Is Medical Cannabis Overly Promoted In Minnesota?

 

Karl Marx wrote his famous metaphor about religion being an opiate for the proletariat in 1843:

“Religious suffering is, at one and the same time, the expression of real suffering and a protest against real suffering. Religion is the sigh of the oppressed creature, the heart of a heartless world, and the soul of soulless conditions. It is the opium of the people.”

He suggests in the next paragraph that the abolition of religion would rid people of the illusory happiness and it would be more consistent with the goal of real happiness for the people.  Marx’s formulation has not withstood the test of time. There is no more happiness now with widespread secularism than there was in Marx’s day.  Despite that fact - his metaphor survives and I thought about it quite a lot as I read through the Minnesota Medical Cannabis Program Report (MMCP) Anxiety Disorder Review.  The main difference of course is that cannabis is an equivalent metaphor only at the level of the idea of what medical cannabis can do.  When some writers suggest that religion can cause people to sleep and dream unrealistically, cannabis can physically do the same thing.  But it is promoted as doing many other things for many people – despite a profound lack of evidence.

The MMCP has been around for a number of years. I have taken the longstanding position that the medical cannabis concept is basically a way to legitimize cannabis and eventually get it legalized. I have also taken the position that physicians should not be involved in what is essentially a political maneuver.  The grandest aspect of that political maneuver has been the MMCP acting as a mini-FDA and coming up with their own indications for cannabis use. Initially, the idea was to use cannabis for the treatment of chronic pain and hospice care. I attended one of the early CME courses where most of the speakers were pain doctors and oncologists. Psychiatric input on these decisions has generally been minimal, despite the fact that psychiatric populations are at the highest risk from cannabis exposure and psychiatrists typically see most of the complications of cannabis.  The initiative to treat anxiety (in all forms) has not been approved by the MMCP and they state that was the reason for a more detailed look at the literature on cannabis as a treatment for anxiety and producing the report. 

Reading the report is an interesting exercise. It is not written very much from a scientific standpoint. They are very explicit about what they are considering as evidence.  For example they consider a literature search, a small panel of experts that does not really come to any consensus, and the experience of other states with medical cannabis and the indication of anxiety to be the basis for the report.  There are significant problems with all of those sources. 

 

The Research Matrix

At first the Research Matrix of papers included in the appendix looks impressive. There are 30 papers listing the reference, study type, total number of participants, dose and results.  Reading through the studies - some are single person case reports, some are reviews, and there are 15 studies listed as randomized controlled trials (RCTs). Looking at the RCTs there are probably one or two studies with an adequate number of participants to be adequately powered to show a statistical difference. Additional problems include the lack of an actual anxiety diagnosis.  In fact the diagnoses involved were frequently not anxiety related at all. Three observational studies at the end probably had the most merit and their results were equivocal. So the research studies really add nothing toward answering the question of whether medical cannabis should be used to treat anxiety and certainly nothing about the dose, delivery, or cannabis subtype.

Experience of Other States

Tables 1 summarizes the information about how other states have handled the question about medical cannabis and anxiety.  The states listed are Nevada, New Jersey, North Dakota and Pennsylvania.  In Nevada and North Dakota, the legislatures were petitioned to add anxiety (as DSM-5 Generalized Anxiety Disorder) to the medical cannabis formulary.  In New Jersey and Pennsylvania it was a commissioner decision. The Pennsylvania Secretary of Health was described as being “proactive” by suggesting that medical cannabis for anxiety was a “tool in the toolbox” and recommended duration of use, specific formulations, and avoidance in teenagers.  In all 4 states where cannabis was approved, anxiety quickly rose to the top or second most frequent indication for prescribing medical cannabis. None of the states collects any outcome data. 

What about other countries with more experience with cannabis like the Netherlands?  I contacted a colleague there who forwarded my questions to 2 other psychiatrists who were anxiety experts and doing active research in the area.  They responded that medical cannabis was not prescribed for anxiety and that there was a medical cannabis site for the Netherlands.  The site suggests that a CBD product is recommended. They had the same concerns about THC causing anxiety and psychosis.  A direct comparison of the indications for medical cannabis use comparing the Minnesota program to the Netherlands is included in the following table and linked directly to the respective web sites.

Medical Cannabis Qualifying Conditions

Minnesota   Cancer associated with severe/chronic pain, nausea or severe vomiting, or cachexia or severe wasting Glaucoma HIV/AIDS Tourette syndrome Amyotrophic lateral sclerosis (ALS) Seizures, including those characteristic of epilepsy Severe and persistent muscle spasms, including those characteristic of multiple sclerosis Inflammatory bowel disease, including Crohn’s disease Terminal illness, with a probable life expectancy of less than one year* Intractable pain Post-traumatic stress disorder Autism spectrum disorder (must meet DSM-5) Obstructive sleep apnea Alzheimer's disease Chronic pain Sickle cell disease Chronic motor or vocal tic disorder

The Netherlands   Pain, muscle cramps and twitching in multiple sclerosis (MS) or spinal cord injury; nausea, loss of appetite, weight loss and weakness in cancer and AIDS; nausea and vomiting due to medication or radiation treatment for cancer, HIV infection and AIDS; long-lasting pain of a neurogenic nature (cause is in the nervous system) for example due to damage to a nerve pathway, phantom pain, facial pain or chronic pain that persists after shingles has healed; tics in Tourette's syndrome; treatment-resistant glaucoma

 Expert Consensus

In terms of the professional consensus, the participants were described as  3 psychiatrists, a pediatrician, a person in recovery, a primary care physician, and a marriage and family therapist. On a scale of recommendations, there was one vote for non-approval, one vote in favor of a limited pilot study and follow-up outcomes, one vote for neutral not opposed, three votes in favor of considering for generalized anxiety disorder, panic disorder, and agoraphobia. No consideration is given to the experience of the physicians or the asymmetry of expertise. It appears to be a political approach to neutralizing the opinion of the group of physicians (psychiatrists) who essentially are left treating the complications of cannabis use disorder.  Those complications include acute mania or psychosis, anxiety and panic, chronic depression and amotivational syndromes, and significant cognitive problems.  Cannabis obscures whether the patient has a true psychiatric diagnosis or not.  It also destabilizes psychiatric disorders. That is the common theme I noted above.  This is really not expert consensus – it is a man-on-the street poll.

Apart from the very weak lines of evidence, some of the conclusions in this document are even worse.  There are basically 6 common themes:

1:  Protect the brain: There are longstanding concerns about the new timetable for brain development extending into the mid to late 20s. This is a peak period for drug experimentation and heavy use of alcohol and most substances. There appears to be consensus on this theme and I would agree.

2:  Safer alternative to benzodiazepines: the rationale here is much rockier.  The authors in this case cite the increase in benzodiazepine overdose deaths in the state of Minnesota, but the quality of this data is not clear.  I took a look at the data and contacted the Minnesota Department of Health about it – specifically if opioids were excluded as a primary cause along with fentanyl being sold as benzodiazepines. I was informed by an epidemiologist that a T42.4 code was present and the coding is not mutually exclusive. In other words, more drugs may be involved and fentanyl may have been involved. The death certificates and toxicology confirmations are dependent on the county medical examiner. The accuracy of the data is therefore in question. There are clearly ways to safely prescribe benzodiazepines.  Benzodiazepines are research proven alternatives for severe anxiety when conventional treatments have failed as a tertiary medication and cannabis is not.

In terms of addiction risk, the risk with cannabis is 8-12% overall and 17% for people who start using cannabis in their teens (1-6).  That compares with an addiction liability of about 10% with benzodiazepines (7).  Benzodiazepines are used by people who are taking multiple addicting drugs to amplify the effect, treat withdrawal symptoms, and treat the anxiety and insomnia that accompanies chronic substance use or opioid agonist therapy.  This population is often acquiring benzodiazepines from non-medical sources. There is no real good evidence that medical cannabis will replace non-medical use of benzodiazepines in that setting, since benzodiazepines are easily acquired from non-medical sources.

3:  Therapy is the standard:  Therapy is not the standard. The standard is whatever works for a particular practice setting.  Psychiatrists see people who have already seen a therapist and quite probably a primary care physician where their anxiety was diagnosed with a rating scale. That means they will have failed therapy and at least one or two medication trials. Psychiatrists are not going to start treatment by repeating ineffective therapies. In many cases, substance use including cannabis use is the main reason for the anxiety disorder in the first place.

4: Health Equity:  This was perhaps the most unlikely reason for cannabis use. To emphasize how far this document goes off the rails I am going to quote this section directly:

 “Known disparities exist in the level of care available for anxiety disorder among historically disadvantaged communities. Medical cannabis may offer these individuals the option for an alternative to current medications, however this view was not shared by all participants.” (p.15)

Are the authors of this document really suggesting that disadvantaged communities should settle for a substance that has been inadequately studied, has known severe medical and psychiatric side effects, and is associated with higher rates of suicidal ideation and suicide attempts in these disadvantage communities (14) rather than providing them with standard care? That statement to me is quite unbelievable. It is the first time I have seen a recommendation to use a prescription substance to address a social problem.  It may happen by default – but if you really want to promote health equity equivalence evidence based treatments are the only acceptable standard.

When  "an alternative to current medications" is mentioned cost is not discussed as a factor. In my discussions with people who have received medical cannabis from the Minnesota dispensaries, high cost was often mentioned as a limiting factor. This current price list from one of the dispensing pharmacies shows that nearly all of their products are much more expensive than the generic antidepressants used to treat anxiety disorders.

5: Limited research:  Cannabis advocates point to the lack of research due to the fact that cannabis is a Schedule 1 compound. That means there is no known medical use and a high potential for abuse. Since certain compounds have been FDA approved for specific indications, I anticipate that these compounds will be rescheduled.  That is one of many hurdles in researching cannabis.  A few of the others would include the issue of subject selection (cannabis naïve or not), placebo controls, specific form (THC:CBD ratio), type of drug delivery, and a general methodology that would capture a good sample of persons with an anxiety disorder in adequate numbers for the trial.

6: Harm Reduction:  The authors suggest that medical cannabis could serve to limit exposure to other more harmful drugs obtained on the street to treat anxiety like benzodiazepines. There is no evidence that this would occur given the availability and preference for non-prescribed benzodiazepines.  The issue of polysubstance dependence is complex.  A significant number of opioid users also use benzodiazepines. Despite a black box warning about respiratory depression from using that combination, the FDA has been clear that the medications can be prescribed together. Further, a recent study suggests that retention in a methadone maintenance program was twice as likely if the patients received prescription benzodiazepines as opposed to non-prescription benzodiazepines (10).  No such data exists for cannabis.

In terms of substituting cannabis for benzodiazepines the only study I could find was a retrospective observational study of new patients in a cannabis clinic. Over the course of 2 months 30.1% were able to stop benzodiazepine use and at 6 months that number had increased to 45.2%.  These authors (11) conclude

“Without dependable safety data and evidence from randomized trials for this cohort, cannabis cannot be recommended as an alternative to benzodiazepine therapy.”

 The conclusion of this paper suggests the options of maintaining the status quo or no approval for anxiety, approve for a limited number of “subconditions” defined as specific anxiety disorders, or approve for anxiety disorders.  They list the pros and  cons associated with each approach but not much was added relative to the above discussion.  There are a few comments that merit further criticism. The risks of maintaining the status quo are seriously overstated.  From reviewing previous tabulated data from the MN Medical Cannabis program, it is unlikely that any meaningful real world data will be collected. It is not possible to collect non-randomized, uncontrolled data on a substance that is highly valued and reinforces its own use that has any meaning. The results will predictably be like the comments solicited by this program that are 96% favorable. There are similar speculative predictions of the direct consequences of not providing medical cannabis in terms of not seeking therapy if using cannabis off the street, suicides due to not tolerating SSRIs, and patient harm from “illicit use”. Similar speculation occurs throughout the remaining bullets points and there seems to be a strong pro-medical cannabis for anxiety disorders bias.

To summarize, I am not impressed with the Minnesota Medical Cannabis Program report on the use of medical cannabis for anxiety. It clashes with my 35 years of clinical experience where cannabis has been a major problem for the patients I treated in community mental health centers, clinics, substance use treatment centers, and hospitals. It suggests a great potential for a substance that has been around and used by man for over 7 millennia.  You would think with that history, man would have realized by now that it was a panacea for his most common mental health problem – anxiety. The report also ignores the commonest role of cannabis in American society and that is as an intoxicant and not a medication.  Physicians should not be prescribing intoxicants.  You don’t need a prescription to go to a liquor store and purchase alcoholic beverages. If the real goal is to get cannabis out to the masses, the option is legalization of cannabis not medical cannabis.

 

George Dawson, MD, DFAPA

 

References:

1:  Anthony JC, Warner LA, Kessler RC. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Exp Clin Psychopharmacol. 1994;2(3):244-268. doi:10.1037/1064-1297.2.3.244

2:  Lopez-Quintero C, Pérez de los Cobos J, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011;115(1-2):120-130. doi:10.1016/j.drugalcdep.2010.11.004

3:  Anthony JC. The epidemiology of cannabis dependence. In: Roffman RA, Stephens RS, eds. Cannabis Dependence: Its Nature, Consequences and Treat:ment. Cambridge, UK: Cambridge University Press; 2006:58-105.

4: NIDA. 2021, April 13. Is marijuana addictive?. Retrieved from https://www.drugabuse.gov/publications/research-reports/marijuana/marijuana-addictive on 2021, September 13.

5:  Moss HB, Chen CM, Yi HY (2012). Measures of substance consumption among substance users, DSM-IV abusers, and those with DSM-IV dependence disorders in a nationally representative sample. J Stud Alcohol Drugs 73: 820–828

6:  Perkonigg A, Goodwin RD, Fiedler A, Behrendt S, Beesdo K, Lieb R et al (2008). The natural course of cannabis use, abuse and dependence during the first decades of life. Addiction 103: 439–449 discussion 450–451.

7: Becker WC, Fiellin DA, Desai RA. . Non-medical use, abuse and dependence on sedatives and tranquilizers among U.S. adults: psychiatric and socio-demographic correlates. Drug Alcohol Depend. 2007; 90 2-3: 280- 7. DOI: 10.1016/j.drugalcdep.2007.04.009 PubMed PMID: 17544227.

 

Harm Reduction:

8: Okusanya BO, Asaolu IO, Ehiri JE, Kimaru LJ, Okechukwu A, Rosales C. Medical cannabis for the reduction of opioid dosage in the treatment of non-cancer chronic pain: a systematic review. Syst Rev. 2020 Jul 28;9(1):167. doi: 10.1186/s13643-020-01425-3. PMID: 32723354; PMCID: PMC7388229.

9: Shover CL, Davis CS, Gordon SC, Humphreys K. Association between medical cannabis laws and opioid overdose mortality has reversed over time. Proc Natl Acad Sci U S A. 2019 Jun 25;116(26):12624-12626. doi: 10.1073/pnas.1903434116. Epub 2019 Jun 10. PMID: 31182592; PMCID: PMC6600903.

10: Eibl JK, Wilton AS, Franklyn AM, Kurdyak P, Marsh DC. Evaluating the Impact of Prescribed Versus Nonprescribed Benzodiazepine Use in Methadone Maintenance Therapy: Results From a Population-based Retrospective Cohort Study. J Addict Med. 2019 May/Jun;13(3):182-187. doi: 10.1097/ADM.0000000000000476. PMID: 30543543; PMCID: PMC6553513.

11: Purcell C, Davis A, Moolman N, Taylor SM. Reduction of Benzodiazepine Use in Patients Prescribed Medical Cannabis. Cannabis Cannabinoid Res. 2019 Sep 23;4(3):214-218. doi: 10.1089/can.2018.0020. PMID: 31559336; PMCID: PMC6757237.

 

Cannabis and Psychosis:

12: Kuepper R, van Os J, Lieb R, Wittchen H, Höfler M, Henquet C et al. Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study BMJ 2011; 342 :d738 doi:10.1136/bmj.d738

13: Murray RM, Mondelli V, Stilo SA, Trotta A, Sideli L, Ajnakina O, Ferraro L, Vassos E, Iyegbe C, Schoeler T, Bhattacharyya S, Marques TR, Dazzan P, Lopez-Morinigo J, Colizzi M, O'Connor J, Falcone MA, Quattrone D, Rodriguez V, Tripoli G, La Barbera D, La Cascia C, Alameda L, Trotta G, Morgan C, Gaughran F, David A, Di Forti M. The influence of risk factors on the onset and outcome of psychosis: What we learned from the GAP study. Schizophr Res. 2020 Nov;225:63-68. doi: 10.1016/j.schres.2020.01.011. Epub 2020 Feb 6. PMID: 32037203.

 

Cannabis Use and Suicide:

14:  Kelly LM, Drazdowski TK, Livingston NR, Zajac K. Demographic risk factors for co-occurring suicidality and cannabis use disorders: Findings from a nationally representative United States sample. Addict Behav. 2021 Nov;122:107047. doi: 10.1016/j.addbeh.2021.107047. Epub 2021 Jul 12. PMID: 34284313; PMCID: PMC8351371.

 

Cannabis Use and Life-Threatening Medical Problems:

15:  Ladha KS, Mistry N, Wijeysundera DN, Clarke H, Verma S, Hare GMT, Mazer CD. Recent cannabis use and myocardial infarction in young adults: a cross-sectional study. CMAJ. 2021 Sep 7;193(35):E1377-E1384. doi: 10.1503/cmaj.202392. PMID: 34493564.

16:  Parekh T, Pemmasani S, Desai R. Marijuana Use Among Young Adults (18-44 Years of Age) and Risk of Stroke: A Behavioral Risk Factor Surveillance System Survey Analysis. Stroke. 2020 Jan;51(1):308-310. doi: 10.1161/STROKEAHA.119.027828. Epub 2019 Nov 11. PMID: 31707926.

17:  Shah S, Patel S, Paulraj S, Chaudhuri D. Association of Marijuana Use and Cardiovascular Disease: A Behavioral Risk Factor Surveillance System Data Analysis of 133,706 US Adults. Am J Med. 2021 May;134(5):614-620.e1. doi: 10.1016/j.amjmed.2020.10.019. Epub 2020 Nov 9. PMID: 33181103.

18:  Desai R, Fong HK, Shah K, Kaur VP, Savani S, Gangani K, Damarlapally N, Goyal H. Rising Trends in Hospitalizations for Cardiovascular Events among Young Cannabis Users (18-39 Years) without Other Substance Abuse. Medicina (Kaunas). 2019 Aug 5;55(8):438. doi: 10.3390/medicina55080438. PMID: 31387198; PMCID: PMC6723728.

Pharmacokinetics and Adverse Effects of Cannabis:

19:  Schlienz NJ, Spindle TR, Cone EJ, Herrmann ES, Bigelow GE, Mitchell JM, Flegel R, LoDico C, Vandrey R. Pharmacodynamic dose effects of oral cannabis ingestion in healthy adults who infrequently use cannabis. Drug Alcohol Depend. 2020 Mar 21;211:107969. doi: 10.1016/j.drugalcdep.2020.107969. Epub ahead of print. PMID: 32298998; PMCID: PMC8221366.

20: Spindle TR, Cone EJ, Goffi E, Weerts EM, Mitchell JM, Winecker RE, Bigelow GE, Flegel RR, Vandrey R. Pharmacodynamic effects of vaporized and oral cannabidiol (CBD) and vaporized CBD-dominant cannabis in infrequent cannabis users. Drug Alcohol Depend. 2020 Jun 1;211:107937. doi: 10.1016/j.drugalcdep.2020.107937. Epub 2020 Apr 1. PMID: 32247649; PMCID: PMC7414803.

21:  Spindle TR, Martin EL, Grabenauer M, Woodward T, Milburn MA, Vandrey R. Assessment of cognitive and psychomotor impairment, subjective effects, and blood THC concentrations following acute administration of oral and vaporized cannabis. J Psychopharmacol. 2021 Jul;35(7):786-803. doi: 10.1177/02698811211021583. Epub 2021 May 28. PMID: 34049452. 

22:  Spindle TR, Cone EJ, Schlienz NJ, Mitchell JM, Bigelow GE, Flegel R, Hayes E, Vandrey R. Acute Effects of Smoked and Vaporized Cannabis in Healthy Adults Who Infrequently Use Cannabis: A Crossover Trial. JAMA Netw Open. 2018 Nov 2;1(7):e184841. doi: 10.1001/jamanetworkopen.2018.4841. Erratum in: JAMA Netw Open. 2018 Dec 7;1(8):e187241. PMID: 30646391; PMCID: PMC6324384.

Vaping and Pulmonary Toxicology:

23:  Meehan-Atrash J, Rahman I. Cannabis Vaping: Existing and Emerging Modalities, Chemistry, and Pulmonary Toxicology. Chem Res Toxicol. 2021 Oct 8. doi: 10.1021/acs.chemrestox.1c00290. Epub ahead of print. PMID: 34622654.

24:  Tehrani MW, Newmeyer MN, Rule AM, Prasse C. Characterizing the Chemical Landscape in Commercial E-Cigarette Liquids and Aerosols by Liquid Chromatography-High-Resolution Mass Spectrometry. Chem Res Toxicol. 2021 Oct 5. doi: 10.1021/acs.chemrestox.1c00253. Epub ahead of print. PMID: 34610237.

25:  McDaniel C, Mallampati SR, Wise A. Metals in Cannabis Vaporizer Aerosols: Sources, Possible Mechanisms, and Exposure Profiles. Chem Res Toxicol. 2021 Oct 27. doi: 10.1021/acs.chemrestox.1c00230. Epub ahead of print. PMID: 34705462.

Epidemiology:

26: Lim CCW, Sun T, Leung J, et al. Prevalence of Adolescent Cannabis Vaping: A Systematic Review and Meta-analysis of US and Canadian Studies. JAMA Pediatr. Published online October 25, 2021. doi:10.1001/jamapediatrics.2021.4102

Prevalence of cannabis vaping by adolescents has recently increased for lifetime use, use in the past 30 days and use in the past year.

Maternal Cannabis Use and Anxiety in Offspring:

Rompala G, Nomura Y, Hurd YL. Maternal cannabis use is associated with suppression of immune gene networks in placenta and increased anxiety phenotypes in offspring. Proc Natl Acad Sci U S A. 2021 Nov 23;118(47):e2106115118. doi: 10.1073/pnas.2106115118. PMID: 34782458.

LaSalle JM. Placenta keeps the score of maternal cannabis use and child anxiety. Proc Natl Acad Sci U S A. 2021 Nov 23;118(47):e2118394118. doi: 10.1073/pnas.2118394118. PMID: 34789581.

Graphics Credit: The graphic at the top of this post is from Shutterstock per their standard user agreement.

 

 

Inappropriate Sinus Tachycardia (IST) In The Psychiatric Clinic

I don’t recall what I was researching the other day but I happened across a brief review paper on a subject I have been following for a while (2). That subject is inappropriate sinus tachycardia (IST). I posted recently about closely following the cardiac status of patients being seen by psychiatry both on the inpatient side and in the outpatient clinic. When that is done a significant portion of those patients will have tachycardia defined as heart rate of greater than 100 bpm. In some cases the heart rate ranges as high as 120 to 130 bpm.  Many of these patients are surprised to learn how high their heart rate is and what constitutes a normal heart rate. Others are very focused on the cardiac status and experience palpitations in periods of rapid accentuated heart rate. I commonly hear “it feels like my heart is coming out of my chest”.

That type of cardiac symptom can certainly occur during panic attacks. The majority of people I see with sinus tachycardia do not have panic attacks or panic disorder. They are generally anxious but the phenomenon I have not seen addressed is how much anxiety is due to the cardiac symptoms? Many have what I describe as cardiac awareness. By that I mean they can sense their heart beating by various mechanisms. Many can feel the pulsation of blood through the body especially in the head and neck area. Others can hear their heartbeat. Many can sense their heart beating against their chest wall. The person has that kind of focus any irregularity like occasional pauses or extra beats leads to heightened anxiety. As that anxiety builds some people will feel chest pain, chest pressure, and shortness of breath or near panic symptoms.

 A significant number of those patients will have anxiety associated with symptomatic IST. There are also groups of patients with frequent panic attacks, nocturnal panic attacks, night terrors, and medical problems associated with tachycardia and other cardiac symptoms.  It has been surprising to me to find that significant sustained sinus tachycardia is often ignored in primary care settings. The reason for that may be the latest review in UpToDate (1). In that review the authors define the syndrome and the evaluation and conclude that the condition generally has a benign course in that tachycardia induced cardiomyopathy is rare. They suggest that diurnal variation of the tachycardia may protect against that.

Since IST is by definition tachycardia with no known medical cause intrinsic heart disease and associated causes of tachycardia need to be ruled out. In psychiatric patients panic attacks and anxiety are typically considered psychiatric causes of tachycardia but they are rare causes of sustained tachycardia. The hyperadrenergic state of panic attacks generally resolves when the panic attack resolves and that is frequently in 20 minutes or less.  It is common to see very anxious people in clinics and when their vital signs are checked they are typically normal. Sustained tachycardia is more common with other comorbidities such as medication side effects, excessive caffeine use, stimulant use, alcohol or sedative hypnotic withdrawal, and in some cases insomnia. Deconditioning can also be a factor one person has been isolated and sedentary for any reason and they suddenly need to walk a distance to get to the clinic. There is a gray zone of overlapping conditions that need to be considered. For example, an acute pulmonary embolism, congestive heart failure, and emphysema or COPD can lead to cardiopulmonary symptoms including tachycardia. They can generally be ruled out by a medical history, review of systems, and brief examination.

Tachycardia secondary to medication side effects often requires tracking several variables.  In the ideal case, an indicated medication can be selected that does not have the side effect - in this case tachycardia. But there re some medications that are unique enough that they may be used in situations where the tachycardia persists because there are no other good alternatives. With clozapine (3) the tachycardia can be secondary to anticholinergic side effects, alpha blockade and hypotension, or intrinsic cardiac side effects like myocarditis. Patient often get tachyphylaxis to the anticholinergic effects but all of these variables need close monitoring. It takes a lot of ruling out to conclude that a patient on clozapine has IST and this is a good example of the importance of the baseline evaluation and reviewing avaiable records and vital signs in the electronic medical record.

A more common scenario is the anxious patient with no clear cardiac or pulmonary disease who has persistent tachycardia and in many cases palpitations. They are often treated with beta-blockers with some success. I have seen people have been unable to tolerate beta-blockers, people who did not respond beta-blockers, and some people with beta-blocker withdrawal who had severe anxiety panic and tachycardia because the beta-blocker was stopped too quickly. In both the review and the up-to-date summary, IST patients are commonly resistant to beta-blockers and need another intervention. The suggested intervention is ivabradine a novel medication described as a blocker of the hyperpolarization-activated cyclic nucleotide-gated (HCN) channel responsible for the cardiac pacemaker I_f current. That directly affects heart rate at the SA node. It also affects retinal currents leading to phosphenes or transient bright spots in the visual fields. 

The main indication for ivabradine is congestive heart failure. There are cardiac complications including atrial fibrillation. That suggests to me that most psychiatrists should probably not consider prescribing this medication unless there is ample clinical experience and the required monitoring is not intensive - similar to beta-blockers today.

The main message in this post is that close attention does need to be paid to vital signs on every inpatient unit and outpatient psychiatric clinic. It is not enough to say that tachycardia can be dismissed as anxiety. It is also not enough to use a quasi-medical intervention like telling the patient to drink more fluids if they have not been assessed for hypovolemia. A close look for intrinsic cardiac conditions and the list of conditions and the differential diagnosis from the review article below and the UpToDate review should be a minimal requirement for medical psychiatrists. If that cannot be done, the patient should definitely see their primary care physician preferably prior to initiating any treatment with a medication that would obscure the clinical picture. The evaluation and recommendations of the primary care physician should be available in the patients psychiatric chart. For completion, I also get copies of other cardiac testing that has been done including echocardiograms and exercise stress tests.

The advantage of a diagnosis of IST is that it recognizes there is a specific diagnosis to account for inappropriate tachycardia rather than a default psychiatric diagnosis. That is important because it protects the patient and potentially offers more effective care. The treating psychiatrist should still be in the loop for the necessary lifestyle modifications, education about the condition and monitoring and treating any associated anxiety.

George Dawson, MD, DFAPA

References:

1.  Munther K Homoud. Sinus tachycardia: Evaluation and management.  Section Editor: Jonathan Piccini, MD, Deputy Editor:Brian C Downey, MD in UpToDate.  Accessed on October 6, 2019.

2.  Ruzieh M, Moustafa A, Sabbagh E, Karim MM, Karim S. Challenges in Treatment of Inappropriate Sinus Tachycardia. Curr Cardiol Rev. 2018 Mar 14;14(1):42-44. doi: 10.2174/1573403X13666171129183826. Review. PubMed PMID: 29189171; PubMed Central PMCID: PMC5872261

3. Miller DD. Review and management of clozapine side effects. J Clin Psychiatry.2000;61 Suppl 8:14-7; discussion 18-9. Review. PubMed PMID: 10811238.

NEJM Case: Brain, Heart, and Parsimony

Cardiology factors prominently in psychiatry and psychiatric care. I have been fortunate on many occasions to work with psychiatrists who were also cardiologists and to have access to outstanding cardiologists as consultants. That gave me a great appreciation for what was possible in the detection treatment of cardiac problems. It also help me appreciate the importance of treating psychiatric disorders in patients with cardiac problems. The recognition that some medications can cause problems and the need for ECG screening was another change in psychiatric practice. Prior to that knowledge, there were some medications that delayed cardiac conduction to the point that they are no longer used.

One of the commonest scenarios I currently see is at the interface of anxiety and the effect it has on the heart. About 20 to 30% of the people I see have severe anxiety and panic attacks. About two thirds of them have made at least one trip to the emergency department because they thought they were experiencing a heart attack. They are generally young people with limited cardiac risk factors. When I asked them about the symptoms that led them to the ED, the most common answer is “my heart was pounding out of my chest and I thought I was having a heart attack”. Palpitations are another common symptom. They are harder to get at and people who have talked to cardiologists are better at describing them. I demonstrate by making an irregular thumping noise on my chest with my hand to indicate what it might feel like. The associated symptoms of panic attacks like swelling, lightheadedness, dizziness, chest tightness, shortness of breath, hyperventilation, and dizziness all reinforce the thought of a heart attack. Once the ED staff determine the patient is having a panic attack the way they are educated is critical in reducing ongoing symptoms. But that is another story.

An associated symptom in anxiety is what I like to call “cardiac awareness”. It happens in anxious people whether they have an anxiety disorder diagnosis or a stressor making them anxious. Laying in bed at night waiting to fall asleep many people can sense their heart beating without taking their pulse. They can sense other pulse points in the body and frequently they can sense large pulsations. This is a normal physiological process but anxiety can lead to a focus on it. I also lead to attaching other meetings to it such as the occasional palpitation is seen as evidence of heart disease leading to increased anxiety. In that situation it becomes very difficult to sleep leading to more anxiety and frequently - a faster heart rate the next day.

Cardiac pathology can compound the problem because there are various conditions like atrial fibrillation that can lead to people paying much more attention to their heart rate and rhythm. Atrial fibrillation is interesting in that regard because there are two management strategies. In a rate control strategy the person is given a medication to generally keep their heart rate less than 100 bpm but the rhythm could still be irregular and experienced as frequent palpitations. In a rhythm control strategy the person is either given a medication or treatment to maintain a regular sinus rhythm and palpitations would be much less frequent to nonexistent. Current thinking on treating atrial fibrillation is that the outcomes of both strategies are equivalent in terms of mortality but that patients with a rhythm control strategy rate themselves as having a higher quality of life.

That brings me to the New England Journal of Medicine case listed in the references below.  This case continues a recent trend in incorporating more psychiatric expertise into these cases with psychiatrists as discussants. The patient was a 62-year-old man with depression and anxiety. The depression dated back 15 years with onset after he learned that his wife had cancer. His wife eventually died. Whichever psychiatrist are about seven years and eventually found that citalopram and clonazepam are effective. He continued with his primary care physician and eventually discontinued the citalopram. He was seen by one of the discussants due to recurrent anxiety depression and lethargy. Vital signs were noted to be abnormal with an irregular pulse of 130 bpm blood pressure 108/75. An ECG was done that showed new onset of atrial fibrillation. 

Echocardiography showed an enlarged left atrium and left ventricle, low normal LV ejection fraction, mild left ventricular hypertrophy, and no valvular disease. The subsequent ECG showed a prolonged QTc interval of 466 ms. At a subsequent visit he had an additional significant stressor also had started to binge drink. At that time he had weekly panic attacks that correlated with increased alcohol intake. When he was seen in the psychiatric clinic had weekly panic attacks that consisted of “racing heart, lightheadedness, restlessness, shaking, and generalized weakness and so the episodes lasted for several hours. A family history of depression and suicide was noted. He was noted to be drinking 4 to 6 standard drinks per week with occasional binges. Aripiprazole was added to the clonazepam and citalopram.

The patient subsequently had a near syncopal episode three weeks later I was noted to be hypertensive and tachycardic. The ECG showed atrial fibrillation and sinus pauses of six and seven seconds. A permanent pacemaker was placed in the metoprolol was discontinued.

He was noted to be improved on the psychiatric medication changes but the metoprolol is discontinued because of fatigue. Three weeks later he had increasing anxiety and the feeling that his heart was racing and “thumping” in his chest and that he was excessively worried. They aripiprazole was increased at that time.

Like most of these cases there is a differential diagnosis exercise included and the discussant in this case is a psychiatrist.  The exercise focuses on the fact that the central symptoms in this case-anxiety, palpitations, racing heart, restlessness, and fatigue are not specific for cardiac or psychiatric diagnosis. In fact all DSM diagnoses included criteria to rule out any medical causes of the syndrome. In this case all the usual suspects are discussed. From the medical side hyperthyroidism, return atrial fibrillation, dilated cardiomyopathy, Torsade de pointes, and rare medical causes are discussed. The duration of the patient’s symptoms rules out a lot of the acute causes. From psychiatric standpoint panic disorder, substance intoxication, and substance withdrawal were the primary considerations. The discussant Dr. Chen uses the term that we don’t hear enough of lately and that is parsimony specifically “The best diagnosis would parsimoniously explain the patient’s symptoms and the time course of his illness”. He concludes that there is a clear correlation with discontinuing metoprolol and experiencing recurrent atrial fibrillation.

From a cardiology standpoint the decision was made to improve rhythm control with sotalol and the rationale for choosing that agent was provided. He experienced a decrease number of episodes of atrial fibrillation that he was correlating with anxiety.

The discussion highlights the correlation of anxiety with atrial fibrillation. That anxiety is a product of experiencing the palpitations and also can be an etiological factor in the episodes of atrial fibrillation. Depression and anxiety also predict who experiences more severe symptoms of atrial fibrillation. Patient medications also discussed in terms of the prolonged QTc interval. The authors comment on the FDA warning about QTc prolongation with higher doses of citalopram. They point out that although citalopram prolongs QTc interval more than other antidepressants there is little evidence that it leads to torsade de pointes or sudden cardiac death. They also point out that the literature shows that when this warning led to decreasing the dose of citalopram the result was no worsening of cardiac outcomes but less than optimal psychiatric outcomes including more frequent hospitalizations and increased sedative hypnotic prescriptions.

Overall this was an excellent discussion of the cardiology-psychiatry interface. Psychiatrists are likely to see increasing numbers of patients with atrial fibrillation. I currently see number of patients who are taking multiple cardiac medications. Any patient with this degree of complexity it is important to discuss the possibilities in order to determine the likely sequence of events. In patients with cardiac risk factors who are hypertensive and appear to be describing panic attacks caution is necessary to make sure that there are no underlying cardiac conditions that need to be attended to. As illustrated in this case I have seen patients with severe panic attacks (but no atrial fibrillation) due to the abrupt discontinuations of metoprolol. In patients who have recently discontinued antihypertensive therapy and have panic attacks - clarifying whether there has been any exposure to beta blockers is important.  

Another relevant factor in this patient's demographic is that the sympathetic tone of the peripheral nervous system in humans seems to increase with age. That may predispose older populations to tachycardia, palpitations, hypertension, and anxiety either directly or indirectly by experiencing the cardiac symptoms.

Being able to make an assessment and determination of patient stability, whether or not they need urgent care, what further testing is needed, and what further referrals are necessary is a skill that every psychiatrist should have.

George Dawson, MD, DFAPA

Reference:

1: Chen JA, Ptaszek LM, Celano CM, Beach SR. Case 9-2019: A 62-Year-Old Man with Atrial Fibrillation, Depression, and Worsening Anxiety. N Engl J Med. 2019 Mar 21;380(12):1167-1174. doi: 10.1056/NEJMcpc1900140. PubMed PMID: 30893540. Full Text

See also for the critical references in this case.



Graphics Credit:

The human heart line drawing in the above graphic is from Shutterstock per their standard agreement.

Abortion, Women's Mental Health, and Politics...

Let me preface this post by saying that I am not a member of a political party and I do not endorse any political views about abortion.  The only interest that I have in abortion is what women tell me about it in the context of a psychiatric evaluation and treatment.  I also do not want to see women's mental health become a surrogate end point for the political debate on abortion.  In the state where I practice the Minnesota Department of Health mails a report on the number of abortions in the state with a number of warnings about the legal requirements of reporting abortions (p 51-57 of this report) despite that fact that 99+% of all physicians and 100% of psychiatrists do not perform abortions.  I bristle when I get that politically motivated report each year.

I am writing this post to examine whether or not any objective research on the mental health effects of abortion can be done.  This examination was precipitated by a post on a forum of the Time story "Abortion Doesn’t Negatively Affect Women’s Mental Health: Study".  Whenever I see an article like that I think of two things - the life experiences that women have told me over the years and where abortion fits in.   I also try to think about how I would do a study of this issue.  What would constitute mental health?  Most large studies don't depend on interviews anymore and that typically means a checklist or some sort of psychometric instrument.  There are typically cutoff scores and comparisons of cutoff scores between the research subjects and a control group.  Correlations are made with come psychiatric diagnosis or psychological construct to determine mental health.  With that kind of technology the underlying assumption is that these are good measures of mental health and that it covers all of the possibilities.  Human consciousness covers a lot of ground and there are generally subtle problems that don't get covered by these gross measures.

The study in question (1) is based on telephone interviews semiannually over a period of 5 years of a cohort of women selected for having an abortion, having a first trimester abortion, being turned away from access to an abortion and giving birth and being turned away from access to abortion and not giving birth.  In their results section, the authors plot the results of 11 interviews, but they point out that the subjects participated in an average of 8 over the 5 year period.  The women who received an abortion presented within 2 weeks of the clinics gestational limit for abortions (N=452).  Women with pregnancies up to 3 weeks past the gestational limit were turned away.  The turnaway group either gave birth (N=161) or had an abortion or miscarried (N=70) as possible outcomes.  Based on those outcomes they were identified as the turnaway-birth and turnaway-no-birth groups.   The first trimester group (N=273) was included to study whether or not the psychological outcomes differed if a woman had an abortion early or late during the pregnancy.

The test metrics were all Likert scales.  The depression and anxiety ratings came from the Brief Symptom Inventory (BSI) a 53 item rating scale of various psychological symptoms.  There are grouped ratings for 9 different symptom constellations including anxiety and depression.  All subjects are asked to rate their level of distress due to a symptom on a severity score ranging from 0 (not at all) to 4 (extremely).  For anxiety and depression their are 6 items each and subjects were identified as a "case" of anxiety or depression if their aggregate score were 9 of the total possible score of 24.  

Life satisfaction was determined by one item from the Satisfaction with Life Scale: "I am satisfied with my life."  One item was also included for self esteem.  Both were rated on a 5 - point scale from 1 (not at all) to 5 (extremely high life satisfaction/self esteem).

Using these variables, the trends were best illustrated in graphics of depressive cases versus time and depressive symptoms versus time (figure 1 above) and similar graphics for anxiety, self esteem, and life satisfaction.  The general trend was for less anxiety and depression slightly higher self esteem and life satisfaction over the 5 year course of the study.  I think analysis of the latter two elements was limited by the the single items 5 point scale and a regression toward the midpoint of the rating.  There is the usual extensive statistical analysis of what I would see as fairly limited data.  The turnaway groups and the near limit group generally had more depressive and anxiety symptoms and cases and lower self esteem and life satisfaction that the first trimester abortion group.  Their statistical analysis is consistent with those observations.

The authors conclude:  "Our findings add to the body of evidence rejecting the notion that abortion increases women’s risk of experiencing adverse psychological outcomes. Women who had an abortion demonstrated more positive outcomes initially compared with women who were denied an abortion."  In their secondary analysis they show that a history of previous mental health problems or psychological trauma correlated with adverse outcomes and may have worse outcomes if they are denied an abortion.  They discuss the importance of individualized care and recognizing the response to an abortion or in this case denial of abortion.  One trend that I did not see any specific comments on was the turnaway-no-birth group and the fact that it seemed to have the best outcome at 5 years in terms of depressive symptoms/syndromes and higher self esteem and life satisfaction.  In their overall conclusion the authors believe that their study shows that there is no necessity for laws warning women about the adverse psychological consequences of abortion and that being denied an abortion is potentially more detrimental.  

In their own discussion of the limitations of the study, loss of subjects over time was significant - 43% over 5 years.  They discuss the methods they used to limit bias due to loss (potentially of subjects with mental illnesses).  They discuss their alteration of the BSI and point out that it is really a screening instrument so that the identified cases in their study would require additional screening for an actual diagnosis of an anxiety disorder or depressive disorder.  

I had several thoughts when I read this study.  Women don't generally come in to psychiatrists and say they are depressed or anxious as the result of an abortion or a denied abortion.  That might be different in psychiatric clinics that specialize in women's health issues.  They often don't discuss the issue at all in the initial diagnostic evaluation.  They disclose these details along with other sensitive issues after a relationship has been established with a psychiatrist.  In that context there can be discussions about thoughts, images,  and feeling states related to abortion into other forms of psychopathology.  An example would be intense guilt, rumination, and self criticism about the abortion during an episode of depression.  When any person gets depressed it is a common experience to scan past personal history for stressful events from the past that lead to the same emotion.  There can be daydreams and fantasies of what the child would have been like.  There can be brief episodes of depression or anxiety related to self criticism, doubt, shame, or interpersonal conflict about having had an abortion.  Many of these thoughts can occur at a future date when the history of an abortion can take on new meaning such as a new committed relationship.   Any life event that impacts person's conscious state and causes them distress is significant to me, whether it is picked up by rating scales or not.  I would see these reactions as being part of normal emotional life rather than anything pathological.

Equating the mental health of women to a DSM diagnosis  or psychometric construct is a mistake.  The DSM is a product of looking at the 5% of people who are outliers and trying to characterize their problems with with categories or continua.  That approach removes human consciousness from the equation and that should no longer be acceptable to psychiatry or anyone interested in the conscious life of real people.  An event with as much potential meaning as abortion can never be adequately characterized as a psychiatric diagnosis or a psychometric scale.  The reactions are too diverse and nuanced.  Suggesting that abortions or the lack of abortions does or does not affect women is more of a political statement than a statement that takes into account the most important aspect of the human psyche - the unique conscious state of every person.  That conscious state is unique because what happens over the course of your lifetime matters and some events matter more than others.

My conclusion from practice is that abortion is one of many events that has the potential to significantly impact the conscious state of a woman.  That should be the consideration in the case of contraception, pregnancy prevention, and abortion and not whether or not it causes mental illness or symptoms.  A woman's unique conscious state should also be considered in the case of unplanned pregnancies and why that decision is much more complex than a list of social variables or whether or not contraception is used.  A more appropriate focus on conscious state rather than mental illness or symptoms would yield a more realistic idea about the effect of life events like abortion.  That result will be anything but simple and that is why simplistic political solutions or response to those solutions do not apply here.

I have a secondary conclusion about the place of politics in both the research and clinical care of women.  It has no place at  all.

It is as obvious as an annual vaguely threatening letter about abortion reporting to a psychiatrist from the state government.  When politicians practice medicine nothing good happens, but this letter goes way beyond that.


George Dawson, MD, DFAPA


References:

1:  Biggs MA, Upadhyay UD, McCulloch CE, Foster DG. Women's Mental Health and Well-being 5 Years After Receiving or Being Denied an Abortion: A Prospective, Longitudinal Cohort Study. JAMA Psychiatry. 2016 Dec 14. doi: 10.1001/jamapsychiatry.2016.3478. [Epub ahead of print] PubMed PMID: 27973641.

Attributions:

1:  Graphic at the top is from Reference 1 with permission from the American Medical Association - Order Number 4024950066424

2:  Thanks  to Pearson Assessments for sending me a sample copy of the Brief Symptom Inventory.  www.pearsonassessments.com

Catastrophic Thinking About Catastrophes

A storm rolls into Minneapolis - photo by Eduardo Colón, MD

Like most psychiatrists, I have spent a lot of time listening to anxieties about hypotheticals.  Are people judging me when I am out in public?  Will I fail an examination?  Will I end up penniless and homeless?  Am I really dying of something that the doctors can't diagnose? Am I going to lose control and drive off a bridge on the way in to work?  Now that my relationship is over will I ever find another person who will love me?  The human mind is set up to obsess about the improbable and if you have the predisposition to create a hypervigilant approach to this anxious stream of consciousness it will lead to much less sleep and a number of physical symptoms.  Many  people have had these patterns of thoughts for years or decades before they decide to see a psychiatrist or a psychotherapist.  This kind of anxiety can be disabling even without any panic attacks or significant physical manifestations.  It is an outstanding example of how emotion impacts decisions - in this case the decision to worry about something that is recognized as illogical.   One of my standard questions of the anxious person involves catastrophizing or jumping to the worst possible conclusion.  It is also a universal human experience.  The best example is assuming the worst if a family member is late when driving over to your place.  Are they in a ditch?  Are they in the emergency room?  Have they been in an accident?  Are they dead?  Common thoughts that various people get in that situation.  When it comes to real catastrophes, the thought patterns change significantly.

I have always been interested in catastrophes - ever since I read a book as a kid about a meteor hitting earth.  In those days we used to have to go to a bookmobile stop, get on a large recreational vehicle that functioned as a mobile library and borrow books to read every week.  That book caught my eye, because it had a picture of the collision on the cover and a detailed description of events on the inside.  At the time, the real risk of massive destruction was a standoff between the US and the USSR in the Cuban missile blockade and a decision by a Soviet submarine commander - but taxpayers are always the last to know.  We were worried plenty about that real crisis, but at about the same time - I was reading my first 400 page novel on a meteor hitting earth and all of the destruction that would involve.  Over the years it has lead to a focus on how to survive, the unsurvivable,  I have referred to myself as a survivalist at times but realize the I am half joking.  Real survivalists tend to see catastrophic events as impacting on the food supply.  I have heard the credo that "We are only 5 meals away from chaos."  The associated strategies are food hoarding, secure locations, and plenty of firearms if necessary.  I think it is logical to think that the food supply may be constrained, in quantity and volume - but I think that is also logical to take an approach that involves that maximizes the survival of the human race - from anything just short of the destruction of the planet.

My personal involvement with disaster planning peaked about 8-10 years ago.  At that time I was involved in 2 avian influenza task forces - one localized to the hospital where I was working and the other metro and statewide.  An influenza pandemic is a very lethal event that can result in tens of millions of deaths.  The last time the world population was subjected to a highly lethal strain in 1918, people were going to work in the morning and dropping dead in the streets on the way home in the evening.  My participation in these task forces was highly instructive on a number of issues.  I was involved in teaching psychological first aid (PFA).  The theory was fairly simple.  Most people who suffer the psychological trauma of a mass event like an epidemic will recover psychologically.  The focus is reassurance, providing information, and preventing surges of activity in hospitals and emergency departments that would overwhelm resources.  That theory was based on what happened after the concern about anthrax being sent to the US Capitol building occurred.  In that event emergency department (ED) services were immediately overwhelmed by people who thought they were exposed to anthrax.  To prevent that - trained PFA staff would be in ED areas to assist with keeping people moving.  The unfortunate reality was that the real infrastructure, ventilators and isolation rooms would be almost immediately overwhelmed even with the appropriate surge protection.   Nobody had adequate infrastructure to treat high numbers of people with respiratory failure who were infected with a highly virulent strains of influenza virus.  Nobody was interested in building that infrastructure.  Nobody was interested in HVAC (heating, ventilating, air conditioning) systems that did more than isolate a few infected people.  There was an interest in getting oseltamivir phosphate (Tamiflu ®) to whoever needed it.  I saw a slide several times of large pallets of boxed oseltamivir sitting in a large government hangar somewhere and being told that it was ready to be shipped to whoever might need it.  There was also an interest in what to do with large numbers of dead bodies and fairly specific plans for that detail.  In the end, the only logical conclusion was that the planners of this event were fairly hopeless about the outcome and trying to quell either the expected mass hysteria, the inability to marshall any realistic resources, or both.  From what I have seen, I would not expect a better outcome than 1918, unless there are effective vaccines immediately available.    

Non-Biological catastrophes are broader in scope and potentially more devastating.  The recent overview by Julia Rosen in Science (1) illustrates the possibilities.  An interesting aspect of the non-biological catastrophes is that they necessary need some kind of a hard fix.  There needs to be a basic shelter or someone has to figure out how to go out into space and either destroy or displace that asteroid hurtling toward the Earth.  There is no imaginary hospital bed capacity like with a biological epidemic.  If you don't have a real shelter or a real intercept device - all or part of the human race perishes. According to Rosen,  even these scientists are subjected to a "pervasive giggle factor".  Many do not see the study and prevention of catastrophes as mainstream science.

The body of Rosen's article discusses natural events that can decimate the infrastructure and other that could lead to the extinction of humans.  An example of an event that is probably not directly harmful to humans is a coronal mass ejection (CME) from the sun.  High energy particles are ejected from the sun and into the Earth's magnetic field.  The particles can destroy power grids and other electrical transmission gear.  CME events have occurred on Earth, one of the largest in 1859 called the Carrington Event.  Any similar event today might place power transformers at risk and create widespread havoc with the power grid resulting in large section of continents going dark for as long as years.

Near-Earth Objects (NEOs) are a more clear danger and probably have the most scientific investigation.  The Spaceguard survey by NASA identified 90% of the NEOs larger than 1 kilometer by 2010.  They are currently working on identifying 90% of the NEOs greater than 140 meters by 2020.  No NEO identified so far is on a colleion course with Earth.  The article contains a graph of Damage/Fatalities versus Recurrence Period in Years for Volcanoes, Impacts, Earthquakes, Floods and Tsunamis.  According to that graphic - a global catastrophe from an NEO impact recurs about once in 100,000 years.  From the graphic below, that event would have been the eruption of Mt. Toba in Indonesia about 74.000 years ago.  That may have killed most humans and led to a bottleneck event in human evolution where climate change led to a rapid paring of certain populations and more rapid adaptive changes.  Interestingly some fossil evidence suggests that native people in the vicinity of the eruption survived it and adapted to it.  The 1980 Mt. St. Helen's eruption is shown for relative scale.  That event killed 57 people and covered 22,000 square miles.  At 10 miles the ash was 10 inches thick.         

Graphic From US Geological Survey - Public Domain

I took the above events and tried to order them chronologically in the following graph.  For comparison with human evolution the first ancient humans (Homo erectus, Homo heidelbergensis) started out in East Africa about 200,000 years ago and started to migrate north.  The evolutionary changes necessary for modern humans happened about 50,000-75,000 years ago - sometime after the Mt Toba eruption.  The fossil evidence from Mt. Toba suggests that a supervolcano eruption in Yellowstone is survivable.  The critical question is how?  Various scenario have suggested that the sulfur dioxide content in the air will lead to climate change and a much higher prevalence of pulmonary illness.  Climate change will likely be a problem.  Fossil evidence suggests that there was a decade long period of cooler drier weather after the Mt. Toba eruption.    Computer simulations of the ash distribution from a Yellowstone supervolcano event would cover most of a triangular area from Los Angeles to Chicago to Calgary would be covered in ash varying in depth from 40 inches or more at the center to about an inch at the periphery.  With volcanos there is also a significant environmental impact from both the direct blast and and toxic gases like sulfur dioxide.

Whenever I discuss some of the issues with friends or coworkers - I get the same nervous laughter mentioned in the Science article. People can't seem to believe that there is anyone out there thinking about these things. The endpoints of the spectrum include: "You are nuts!" at one end to "I am just going to run outside and stand under the mushroom cloud. I would rather be dead than living in my basement for a year." at the other.   These sentiments were captured by Cormac McCarthy in his post-apocalyptic novel The Road. In the novel a boy and his father wander a dangerous post-catastrophe countryside. The actual event is never specified but there is widespread famine, climate change, and primitive behaviors including constant confrontations about food and cannibalism. There are flashbacks about the wife and mother of this dyad and we learn that she was not able to cope with the new reality and committed suicide. At one point they encounter an old man along the road who wants some of their food. There is tension between the father and son - the father wants to move on and the son is still altruistic and wants to help the old man. At some point there is a conversation and the old man sums up the situation when asked if he tried to "get ready for it":

"What would you do?....Even if you knew what to do you wouldn't know what to do. You wouldn't know if you wanted to do it or not. Suppose you were the last one left? Suppose you did that to yourself?" (p168-169).

McCarthy does a masterful job of capturing the attitudes of the resilient, the hopeless, and the altruistic after a catastrophe. He also illustrates that in truly catastrophic conditions nihilism may be a logical conclusion, but hope still lives on in the minds of others.  I have encountered all of these attitudes in discussing the prospects for survival, but my anecdotal experience is that most of the people planning to survive seem to be planning on confrontations and shoot outs that are directly out of The Road.

I think the outcome can be much more positive, survival enhancing and optimal when it comes to the survival of the human race.  It does take a more enlightened approach to food and shelter. It requires generations of planning. It requires multidisciplinary planning to gradually change the infrastructure. I was not able to get a critical reference to complete this post that was listed in the Rosen article (5). This book has been widely reviewed as a possible solution when food storage is not possible. Their suggested food sources would be useful in any sun blocking catastrophe like a supervolcano, nuclear winter or high speed impact by an NEO where vegetation could not be grown. Gradual but large scale changes to the infrastructure could also result in permanent dwellings designed to provide fresh food and water to the occupants as well as waste disposal and HVAC systems that would function in a highly adverse environment and supply clean air in the absence of any major power disruptions.

Encouraging gradual change with these goals in mind is a much better position to take than preventing post catastrophe panic. As a psychiatrist who has been involved in disaster planning - having a real solution is always superior to meaningless reassurance. That would never work in one-to-one psychotherapy. Why would anyone expect it to work for agitated crowds?

George Dawson, MD, DFAPA




References:

1: Rosen J. Thinking the Unthinkable. Science. 2016 Jul 15;353(6296):232-7. doi: 10.1126/science.353.6296.232. PubMed PMID: 27418500.

2: United States Geological Survey (USGS). Yellowstone Volcano Observatory. Questions about supervolcanoes. Accessed August 2016.

3: United States Geological Survey (USGS). Fact Sheet 2005-3024. Steam Explosions, Earthquakes, and Volcanic Eruptions—What’s in Yellowstone’s Future? Accessed August 2016.

4: Cormac McCarthy. The Road. Vintage Books, New York, 2006. 287pp.

5: David Denkenberger and Joshua Pearce. Feeding Everybody No Matter What: Managing Food Security After Global Catastrophe, First Edition. Academic Press, 2014

Appendix 1: Estimated ash distribution from a Yellowstone supervolcano event.

From United States Geological Survey - Public Domain

Appendix 2:

I wrote a brief science fiction piece about psychiatric treatment after a supervolcano eruption in both original and annotated forms.