“The devil is talking to me.”Briefly on God and Psychiatry

“The devil is talking to me.”

Her lips shaped words but her voice was like a robot. 

My gorgeous tall black thin framed model-bodied patient looked at me with a face that barely moved. Almost flat. Her eyes rarely blinked, with orbs that seemed to jump out at me when she spoke. 

This is Talia, a 3.8 GPA college grad last year who just started her first job in marketing. She has been a Jehovas Witness for about ten years and is passionate about her God and religion. She has been attending church related meetings lately about 6-7 days a week and loves to read her Bible for hours. However, over the past six months when she reads the devil and his minions cuss loudly in a cacoffany of foul persecutory language. She is afraid all the time and has high inner tension. 

Talia cannot sleep any longer for more than a few hours at a time. She has been losing weight. She has lost her job, and is panicking, terrified to read her Bible or go to church. 

Her family says she is talking to herself, and has “crazy eyes”.  They do not know what to think. Maybe she is possessed as well as crazy. Maybe both. 

Is Talia possessed by the devil? Is Talia crazy?

I was in Los Angeles this summer with my kids, walking on Hollywood Blvd. We passed several people who were responding to internal stimuli. One extremely saddening lady was slumped against a shadowed corner sitting in her own piss leaking down the street, her shirt half open, as she spoke to various targets. My kids were afraid. We were all, frankly, sad. My kids did wonder, too, were these people possessed by the devil?

Have you ever wondered if the devil was talking to you? Or working on you? 

The question is, if you want to ask this, rather ask, “What does this say about the character of God?” Included in all the biology explanations and psychosocial intersections, we bring the magical and spiritual. If you ask about the devil, ask rather about God. What does this say about God?

Talia had been adhering to her treatments and now celebrates that she is able to read her Bible again, go to her religions meetings, and has even driven around a parking lot once with a family member in the seat beside her. She is sleeping through the night, able to enjoy life, the simple and large things like the touch of shower water or taking a walk. 

When Talia hears voices, she no longer believes the voices come from the devil but rather demonstrate that she has missed something bad inside of herself that she hasn’t yet surrendered. I asked her, “What does that tell you about God? The character of God.”

We are so quick to assign nonbiological causality to emotions, thoughts and behaviors. It turns out that when the brain gets sick, emotions, thoughts, and behaviors generally go the direction of bad, rather than “good.” Naturally we ascribe moral value to what we are culturally primed to believe has moral value – emotions, thoughts, and behaviors. The question becomes, “What does it say about who God is when we do this?”

I like to think about the character of God. It is a picker upper. When I get enmeshed in some line of thought that demonstrates a poor reflection on Gods character, I figure at some point that I’m not seeing things clearly. It’s always a relief. I don’t know it all. If it says horrible things about God’s character, than I must have some misinformation or misinterpretation. 

Others may say rather, I am misreading Gods character as good. That’s not a perspective that is friendly to me in the end. One of the reasons I reject it. 

Self care tip: Ask yourself, “What does this say about God’s character?”

Questions: Have you ever wondered if the devil was talking to you? Or working on you? 

Do you ascribe moral value to emotions, thoughts, and behaviors?

What does it say about who God is?

It’s not my fault

It’s not my fault

The new on-call resident – Jonathan, I think was his name? – was trying to present another admission to me. He was visibly annoyed.

“…so, the ER calls me and says, you have a patient with chest pain, and I say, what kind of chest pain, and they say, oh, we don’t know, but the patient needs to be admitted, and then I go down and try to talk to this guy, and he is just the worst historian in the world and just stares at me, and says I don’t understand him, and…”

I cut through the never-ending sentence. “Let’s just go down and see him together, hm?”

The light was on in the ER urgent room but I couldn’t really see the patient. The gurney had its rails pulled up, and I could make out a small lump breathing heavily under the blanket. We stepped closer and I called out,“Mr Jones? We came to see you, can you come out from under the blanket?”

The top of a knitted cap made an appearance, with two dark eyes peering out from under it. “Mr Jones?” I tried again. “I hear you were having some chest pain? Are you still having any now?”

The eyes got suspicious. “Ahah,” came a noncommittal reply.

“Well, can you tell me more about it?” I persisted.

“I waited until the morning”, was a cryptic response.

“What do you mean, you waited until the morning?”

The resident interrupted. “He was actually here last night and was sent home, and he came back today morning saying he has chest pain.”

I looked at Mr Jones again. It is not uncommon for patients who have no place to be, to complain about chest pain as they know it is a sure way to get admitted. This guy really did look sick, however. After some grumbling, he sat up for an exam. Clearly, he was in decompensated heart failure, and had been for a while. I motioned to Jonathan to step outside the room. “Is there anything about heart failure in the chart?” I asked him. “Yes, he has had heart failure for a while now – methamphetamines,” he added quietly under his breath, “EF, ten percent, but noncompliant with treatment, still meth positive last month though he denies using”. EF stands for ejection fraction – the normal being 60 percent – the lower it is, the weaker the heart muscle. I glanced at the monitor – heart rate at hundred and ten, blood pressure 80 systolic – he really should have been admitted last night. The ER attending had completely missed the heart failure part. I suppose Mr Jones didn’t make it easy.

I tried to get a little more information. “Mr Jones, when you say you waited until the morning, where exactly were you waiting? Did you go home?” The patient was evasive. From the bits and pieces of his broken sentences, it became obvious that he had somehow hid himself on the hospital grounds all night and come back to the emergency room when he thought the shift had changed and he would get a chance with a new physician. I decided not to press him further until he had gotten a little better.

As the day progressed, more wrinkles appeared in Mr Jones’s case. It turned out he had been diagnosed with a lung mass two years earlier and biopsies and surgical follow-up appointments had been scheduled that Mr Jones had not kept. He had not seen a health care provider other than the emergency room for at least couple of years. His heart disease was thought to be related to his drug use – initially, he had admitted heavy methamphetamine and alcohol use that he now denied. Unsurprisingly, his urine drug screen still came back positive.

****

The next day, Jonathan and I went to see our patient again. He was breathing a little better but had an expressionless look that was speaking louder than any words. I decided to press for words.

“Mr Jones, what do you know about your cancer?”

Blank eyes turned toward the wall.

“Well, they said I had one but then that’s the last I heard about it, couple of years ago.”

“Why didn’t you keep your appointments then?”

The eyes blinked rapidly. “Well, I didn’t know I was supposed to keep them, did I? They didn’t tell me what I was supposed to do…” The tail-end of the sentence ebbed away as Mr Jones was feebly trying to come up with a justification. The defense was half-hearted, as if he knew there was really nothing to say, and nothing he said changed anything anyway.

Jonathan at my side was struggling to remain silent. As a young physician, he was taught to help people, and it was frustrating to him that the help had not been accepted. Mr Jones was a veteran – all the healthcare for his cancer would have been free. Now it was too late. For Jonathan, it seemed like a failure, and what young physician likes that?

****

In the end, we were able to stabilize Mr Jones’s heart failure but his cancer was already spread to most of his body and could not be treated. He was no longer able to take care of himself, and was packed off to the nursing home for the rest of his short days.

It had been a good learning case for the residents – not because Mr Jones had presented a medical challenge – but because he had taught the limitations in our communication skills. We had never been able to engage Mr Jones in any meaningful way, and he remained as absent on the day of discharge as he had been on admission.

As an attending physician, I struggled to make sense of it to myself, so I could explain it to my residents. Was it supposed to make sense? Had we failed somehow, or was the outcome already determined before we got involved?

I tried to put myself in Mr Jones’s shoes, knowing for years that he had cancer but putting it out of his mind. Was he sorry now? Or was the current indifferent attitude merely an acceptance of his fate, knowing deep down that he would rather have chosen those carefree years again, living alone in his trailer, drinking, smoking cigarettes and weed, and allowing himself a hit of meth whenever he could spare the money? He had missed countless procedures and surgeries, doctor visits, blood draws, and lectures by the likes of me about his drug habit. Now in the end of these years, the choice was no longer his.

Remembering the vacant stare, I suspect Mr Jones may not have known himself.

****

I told Jonathan that he had done well, and that he should not give up on people. I suspect there will be time for more cynical life lessons later.

 

Self-care tip: Good intentions do not always result in good outcomes. Recognize when your help is not accepted – it is not your fault.

Question: Have you felt helpless in a face of suffering or personal struggle, and found yourself unable to help? Tell us your story.

Introducing our new co-author at Friend to Yourself

Finally!

I’ve been hoping, asking, looking, waving awkwardly in the hospital hallways, trying to find someone who would join me in this great blogging experience with you on self-care. And, finally.

Please join me in welcoming Dr. Helme Silvet! You will love getting to know her, and she will love, as I do, sharing space with you. Keep on.


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Helme Silvet, MD, MPH, FACC
Loma Linda University School of Medicine
Chief of Cardiology, Jerry L. Pettis VA Loma Linda Healthcare System

Hello!

 

My Blog Journey

Sana (or Dr Q) and I have known each other for two decades or so (and yes, we have lived that long). We have spent hours talking about what makes us excited to be physicians, what gets us up in the morning, and what makes us upset. Finally, we decided that it was time to share some of these thoughts together. Taking care of self is a principle that we both try to teach our patients, but also practice ourselves in order to be effective parts of our families, communities, and humanity. The goal of this blog is to attempt both from the, perhaps, somewhat unique perspective of biology, and medicine as the starting point to self-care.

My Professional Journey

My medical experience started in the “old country” behind the Iron Wall – I grew up in Estonia and graduated from medical school there. After the Soviet Union opened its borders, I made my way to the U.S. and finished an internal medicine residency at Loma Linda University and cardiology fellowship at Brigham and Women’s Hospital/Lown Cardiovascular Center. Starting in 2003, I have worked at the VA system as a cardiologist. Along the way, I also graduated with an MPH degree from Harvard School of Public Health. I am passionate about making people get better – this includes preventing, treating and managing heart disease as a cardiologist – but also helping my patients make sense of their life journey. One cannot treat and prevent disease without caring for the whole person.

My Life Journey

Between my two sisters and myself, we have lived in 5 different countries – this has made for interesting holidays! Seeing different parts of the world up close has given me plenty of experience, but has also come with a certain sense of displacement. It has been a continuous struggle in my life to figure out where I fit in the wide world in general, and in my little microcosm of a world in particular. In this context, it has been fascinating to learn different things from different cultures, and observe how people with different life experiences can effectively communicate with each other. And I noticed that somewhere along the way, my quest for truth and knowledge is giving way to a quest of understanding and compassion.

Disclaimer

The thoughts on this blog are my own and do not represent entities I belong to in a professional capacity. The stories that I tell are true in principle but the details may have been changed to protect people’s privacy. The blog is not meant to offer professional advice or treatment advice for specific medical conditions; the goal is to share ideas, general principles and stories of a personal journey.

 

Desperation – When to Speak

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I’m about to park in LA for the LAX protest against the immigration ban.

Last night my husband and I debated whether to come or not and were both disappointed to realize that we both wanted to be here. I mean, it’s Sunday and we don’t get a lot of down space. We have our kids who, thank goodness, still want more time with us. We have projects and exercise and self care that is on our agenda. We are moving away from a “zero percent progress” every day toward something better, right?

Apparently, I’m a moderate. I haven’t felt the pain. I don’t have the fire. But not very long ago was the Jim Crow era, where our parents came from.  When there’s something I’m passionate about, I have to get my feet moving or I’ll miss it.

But this immigration ban is bad. This is just xenophobia and racism.  It is personal. I think of my Lebanese cousins who have been in the war and immigrated to our country with their hairy arms and scars. I think of Mom. I think of my in-laws who arrived in New York from the Philippines with $5.00 in their pocket.

What have immigrants done for America? Well. Look around. What have you done? This is who we are.


In a protest, community is strong. Unity is strong. Today, there was some prodemocracy stuff, but there was also a lot of anti-Trump-eting and name calling.

The protest felt a little like people were peaceful. They were upset. There was a lot of Trump-fest going on. But it wasn’t just that. There was a little anger with a little despair. Those guys were suffering, but it could lead somewhere.

When we start protesting a person, it becomes a zero-sum. We lose the opportunity. We didn’t waste all of the opportunity today. It was mostly a foreboding of what could happen.

When Martin Luther King marched at the Lincoln Memorial, it was very organized. They had basically shut down the city bus transport by not using them and choosing instead to walk seven miles to work, or set up car-pools, an early Uber system. They were unified in their despair. MLK had been put in jail many times for his fire. He was not moderate. When he spoke, he spoke about justice and equality, and didn’t give stage to McCarthyism. He mentioned him, but that was it. If Trump were president at the time, he would have gotten the same mention in his speeches and letters.

MLK said in his letter from Birmingham Jail, that moderates are just as evil because they are not going against what’s wrong. And that’s what’s wrong with all these things is because we are moderate.

So one of the reasons we go to these things is so that we don’t allow things to passively happen.

“Shallow understanding from people of goodwill is more frustrating than absolute misunderstanding from people of ill will. Lukewarm acceptance is much more bewildering than outright rejection.”

We have a general idea that this isn’t right. But we don’t have that despair. We are privileged. But we have a sense that this is wrong. So that’s why I move. To help me understand.

Maybe we, in this generation, have not suffered enough to stay focussed on the principles being violated here. We are America. We believe in humanity. We do not discriminate against another race. We do not believe our race is better than theirs.

The world is small. A refugee physically, manually by another human’s own hands, who is being pushed away back into the ocean from a Greek beach because the Greeks cannot feed their own countryman, affects all of us. Starvation changes one’s belief systems, I am told. These people are not moderate. They are being violated. I don’t want to be a part of who violates them. It doesn’t need to be said that I wouldn’t want to be them.

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Why do we march? To get our feet moving. We want to learn more. We march to help us understand.

 

Self Care Tip: Find your fire, take a stand.

Questions: What’s your story about immigration? How is this personal to you? Keep on

 

This is What America Can Give You

I told my patient today,

“You’re smart, you’re beautiful, you’re young, you’re healthy. This is what you have. Go and do it. Fight hard. You can only control yourself. Don’t wait for someone else to fight for you. This is what America can give you. The opportunity to fight hard for yourself.”

Keep on.

Bad Sleep is Not Sexy

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I tell my patients some rough version of this:

My agenda is that you get sleep.
My agenda is not that you take your sleep meds the way I prescribe them.
Just don’t take them at a higher dose than prescribed.

When prescribed medication, sometimes my patients tell me they think, from me or from other physicians, that they need to do it exactly as prescribed. And that may be true. With most. But there are some medications, which must be specifically described by one’s prescribing provider, that may be used in the way that the patient determines is most useful. The patient needs to look, to think, to speculate, to reflect. Adjust the medication dosages, and try again.

Going forward, before I tell you how you should sleep and what to take for it, think about how your sleep is.  What are the difficulties you have with sleep?
Falling asleep?
Staying asleep?
Early morning awakenings?
Is your sleep refreshing?

Renaldo, (“Please call me Ren”), can’t fall asleep. He lays there for hours, before he finally falls asleep in the early morning hours.

In Spanish we call the early morning hours “la madrugada”. I’ve always enjoyed that word.

It’s been happening on and off for Ren over the past year, but is worsening lately. He is now afraid to go to sleep. Afraid to looking into the dark night while in the company of his thoughts. He has a feeling of dread as his evening comes around. He finds himself avoiding going to bed.

When dealing with insomnia, first we look at these personal observations. They are called “symptoms,” when they are involved in a pathology, a medical illness.

Then we look at why. Why?

To answer this we consider what regulates sleep in our body and outside of our body. These pathologies we suffer come from what is in our body and as they intersect with what stressors come to them from outside of our body.

There are so many medical illnesses that produce insomnia.
Inversely, there are so many medical illnesses that come from poor sleep.
There are also many behaviors and outside-of-our-body stimuli that affect sleep.
Hmm.  Well it’s not either/or. It is likely a tangle of these roots that make this ugly plant grow.

Where to start?

We have covered sleep hygiene a couple times. Have we made the changes in our home and personal sleep culture to groom our sleep accordingly?

Say we have. We don’t read in bed. We don’t have a TV in our room. We don’t use the bedroom except for sleep and for sex. Hey! Sleeping well is sexy! Ahem….          ….We keep the lights low. We try to go to and out of bed around the same times every day. And so forth.

If these were not attended to, a disease process may develop. It is during sleep that our body heals. None of our body rhythms heal during the day. All the neurotransmitters, chemical messengers, hormones, all of these replenish and regulate into a healthy rhythm during sleep. Also, all of our memories consolidate during sleep. That dumbing in parenting syndrome, which I’ve respectfully labelled “DIPS”, may come more from the broken nights, than by the busy busy kids.

Okay. Say we are practicing good sleep hygiene, yet continue to have poor sleep.

There is a reciprocity between symptoms and disease etiologies. In other words, a broken sleep cycle may trigger certain genes to express themselves, and vua-la! Ren is suffering from an anxiety disorder.

Or, Ren’s anxiety genes become triggered for another reason, maybe simply his age, maybe he has low testosterone, maybe he has a thyroid disease, or he snores, and his circadian rhythm, (ie, sleep cycle,) disrupts. Vua-la! Ren is suffering from a sleep disorder.

It’s like the wheels of my mom-van. I bumped the curb the other day and pinched my tire. I disregarded it, …and the orange hazard like on my dashboard. Don’t judge me.

My steering seemed to wobble over the next hour. I pulled over and sure enough. A flat. I wisely (grimace) decided I could just drive it to the repair shop, rather than get a tow. By the time I got there, my wheel was bent and my van alignment was off. There’s a reciprocity to the wellbeing along with the demise of my van’s health.

In my book, Sleep Well, I cover some of these anxiety illnesses. I don’t cover affective illnesses such as depression, or hormone imbalances, or so many other physical pathologies that are involved in generating poor sleep. They are also reciprocally important to emotional health and a quality of life.

I told Ren,

So what do you think is going on with your sleep?…

Questions:
What are your sleep symptoms?
Do they come from a pathology?
Are they triggering other pathologies?

Self-Care Tip: Sleep Well. Be a friend to yourself.

Robin Williams’ Widow Recounts His Story

Robin Williams saw me through my developmental years. His prolific cinematic accomplishments, whit, depth of character, courage in living with and dealing with mental illness – all this configured him into my life story. Never even thought about him dying. Until he did.

Enjoy reading an excellent interview with his wife.

Here’s to Robin

http://m.neurology.org/content/87/13/1308.full

Who Am I? The Threat Of Exploring!

“Talking about me, I sometimes feel like it is scary to know more about me. I’ve found out who I am through very difficult situations so I have an association.”

My hunch is Ericka had many times when information and experiences came to her in her life on gentler carriers than those with this kind of emotional trauma. But she didn’t notice. The coming of kindly delivered insights are easily absorbed and drop from consciousness.

“I feel I overlook those and pay more attention to the bad things.”

It’s like gratitude, a muscle that grows when deliberately developed. That is why we call it the exercise of gratitude. When we deliberately practice noticing, (flex,) recognizing, (now we apply a little fragrant oil to the lovely bulge,) one more rep, (Oh yes! Look out Venice beach!) practicing gratitude, indeed, increases self insight. 

Ericka and I had this discussion in context of discussing her career. The starting point of exploring career choices brought us to look at the different paradigms that may be used to understand our identity, as well as it’s strengths and weaknesses. Poor Ericka felt that using the paradigm of “Personality Typologies” to be like inviting a bully into her living room. One that confined her, boxed her, took away her windows and doors.  However the paradigm of personality typologies is just a paradigm, useful or not, with the power or lack of power that we allow it. It is not a concrete cell, that defines us. It is one more way of increasing self insight, among others.

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“Footsie” by Carl D’Agostino, at, “I know I Made You Smile.”

How to Approach the Myers-Briggs:

Take Three times. Each time, read the descriptors to hone accuracy. (It’s a biased test. Taking it multiple times, as well as reading the descriptions helps eliminate the bias.)

The fourth time, the test is to be taken by someone who knows you the best in the world, answering the questions as if they were answering in your stead, with you standing by. Then read descriptors together.

This approach helps diminish the inherent test-bias in the Myers-Briggs personality test.

Example of free online test, (there are several,  http://www.humanmetrics.com/cgi-win/jtypes2.asp

We don’t have have to give it more power than you are comfortable with

2. Read, Please Understand Me, vol II

-Keirsy

3. Go have fun and…

Keep on!

Disrupt Your Work Agenda

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In the entire South wing of the LA Convention center, jammed packed with bodies, a teeming crowd was organized into sectioned exam rooms, per their needs. I’m writing to you at the tail end of “Pathways to Health” (PTH) in LA. There were some 4,000+ providers who gave their time and resources to many thousands of patients.

It was nice to  work with them for many reasons. The tossing of my standard business agendas was particularly refreshing. Many would have guessed, rather, the patients made it “special.” And the patients did bless me. But all my patients bless. Each person who comes to clinic or surgery, comes as an individual. One person. They are their own story, worth hearing. Worth serving. And worth receiving a blessing from.

When I go to work, I go mainly for three reasons; to serve the needs of my patients, to make a living, and to be to true to my spiritual mission. Going to PTH left two of those in my day and the other was gone, like it slipped into a parallel universe. Removing the agenda of making a living is disruptive, almost to point of being disorienting. And that is why it stands out to me. It was experiencing what was left when it was gone, that tossed my salad.

I’ll tell you one story, …nah. Patient confidentiality and all :). There were a lot of good ones though. Keep on!

Self-care tip: Do something disruptive to your work agenda and see what is left.

Questions: What is your agenda when you go to work? What have you done to disrupt it? What did you get for yourself when you did?

Please tell us your story.

Putting Out and Getting Creative

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Hello friends. I’d like to write more to you. I’m grateful for what I am able to write though. In turn, I’m grateful for your comments. And…I’d love to hear more! But you, like I, might experience difficulties in getting the words out.

Finding “my voice” is sometimes like finding the other sock, a frustrating endeavor that the Universe conspires to obscure. Sometimes we get the best of Her, and match the pair, twinkle toes and all, only to be out, vulnerable to the spin cycle all over again.

My favorite book of all time on this topic is, Bird by Bird, which you’ve probably already devoured before hearing from me. But you might be thinking about your spoken voice, rather than written voice, of course. However, knowing that these share waters, this book by Anne Lamott may still resonate.

I hope you are not frustrated or losing steam. You are important. Keep talking. Keep writing. And, Keep on.

Self-Care Tip: Keep putting yourself out there. Speak. Write. And Keep on.

Question: What helps you write, and speak, and put out into the world creatively? What helps you give of your thoughts?

Christianity and medicine – how do we fit?

There is an awkwardness, like seeing two boyfriends at the dance, when talking about medical treatment along with one’s Christian “treatment” toward health. I’ve heard in public about a Christian depression recovery program, “Daniel and Revelation will help heal your depression because for every negative statement, there is an admonition!” As a strong believer in God who is a better Psychiatrist than I am, I still feel an awkwardness with this approach. Maybe the people in these circles are guarded against the medical community disregarding the power of God. Maybe vice versa. A dear Jewish colleague of mine disclosed his regrets about developing many years ago in a culture of medicine in which he perceived he would be discriminated against if he practiced with faith. It was much stronger in the 60’s. Now it’s almost posh to say otherwise and he feels a bit robbed of experience. 

In church today the man over there said, “Evil causes stress.”  It’s hard for me to take that. My mind envisions a beaker over a flame burning off everything else that intersects in the differential, and nothing but evil is left, like a black stain. 

Question: Christianity and Medicine, how do we go together? Please answer? It helps to be a friend to Me. 

Controversy – ECT machines and the FDA

Hello Friends,

Once again, ECT is being bullied and manhandled by stigma, using fear instead of science, to steer people away from a lifesaving treatment. In this instance, they are targeting the ECT machines as an angle to keep others from having access to treatment. Science and life example clearly states the efficacy and success rates with ECT. The machines, …really?

The best way to diminish stigma is to tell others your own story.

Tell others here:

RE: FDA ECT DEVICE RECLASSIFICATION

Please post your comments to the FDA website: http://www.regulations.gov , as soon as possible.

To post comments for the proposed rule:

http://www.regulations.gov/#!submitComment;D=FDA-2014-N-1210-0001

To post comments for the draft guidance document:

http://www.regulations.gov/#!submitComment;D=FDA-2014-D-1318-0002

_____________________

A colleague, whom I tremendously respect, responded to this elequently. I wanted to share it with the world. He has so many years of practice, a deep skill set in the art of medicine, and in these short paragraphs, captured much of the beast in ECT stigma. Thank you Dr. Guerra!

Electroconvulsive therapy is a treatment for potentially fatal illnesses including major depression, bipolar disorder (manic, depressed, mixed, rapid cycling), catatonia, and schizoaffective disorder. It has a remarkable rate of success. Many patients only remain well with continuation or maintenance ECT. In more than forty years of practice, I have seen hundreds of lives saved and hundreds of my patients restored to productive lives.
ECT remains the most rapidly effective form of treatment for those who have not responded to psychotherapy and/or medication. For the acutely suicidal or catatonic patient the risk of mortality may be equal to that of a ruptured aortic aneurysm.  
As we in psychiatry and medicine are trying to fight the stigmatization of the mentally ill, a few points demand attention:
Among the treatments for potentially fatal illnesses (chemotherapy, radiation, surgery), ECT has the highest rate of success with the least physical damage. In fact, while cognitive difficulties occur with ECT, they are generally short-lived and are not the result of physical damage to the brain. By contrast, treatments for other life-threatening conditions, like cancer, often leave patients permanently damaged in the service of saving lives. Treatments such as those for cancer are embarked upon (with consequent debilitating effects) even when the likelihood of remediation or cure is low. In all cases, clinical judgment and the consent of family and other stakeholders are involved before a decision to treat occurs. Such informed consent is the standard for the practice of ECT as well.

An agreement regarding the safety of ECT machines is reflected in the decision to change their classification. Restricting the clinician’s ability to apply his or her clinical skills and knowledge does not improve the safety of ECT machines. It only communicates that the safety of the ECT apparatus is of concern for some diagnostic categories by not of concern for others. Furthermore, restricting the ability of clinicians to apply treatments according to a set of guidelines does nothing the make the apparatus safer.
Having determined that the machines are safe for some, they must be safe for all. Their use must be left to the discretion of the treating physician.

The restrictions being imposed do not seem logical to me. They tie the hands of clinicians, promote stigma, and will foster diminished access to treatment for those most desperately in need.

Frank Guerra, MD, DLFAPA, FACA
Psychiatrist/Anesthesiologist
Medical Director
The Guerra Fisher Institute
Boulder, Colorado
Clinical Professor of Psychiatry and Anesthesiology
University of Colorado School of Medicine
Past President
Colorado Psychiatric Society

Obstructive Sleep Apnea and Not Watering the Plant

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Ownership of plants is an exercise. For some, their bread won’t ever rise. (Um, me.) Others, apply maschera like a windshield wiper. (Those people. Um, me.) Me, these are true, along with the exercise of owning plants, which is essentially expensive composting. They never live long.

These are different in my book than trees. I’ve got some duplicity here, I realize. Yes trees are plants but I think of them differently. More human. I classify leafy potted things as “plants.” If there were “Plant Protective Services,” (PPS), some social worker somewhere would have thick files on me. I’d never make it out of court.

But even I, plant abuser that I am, know that if you don’t water a plant it will “wilt”. Yup. Bookmark this post. Words of wisdom.

Marvelous as that pearl is, being a brain doctor and all, I can’t help but parallel that the brain will wilt without oxygen.

There is a disease called Obstructive Sleep Apnea which describes this very misery. What generally happens is the tube through which air goes from your mouth to your lungs, called the pharynx, collapses for any number of seconds, over and over throughout your sleep. Over time, the brain cells change, and diseases develop, secondary to “anoxia.”

The story goes something like this. The brain senses that there isn’t enough oxygen. As oxygen is carried on red blood cells to the brain, just like it is to any and every cell in your body, the brain interprets this as not getting enough red blood cells. As red blood cells are pumped to your brain from the heart, the brain tells your heart to “Get working! Pump harder! Pump more oxygen-carrying red blood cells. We’re wilting over here!” The heart dutifully pumps, like a champion.

What is the heart? Mostly muscle. What happens to a muscle when it gets worked is, …It gets sexy! Right? Venice-Muscle-beach type of sexy. Ding! …Um, or just muscly.

Every cell in the body, requires oxygen to live. Even muscle. Even heart muscle. So heart muscle has it’s own arteries that bring oxygen-carrying red blood cells to it’s muscle cells to live. The oxygen “perfuses” the muscle and the muscle is healthy, not like my potted plants. But when that heart muscle gets extra work-outs, like any body builder, the muscle wall of the heart grows thicker. The heart wall however was given arteries to perfuse a wall thickness less robust than that and eventually the heart wall gets too thick for it to get its own oxygen. Compost. You got it. After time enough, the heart wall will die. That thickened muscle won’t get enough oxygen, and it will die. Obstructive Sleep Apnea is a leading cause of early heart attack.

And, oh yes! there’s more! If this isn’t bad enough, boys can’t keep their erections. Wilted.

Related problems are happening everywhere in this body. Brain cells are dying. Any variety of brain diseases develop, including early dementia, depression, anxiety, and more. Day time sleepiness happens, and Boom! You’re falling asleep while driving. And you’re eating more. Yup. Good news after more good news.

When we don’t get enough oxygen at night, we don’t get enough sleep. During the day, therefore, our brain is falling asleep on and off throughout the day. Our eyes may be open, but we are actually in the early stages of sleep. Then, our subconscious tell us to eat. No respect! We can’t catch a break! That’s because food and eating release stimulating hormones and we wake up a bit more. But,… we also get more fat. The fat then pushes down harder on our poor suffering airway at night and our disease, obstructive sleep apnea, worsens! Round and round like that lovely Krispy Cream Doughnut, we go. Eating, obesity, obstructive sleep apnea, eating, more obesity, and more apnea. Burp.

Now why would the pharynx collapse? What is it’s problem, anyway?! Generally it’s because it just can’t stay open under all that weight. We’re too fat and heavy. Those poor oxygen molecules are out of luck spelunking through that tunnel.

The brain, is super tired after all this. All night, it’s been rudely and repeatedly awakened, gasping sounds like fog horns through the night herald the body’s cry for oxygen. Nobody can get any sleep around here, not even you. All night your brain is waking you up, even if you don’t know it, to get a deeper breath of air. You’re constantly being pulled out of a deeper sleep into a state where your pharyngeal muscles can take over again, push open, and allow yourself to breath.

Because you aren’t fully conscious when this is happening, the best way to discover this is to get a sleep study, called a polysomnogram. During this study, you have a type of electroencephalogram, where specialists study your brain activity, as well as your different levels of oxygenation, and more.

After this lovely post, it may surprise you that bucket loads of people avoid getting a sleep study, but they do. There are many barriers to getting treatment in obstructive sleep apnea, that on paper, seem tiny. Today, let’s breathily say, they’re there, they’re real, and we acknowledge them. We are just trying to understand some of the, “why?,” your psychiatrist keeps saying you need oxygen to have a healthy brain. Go figure.

Self-care tip: Everyone deserves a sleep study. Please consider.

Question: What are your barriers to getting a sleep study? What are your barrier toward getting other medical studies? Please tell us your stories. We know the barriers are real. We know the barriers are common. Please speak out!

Keep on!

Responding to Inquiries – The Sabbath, ECT, and The Rabbit Test

rabit tes

Hello Friends.

Today is my Sabbath. If you wonder, I’ll briefly explain. If you don’t, skip this :). I get the Sabbath from the Bible. The validity of the Bible as a mostly unchanged book from the original writers isn’t what I’ll comment on. But as all things, I keep the Sabbath because it has shown my selfish short lived self, (call me Blip,) that it is kind to Me. What the Sabbath is about is still my pursuit to know. My understanding influences my activities, and as my learning is plastic, my activities change over the blinking tinsy trail through space and time I traverse.

Because today is Sabbath, it is the day I choose to reengage in writing. Writing about self-care is something I unwrap with many emotions. The gift brings me here today to respond to a person who reached out a few weeks ago. I felt some inner conflict with the question from the Curious, which may have contributed to why I’ve waited to speak.

Here is an abbreviated bit of the person’s points of interest regarding electroconvulsive therapy (ECT):

  1. I’m concerned about the suicide epidemic in the military and veterans.  I don’t understand why we are not going to ECT in many of these cases (from a scientific standpoint – I understand stigma and pharma lead to meds first).    
  2. Are we in the military and VA missing opportunities to help people by putting ECT as the last resort?

This is how our nurse-ECT specialist responded – (Again I took liberties abbreviating, etc.):

My first exposure to ECT came during my psych rotation in nursing school at the VA in San Diego. I worked with some incredible men struggling  with depression and PTSD and I witnessed some positive results during their treatments. I did notice that ECT was not widely used, and of course had much stigma attached even within the confines of the mental health unit.

A big part of my job here at our center is patient and family education… trying to break down walls, or barriers, that keep people from exploring this treatment as a valuable option. I’ve even visited local psychiatrist’s office to discuss and collaborate – many medical clinicians underutilize it as well… a last resort option for those with “treatment resistant depression/illness.”

I also handle all the insurance authorizations for patients starting ECT, and one of the biggest barriers I come across is the insurance companies asking:

‘How many medications trials has the patient done?’

There have been times that insurances will not authorize the treatments because the patient has not tried ‘enough’ medications or sought out alternate therapies. This is so very frustrating to hear. My response, ‘The patient doesn’t have the luxury of waiting another 2-3 months to try another medication…and suffer any possible side effects!’

What many people don’t understand is that depression and other affective illness is progressive, and it can happen so quickly.

The quicker a patient can have a full treatment response the better… and the success rates lie with ECT as the gold standard… 80-90% success rate.This holds true here at our center.

Patients have come out of some pretty dark places in our small corner of the world with ECT treatment. It is rewarding to watch, to help them, and their families, get their life back.

There’s a study I remember, but can’t quote without looking it up, that unless personal experience is gained in some aspect with ECT, we all will have negative beliefs about it, physicians, medical students, nurses, et al. So, knowing that psychiatry residencies don’t require ECT experience is disheartening. Who do we look to for expert opinions about psychiatric medical treatments, after all? Eventually, those psychiatry residents will become psychiatrists, in a world of underserved mental health care workers. They will become, we might suppose, prejudiced (negative beliefs not based on reason or experience,) and they will act on those beliefs (discrimination.)

One might exhale under the load of it all and reroute. Why do we stay though, dig, and try to grow this poor “fig tree” with water, song, and verse? BECAUSE brain illness is a human condition that kills and destroys and denudes the beloved construct we call, Me. We continue, despite being misunderstood, because each one of us, individually and as a whole, are Loved, valued, and in the end of course, because it serves our selfish desires. Motivation to speak toward the truth about ECT treatment is as complicated as the construction of motivation in any context.

The person who started this dialogue is motivated by “the suicide epidemic in the military and veterans.”

The Curious asked why we wait so long to offer ECT, “from a scientific standpoint,” stating, “I understand stigma and pharma lead to meds first.” Let’s pull on this thread.

  • Is there a “scientific standpoint,” or has the alleged algorithm of treating a certain number of medications first before treating with ECT been scientifically studied and/or proven? No and no.

Some years ago during the Q&A of an expensive international well-attended ECT lecture, by those who have much more experience than I, my wobbly legs took my own curious self to the mike. I felt the years, like a bag of gold on a scale, hanging in a plate. And where I stood, my purse felt too light. But I did ask them why we continue to say this? I did even challenge, like a barking puppy, “We need to stop saying this. We need to support our community of practitioners who do offer ECT to anyone (that needs it) who wants it, at any point in their treatment. We need to stop perpetuating this tradition, that has no scientific support, to treat last.” Ruff. Ruff.

Tradition? Yes, tradition.

In medical practice, it is our standard to weigh the benefits of one treatment against the risks of that treatment. And likewise, against the available treatments otherwise known for any illness. For example, many medications may cause dry mouth. Dry mouth, leads to dry gums. Bad breath is there, sure. But do we think of root canals? When we speak about medical treatments, we consider the possible side effect’s along with the hoped for benefits.

  • Are the risks of the disease remaining unchecked, untreated, progressing over time, burning and pillaging along the way, etc. more dangerous than the risks of treatment?
  • Are the benefits of leaving the disease untreated, more than the potential benefits of the medical treatment?

The standard of one medical practice over time leads to traditions of medical practice. We would like to think that those traditions are based on science. But when they are not, well, here we are.

When I was a kid, I was fortunate to live in the community of FOB’s, (fresh off the boat’ers.) Our boats came from Lebanon. Among the many benefits, like belly dancing, tabouli as a staple, and high volume multi-voiced conversation, I also had to sift through noisy “traditions” not based on science.

Sana, sleep on your back so you don’t get wrinkles in your face.

Sana, pinch your nails so your fingers and nail-beds grow out thin and not flat.

Sana, drink a lot of milk because milk is good for you.

The misconception about when to offer ECT is a tradition that came from a time when many medical treatments were primitive compared to now. For context, imagine that you wanted to know if you were pregnant. You would pee into a cup, (so far so good), and your pee would be injected into a rabbit. (Wait! What!?) In 1935, Portuguese neurologist António Egas Moniz introduced lobotomies. In 1949, he was awarded the Nobel Prize for Medicine. (Clearing throat sounds rattling the air.) This is the company ECT kept.

Have you ever heard the wagging term, “Time will tell”? And it has. We can now leave rabbits perfectly unharmed in our pregnancy tests, and keep drills and saws out of the treatment options for panic attacks. But here, some 80’ish years later, we are still using electricity, a natural process in cell communication, to bring about healing. Why is it still around?

Why is it our tradition to offer ECT so late in the disease? Back in the day of the rabbit test, lobotomy, and when ECT was born, we didn’t have much control in the treatment. It was a wild foal.

  • We had ether-gas, or nothing, for anesthesia, rather than the easily tolerated and highly effective intravenously dosed medications we now use to allow our patients not to feel or remember any of the treatment experience.
  • We had a sign wave of electricity, comparable to a tsunami dosing; rather than the finely tuned small amount of electrical current we now effectively use.
  • We directed the stimulation haphazardly, like a four-year-old playing t-ball as compared to professional baseball. We now place the stimulation more specifically, with deliberation, in areas that are most effective.

The benefits not only stayed through the years, but they have improved. The risks have diminished. Dramatically. This changed the risk-to-benefit ratio, which you remember is our standard to consider in the practice of medicine. But 80-years is a long time. And since anesthesia really wasn’t developed until the 1960’s, fluoxetine was launched in the 1980’s revolutionizing the practice of psychiatry, and the recent changes in the style of practice with ECT have been made now over the last twenty-some years – our traditions have been what traditions are, practices of the old cultures.

This ends my Sabbath writing. Thank you for sharing it with me.

What is the self-care tip? To keep the Sabbath? To get ECT? To change one’s traditions? Laughing. You tell me.

Keep on!

NAMI: National Alliance on Mental Illness

Hello Friends,

I’m enjoying this all too fast passing time at the APA annual meeting in Toronto. What I am most enjoying is the education, the community and connection with new and old friends, and the reminder of what this is all about – you and I. In honor of us, I’m “pressing” this excellent post from our national advocators and stigma-fighters at NAMI.

NAMI: National Alliance on Mental Illness | NAMI: The National Alliance on Mental Illness.

Check it out and let me know your thoughts. How does this resonate, or not, with you. We need to hear!

Be well and keep on!

Q