieces, Pirsig is described as having a genius IQ, high in that range.  He wrote a book that some reviewers equated to Moby-Dick  - commonly seen as one of the greatest American novels.  After the book he moved from his job as a technical writer to an academic and was in the English department at the University of Minnesota for a number of years.

I thought about the description of ECT a lot as I learned it as a resident and referred many patients to our ECT consultants for treatment.  In one of the very first cases, I saw a patient depressed and completely immobilized in a coronary care unit by severe depression.  He was unable to eat and he was dying.  In those days we had few medications that we could safely give him and even they would not work fast enough.  When he consented to ECT, he got significantly better, started eating and within two weeks was back home.

Dr. Weinstein's article is a more matter-of-fact presentation. The Pirsig paragraph is a little dramatic and obsessive.  I can speculate on what happened during the ECT treatment and what happened to Phaedrus, but I won't.  Another element barely mentioned but easily overlooked in both pieces is that treatment was involuntary.  Both patients were ordered by a court to be in a hospital and accept the treatment offered.

Going into my career as a psychiatrist, it is common to have reservations about both ECT and involuntary treatment.  You don't have a lot of time to think about it because of the illness severity of the people you are treating.  In my career on inpatient settings it was common to be seeing people who had attempted suicide or homicide and barely missed completing the act.  I have treated many people who were admitted to hospitals because they had killed someone due to a severe mental illness.  I have also been called years after leaving a clinical setting to be informed about the suicide or homicides committed by patients that I had treated.  An even larger group of patients required treatment because they were unable to function and they were starving to death, not able to take care of their medical needs, or had judgment so poor that they were at high risk of accidental injury or death.  The only way any of these patients got better was with medical treatment by psychiatrists including antidepressants, antipsychotics, and electroconvulsive therapy.

To those people who are thankful that Dr. Weinstein published his experience in the NEJM, I agree with that opinion.  But to me as an inpatient psychiatrist who saw all of the people that are too ill to be included in clinical trials of antidepressants and in many cases too ill to consent to treatment there is a much bigger lesson here.  That lesson is that involuntary treatment, antidepressant medication, mood stabilizing medication, antipsychotic medication, and electroconvulsive therapy all work.  If you are a person with a severe disorder, see a psychiatrist who prefers treating severe problems. If you are a concerned family member, make sure that involuntary treatment is an option.  If it is not, find out why the county you live in is not protecting the most vulnerable people in our society.

But most of all don't let the the media circus about whether antidepressants work or all of the problems with psychiatric medications throw you off.  Psychiatrists know what they are doing and they are good at their job.  Health care corporations and governments do their best to restrict access to psychiatrists but this current paper is evidence why this access is critical and needs to greatly increase.

Nobody should be disabled by severe depression.  Nobody should die from it. The only acceptable outcome is complete recovery of a stable mood and ability to function.       

George Dawson, MD, DFAPA


1: Weinstein MS. Out of the Straitjacket. N Engl J Med. 2018 Mar1;378(9):793-795. doi: 10.1056/NEJMp1715418. PubMed PMID: 29490178.

2:  Robert M. Pirsig.  Zen and the Art of Motorcycle Maintenance.  Bantam Books, New York.  Copyright 1974 by Robert M. Pirsig, p. 77.

Graphic Credit:

The photo at the top of this post is downloaded from Shutterstock and licensed per their standard agreement.

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