Is Modern Psychiatry Too Intellectually Restrictive?

The inspiration for this post comes from my reading the history of psychiatry. That was not a particular interest of mine until I began researching threads of knowledge going back into time. Then I started to look at how American psychiatry evolved and the fact that it did not really exist at the same time psychiatry existed in Europe.  This is historically confusing in the US, where certain movements try to connect psychiatry to historical events where there are no connections.  The development of psychiatry in Europe is a complicated and interesting story.  The most striking feature is that those early psychiatrists were trained in neuroanatomy, neuropathology, neurology, and psychiatry.  Freud was a Privadozent in neuropathology.  Adolph Meyer emigrated to the US as a neuropathologist and eventually became the chairman of psychiatry at Johns Hopkins eventually influencing a significant number of American psychiatrists. 

In reading about these early psychiatrists, some authors will refer to them as neurologists even though the person in question identified as a psychiatrist (examples include Otto Binswanger ((1852–1929) and Wilhelm Griesinger (1817-1868)).  Others like von Economo (1) were designated psychiatrists and neurologists.  After graduating from medical school in 1901 von Economo spent a year working in an internal medicine clinic and over the next four years worked at various clinics in Europe with Marie, Kraepelin, Alzheimer, and Oppenheim learning psychiatry, neurology, and hypnosis. He returned to the University of Vienna in 1906 and was appointed Professor of Neurology and Psychiatry in 1921. This was an observation from his book Encephalitis Lethargica (2):

"Towards the end of 1916 the wards of the Vienna Psychiatric Clinic contained quite a number of patients with a strange variety of symptoms - cases which had apparently only one feature in common - a difficulty to fit into any known diagnostic scheme.  They had been admitted under the most varied descriptions, such as meningitis, acute disseminated sclerosis, amentia, delirium &c.  The patients all showed a slight influenza-like prodromal condition with trifling pharyngeal symptoms, a slight rise in temperature, soon followed by a variety of nervous symptoms, though generally one sign or another pointed to the midbrain as a source...."

From there von Economo goes on to describe encephalitis lethargica in great detail.  He was subsequently nominated for the Nobel Prize in Medicine four times for this work.  He also worked on neuroanatomy - where he made additional discoveries. His education and career contrasts well with current psychiatric education in the US where it seems that too little content is being spread over too many years - even more if you want to be certified in both neurology and psychiatry. He apparently got what he needed in 4 years while living in 4 different European cities.  Places like the Vienna Psychiatric Clinic also do not exist today - where the only solid criteria for admission is dangerousness and all admissions need to be medically cleared  by somebody (physician or extender) that may be oblivious to neurological and psychiatric presentations of acute illness. 

More to the point – they were probably neuropsychiatrists and that has relevance for the system of board certification in the US.  Prior to board certification most psychiatrists in the US were neuropsychiatrists and practiced neurology and psychiatry. That all changed in 1934 when the American Board of Psychiatry and Neurology (ABPN) – made the rule that all psychiatrists practicing both specialties must pass both board certification exams.

Reading the paper (3) about Bleuler was interesting because it is an easy read that emphasizes several concepts in psychiatry that just repeat if you don’t understand them.  First is the age-old debate about categorical versus dimensional diagnoses.  The author’s conclude that Bleuler supported dimensional diagnoses but it seems they are describing his process as one of detailed formulation rather than dimensions. This was rooted in his method of clinical psychiatry. I suppose a four dimension scale could be envisioned based on Bleuler’s “4 As” (see below) – but my interpretation is that he was looking for detailed medical, family, social, and developmental history.  He is described as a clinician who had close contact with patients rather than an experimentalist – that is the data he was interested in.

Second, the richness of the psychiatric landscape during Bleuler’s time cannot be denied. The psychiatrists were writing and researching across the spectrum of neurology, neuroscience, psychology, and theoretical psychiatry. There was no shortage of ideas about describing clinical phenomena or possible treatments.  Bleuler had contact with many prominent psychiatrists of his time and his opinions about some of their theories was known.

Third,  Bleuler’s approach could be considered pluralistic to use today’s jargon.  He was  clearly engaged in doing the subjective realm and individualized evaluations.  He thought that schizophrenia could be an exaggerated neurosis from psychological conflicts.  He believed that the disease process had a biological basis but he was focused on a psychological treatment.  He also did not see schizophrenia as having a uniformly deteriorating course. His thoughts about the biology of the disorder were undoubtedly affected by the facts that he was not an experimentalist, there were no useful biological treatments and despite many autopsy studies there were no good gross anatomical or histological correlates of schizophrenia.

The patterns and themes noted in this paper run throughout the history of psychiatry.  Since psychiatry became the default profession for treating severe mental illnesses, there have been hypotheses about the nature of the illnesses, how to medically evaluate them, and how to treat them. As illustrated on this blog, there are often critics outside of the field who seem to ask these questions as if no psychiatrist has ever thought about them in the past.

In many ways the intellectual landscape of turn of the century psychiatry was richer than it is today. We currently have a refined product in terms of classification, but many of the questions relevant of psychopathology and neuroscience remain open. The basic problem of biological complexity is not easily answered and it is only recently being approached.  Biological and psychotherapy options appear to have been maxed out by heterogeneity problem.  From a historical perspective, what is most alarming to me is that there has not been a synthesis of these questions and approaches to bring current psychiatrists and trainees up to speed.  Much of the time seems to be spent on the same research techniques and critiquing endless clinical trials.

At a global level, the intellectual landscape of the field seems constricted.  The board certification process has certainly been part of that as well as the general goals of standardization.  There has been an enormous effort on standardizing nomenclature at the cost of de-emphasizing psychopathology. Clinical practice has been standardized largely based on settings and administrative codes. Documentation has been standardized by the same codes and electronic health records.  Much of the documentation is essentially worthless in describing patient progress or the unique features of the individual and is essentially there to satisfy business administrators.  The training of new psychiatrists is standardized in some areas - but there are very few specifics in terms of what trainees need to see in order to be good psychiatrists.  For example, there is an apparent assumption that if you spend a month or two in a neurology clinic - you will have adequate exposure to accurately assess neurological problems presenting as psychiatric problems and make the correct triage or treatment decisions.   

 I don’t think expanding the intellectual landscape for residency programs would take much.  It will take a bit of integration.  The sanctioning bodies of medical education have made the task harder than it should be by not specifying all of the important educational topics and letting the programs each sort it out on their own.  That means residents will see certain concepts inconsistently if at all, presentations and seminars will depend on the availability, interest, and quality of the teaching staff, and even then, topics are likely to be followed too rigidly.

The first question is what exactly should that landscape be?  Residency requirements by the ACGME are surprisingly vague.  They are focused primarily on clinical experiences based on clinical populations and settings, availability of supervision, and overriding goals of excellence, motivation, and interest on the part of the teaching faculty. There are some broad technical markers of specific experiences by psychiatric subspeciality or skill (eg. psychotherapy, managing drug interactions, etc).  I know that the residency directors meet frequently and it would not surprise me to find out that there are more detailed approaches shared among them – but if that occurs, I do not know where to access it.

My suggested approach at integration would be teaching the historical controversies and concepts that are still relevant all at once.  There are several integrative papers in the literature already.  There are also still some big concepts that need formulation and discussion like the biological diversity and heterogeneity issues that run throughout all of medicine. A potential academic model for this approach already exists and I suggest it is in the Voet, Voet, and Pratt - Fundamentals of Biochemistry - 6th edition.  One of the issues that frequently arises during discussions of this nature is how much philosophy needs to be included. My reading of the literature suggests that if anything there has been an excess of philosophy being applied to psychiatry.  At times psychiatry is made to seem like psychiatrists themselves have never considered the obvious questions. Teaching residents about psychiatry and the way that psychiatrists have attempted to formulate and solve problems seems like as good a place to start as any to me.

It can start with the names in this paper.    

Pattern matching also needs to be reemphasized. The reason a psychiatrist can diagnose bipolar disorder is that they have seen many cases and many variations - not because they have read the DSM.  The same is true for all of the mimics of bipolar disorder including neurological conditions. I am concerned about the level of exposure that residents have to acute neurological problems, especially now that many inpatient neurology services have been replaced by hospitalists with neurology consultants. There is a long list of acute neurological presentations that every psychiatrist must see and diagnose in training and distance from our neurology colleagues makes that more difficult. 

 

George Dawson, MD, DFAPA

 

References:

1:  Kaya Y, Uysal H, Akkoyunlu G, Sarikcioglu L. Constantin von Economo (1876-1931) and his legacy to neuroscience. Childs Nerv Syst. 2016 Feb;32(2):217-20. doi: 10.1007/s00381-015-2647-0. Epub 2015 Feb 24. PMID: 25707481.

2:  von Economo C.  Encephalitis Lethargica.  Oxford University Press, London. 1929. page B.

3:  Heckers S. Bleuler and the neurobiology of schizophrenia. Schizophr Bull. 2011 Nov;37(6):1131-5. doi: 10.1093/schbul/sbr108. Epub 2011 Aug 26. PMID: 21873614; PMCID: PMC3196934.

Open Access <-you can read this paper

Supplementary:

I just accessed and read the following paper this morning several days after the above post.  It is an open access paper that can be read and downloaded.  It basically makes the same argument that my post makes - an integrated approach to psychiatry and neurology (and neuroscience) is preferable.  It is written from the neurology perspective and that may be why the suggested remedies fall short.  Integration between the specialties is really not possible as long as one (psychiatry) is disproportionally rationed and is under an administrative burden that divorces it from clinical reality. 

Perez DL, Keshavan MS, Scharf JM, Boes AD, Price BH. Bridging the Great Divide: What Can Neurology Learn From Psychiatry? J Neuropsychiatry Clin Neurosci. 2018 Fall;30(4):271-278. doi: 10.1176/appi.neuropsych.17100200. Epub 2018 Jun 25. PMID: 29939105; PMCID: PMC6309772.

What Does the DEA Drug Trafficking Report Really Mean?

 

The DEA just published a significant report on the drug threat in the United States. I read the entire document and will review a few of the high spots here highlighting why it is not too relevant for most parts of the country.  I am on record in several places on this blog making similar comments. My basic argument has not changed significantly and that is that the demand for illegal and often fatal drugs is driven by the culture in the US and I would not expect law enforcement to make much of a difference. The case in point is Prohibition and the ban on alcohol.  Of course it was not a real ban.  Criminals still bootlegged alcohol into the country, religious groups found a way to circumvent the law, and there are always people producing illegal alcohol as a significant percentage of alcohol consumed every year.

These facts are most often distorted into the argument that Prohibition or any War on Drugs is doomed from the outset. That argument is most frequently used to implicitly suggest that any attempt to legally restrict intoxicants will be righteously overcome by people with a natural right to pursue intoxication.  That is extrapolated to practically any scenario short of negligent homicide due to intoxication or drug dealing. But even the drug dealing scenarios are being rapidly modified to allow possession of certain amount of cannabis or in some cases legitimizing drug dealing as a useful occupation. The direct and indirect costs of drug use to both individuals and society are typically ignored by anyone without a medical or public health interest. Intoxication is a cultural right, a right of passage, and every effort of being made to expand the availability of intoxicants to everyone in the US.

The DEA (1) states their role is to expand awareness, preserves lives, and provide intelligence to law enforcement that might be useful for resource allocation and prioritization.   Synthetic opioids and stimulants are described as the biggest threats.  Both can be easily mass-produced by the cartels in Mexico.  Fentanyl alone has accounted for a massive increase in mortality due to its potency and low therapeutic index – accounting for 74,225 deaths in 2022.  China is implicated as the main source of precursor drugs to produce fentanyl.

The report clearly states that two Mexican cartels are responsible for the drug flow into the US and the most significant drug crisis in the history of the US.  Further – the cartels have penetrated most states in the US to varying degrees.  The Internet has facilitated drug sales in the US and made these transactions more difficult to track.  The cartels are also producing methamphetamine leading to an increase in stimulant associated deaths.  There is also a China connection.  Chinese criminal operations supply precursors for the synthesis of opioids and methamphetamine as well as money laundering operations to make the money from illegal drugs sales useable. 

One of the strategies these criminal enterprises are using is adding additional intoxicants to the drug that users are purchasing.  This has the effect enhancing the intoxicating effects but with a much higher risk of overdose and death – especially if the user is naïve to that drug or the seller is ignorant about the potency of the additional intoxicant.  I became aware of this phenomenon about a decade ago when I was being told that users witnessed fentanyl being pressed into alprazolam tablets and sold as alprazolam.  A secondary phenomenon was that many people were not averse to fentanyl but actively sought it out to enhance the period of intoxication.  The DEA report describes the following combinations:  

Fentanyl plus:

Heroin, cocaine, methamphetamine, xylazine, Counterfeit prescription drugs: (oxycodone (M30, Percocet); hydrocodone (Vicodin); or alprazolam (Xanax)

 

The DEA report addresses many of the logistics of the substance use problem and it does raise awareness – especially of the dangers of getting adulterated drugs and the severe side effects including death. It also highlights drug counterfeiting and it gives a great example of an Adderall tablet counterfeited from methamphetamine (see below).  That is especially problematic during a time of Adderall shortages from legitimate suppliers.

 

The unaddressed problem is American culture.  I don’t want to suggest that large groups of sociopaths intent on making money no matter how many people they kill don’t bear some responsibility. I also don’t want to suggest that reducing the availability of these drugs by any means is not a good idea.  But one of the takeaways from reading this report is that law enforcement is clearly not winning and it is a huge burden on them in both the US and Mexico.  Former President of Mexico Vincente Fox characterized the problem well as “America’s insatiable appetite for drugs.”  Right now, it is a multigenerational chronic problem. People can get effective treatment and recover but too many die and too many become chronic users. There needs to be an effective strategy for primary prevention or preventing use in the first place. Suggestions along these lines typically end up caricatured as the 1980s “just say no” public service ads or the "failed war on drugs", but this strategy was clearly effective in reducing cigarette consumption and decreasing the population of smokers. It has had the expected effects of decreasing smoking related mortality in both the general population and in smokers who quit.  The same population-wide benefits would be expected from any public health measure that effectively reduced the use of alcohol, stimulants, opioids, cannabis, or any other intoxicants.  What are the cultural factors that keep this drug epidemic going?  Here are a few:

1:  Cultural acceptance of substance use as a rite of passage:  The stories are endless. Fraternity and sorority hazing involving excessive alcohol use.  High school graduation parties associated with multiple driving while intoxicated deaths. Incarceration from assaults and homicides from barroom fights. Consumption of alcohol and other intoxicants in high school well before the legal age for consumption has been reached. Much of this has to do with immaturity.  The Decade of the Brain did inform us that just on a biological basis human brains do not mature until the mid 20s and in the case of men possibly even later. Immersing an immature brain in intoxicants is generally not a recipe for success and may be a developmental risk for substance use disorders and mental illnesses.

2:  Consumerism and the selling of intoxicants:  This is a widespread phenomenon in the US.  Alcohol commercials typically suggest success, sexual attractiveness, popularity, sophistication, and glamour.  Identification with Hollywood A-listers is a plus and many of them are marketing their own brands to capitalize on that fact. The expensive packaging is often more significant than any difference in taste or quality. The only downsides are a very brief allusion to the Surgeon General’s warning about alcohol use in pregnancy or a disclaimer to “use responsibly.”  Not much about alcohol poisoning, cancer, cirrhosis, pancreatitis, cardiac problems, dementia risk, or substance induced psychiatric disorders. For a long time alcohol was hyped as a heart health beverage.

3:  Your right to intoxicants:  The subculture of users has a mixed agenda in promoting this idea.  There are a few people who believe that their lives are better by using drugs or alcohol, that they are using these substances in a controlled manner and “not hurting anybody.” And therefore, anyone should have the right to use them under these conditions.  On the face of it – few people would argue that point – even though it does assume that self-report about use and its consequences are always accurate.  A subgroup is promoting widespread intoxicant use as a business.  Many in this group see it as a get rich quick scheme. Many see it as a diversity equity inclusion (DEI) issue.  That is – minority groups sustained harm from excessive legal penalties against cannabis and other drug possession and therefore they should be given advantages in setting up businesses that profit from legalization.  Many want to extend cannabis law changes to include all drugs and legalize access to everything. The DEA report stands in contrast to mass legalization because it estimates how much the country would be awash in fentanyl if it was legal. It also ignores why substances were controlled in the first place and what happened when physicians started to prescribe more opioids both as "dope doctors" in the early 20th century maintaining people in addiction and in the late 1990s leading to the beginning of the current opioid epidemic.

4:  Cannabis misinformation:  There has not been much reflection of the medical cannabis period of the early 21^st century.  Cannabis was touted as a miracle drug whose benefit was being neglected due to archaic drug laws and the lack of modern research. Nothing was said about cannabis being around for over 700 years and having no clear cut indications for use or the fact that earlier cannabis compounds fell into disuse with modern therapeutics. That led to a patchwork of state-level medical cannabis laws, making each of those states a Mini-FDA with their own indications for use and in some cases limited forms of cannabis that could be dispensed for those indications.  Just as it became apparent that cannabis really was not much good for medical applications or even pain – the real motivation for the medical cannabis Trojan Horse became apparent.  That was of course recreational use. The Biden administration is currently considering rescheduling cannabis from a Schedule I to a Schedule III substance. That takes it off the experimental/no medical application category but still suggests that it will be prescribed and supervised by a physician.

5:  Widespread promotion of hallucinogens and psychedelics as miracle drugs: Building on the success of promoting cannabis as a medicine – we are now seeing frequent hype about the wonderful effects of psychedelics along with practically no discussion of the side effects. MDMA and LSD are being seen as wonder drugs that successfully treat depression, anxiety, PTSD, and substance use disorders. The cannabis promoters successfully promoted cannabis as a nearly completely benign substance and the hallucinogen/psychedelic promoters have used the same tactic.  I only recently read an account where the following side effects during a clinical trial of an LSD based drug were listed: illusion, nausea, euphoric mood, headache, visual hallucination, mydriasis, altered state of consciousness, anxiety, blood pressure increase, and abnormal thinking (all in significant numbers). In my clinical experience I have treated people with permanent side effects from this drug class after a single dose.

6:  Better living through chemistry:  There is a current wave of euphoria in the popular culture about GLP-1 agonists like Ozempic and Monjauro. It has been accompanied by FDA approved indications but also a very public reexamination of the usual prescriptions of diet and exercise for weight loss. The pendulum seems to have swung to the point that all excessive weight is a disease state that can only be approached with a powerful drug that has potentially powerful side effects.  From a cultural perspective this class of drugs reinforces the American dream that we can tune our bodies like we tune our cars and if we have the right drugs – we can have whatever kind of body or mind that we want. More longstanding evidence of this attitude is evident from anabolic androgenic steroid use and stimulant use for - both for performance enhancement.  All three are grand illusions. Hominid biology has evolved to incredible complexity over the past 2 millions years.  Any group of people may look alike but there are hidden differences in physiology and pharmacological response. One person’s medication is another person’s poison. As a result there are very few miracle drugs and some intoxicants have been around for centuries making it even less likely.

7:  Sobriety as a subculture:  In most societies certain religions and life philosophies are the most likely promoters of sobriety.   Most sobriety in the US is not thought about too much.  There are about 60% of people who never drink. There is a group of people in active recovery who had a problem with intoxicants and were successful in discontinuing them.  There is a small movement right now of young people who are not in recovery promoting sobriety.  The cultural resistance against substance use in the US seems trivial compared with the promotions.

8:  Treatment is secondary prevention: A standard political approach to the drug epidemic these days is to suggest that more availability of treatment centers and providers is a needed approach.  This is correct in so far as treatment for these conditions has always been deficient. Treatment has had a role in terminating localized drug epidemics in both Chicago and Washington DC.  There is a question about how well it will work now that just about every county in the US is awash with opioids and methamphetamine.   A logical approach may be to prevent new users from entering this cycle – in other words decreasing the incidence of the problem. Unfortunately there are fewer resources to address this problem and a lot of pessimism about that approach.  

9: Intoxicant use is a choice: Even though there is obvious evidence out there that a significant percentage of the population develops uncontrolled use of drugs and/or alcohol denial and rationalizations about this continues to persist. It has to in order to maintain the myth that people with substance abuse disorders really have a moral defect rather than a biological propensity.  In other words – repeatedly telling them to stop and blaming them for the problem is all that is required. That approach ignores the real problem that if you are biologically disposed – all it takes is access to substances to keep that process going. The moral approach also allows for a legalization position by simply stating that the people who cannot control their use are irresponsible.  

10:  Deaths of despair: This concept was popularized by Dean and Case (2) to explain increased mortality due to intentional injury and drug overdoses caused by hopelessness due to economic problems and the associated stress. Deaths due to alcohol and drug use were seen because of economic stress rather than a consequence of excessive use for other reasons including the cultural factors that have been specified. The concept minimizes the fact that severe alcohol and drug problems exist in populations that have no economic stress and that most of the people with severe economic stress do not have drug and alcohol problems. It also minimizes the fact that we are still in the midst of a multi-decade drug epidemic and there is no end in sight.  

11:  Legalizing drugs will put the cartels out of business:  This has always been an extremely naïve argument.  Alcohol and tobacco sales are legal and taxed but that does not prevent their illegal sales.  Prescribing opioids, stimulants, and benzodiazepines does not prevent their illegal sales.  The DEA report highlights continued involvement by organized crime in cannabis production and sales - even after it has been legalized. Illegal production has led to violent crime and adverse environmental impact.  These same organizations are currently producing counterfeit name brand pharmaceuticals.  There is no reason to expect that legalizing very high risk drugs will stop criminals from producing or selling them.

12:  No education about who may be at higher risk:  To an addiction psychiatrist seeing people after acute events the risks are obvious.  People who use intoxicants and get extremely euphoric or aggressive to the point that it impairs their judgment are clearly at high risk and should consider not using them at all. Unfortunately that self examination often does not happen until there has been a life changing event.  People with a strong family history of substance related problems are another high risk group.  Some individuals come to the conclusion that intoxicants are too risky for them to use.  I have heard this in many psychiatric evaluations: "My father and his father were alcoholics.  I knew I should probably not drink on that basis."  But this knowledge does not seem to be widely disseminated.  

Where does all of this leave us?  Not in a very good place. The DEA is describing its efforts to intercede in what is a massive effort originating from several countries to import highly dangerous substances into the United States. Although it is never overtly discussed this is clearly a national security problem. The immediate problems of deaths and morbidity from drug addiction seem to depend very little on how successful the DEA is in its efforts. The reason for that is the massive promotion of drugs at the cultural level both in direct advertising and false political philosophy equating drug use with freedom. It parallels the use of the Second Amendment to promote the widespread dissemination of firearms – even though there is no similar amendment for drug use. All the popular myths about drug use need to be actively countered and the advantages of a sober life need to be promoted. Those myths are a more subtle but equally dangerous threat to what the DEA is describing in this report.   

 

George Dawson, MD, DFAPA

 

References:

1:  Drug Enforcement Administration. National Drug Threat Assessment.  US Department of Justice.  May 2024.  57p.

2:  Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015 Dec 8;112(49):15078-83. doi: 10.1073/pnas.1518393112. Epub 2015 Nov 2. PMID: 26575631; PMCID: PMC4679063

The Retired Consultant Redux – A Conversation With Two Internists

In retirement I run into colleagues who are interested in the process and how it is going. I was greeted with a “How is my favorite retired psychiatrist” yesterday. It originated from a highly qualified subspecialist who was immersed in hospital work when I first met him. We talked briefly about his changing roles over the years going from hospital based acute care practice, to an outpatient specialty practice, to his current role of tertiary consultant seeing the most difficult problems in his field. I told him that was the role I miss the most – seeing the most difficult to diagnose and treat cases and being the one to figure out what to do.

It is not an easy life – especially if you are as neurotic as me.  It involves constant research and revision of approaches. It involves close follow up.  It involves sleepless nights and anxiety.  It involves balancing innovation against not wanting to make a mistake.  Sometimes it involves convincing other people to go along with you when they may be reluctant. It also involves tolerating the suffocating routine of excessive documentation and jumping through unnecessary administrative hoops as well as the occasional overt harassment. But in the end – you end up being a physician that both your patients and colleagues can count on and that’s something.

We discussed the nature of treating these populations. He told me he likened his practice to neurology because of the reputation that the level of esoteric diagnoses are not matched by esoteric treatments and often there is not much that you can do. I never understood this degree of pessimism.  I have been confronted with people who told me their last doctor told them: “Look there is nothing more I can do for you.”  And we were able to make some progress.     

Finally – we discussed the 2 year milestone and how many people leave retirement and have to go back into active practice at that point.  He made the observation that this seems to happen across professions where possible – and it seemed to depend on attitudes to retirement and whether you had anything to do.  He did not think retirement would be a problem.  I estimated he had about another 8-10 years of practice left.  I had my usual thoughts about all of the people I knew who never made it to retirement.  I also thought about retirement from physically taxing work and the problems that involves - not the least of which is adjusting caloric intake to prevent excessive weight gain.  

The second conversation was more technical. It was an opinion about gabapentin.  The patient in question was taking it long term for back pain and had a history of back surgeries. More recently she was on diuretics and other medications for atrial fibrillation and congestive heart failure. She was seeing several specialists and they were dutifully getting all of the correct labs but nobody seemed to notice the gradual increase in creatinine to 1.7 and 2.4.  That correlated clinically with increasing somnolence, ataxia, and falls.  After reading the package insert on gabapentin he called me to discuss a dosage adjustment with renal insufficiency.

I recalled a healthy young man I was treating who became acutely confused and ataxic after he was started on simvastatin by a consultant. In psychiatry, this scenario raises suspicions of intoxicants even in a hospital setting. But given the circumstances I decided to also look for a cause of delirium.  The acute labs showed that he had acute renal failure as an idiosyncratic reaction to the statin and he was transferred to medicine to treat the problem.  The acute renal failure led to the accumulation of gabapentin and the delirium and ataxia.

As we discussed the cases, the internist pointed out the difficulty with today’s fragmented medical care.  All of the medication were ordered and the labs were done – but nobody seemed to be paying any attention to how the patient was doing. It reminded him of a quote from one of his mentors George Magnin, MD who used to say to his Medicine residents: “What are you going to do until the doctor gets here?”

That quote struck me as genius both as a motivating factor and the immediate reality of the situation. When you are confronted with a patient who is having a problem – you need to be able to do something about it. That doesn’t mean that you will always know what to do – and if you don’t you at least need to know how to triage the problem so that the patient gets the correct care.  We try to increase the likelihood that will happen by specialization, subspecialization, and settings to match the illnesses with the specialists, but those matches are far from perfect.

I had this experience to illustrate.  I got a call from an emergency medicine physician who was seeing a patient I was treating for bipolar disorder. I knew him and his family very well from years of treatment. The ED doc wanted me to hospitalize him for acute mania but his wife who was with him said he was not manic and she did not want him admitted to a psychiatric unit.  After a brief description of his symptoms I said: “Put him on the phone so I can talk with him.”  Within 30 seconds I could tell he had a fluent aphasia with paraphasic speech errors.  When the ED doc came back on I told him that this was not mania – but most likely an acute stroke syndrome and he was hospitalized on Neurology where the stroke diagnosis was confirmed.

“What are you going to do until the doctor gets here?” – means that doctor.  The one who can diagnose and treat your problem.  That is the one that matters.  In this era of health apps, checklists, self-diagnosis, electronic health records, telemedicine, and so-called artificial intelligence that is still all that matters.

Being that person is hard to attain and hard to walk away from.

 

George Dawson, MD, DFAPA 

Image credit:  Wikimedia Commons per their CC licensing the details of which are available by clicking on the graphic.

Additional:  The identities of the physicians were anonymized in this post. I doubt that any physician benefits from being associated with me or this blog.

Rick Sings - poetry by Phill Taggart

“Well I woke up this morning and I had myself a beer.” Roadhouse Blues (1970) Jim Morrison Lyrics The Doors Composition

Many years ago, I was asking a patient about his morning routine and he replied with the Roadhouse Blues lyric and started laughing. At the time he was taking medications that I prescribed but also seeing a naturopath who was giving him a complex solution of minerals that was supposed to treat his mental illness. His family was more concerned about him than he was concerned about himself.  Severe mental illness leaves a person focused on irrelevant pieces of information out in the environment for amusement/entertainment/meaning while ignoring the basics – like self-care and not standing out too far in public.  Clinicians refer to some of that as inappropriate social behavior, but it is a complex multi-layered problem. The same process can result in a great deal of difficulty staying focused on the necessary day-to-day routine. In that mix, there are boundary problems that can contaminate the most altruistic impulses and affect personal safety.  Phil Taggart does a great job of painting that picture in his book of poetry Rick Sings.

In a brief introduction we meet his brother Rick.  Rick has a severe mental illness that clearly affects his ability to function. I am writing that after reading the entire book and all the poetic descriptions. We find out that Rick has a lot of problems in living, managing his self-care and medications.  There are times when he is not eating well, where he is in an agitated state, where his hygiene is affected, and where he puts his housing security at risk by taking in women who have lost housing or were the victims of violence. His brother is a force to help keep him on track and check in with him.  Those encounters are the basis for this book.

The first images we get are family chaos – the product of mental illness, alcoholism, aggression and violence, and the death of a young sibling.  Rick’s modern-day world is tied in with that early history. Here are two stanzas from the poem Morning Coffee

 

The rest of this poem has stark images of people who come into your life and leave with you liking or not linking them or yourself along the way.  At some point it is hard to know if the memory is that sad or current sadness clouds the memory.

I recently read an essay on how art can be rhetorical in the persuasive sense. This poetry consists of observations and emotions that the imagery elicits. There is no hint of bias – only the empathy elicited by images and situations.  I had not thought of this before but Taggart’s poetry is the perfect medium to communicate the major problems facing people with severe mental illnesses and anyone trying to help them. You can’t help being pulled in when he advises his brother to stay away from the police for his own protection or when he has to let a security guard know that “he’s with me” to avoid awkward social situations.

There is a stream of consciousness flow to the poetry with associations across the lifetimes of Taggart and his brother. I liked this feature because it is the way a lot of people (including myself) think. Focus on the present and in some downtime – think about an event that happened in 1975. When your brother is in the picture – think about common events. Several of those themes run through this book of poetry and it is masterfully done.   No associated explanations – just a description of an event with a universal emotion.

I liked this book of poetry.  In keeping with my book reviews, I like the idea of conditional recommendations.  In this case – liking poetry will help.  It will even be better if poetry stimulates your mental imagery and emotions. I call the writing style of this poetry free verse like E.E. Cummings.  The phrases are also arranged differently on the page to emphasize different thoughts and actions.  If you like that style, you will like this book even more. Beyond liking poetry, this book will potentially help you understand the problem of severe mental illness and its effects on people and their families. Even though there are efforts out there to decrease stigma and attributing stigma to a lack of understanding of the problem – stigma has always been a problematic concept for me. If more people experienced what Phil Taggart puts into his poems there would be a greater understanding. He is a strong voice in this area.  Read this book if you are interested in a deeper understanding the problem.

 

George Dawson, MD, DFAPA

 

Reference:

Phil Taggart.  Rick Sings.  Santa Barbara, California. Brandenberg Press 2014: 67pp.  https://philtaggartpoet.com/