Opiates And Moral Dilemmas For Physicians

I became aware of an article from Reason magazine written by a physician Jeffrey A. Singer titled Physicians Face A Moral Dilemma In Conscription on War on Drugs (1). In keeping with the main theme, the subtitle was “In the government’s new war on opiates, physicians and their patients find themselves caught in a crossfire.”  Physicians are generally in the crossfire of any number of government healthcare reforms. The opening lines of this essay should not surprise any physician.  We have been in the crosshairs for thirty years.  There is a tangible difference in the War on Drugs.  In the 1990s, I can recall a vague threat about incarceration for not doing my notes properly.  That wasn’t a threat to me specifically but an entire clinic of physicians than I belonged to at the time.  In retrospect it sounds absurd, but that the was pre-911 days when the FBI spent a lot of time reading physician notes and deciding whether or not they had committed health care fraud by not doing enough documentation.  These days physicians can be prosecuted and incarcerated for the way that they prescribe opiates. The threat is much more real.

Dr. Singer’s introductory paragraph points out that when any health crisis occurs politicians are eager to step up and offer their solutions and throw a lot of money at the problem.  In this case President Obama is building new drug addiction centers and “training” government physicians on opioids to the tune of $100 million.  Hillary Clinton is promising $10 billion as a criminal justice initiative as grant for drug treatment centers and training for first responders to administer opiate antidotes.  I have never seen a single politician or government bureaucrat acknowledge that the reason why the opiate epidemic exists has to do with policy initiatives that occurred right around the year 2000.  At that point, physicians were encouraged to treat pain more aggressively and with fewer checks and balances than they had in the past.  The cumulative effect of these policy changes was a lower threshold for prescribing opiates for chronic noncancer pain and a removal of some of the gatekeeper mechanisms – like getting second opinions from pain specialists on this practice.

The First War on Drugs was described as the initial prohibition of opiates and cocaine by the Harrison Act in 1914.  Singer describes a scenario where a physician who would prescribe an opiate to help a patient “cope with their addiction” as being in conflict with the law.  The Harrison Act prohibited physicians from prescribing opiates to maintain an addiction.  He cites this example as being the first moral dilemma.  It is more complicated than depicted.  There have always been a number of physicians who consciously or unconsciously maintained large numbers of patients in addiction and that was their medical practice.  That practice does not pass current conflict of interest considerations much less the ethical obligation of physicians to do no harm.  It is a given that legal interventions are generally blunt instruments for protecting people from their problematic decision-making and that a complete picture of all of the data (the number of people addicted by medical treatment versus non-medical sources) is never clear.  Is there a problem with suggesting that physician themselves should not be a primary source for creating and maintaining addiction?  The main problem is that even the most well-informed and well-intentioned physician can end up with a patient who is addicted to a medication.  There is currently no known way to prevent that.  Are those physicians criminals in any way?  I don’t think so.  At the same time, should there be a prohibition against physicians setting up a practice that maintains high number of patients in addiction, does nothing to facilitate their recovery from addiction, and has no other purpose – of course there should be such a prohibition. 

The next argument in the essay has to do with the safety of opiates versus alcohol.  This is a common argument by people who see nothing wrong with the legalization of drugs.  I am not suggesting that Singer is making this argument; he is trying to point out that opiates are relatively safer than alcohol and alcohol is a legal drug.  I think that he is wrong on several counts in this argument.  The first point has to do with the overall toxicity of alcohol.  He cites a number of diseases that have to do with the long-term toxicity of alcohol.  Alcoholic cirrhosis for example is typically the fifth or sixth leading cause of death in middle-aged men.  The estimated dose required in most cases is 15-pint years or drinking one pint of whiskey per day for 15 years (2).  Doing a quick calculation shows that this is about 143.26 grams of ethyl alcohol per day.  The progression to cirrhosis will vary based on sex, genetic factors, and rates of metabolism.  The overriding point is that alcohol consumption at this rate is limited to a small percentage of drinkers and the population exposure to alcohol is relatively stable based on current legal and cultural factors.  A related issue is that if you are alcohol dependent tolerance and withdrawal phenomena may lead to a marked increase in consumption – up to 750-1,500 ml/day in order to maintain blood levels high enough throughout the day to prevent withdrawal.  The exposure of multiple tissues over time causes the damage.

The primary mechanism of injury and death from opiates is respiratory ataxia and arrest by the direct action of the drug on small clusters of cells in the midbrain and medulla.  Opiates have a direct effect on the center that determines respiratory rhythm and the center that responds to chemical changes due to oxygen deficiency and carbon dioxide accumulation.  Benzodiazepines, alcohol and sleep medications are often involved in these situations and have a combined effect.  Alcohol in high enough doses can have a similar effect in depending on the individual and their state of tolerance.

Looking at the acute mortality related to alcohol and opiates, I don’t think that there should be any doubt that opiates are probably more lethal than alcohol.  The CDC states that about 2,200 people die every year from acute alcohol poisoning (3).  The population at risk appears top be 38 million binge drinkers.  Men ages 35-64 are at highest risk.  In 2014, there were 18,893 overdose deaths from prescription painkillers and 10,574 deaths from heroin overdose (4).  In this case the estimated populations at risk include 1.9 million people with a prescription painkiller problem and 586,000 heroin users.  Furthermore the death rate from prescription painkiller and heroin use parallels the availability.  I am puzzled by the author’s suggestion that opiates are “much safer” and that there is “honest disagreement among health care practitioners over just how harmful long term opiate use can be…”.

I guess that I am one of those disagreeable health care practitioners.  Anyone can fact check the above argument for acute toxicity and I would encourage a close look at the trendlines over the past 15 years.  If you look at this lines, you will find that the rate of deaths due to heroin overdose was relatively stable for at least a decade before a sizable number of prescription painkiller users decided to start using heroin.  The decision is a strictly economic one.  The most commonly abused prescription painkiller costs a dollar per milligram on the street.  Addicts are typically using 120-240 mg per day.  The equivalent amount of heroin can be purchased for about ¼ as much.  The end result is that stable rate of heroin overdose deaths has quadrupled in the last 5 years.  It is stark to contemplate that the total opiate death rate is based on a population at risk that is about 10% the size of the drinking population at risk.

Dr. Singer describes the movement that led to increased opiate prescribing at the beginning of the 21^st century as “enlightened” and “compassionate.”  He uses the term opiophobia as the irrational fear that doctors and patients have about these medications.  I think it is very clear that these advocacy groups and bureaucrats had no clue that increased access would lead to an epidemic of addiction and overdose deaths.  The moral dilemma for physicians is not colluding with law enforcement in the War on Drugs and “cutting patients off.”  The moral dilemma is practicing sound medicine in a system that blames them for not prescribing enough opioids and then ten years later blames them for prescribing too many.  All of this occurs against the backdrop of a culture that has an insatiable appetite for intoxicants in a country that has one of the highest per capita opiate consumption rates in the world.  The moral dilemma for physicians is recognizing that they can’t predict who will or not become addicted to an opiate and that many physicians do not have the skills necessary to not prescribe to patients who either really don’t need the drug or are probably addicted to it.

There is more than one moral dilemma in the opiate epidemic.  On the patient side should you let your doctor know if you have an addiction before the opiate prescription is written?  Should you let your doctor know that the first pill from the prescription left you feeling euphoric, energetic, confident and like you have never felt before in your life?  Should you let your doctor know that you are continuing to take prescription painkillers even though they don’t work for the pain or because the pain is gone?  Should you tell your doctor or pharmacist know that you suddenly have access to all of the opiates from a deceased family member who was in hospice care and ask how to keep them off the street?

There are many moral dilemmas associated with opiates for everyone and very little moral guidance.

      

George Dawson, MD, DLFAPA


Supplementary:

To calculate the mg alcohol in a pint of whiskey:

1 pint = 473.18 ml

473.18 ml x 0.4 (percent alcohol) x 0.757 g/ml (specific gravity of alcohol) = 143.26 g ethyl alcohol

References:

1:  Singer JA.  Physicians Face Moral Dilemma In Conscription on War on Drugs.  Reason.com  March 23, 2016.  Accessed on March 25, 2016.

2:  Lefton HB, Rosa A, Cohen M. Diagnosis and epidemiology of cirrhosis.  Med Clin  North Am. 2009 Jul;93(4):787-99, vii. doi: 10.1016/j.mcna.2009.03.002. Review. PubMed PMID: 19577114.

3:  Centers for Disease Control and Prevention.  Alcohol Poisoning Deaths.  CDC Vital Signs, January 2015.

4:  American Society of Addiction Medicine.  Opioid Addiction 2016 Facts and Figures.  ASAM web site accessed on March 26, 2016.   

       

The Screeners - Annotated: Psychiatric Lessons From A Short Science Fiction Story

I recommend reading the original version (preceding post) first before reading the annotated version.


What follows actually happened in the year 2066......

I could tell my brother needed help. We had been underground for too long. Whenever that happened he stopped sleeping regularly, he started to act crazy. This time he was looking for footprints - evidence that somebody was trying to get in through the hatch. I explained to him that the hatch was hydraulically locked from the inside. It was designed to take a direct hit from a grenade-launcher. But who could even hit it at that angle, flat against the two foot thick concrete roof of our bunker. This time he was sprinkling flour rations on the floor under the hatch. Anyone who came in had to step on that area and he would have their footprint in the flour.

This is an almost universal experience of family members directly observing their relatives with bipolar disorder.  They notice they become unpredictable sometimes to the point that they are frightening.  This is often manifested in their capacity for rational thought and personality changes.  In this case they observe paranoid behavior - defined as an unrealistic fear of harm or manipulation.  Family members are often at a loss in this situation because the person with the problem denies that there is anything wrong.  In many cases, the personality changes go on for months and lead to problems with employers and spouses.   

But the powder around the entrance was the least of our worries. His apartment was within a hundred feet of the hatch. He sat in his apartment looking out the window. He kept a plasma cutter nearby. It was for self defense, but he also told my son that if anyone did breach the hatch and they came for him - he knew exactly what to do. He would turn the plasma cutter on himself. He did not want to give the invaders a chance to torture and kill him. He would kill himself first. It would be over quickly.

This is a little known form of suicidal thinking that occurs in paranoid people.  They are so fearful of the unknown assailants that they are prepared to kill themselves - rather than be tortured or slowly killed.  In fact, they are not in danger at all.  This problem requires an intense effort to diagnose and treat - independent of any medications.

He had been getting worse for the past ten years. Long periods of laying in bed for days and weeks, barely eating and drinking. Not saying a word. That usually happened after weeks or months of being hyper, talkative and staying up all night. If you caught him at exactly the right time, he was interesting, funny, and you felt good talking with him. At the wrong time - it could be a nightmare. He could accuse you of trying to steal his American Gold Eagles. Everybody knew he had a tube of them somewhere in the bunker. Everybody knew because whenever he got hyper and started talking a lot, he would hold some of the coins in his hands and show everybody that he had them. During one of these episodes, he gave a couple of them away. Gold Eagles worth tens of thousands of dollars - just handed out to strangers at a watering hole.

Very typical behavior of untreated bipolar patients.  During periods of hyperactivity and euphoria they may give away large sums of money to casual acquaintances without being able to assess the consequences.  This can lead to financial duress or in the extreme, financial ruin. 

He had bipolar disorder, just like our mother. He has never seen a doctor, I just know from my experience with my mother. I remember going to see the doctor with her. She would see her every couple of months, unless she was having problems and then it would be more frequently. She liked that doctor and trusted her. She would always tell me that if she got too sick to make it to the doctor, my job was to call the doctor's office and let her know that she was not doing well. The doctor came over to our house one day to see my mother. Mom didn't say much, but the doctor knew what she needed and a short time later she was better. That went on like that for about ten years until I was ready to go to college. That was when the Supervolcano blew and we all had to go underground for three years. Mom was 60 by then. She couldn't adapt to living underground. She could not sleep underground in the phosphorescent lighting. She would stay up for weeks and get harder and harder to understand. She would start swearing and eventually made no sense at all. Then she would crash and not be able to eat. My wife and I would encourage her, but she would say: "Let me die....pick up that knife over there and kill me." We knew that she was not joking. Until the air finally cleared, there were no doctors and no medicines. She only had a month of medication when we went underground. Nobody could get more than a month at a time - even though everybody knew it was going to be a long time before we could come up for air.

Bipolar disorder definitely runs in families with what appears to be sporadic inheritance because of the polygenic nature of the disorder.  Bipolar disorder is sensitive to sleep and circadian rhythm disruptions and patients need to be counseled and constantly reminded about this.  Severe cognitive problems and catatonia can result and lead to severe disability. 

At about the one year mark - Mom died. She just got more and more confused. She stayed in bed and did not eat or drink anything for five days. The paramedic in our bunker said that she probably died from dehydration.

I don't think it is common knowledge that bipolar disorder can be a fatal condition.  At the turn of the 19th century, well before there were any useful medications - some forms of bipolar disorder were highly fatal.  Estimates from Boston Hospitals at around that time suggested that malignant catatonia resulted in about an 80% fatality rate.  Untreated mania in those days also resulted in a significant number of deaths from congestive heart failure due to constant agitation.  These facts are often ignored during an era where even episodic care during exacerbations of illness can prevent death.  Inpatient psychiatrists and consultation-liaison psychiatrists still find themselves in many life and death situations per year with hospitalized patients on the verge of dehydration and starvation due to severe psychiatric disorders.  In many situations, one of the best treatments available for this problem - electroconvulsive therapy is unavailable due to legal and political constraints.   

"Kevin is getting bad again" - my wife walked in. She was wearing standard desert camouflage hardened to withstand all of the fly ash. "I just saw him. He had melted a jar of peanut butter in the microwave and and he was throwing it all over the place. He has it splattered all over the walls. It looks like a Jackson Pollock painting." My wife was going to study art before the Supervolcano or "SV" as some call it now. Most people just talk about surviving it by using the phrase "when the air cleared." "We have to do something before he ends up like your mom or somebody takes advantage of him and gets his gold."

Highlights the familiy predicament of dealing with a family member who has had a transformation of their conscious state.  They are no longer predictable or rational.  Most emergency medical personnel confronted with this situation would ask the person a few questions and leave.  If the person became verbally aggressive, the outcome of the situation is highly dependent on the skill of the emergency personnel or involved law enforcement officers and there can be very adverse outcomes.

"More like hitting him over the head and taking it you mean. You would think that a guy who can be that paranoid would not put himself in those situations." I knew the words were meaningless as soon as they rolled off my lips. I had been watching bipolar people in my family for decades and they are unpredictable. Expect to see them in a certain situation and they disappear for weeks or months. "We have to try to get him to Minneapolis and see if they have scavenged any medication or if any new medical supplies have been flown in."

We had been to Minneapolis a couple of times since the air cleared. The trip is not too bad - 300 miles by a skimmer across the fly ash. So far nothing was growing up through the fly ash. We make good time with a skimmer and the metal composite tires make that trip many times before they need to be replaced. It just takes 20 minutes to recharge the batteries and we are back home the same day. The medical infrastructure was slowly being rebuilt. Practically all of the health care administration in the state was in Minneapolis and many of these bureaucrats survived the near extinction event. Surgical services and Cardiology had been restored. Last year they began doing heart, lung, liver and pancreas transplants at what used to be University Hospital.

There is a long history of discrimination against psychiatric and addiction services, despite the fact that they are routinely assessed as being in the top 10 disabling conditions world wide.  The discrimination is well documented on this blog and it occurs at all levels.  The so-called critics of psychiatry do not mention this phenomenon because it is inconsistent with their view that psychiatry is the source of all problems and not the selective rationing.

Treatment for mental disorders was always a problem. As people started coming out of their bunkers and heading back into the city general medical care was available in many places. The only treatment for mental disorders occurred in the same clinics where people went to get treated for infections and lung problems from the fly ash. People still got cancer and heart disease. People still got involved in accidents and injured themselves. Doctors with various skills were still around even though training programs were just restarting. Doctors tended to be old or really young.

In this piece, collaborative care and its ultimate goal of eliminating psychiatry rules the day.  An interesting proposition is who all of the critics will blame when psychiatrists are gone.  The obvious choice would be the next batch of prescribers, but in my story they became history as well.  There is clear history of mismanagement in medicine - rationalized by "cost effectiveness".  The most cost effective approach is to marginalize all professionals and pretend to replace them with checklists or artificial intelligence. 

My wife and I did some fast talking, convinced Kevin it would be an exciting trip, loaded him in the skimmer and took off. Within 4 hours we were standing in line in a large warehouse that had been converted to a medical clinic. Half an hour later we were face to face with a triage person:

"Nature of the problem?" he said matter of factly.
"My brother has bipolar disorder and he needs treatment." I replied.
"We don't see a lot of that here, are you sure about the diagnosis?" The triage person seemed a little impatient.
"My mother had it and she told me that her grandfather had it. He does a lot of what she used to do. His whole personality changes at times and he has problems taking care of himself. She used to see a doctor who treated bipolar disorder. Do you have a doctor like that?"
"Not anymore...but we do have screeners."

You don't have to live in the year 2066 to experience the above dialogue.  It is occurring right now in hundreds of clinics across America.  No access to psychiatrists or mental health professionals who could be very useful in treating the problems that they were trained to treat. 

We walked to the west side of the warehouse and entered a small room. There were a few people there. We got in to see the screener in a about 20 minutes. He looked like a clone of the triage person right down to the American Health Care pin on his lapel. He listened to me describe the problem for about two or three minutes, reached in a drawer and pulled out a piece of paper. It had three questions on it. After every question there was a line that varied from "None" to "Most of the time." Kevin made three checkmarks - one on each line at about the 75% mark.

This is a standard approach being used right now.  A checklist will be made right out of the DSM criteria.  Then it will be pared down to 3 or even 1 question rating scales.  Without the presence of a diagnostician, the checklist score and cutoff becomes the default diagnosis.  The interesting aspect of a screening instrument for bipolar disorder is that in many cases the affected person will not endorse any problems on the scale even when they are quite symptomatic.  

"Well he qualifies for treatment." the screener remarked. "The Army just brought in a shipment of medication for mood problems."
"My mother used to take Phosphotide 23, before the volcano blew. It worked pretty well."
"No ... all I have is this stuff.   It is taking a while to get drug manufacturing up and running again. Only the west coast facilities were untouched and they have shifted all of their production to what people really need...you know antibiotics, heart meds, asthma medication. But I have plenty of this medication. Give it a try. Take two of these tablets every night".

There are widespread complaints about Big Pharma and medication prices.  I have written several pieces on this blog myself.  Medication expenditures have created a large number of medications and a significant surplus, but they are ironically rationed by Pharmacy Benefit Managers and managed care companies, even to the point that generics drugs require a negotiation.  In this case the patient is being given a medication that is probably not indicated for his condition and may make him worse.  Similar problems can occur with treatment based on screening tests.   

He handed me a large bottle of medication. The darkened label on the bottle read: "amitriptyline 25 mg tabs". The expiration date was July 20, 2025. I looked back at the screener and asked: "Is there anybody he can talk to about some of his problems? He goes off on a tangent and my wife and I don't know what to say to him."

This is a current problem in the business oriented behavioral health system.  Psychotherapy is rationed and in many case therapists have productivity expectations that they cannot sustain and that leads them to quit.  Contrary to popular myths people with severe mental illnesses benefit greatly from talking with their psychiatrists and are often reluctant to see other therapists or physicians.  In many systems of care today patients with severe mental illness see a "prescriber" for 15-20 minutes - 2 - 4 times a year. 

"No I'm afraid not. At American Health Care we do screening. My understanding is that the new government and the remaining businesses got together and decided that was the most cost-effective approach."

"Cost-effective" is a buzzword that is unevenly applied.  That should be evident from comparing psychiatric services (or behavioral health services) to every other medical specialty in any health care system.  There is a sharp contrast between what this concerned family member knows about bipolar disorder (disabling and killing his mother and disabling his brother and making him unpredictable) and how the health care system responds to his concerns.  It is as if  he is talking about a trivial condition.

Within thirty minutes we were back in the skimmer, moving at good speed across the fly ash. I glanced over at my wife. Her large blue mirrored-out glacier glasses did not conceal her worry. I looked at the plume we were kicking up in my rearview screen and thought:

"I hope this works."

Our concerned family member here is hopeful, but it is highly unlikely that the medication he picked up will be effective and it may make the situation worse.  The patient and family would have benefited by a detailed risk-benefit and monitoring discussion, as well as a follow-up plan.  In a typical screening procedure that occurs today, a person may leave the office with one or more month-long prescriptions and no clear plan for monitoring or contingencies if the medication does not work or it is not tolerated.  Follow up periods are frequently too long to make much of a difference and many people either discard the medication immediately, don't get it refilled, or get side effects - don't report them and discard the medication.  More frequent meetings for psychotherapy or closer monitoring are the exception rather than the rule.  

The more I thought about this near apocalyptic science fiction story, the more I realized that this is the type of care that many (if not most) people get right now and it is the type of care that is being promoted over seeing psychiatrists.



George Dawson, MD, DLFAPA


Supplementary:

I tried to write this science fiction piece in the spirit of the one page sci-fi stories that are always on the last page of the journal Nature under their heading Futures Science Fiction go.nature.com/mtoodm

From the perspective of a psychiatrist (and a family member) of course.

This is a pure fiction and it contains no references to any real people or corporations. Any resemblance is purely coincidental.


Attribution:

The picture at the top of this file was uploaded from Wikimedia Commons.  This attribution is from their side and when the file was accessed on March 19, 2016, the link in this reference did not work:  Work of the Bureau of Land Management, a U.S. Government Agency. Taken from the BLM website: http://www.blm.gov/style/medialib/blm/wy/rsfo/recpics.Par.0272.Image.640.427.1.gif  No photo credit is given.

The Screeners

What follows actually happened in the year 2066......

I could tell my brother needed help.  We had been underground for too long.  Whenever that happened he stopped sleeping regularly.  He started to act crazy.  This time he was looking for footprints - evidence that somebody was trying to get in through the hatch.  I explained to him that the hatch was hydraulically locked from the inside.  It was designed to take a direct hit from a grenade-launcher.  But who could even hit it at that angle, flat against the two foot thick concrete roof of our bunker.  This time he was sprinkling flour rations on the floor under the hatch.  Anyone who came in had to step on that area and he would have their footprint in the flour.

But the powder around the entrance was the least of our worries.  His apartment was within a hundred feet of the hatch.  He sat in his apartment looking out the window.  He kept a plasma cutter nearby.  It was for self defense, but he also told my son that if anyone did breach the hatch and they came for him - he knew exactly what to do.  He would turn the plasma cutter on himself.  He did not want to give the invaders a chance to torture and kill him.  He would kill himself first.  It would be over quickly.

He had been getting worse for the past ten years.  Long periods of laying in bed for days and weeks, barely eating and drinking.  Not saying a word.  That usually happened after weeks or months of being hyper, talkative and staying up all night.  If you caught him at exactly the right time, he was interesting, funny, and you felt good talking with him.  At the wrong time - it could be a nightmare.  He could accuse you of trying to steal his American Gold Eagles.  Everybody knew he had a tube of them somewhere in the bunker.  Everybody knew because whenever he got hyper and started talking a lot, he would hold some of the coins in his hands and show everybody that he had them.  During one of these episodes, he gave a couple of them away.  Gold Eagles worth tens of thousands of dollars - just handed out to strangers at a watering hole.

He had bipolar disorder, just like our mother.  He has never seen a doctor, I just know from my experience with my mother.  I remember going to see the doctor with her.  She would see her every couple of months, unless she was having problems and then it would be more frequently.  She liked that doctor and trusted her.  She would always tell me that if she got too sick to make it to the doctor, my job was to call the doctor's office and let her know that she was not doing well.  The doctor came over to our house one day to see my mother.  Mom didn't say much, but the doctor knew what she needed and a short time later she was better.  That went on like that for about ten years until I was ready to go to college.  That was when the Supervolcano blew and we all had to go underground for three years.  Mom was 60 by then.  She couldn't adapt to living underground.  She could not sleep underground in the phosphorescent lighting.  She would stay up for weeks and get harder and harder to understand.  She would start swearing and eventually made no sense at all.  Then she would crash and not be able to eat.  My wife and I would encourage her, but she would say: "Let me die....pick up that knife over there and kill me."  We knew that she was not joking.  Until the air finally cleared, there were no doctors and no medicines.  She only had a month of medication when we went underground.  Nobody could get more than a month at a time - even though everybody knew it was going to be a long time before we could come up for air.

At about the one year mark - Mom died.  She just got more and more confused.  She stayed in bed and did not eat or drink anything for five days.  The paramedic in our bunker said that she probably died from dehydration.

"Kevin is getting bad again" - my wife walked in.  She was wearing standard desert camouflage hardened to withstand all of the fly ash.  "I just saw him.  He had melted a jar of peanut butter in the microwave and and he was throwing it all over the place.  He has it splattered all over the walls.  It looks like a Jackson Pollock painting."  My wife was going to study art before the Supervolcano or "SV" as some call it now.  Most people just talk about surviving it by using the phrase "when the air cleared."  "We have to do something before he ends up like your mom or somebody takes advantage of him and gets his gold."

"More like hitting him over the head and taking it you mean.  You would think that a guy who can be that paranoid would not put himself in those situations."  I knew the words were meaningless as soon as they rolled off my lips.  I had been watching bipolar people in my family for decades and they are unpredictable.  Expect to see them in a certain situation and they disappear for weeks or months.  "We have to try to get him to Minneapolis and see if they have scavenged any medication or if any new medical supplies have been flown in."

We had been to Minneapolis a couple of times since the air cleared.  The trip is not too bad - 300 miles by a skimmer across the fly ash.  So far nothing was growing up through the fly ash.  We make good time with a skimmer and the metal composite tires make that trip many times before they need to be replaced.  It just takes 20 minutes to recharge the batteries and we are back home the same day.  The medical infrastructure was slowly being rebuilt.  Practically all of the health care administration in the state was in Minneapolis and many of these bureaucrats survived the near extinction event.  Surgical services and Cardiology had been restored.  Last year they began doing heart, lung, liver and pancreas transplants at what used to be University Hospital.

Treatment for mental disorders was always a problem.  As people started coming out of their bunkers and heading back into the city general medical care was available in many places.  The only treatment for mental disorders occurred in the same clinics where people went to get treated for infections and lung problems from the fly ash.  People still got cancer and heart disease.  People still got involved in accidents and injured themselves.  Doctors with various skills were still around even though training programs were just restarting.  Doctors tended to be old or really young.

My wife and I did some fast talking, convinced Kevin it would be an exciting trip, loaded him in the skimmer and took off.  Within 4 hours we were standing in line in a large warehouse that had been converted to a medical clinic.  Half an hour later we were face to face with a triage person:

"Nature of the problem?"  he said matter of factly.
"My brother has bipolar disorder and he needs treatment." I replied.
"We don't see a lot of that here, are you sure about the diagnosis?"  The triage person seemed a little impatient.
"My mother had it and she told me that her grandfather had it.  He does a lot of what she used to do.  His  whole personality changes at times and he has problems taking care of himself.  She used to see a doctor who treated bipolar disorder.  Do you have a doctor like that?"
"Not anymore...but we do have screeners."

We walked to the west side of the warehouse and entered a small room.  There were a few people there.  We got in to see the screener in about 20 minutes.  He looked like a clone of the triage person right  down to the American Health Care pin on his lapel.  He listened to me describe the problem for about two or three minutes,  reached in a drawer and pulled out a piece of paper.  It had three questions on it.  After every question there was a line that varied from "None"  to "Most of the time."  Kevin made three checkmarks - one on each line at about the 75% mark.

"Well he qualifies for treatment." the screener remarked.  "The Army just brought in a shipment of medication for mood problems."
"My mother used to take Phosphotide 23, before the volcano blew.  It worked pretty well."
"No ... all I have is this stuff.  It is taking a while to get drug manufacturing up and running again.  Only the west coast facilities were untouched and they have shifted all of their production to what people really need...you know antibiotics, heart meds, asthma medication.  But I have plenty of this medication.  Give it a try.  Take two of these tablets every night".

He handed me a large bottle of medication.  The darkened label on the bottle read: "amitriptyline 25 mg tabs".  The expiration date was July 20, 2025.  I looked back at the screener and asked: "Is there anybody he can talk to about some of his problems?  He goes off on a tangent and my wife and I don't know what to say to him."
"No I'm afraid not.  At American Health Care we do screening.  My understanding is that the new government and the remaining businesses got together and decided that was the most cost-effective approach."

Within thirty minutes we were back in the skimmer, moving at good speed across the fly ash.  I glanced over at my wife.  Her large blue mirrored-out glacier glasses did not conceal her worry.  I looked at the plume we were kicking up in my rearview screen and thought:

"I hope this works."          



George Dawson, MD, DLFAPA


If you read this far, you might be interested in the annotated version with notes on the psychiatric implications of this fictional account.


Supplementary:

I tried to write this science fiction piece in the spirit of the one page sci-fi stories that are always on the last page of the journal Nature under their heading Futures Science Fiction go.nature.com/mtoodm

From the perspective of a psychiatrist (and a family member) of course.

This is pure fiction and it contains no references to any real people or corporations.  Any resemblance is purely coincidental.


Attribution:

The picture at the top of this file was uploaded from Wikimedia Commons.  This attribution is from their side and when the file was accessed on March 19, 2016, the link in this reference did not work:  Work of the Bureau of Land Management, a U.S. Government Agency. Taken from the BLM website: http://www.blm.gov/style/medialib/blm/wy/rsfo/recpics.Par.0272.Image.640.427.1.gif  No photo credit is given.



            

Baseball Caps, Wrap-Around Shades, and Sunglass Theory

I saw Erik van Kuijk MD, PhD present a lecture on macular degeneration at the Minnesota Academy of Medicine a couple of weeks ago.  He is an international expert in the subject and thoroughly reviewed the epidemiology,  basic science and current treatment of the disorder.  He described the risk factors including age (>60 years), smoking (doubles the risk), dietary factors (antioxidants) and sun exposure.  He  suggested the best barrier methods for sun exposure included baseball caps and wrap-around sunglasses.  At that point during the lecture, I had a brief episode of free association about that remark and thought about the sunglasses issue.   Within a few minutes I thought about sunglasses and their multiple roles in society.

To some sunglasses are a projective test.  I recall a college professor who seemed eager to tell anyone who would listen that men who had beards and sunglasses "had something to hide."  I had both, but could have told him that (being an introvert) of course I had something to hide, but it really had nothing to do with the beard and sunglasses.  Sunglasses can have special meaning with some psychiatric disorders that tend to magnify ordinary thoughts like - "These sunglasses make me look like an alien.  I might want to look like an alien."  You don't have to have a psychiatric disorder to have that thought.  Eye contact and facial expression depends a lot on the eyes and there are some people who realize this and do not want to expose that channel of communication.  On inpatient psychiatric units sunglasses are usually forbidden and rationales vary from place to place.  There are typically other patients and staff who are intimidated by people wearing sunglasses.  I was in a meeting at one point where one of the participants asked a late arrival about sunglasses because they were "freaking her out".  There are a couple of books out there that look at the social meaning of sunglasses both in terms of social behavior and fashion.  The scope of these books is discussed in the popular press largely in terms of why people with sunglasses may be more attractive.  The medical literature has surprisingly little to say about these factors. Indirectly there has been some work on facial symmetry as an attractive feature, and speculation that in some cases sunglasses give the appearance of greater facial symmetry.

As a cyclist, sunglasses have a prominent place in cycling literature.  Coaches typically advise eye protection for a number of reasons, but the best articulated one is to reduce fatigue.  If you are training and cycling tens to hundreds of miles per day, in most places you are going to be cycling into the sun at some point.  Without sunglasses there is a reflexive squint that eventually spreads to facial, neck, shoulder, back and chest muscles.  It would not surprise me that this also results in increased grip tension on the handlebars and that can increase blood pressure.  All of that muscle contraction leads to increased fatigue and decreased efficiency.  These factors probably explain why so many professional cyclists have shades and that they are some of the best designed wraparounds on the market.  Epidemiological studies also show that total sun exposure is a risk factor for macular degeneration and skin cancer.  That places certain occupations and recreational pastimes at higher risk.  A sampling of beach goers in Spain showed that there was no correlation between the subjects who sustained sunburns and whether they used adequate skin or eye protection.

Eye protection to prevent cataracts and macular degeneration is the most important application of sunglasses.  Ultraviolet light is to toxic factor and a recent review shows correlations with a significant number of eye diseases including eyelid malignancies, cataracts, photokeratitis, pterygium, and more limited data for other eye diseases (7).  As the eye ages, natural changes make it more susceptible to damage from UV light.  The literature from the National Eye Institute emphasizes that avoiding smoking, exercising regularly, blood pressure control, maintaining a low cholesterol, and eating a diet high in antioxidants and fish are the best preventive measures.  Sunglasses are not listed, but they were factored into the lecture I attended and many research articles. The dietary recommendations are based on trials of nutritional supplements used in the Age Related Eye Disease Study (AREDS-1 and AREDS-2).  In these studies, patients were recruited with early macular degeneration and were followed for progressive visual loss.  The formulation decreased the rate of progression of the eye disease.  The formulation in AREDS-2 consisted of lutein, xeaxanthin, Vitamin C, Vitamin E, zinc, and copper.  

The photobiology of light hitting the retina and macula is important in the development of macular degeneration.  The UV spectrum is typically broken up into UVA (320-400 nm), UVB (280-320 nm), and UVC (< 280 nm).  Only the first two are important since UVC is blocked by the ozone layer.  UVA has the deepest skin penetration and has been shown to generate reactive oxygen species (ROS) like singlet oxygen and hydrogen peroxide.(8)  Peroxiredoxins may be a significant defense against free radicals cause by UV light hitting eye structures.  Peroxiredoxin-3 (Prdx-3) is in the retina and lens of the eye.  In the  retina it is highly expressed in areas where there is high mitochondrial density.  The chemistry of lutein and xeaxanthin and their proposed role in preventing damage is interesting.  Both are 40 carbon conjugated compounds.  They absorb light at the 400 -500 nm range just outside of UV.  One of the ways that UV causes damage is by creating reactive oxygen species (ROS) when it hits susceptible structures in tissue.  The eye becomes more susceptible to UV damage as the chemical composition of chromophores in the eye change with aging.  As UV light hits phototoxic chromophores in the eye producing free radicals and singlet oxygen.  That in turn leads to photooxidation and damage to the eye.  Lutein and zeaxanthin act by quenching these ROS (11).  

Lutein

Zeaxanthin

What are the implications for psychiatrists in all of this?  The first is smoking cessation.  Smoking is a public health problem on its own and nicotine exposure is probably a gateway to further drug use with recent convincing work done on the epigenetic mechanism.  Macular degeneration is just another reason to advise people to not smoke.  The healthy diet and exercise proposed here for ophthalmology patients is another way of saying, avoid obesity and the metabolic syndrome.  Psychiatrists need to be giving their patients the same advice about diet and exercise.  Metabolic syndrome is a significant comorbidity, precursor, and iatrogenic complication of mental illness.  Some theorists have suggested that ROS produced in metabolic syndrome is a reason for the numerous complications.  Another potential research area is whether or not any current medications prescribed by psychiatrists increase the likelihood of cataracts, macular degeneration, or directly affect some of the phototoxic mechanisms that can occur in the eye.  I can recall that as a medical student we emphasized eye exams on psychiatric patients and there was a brief emphasis again when quetiapine was initially marketed, but not much evidence since.  In those days we were concerned about stellate cataracts and retinal hyperpigmentation caused by phenothiazines.  With the institutionalized deterioration in the quality of psychiatric care, this is another area for re-emphasis.  Every practicing psychiatrist needs to be aware of these mechanisms and at the minimum make recommendations for eye care, especially in aging patients.

The ophthalmology lecture was a good reminder that some disease mechanisms like oxidation can cut across several clinical specialties.  This provides a good opportunity for clinical psychiatrists to follow patients closely and potentially make more of a difference in their lives.

George Dawson, MD, DLFAPA

Normal Retina

References:

1:  Schick T, Ersoy L, Lechanteur YT, Saksens NT, Hoyng CB, den Hollander AI, Kirchhof B, Fauser S. HISTORY OF SUNLIGHT EXPOSURE IS A RISK FACTOR FOR AGE-RELATED MACULAR DEGENERATION. Retina. 2015 Oct 5. [Epub ahead of print] PubMed PMID: 26441265.

2:  Yam JC, Kwok AK. Ultraviolet light and ocular diseases. Int Ophthalmol. 2014 Apr;34(2):383-400. doi: 10.1007/s10792-013-9791-x. Epub 2013 May 31. Review. PubMed PMID: 23722672.

3:  Roberts JE. Ultraviolet radiation as a risk factor for cataract and macular degeneration. Eye Contact Lens. 2011 Jul;37(4):246-9. doi: 10.1097/ICL.0b013e31821cbcc9. Review. PubMed PMID: 21617534. 

4: Sommerburg O, Keunen JE, Bird AC, van Kuijk FJ. Fruits and vegetables that are sources for lutein and zeaxanthin: the macular pigment in human eyes. Br J Ophthalmol. 1998 Aug;82(8):907-10. PubMed PMID: 9828775; PubMed Central PMCID: PMC1722697.

6:  National Eye Institute (NEI) Age-Related Macular Degeneration.

7:  Yam JC, Kwok AK. Ultraviolet light and ocular diseases. Int Ophthalmol. 2014 Apr;34(2):383-400. doi: 10.1007/s10792-013-9791-x. Epub 2013 May 31. Review. PubMed PMID: 23722672.

8: Joan E. Roberts and Jessica Dennison, “The Photobiology of Lutein and Zeaxanthin in the Eye,” Journal of Ophthalmology, vol. 2015, Article ID 687173, 8 pages, 2015. doi:10.1155/2015/687173

9:  Szabo KE, Gutowski NJ, Holley JE, Littlechild JA, Winyard PG.  Redox control in human disease with a special emphasis on the peroxidation-based antioxidant system. in Redox Signaling and Regulation in Biology and Medicine.  Claud Jacob and Paul G. Winyard (eds); Wiley-VCH; Weinheim; 2009; 409-431.

10: Poh S, Mohamed Abdul RB, Lamoureux EL, Wong TY, Sabanayagam C. Metabolic syndrome and eye diseases. Diabetes Res Clin Pract. 2016 Jan 15. pii: S0168-8227(16)00065-6. doi: 10.1016/j.diabres.2016.01.016. [Epub ahead of print] Review. PubMed PMID: 26838669.

11:  Terao J, Minami Y, Bando N. Singlet molecular oxygen-quenching activity of carotenoids: relevance to protection of the skin from photoaging. Journal of Clinical Biochemistry and Nutrition. 2011;48(1):57-62. doi:10.3164/jcbn.11-008FR.

Attribution:

Chemical structures were downloaded directly from PubChem accessed on March 14, 2016.

The Goldwater Rule and Political Commentary

The New York Times recently ran an opinion piece by Robert Klitzman, MD on "Should Therapists Analyze Presidential Candidates?"  He provided a good review of the Goldwater Rule, that was put in place after an embarrassing poll of psychiatrists decided that Barry Goldwater was not fit to be president of the United States.  I did not hear much about psychiatrists during the 1964 Presidential election because I was in the eighth grade at the time.  Our civics class was engaged in a detailed version of Risk that allowed us to rule different countries and act like world leaders.  It was the height of the Cold War.  There were a couple of buildings in town that were designated fallout shelters.  In those days there were announcements about nuclear tests and when the radiation cloud would be passing over town.   As a kid, I can remember thinking that nuclear war was imminent and the government was trying to send us the message that it was survivable.  I did not realize that was propaganda until at least a decade later.  The Johnson campaign was able to capitalize on that zeitgeist with the famous attack ad at the top of this post.  It was an interesting ad because Senator Goldwater was never mentioned.  But the implications were very clear - elect Goldwater and there would be nuclear war.  Some political analysts believe that this was the first significant attack ad in American elections.  The reality of Barry Goldwater stood in contrast to the media portrayal.  He was in the Senate for 5 terms ending in 1987.

That was the context for the poll of psychiatrists by Fact magazine that concluded Goldwater was "psychologically unfit" to be president.  Dr. Klitzman lists a number of quotes from some of these psychiatrists and writes a very informative article on both the Goldwater Rule and subsequent modifications for the profiling of political leaders.  He cites the profiling of Saddam Hussein by Jerrold Post, MD, the first psychiatrist to develop expertise in this area.  He goes on to list a number of profiles of historical figures as well as non-psychiatrists in the news who do not hesitate to offer diagnoses of political figures or criminals who they have never personally examined.  Senator Goldwater sued Fact magazine and was awarded damages but that happened 3 years after the election was over.  The American Psychiatric Association rewrote a section of the ethics manual that became known as the Goldwater Rule in response to the Fact magazine poll.

The Goldwater Rule is technically a section in The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry.  Here is the section copied directly from that manual:

Section 7.3

On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

There have been a lot of debates about how the rule should be reworked so that psychiatrists can share their expertise with the public.  The rule as it is written seems to depend on the lack of an examination or a release ruling out the public presentation by a psychiatrist.  I would not have a problem with the section being written to say that psychiatrists should never offer an opinion in the media about a person of interest and it all comes down to conflict of interest considerations.  Commenting on national television is a case in point.  There seems to be no shortage of therapists who seem quite willing to present their analysis of body language or speculation about diagnoses in the absence of any examination of the patient.  Psychiatrists should not engage in this activity, because it is basically speculation and not based on any scientific or clinincal method.  Assuming the psychiatrist has conducted an examination, the issue of authorization looms large in the rule.  Should a psychiatrist ask a patient for a release just to present their diagnosis or formulation to the public?  I don't think so.  The only leeway I am willing to grant is for research purposes as authorized by an Institutional Review Board using deidentified data.  An interested public or media representatives does not come close to the threshold for maintaining confidentiality.  Any psychiatrist knows that reporters do not want general statements about mental illness or psychiatric disorders, even if they present their proposal like that in the first place.  Once the interview starts, they want speculation about the person of interest and that should be unacceptable for psychiatrists.

There is the potential case of a person who may really want this information out in the media and I would question that intent if there was an active legal case.  Would the psychiatrist be getting the authorization as part of a larger legal strategy to get favorable public opinion?  I do think that commenting on stories that are already out in the press, and making a point about those stories is perfectly acceptable.  I have done that here on this blog, pointing out that I have no personal knowledge of the person involved or their psychiatric diagnosis, but that the issue has broad implications for the field and therefore merits discussion.  The commentary here has been about Greyhound therapy and the way that violence and aggression are approached in community and state hospitals.

The context is important.  Psychiatrists are trained to operate in a very specific environment.  They are supposed to determine who has significant mental illness and then treat those people in hospital and clinic settings.  Those methods are not generally applicable to people who don't have mental disorders.  This is a limitation of psychiatry that most people don't understand.  In the absence of clear biological markers, psychiatric disorders are defined as conditions that cause impairment in academic, family or personal life.  Many of the politicians in this case (including Senator Goldwater) had no such impairment.  The comments presented about him were essentially another version of an attack ad.  There was no reason to suggest he had any diagnosable condition and the other technical terms used are even more vague in the absence of a clearly defined disorder or problem.

The technical jargon used by psychiatrists is generally meaningless to the public.   Terms that I hear quite a lot of these days include narcissism, psychopathy, and even antisocial personality disorder.  I can imagine that the next step of interested viewers is to look up the "criteria" for these traits or diagnoses online.  When looking them up, the same mistake is duplicated - the viewer is reading words on a page describing an experience they have never experienced.  A significant number of viewers will conclude that they may have the same problem or at least they know a lot of family members and coworkers who do.  Making all of this jargon readily available has been a greater disservice than a service to the public.  

And finally, at least in the case of Goldwater - the fact that most psychiatrists are Democrats cannot be ignored.  The last time I heard any analysis of this point psychiatrists were described as the only medical speciality that was predominantly Democrats.  From listening to the political commentary of some of my colleagues,  psychiatrists are no more immune to standard political biases or rhetoric than the average person.  It is a major problem to have a conservative Republican analyzed by the political opposition.  That should be an obvious point but I don't see any of the pundits these days disclosing their political affiliations.      

Psychiatry is a medical speciality that is meant to be practiced like all other branches of medicine - behind closed doors.  Medicine is supposed to be practiced for the benefit of the patient and not the physician.

We should never lose sight of that.



George Dawson, MD, DLFAPA



References:

1:  Robert Klitzman.  Should Therapists Analyze Presidential Candidates?  New York Times.  March 7, 2016.

2:  R. Ginzburg (ed).  1,189 Psychiatrists Say Goldwater Is Psychologically Unfit To Be President.  Fact Special Issue; September-October 1964; pp 24-64.



Disclosure:

Not a Democrat or Republican.  I will leave it at that.

At The Edge Of My Notes........

For all of my professional life I have done my original notes the same way.  There is usually some kind of form anywhere from 4 to 8 pages long.  I list a few things on it, but for the majority of the interview I flip it over to the blank side and write free hand.  I have to write fast and my handwriting is bad - no cursive, just a crude combination of capitals, lowercase, and symbols that only I know the meaning of.  At some point back in the 1990s when I was studying medical decision making and reading how experts move between chunks of data - I started to draw out chunks of data on the paper.  Circles, squares, timelines, triangles with various connectors to show relationships.  There is a rhythm to it depending on how fast the person I am interviewing is talking and how much information is being discussed.  I have as much time if the person is mostly silent as I do if the person is rambling and including far too many details.  When you write that much, the feel of the pen in your hand and how it moves over the paper can be extremely important.  I only use Pilot G-2 pens.  I alternate between the 1.0 and 0.7 mm tips in black, red, and blue.  The red and blue are only for highlighting and editing.  Gel ink has a perfect feel as your hand is gliding across the page but it is messy.  At the end of a busy day my hands are smeared with ink.  After writing it all down the next step is dictation.  I have to translate all of my non-linear scratchings into a very linear and coherent report with a formulation, various diagnoses, and recommendations for a treatment plan.

The diagram at the top of this post is an example of one collection of words and symbols that are in the corner of one page of my notes.  It took me about 38 seconds to draw it, in pieces as I heard the various elements being described.  The HR in the middle of the circle here is heart rate.  Arrows in the up direction mean increasing and the down direction is decreasing.  I don't like to see elevated heart rates.  I have seen too many middle aged stimulant users with cardiomyopathy and had too many conversations with Cardiologists about whether or not sinus tachycardia is a benign finding or not.  I have obsessed far too long about who I can treat with medications based on their heart rate being greater than 100 beats per minute (bpm).  I am not reassured by the latest review in UpToDate on idiopathic sinus tachycardia and benign outcomes (1).  I doubt that the people in those studies are the same people I am seeing on stimulants, antidepressants, antipsychotics, street drugs, alcohol, caffeine and plenty of tobacco.  In the middle of trying to construct an impossible timeline of insomnia, anxiety, depression, childhood adversity, adult psychological trauma and multiple medical problems I am drawn temporarily to the little heart rate circle and I am trying to figure it out.  It all starts with THC and proceeds clockwise.

I have been impressed by the number of daily cannabis smokers who at some point notice that they are getting anxious and panicky from it.  Despite all of the hype by the pro-marijuana contingent, most people can relate to augmented heart rate and increased intensity of heart beats when smoking marijuana.  It happens when THC drops the blood pressure and your heart acts reflexively.  That is typically ignored by young smokers, unless they have had a panic attack.  In that case, it feels like they are starting to have a panic attack and they start to feel very uneasy.  In many cases they start to develop panic attacks every time they smoke.  That often leads to them discontinuing the use of cannabis, since panic attacks are very unpleasant experiences.  So THC can lead to increased heart rate.

Caffeine is ubiquitous in American society.  It affects too many dimensions in psychiatry to not be asked about.  The answers are often shocking.  With the availability of espresso in most places, I often get an estimate in shots of espresso per day.  For filtered coffee fans, I learned to ask the question: "If you are home alone - do you ever drink the whole pot of coffee by yourself?"  And then there are the additional estimates of mg caffeine in terms of black tea, green tea, and every form of esoteric energy drink.  I can usually track down the mg caffeine using some online resource.  The DSM-5 suggests that caffeine consumption "...well in excess of 250 mg" can be a problem.  I find myself routinely advising people on how to get their caffeine consumption down to less than 1,000 mg/day and use it in the mornings - as a starting point.  In some cases, I am told that people are drinking beverages that combine alcohol, caffeine, and some other questionable compounds.  The pharmacokinetics of caffeine are important.  Most people know what happens if they get wired or precipitate a panic attack with a triple shot of espresso, but they don't know what can happen to sleep with steady state levels of caffeine.

Exercise can be an important source of accelerated heart rate.  In most cases it is just rushing to get the vital signs done, but there are  other important causes.  There are the deconditioned folks who decide that they are going to turn over a completely new leaf by starting to exercise vigorously.  I may be seeing them a day after and exercise session and they still have an elevated heart rate.  There are the conditioned folks who still overdo it.  That has led me to ask people if they are wearing a heart rate monitor and what their goals are.  Some of the responses are shocking.  I have had many people tell me that they are running their heart rate well beyond their age-determined maximal heart rate for a long time.  I have never had a person tell me why that might not be a good idea.  It is an opportunity to educate people on how to not overdo it and either maintain conditioning or start some basic conditioning.  It also leads me to consider some people who may have undiagnosed intrinsic heart disease and what further evaluations need to be done.

Medications can be an important direct or indirect cause of tachycardia.  As a group, older medications like tricyclic antidepressants and anticholinergics were more reliable causes.  Of current day medications stimulants are probably the most important cause of increased heart rate.  In general stimulants increase heart rate 3 - 10 beats per minute (bpm) and increase blood pressure by 1.5-14 points.  More recent generation medications are rarer causes, but it is always important to look for that one person in a hundred or a thousand.  Is that really an idiosyncratic reaction or is it a sign of something worse like neuroleptic malignant syndrome or serotonin syndrome?  In my current line of work withdrawal from medications is a more important cause of tachycardia than a direct effect of the medication itself.  Coming off of benzodiazepines, barbiturates, and clonidine are important causes. Tachycardia and various rare cardiovascular effects are still listed in most package inserts and that is an important reason for monitoring vital signs and electrocardiograms.

A lot of people seem to think that anxiety is a potent cause of tachycardia.  That may be true for panic attacks but on an ongoing basis I have found that anger is much more likely to elevate pulse and blood pressure.  I have seen persistent tachycardia in the 120-130 bpm range due to anger.  I have seen patients started on antihypertensives because of this and I think it is a good idea as long as there is a plan to decrease and stop the medication when the anger resolves.  I always tell my patients that an explanation (a white coat, life stressors, too much caffeine, etc) only gets you so far.  If you are still running a high pulse and blood pressure at home it should probably be treated and closely followed.  I personally don't like to see people running systolic blood pressures in excess of 150, diastolics greater than 95, or pulses greater than 100 while they wait for "lifestyle changes" to take effect, but I know for a fact that there are primary care physicians out there who disagree with me.

Anxiety especially the persistently panicky person can have elevated pulses.  Many of these folks look thin and hypermetabolic.  They are routinely checked for hyperthyroidism and they are always negative.  I listened to a NASA physician lecture about a subgroup of patients with this body habitus many years ago.  He said that thin people with arachnodactyly can be bothered by anxiety and panic and the best treatment was moderate levels of exercise like walking rather than medication.  He defined the condition as anyone who can grasp their wrist with their thumb and middle finger and notice that they overlap at least to the most distal joint of the middle finger.

Epidemiological studies show that people who are sleep deprived or have their circadian rhythm disrupted have poorer cardiovascular health.  There are many people who develop tachycardia in this setting.  Sleep disordered breathing disorders can also be an important cause of tachycardia in the daytime.  These folks often have an associated problem like undiagnosed atrial fibrillation.  Many of the commercial automatic blood pressure machines do not detect irregular pulses, so it is important to check pulses and pulse deficits in the office.  All psychiatrists should have access to lab facilities where electrocardiograms can be run and referral facilities to do the necessary testing and management of the identified conditions.

All of that and more flows from a little 2 x 2 inch drawing on one of my intake notes.  I would have thought by now that some enterprising software developer would have come up with a system of icons that I could just point to and grow on a computer tablet, but so far it seems that electronic health record developers really are not designing software with physicians in mind.  They would rather have us enter full text or more commonly very choppy phrase based notes than using icon based full information approaches.  My little HR circle contains a lot of information and the only way I have seen the information content estimated is by constructing all of the possible text based narratives and then measuring the amount of text.

That method has its limitations because when I (or any other physician) makes a drawing it is connected to our own unique conscious state.  There is certainly overlap with all physicians to some extent or at least the ones with an HR icon in their notes.  The overlap gets closer among those of us who are looking for arachnodactyly.      


George Dawson, MD, DLFAPA


References:

1:  Homoud MK .  Sinus tachycardia: evaluation and management.  In: UpToDate, Cheng A, Downey BC (Eds), UpToDate, Waltham, MA. accessed on March 5, 2016.

Psychiatry With And Without A Conscious State

One of the great attractions of psychiatry for me - is the skill set that you have to develop to understand a person's real problems.  By real problems - I mean the problem or problems that brought them in to see you in the first place.  I am not talking about the problem listed on a referral sheet, or spoken in a telephone call, or even described to you by another physician or family member.  Advocacy groups and some psychiatrists tend to be self congratulatory on the amount of information about psychiatric disorders that is out there.  There is an excessive amount of confidence in lists of symptoms being the same thing as a diagnosis.  Any psychiatrist will tell you that the number of people who walk into the office and proclaim they have depression, bipolar disorder, or attention deficit-hyperactivity disorder is at an all time high.  They typically come to that conclusion by some combination of listening to TV ads or friends and family members.  In some cases they are directed to Internet sites where they can take a brief quiz to determine the diagnosis.  In almost all cases they are wrong.  Interviewing people to come up with both diagnoses and diagnostic formulations - is a considerable skill set that cannot be replicated by handing that person a symptom checklist or interviewing them like a talking checklist.

The problem in cases of self-diagnosis is that most people have a limited awareness of what diagnosable mental illness is.  They get their ideas from a static checklist or advice from a person who has not seen hundreds of people with the condition.  That process is often a checklist by proxy as in "I read this checklist in a magazine and you seem to have the symptoms.  You must have bipolar disorder."  In many ways that is like reading a manual about how to repair a complicated problem with your car.  Some untrained people may be able to pull that off, but the vast majority will fail.  The failure will occur at the level of pattern matching with the severe problems as well as the appropriate assessment of biases along the way.  That is not to say that experts are free of bias, but they are less susceptible to the common biases that occur along the way largely due to an accumulation of patterns that they have encountered over the course of their careers.

To develop the best possible understanding of psychiatric diagnosis and how it works might require consideration of some overlapping models of the conscious state in humans.  Consciousness is a complicated process concept, but it basically refers to the collection of mental processes that result in a stable personality and behavior over time.  An example of elements of consciousness is included in the representation below.  It contains descriptions that are found in the writings of David Chalmers and other authors on consciousness.  Chalmers breaks consciousness down into the easy problems or readily observable properties of consciousness and the hard problem.  The hard problem involves figuring out how the neurobiological substrate can generate conscious states and how those states are all unique.  There are a lot of theories about how that might happen, but none of them have been proven.

 The psychiatric assessment is trying to determine the parameters listed in the box at the right.  Some of the properties of consciousness are listed in the box at the left.  There is not a clear correlation between these elements, but what needs to be elicited in the interview will be determined to a large extent by the conscious state of the individual.  As an example, if I am interested in asking about sleep, I routinely take a sleep history that goes back to childhood.  I ask about insomnia, nightmares, night terrors, sleepwalking, and all of those states over the decades that gets me to the current age of my patient.  As an adult I ask about whether or not they have had polysomnography, whether they snore or have restless legs at night.  I ask them about the medical and non-medical treatment they have received for insomnia and if there were any complications.  I have to observe whether or not the person can reasonably respond to those questions or not and a lot of that depends on their conscious state.

In order to make a psychiatric diagnosis of a basic mood disorder, the primary criteria is that there has been a phasic mood disturbance for a certain duration.  In the case of depression the primary DSM-5 criteria is:  "Depressed mood most of the day, nearly every day, as indicated by subjective report or observation made by others" or  "Markedly diminished interest or pleasure in all, or almost all activities, most of the day, nearly every day."  That basic distinction taxes the conscious state of many people who are already diagnosed with mania or depression.  Wait a minute - "most of the day, nearly every day" - don't I have good days and bad days."  The number of people who make that observation when they are asked the specific question is significant.  When I hear that response, I remember the pre-DSM Feighner criteria for intermittent depression.  In those days it was acceptable to have good days and bad days.  Today in a complicated process occurring in the person's conscious state they need to decide if this phasic mood disturbance really applies or if there are other reasons for endorsing a positive response.  If they are handed a standard checklist for depression like the PHQ-9, the conscious thought process is much different than a psychiatrist asking them about an all encompassing mood disorder rather than "good days or bad days."

The process might even have to take a step farther back when the patient states:  "Wait a minute doc, I am not sure that I know what anxiety or depression really is.  Aren't they the same thing?  Doesn't one turn into the other? Can you explain it to me?"  This is a much different interview than a person coming in and declaring a problem.  This person is aware that some kind of problem exists.  They may have learned that from feedback from a spouse or an employer.  They don't know what to call it.  They might be aware of physical distress, but be unable to make the connection to emotional perturbations.  Is their concept of a disorder the same as the person who comes in declaring themselves to have the problem.  Probably not, but it is apparent to me from interviewing tens of  thousands of people over the past thirty years that everyone has a slightly different idea of the problem.  It is obvious that it is also a much different situation when the patient is handed a checklist of symptoms of depression and makes what is essentially a series of forced decisions about if they have depression and how severe it is.   Consciousness researchers have used the thought experiment about the color red for years.  That is, my experience of the color red, is probably different from your experience of the color red.  In other words, my conscious state processes the color red in a different and unique way compared with your conscious state.  Why would that not be true with regard to the various types of depression and anxiety?

 That brings me to another conceptualization that is often used to look at diagnoses like the dementias, schizophrenia, and attention deficit-hyperactivity disorder.  The abilities to plan, act, and perform these acts successfully is often referred to as executive function.  Although these functions tend to be arbitrary and arrived at by consensus, they have always been important in psychiatric diagnoses.   Major mood disorders, schizophrenia, and neurocognitive disorders may all have varying degrees of impairment in executive function.  Testing specific functions and trying to correlate them with behavior at the clinical level is frequently disappointing except in cases of significant brain damage.  By inspection, it is apparent that there is an overlap between executive functions and consciousness - but not a complete mapping by any means.  DSM-5 has a fairly extensive table on six Neurocognitive Domains (pages 593-595) that describes executive function as one of these domains.  Executive function is defined as planning, decision-making, working memory, inhibition, mental flexibility, and responding to feedback.  Clear examples of what can be observed in each case are given.  Neurocognitive disorders are clear problems in consciousness.

The common psychiatric approach to diagnosis and treatment is what I would call a biomedical approach.  It was elaborated on by George Engel in his famous paper on the biopsychosocial approach to medicine, but it was practiced extensively before that paper was written.  A lot of the social and familial aspects of this interview were undoubtedly influenced more by epidemiology and genetics rather than consciousness factors.  It has been known for some time that you make be more likely to have a heritable illness if it runs in your family or it occurs in members of your occupation.  But what does a psychiatrist also need to know about how anxiety develops.  Can it be transmitted directly from a parent who is a "worry wart" to a child?  Does the child recognize it at the time?  Do children remember when their father was enraged or their parents were fighting and they were wide awake listening to it all night long?  Do people remember what it was like to "walk on eggshells" due to all of this adversity occurring during their childhood?  Do all of these incidents affect elements of their conscious state that keep them stuck in what are defined as psychiatric disorders?  Without a doubt.

 Conscious states are important in both the diagnosis and treatment of psychiatric disorders, but for the purpose of this post I am ending on diagnostic considerations as noted in the first slide of this series.  I will briefly comment on the importance of each dimension.


Interview Context:  Psychiatrists are called on to provide services in a wide variety of environments.  The appropriateness of the environment for both assessment and treatment needs to be assured.  It is common for a third party to want to restrict access to the time of psychiatrists by rationing their time with the patient or total time allowed to see each patients.  Times vary greatly from system to system.  In some cases, a the time allocated for a new evaluation is 30 minutes and in others it can be up to 90 minutes.  I have completed complete interviews at both ends of the spectrum, but the limiting factor can never be some preconceived notion by an administrator.  The patient's conscious state is the limiting factor.  That includes how they respond to the psychiatrist and the introductory process of the interview.  It also depends on a quiet confidential environment and whether there are any observers in the room.  I have had many colleagues tell me that their interaction with patients is definitely affected both other people in the room.  This is a factor that can affect both the conscious state of the psychiatrist and the person being interviewed.

Empathy:  All psychiatric trainees learn a lot about empathy in early interviewing courses.  The necessary prelude to empathy is therapeutic neutrality.  That is a confusing term to nonpsychiatrists, but it essentially means not bringing in any extraneous interpersonal factors or emotions into the interview of a specific patient.  That ability is gained by self-analysis, experience, and in some cases personal psychoanalysis.  From the patient perspective, emotional reactions often surface as part of longstanding patterns of behavior.  They are often proximate to the problem at hand and very relevant in the initial interview situation.    

Empathy is taught as essentially a cognitive appreciation of the patient's emotional state.  The single best definition of empathy is from Sims in his book on descriptive psychopathology.   “In descriptive psychopathology the concept of empathy is a clinical instrument that needs to be used with skill to measure the other person’s internal subjective state using the observer’s own capacity for emotional and cognitive experience as a yardstick. Empathy is achieved by precise, insightful, persistent and knowledgeable questioning until the doctor is able to give an account of the patient’s subjective experience that the patient recognizes as his own.”  Sims captures the dynamic basis of the interview in this definition.  An empathic interview should result in a patient feeling very understood by the end.

Intellectual Capacity:  The intellectual capacity of the patient may vary considerably based on the psychiatric disorder they are experiencing.  By intellectual capacity, I am not referring to IQ scores.  I am referring to the ability of both the patient and the psychiatrist to recall and process information and consider a maximum number of explanations for what the patient is going through.

Emotional Capacity:  In the dyadic interview, the emotional capacity of both the psychiatrist and patient are important.  Can the patient describe the extent of any emotional disruption and the time course of that process.  Are they psychologically minded or can they appreciate social or psychological etiologies for these symptoms or do they view the problems as being treated only with a medication.  Psychiatrists are to a large degree self-selected on the basis of their interest in emotional problems. Many psychiatrists have had first hand experience in families where members have had a mental illness or addiction.  They had experience with all of the difficulties of getting that family member adequate treatment.  They recognize that these problems are very real and are generally highly motivated to provide treatment and advocacy.  As previously noted in the discussion of empathy, the ability to experience the emotional states of patients and describe them is necessary.  Sampling one's emotional state during the interview can also provide insights about the interview process, diagnosis, and overall meaning of the information being discussed.  As the average age of psychiatrists has increased, they have also seen thousands of patients with different kinds of emotional problems and successfully treated them.    

Information Content:  I find it surprising that the information content of diagnostic interviews is never estimated and the importance is never really taught.  There may be a correlation with the length of the interview, but not necessarily.  I can interview a person who gives brief high information content responses and do a reasonably good assessment in 30 to 45 minutes.  I can talk with a person who digresses and gives a lot of irrelevant details and still not have what I need at the end of 90 minutes or an hour.  The person who can assist me in doing the brief interview is not as common in my experience and I would say they represent 5% or 10% of the people I have seen.  There are also the Augenblick diagnoses or ones that can be made in the blink of an eye.  If I see a person with catatonia, delirium, or a stroke - I may not have to have them say anything to me.  Those rapid diagnoses will precipitate a thought process about what else needs to be ruled out and what tests need to be done immediately to confirm the diagnosis.  The information content in an interview is bidirectional and probably encompases severe channels including speech and paralinguistic communication.  The paralinguistic channel also contains information about the affiliative behavior of the participants.

Therapeutic Alliance:  An optimal diagnostic and treatment relationship flows from therapeutic alliance between psychiatrist and patient.  In other words - both are working together on a problem or set of problems that is bothering the patient.  It proceeds lie all patients interactions in medicine on an informed consent model.  Acute care psychiatry often involves the assessment and treatment of patients who are being detained on an involuntary basis because of safety concerns and in that situation the psychiatrist can be perceived as an agent of the state.  In that case and in many cases of long term treatment, it is often a good idea to review this principle with people in treatment to reorient them to the process.  Even a person who is being briefly seen for medication can have a problem in treatment if they perceive a psychiatrist a being poised over a prescription pad, ready to address their briefly stated problems with a new prescription.

Structure:  The psychiatrist has a responsibility to structure the interview so that the time is ultimately used to get results for the patient.  That means a singular focus on the patient, how the patient is proceeding in the interview, and how they are presenting the information.  That can mean giving additional information about the interview to the patient, providing necessary definitions, and doing whatever can be done to enhance the information content of the interview.  The introduction to the patient is critical because to this day there is still confusion over the definition of psychiatry.  I generally tell everyone my name, my years of experience, and present them with my business card.  After that I clear up any questions about psychiatry.  Some people ask about where I trained and I provide them with that information.  Some ask for clarification about the interview as we proceed.  A common question is: "Do you want the long version or the shirt version?"  Some early questions are also red flags and may be an indication of strong biases by the person being interviewed that may even preclude the interview itself.  Some of those decisions may also depend on the interview setting.  An example might be religion as a selection factor.  If a person tells me that they can only talk to a Christian using their specific definition and they want to ask me questions to determine my status, it might be easy to suggest that they see someone else in an outpatient setting, but a lot more difficult if you are the only available psychiatrist on an inpatient unit.

Technical Skill:  Like most professions, there is some variation in the interview and interpersonal skills of psychiatrists.  A psychiatric interview requires technical skills that psychiatrists have been focused on since early in their training.  Those skills are the focus of courses, seminars, books, papers and direct observation by training supervisors.  Since the oral board examinations have stopped, psychiatric residents now do the equivalent of oral board examinations on interview techniques during their training.  During an interview, a psychiatrist is listening for patterns and inconsistencies.  A psychiatric interview is not an interrogation.  In an interrogation, the interviewer generally has a bias and asks very leading questions to confirm that bias.  That style is evident in any number of police and crime television shows and films that are easily accessed these days.  In a psychiatric interview, the psychiatrist is developing hypotheses about diagnoses and formulations and inconsistencies with those hypotheses.  The interview itself can be very nonlinear and the psychiatric directs the interview from one major cluster of information to another.  A parallel process during the interview is recognizing the person's mental state and its potential origins.  Empathy as noted above is a critical aspect of that process.

Psychiatry is currently being practiced with an implicit rather than explicit focus on consciousness.  Making consciousness more explicit adds a lot to assessment and treatment.  The idea that every new patient being seen is truly a unique individual based on their conscious state is a primary organizing factor.  Their experience of mental distress is unique and can only be categorized with the broadest categories.  That emphasis creates a high bar for anyone who wants to be a good psychiatrist.  That psychiatrist by definition will critique each interview while they are documenting it and consider what was missed.  That psychiatrist will also critique any practice setting that requires them to interview patients according to electronic health record forms, diagnose people based on rating scales, or respond to patients in a stereotypical manner.  The recent emphasis on collaborative care is also a dead end in terms of consciousness.  The idea that a psychiatrist looking at rating scales and "managing populations" without ever talking to any of those patients is absurd from the standpoint of conscious states and diagnostic precision.

Human consciousness doesn't work that way and psychiatrists can't either.




George Dawson, MD, DLFAPA