The first patient I cured

“So ya, that’s everything that’s going on…”

There was a long silence before I responded, “that fucking sucks, it really does.”

“You’re telling me…”

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I had just started as a resident doctor at a hospital in Ontario, Canada, and was working with one of the first patients I would ever follow in my outpatient psychiatry clinic. I met a woman, Ms. G, who worked as an engineer. Ms. G had been referred to the clinic by her family physician (known as a general practitioner outside of Canada) for an assessment of low mood and sleep disturbance.

As these things go, you get some information in advance of the consultation from the referral form. Ms. G had never been involved with the mental health system. She was in her 50’s, married, and had three adult children. She was also not presently taking any medications.

I’m excited. A blank slate, a canvas ready to be worked with. So much potential. I quickly opened by copy of Prescriber’s Guide, and reviewed the starting doses for all of the basic antidepressants. Would today be my first fluoxetine start? Sertraline? Maybe even escitalopram?

The consultation time quickly arrived and I stepped out into the waiting area to ask for my client. Ms. G was average height, was wearing business attire, and had been using her cellphone immediately prior to my arrival, which she peered at through a pair of thin, golden reading glasses. Ms. G shook my hand and we walked together to the office.

Ms. G and I spoke for almost an hour. She detailed her struggles with low mood, decreased enjoyment in life, poor sleep, poor appetite, and difficulties concentrating. There were profound feelings of guilt and worthlessness. Her mental status exam was actually relatively benign. You were certainly given the impression that this person was tired and frustrated, but you certainly weren’t put in mind of someone in the throes of a severe depressive episode. With this information alone, I was able to determine that Ms. G met criteria for a Major Depressive Episode, mild/moderate severity.

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Ms. G also owned her house. Her and her husband had just renovated the home, and it was beautiful. That was before the flood. A month prior, Ms. G’s home was the most recent victim in a spat of Toronto city floodings. Everything in the basement was destroyed. A lot of the renovations, which included the downstairs bar and family room, had not even been properly enjoyed yet, only to be destroyed by the flood. Even worse, Ms. G’s home was the only one on her block to sustain significant damage.

“that fucking sucks, it does.”

“You’re telling me…”

Our consultation wrapped up and it was time to discuss the impression, plan, and treatment with Ms. G.

“Based on everything we have discussed, your presentation is not suggestive of any mental illness.” This peaked her interest.

“Then how do you explain what’s going on? I can’t sleep, I feel awful all the time…”

“Well, you have a lot on the go. You just renovated your home, spent tens of thousands of dollars, and now you’re faced with the flood. In a way, you’re re-traumatized every single day when you get home from work and have to be reminded of the damage, since the repairs are yet to be done. It makes sense to feel this way.”

Ms. G liked my opinion and asked me what she could do to feel better. I told her to hang in there, and to continue working on the repairs. I told her my suspicion was that she would feel a lot better once the repairs were taken care of. She would be able to move on.

I also told her I did not expect medications to have any effect on her mood. This wasn’t depression. This was an exaggerated form of a really, really bad day. I did offer a short supply of some sleeping pills which she gladly accepted.

I also told her I wanted to see her again, and I followed up with her twice over the coming months. At the second follow up, she was smiling, and I noticed the bags under her eyes were quite less pronounced.

“Good morning doctor.”

“Good morning Ms. G. How are you today?”

“I’m great – you were right!”

“I tend to be,” I said as I laughed. “But just so we’re on the same page, what are you referring to?”

“It’s finally over.”

“The renovations?”

“Yes!”

“I’m so happy for you.”

“Thanks for everything, doc! You cured me.”

Editor’s note: I didn’t cure this woman – as these things often go, time in many ways heals most wounds. This was the natural history of getting through psychological distress following something like a home flooding. This is not what I would expect to happen with true and blue depression, which often needs a combination of therapy and medications.


Ms. G met criteria for depression; that does not mean she has depression. You can meet criteria for any number of mental illnesses, and it is up to you and your doctor to synthesize all of the available information, and to interpret it in the way that makes the most sense.

 

Dr. Travis Barron is a resident physician in Toronto, Canada.

 

Depression-Go-Round

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I’m not feeling great today, maybe I should skip the party…

“Hey, Jen! Are you coming?”

“No, I think I’m going to stay in.”

Later that night, you find yourself thinking, I’m such a failure, I’m so useless, I couldn’t even get to the party… And I’m not any kind of company right now…

When you have depression, it is absolutely exhausting. A big part of that is because it seems like this sick, endless loop. Like you’ve been cursed to listen to your least favourite song on repeat for the remainder of eternity.

People with depression often become progressively withdrawn over the course of their illness. Often times, people with depression will skip events because they feel like they are incapable of having fun. They may worry about ruining others’ evenings. In the immediacy, this strategy seems like the only tolerable option. In the long-term, social withdrawal, caused by depression, also exacerbates depression, which in turn leads to further avoidance.

These cycles of thinking and behaviour are well recognized in the field of psychiatry, and we utilize our understanding of this phenomenon to guide our treatments.

In broad strokes, psychiatric illnesses have two main modalities of treatment – medication and therapy based. They often work best in conjunction with each other. Today, I’ll be discussing cyclical behaviours and the role of cognitive behavioural therapy in the treatment of depression.

Cognitive behavioural therapy (CBT) is a manualized, evidence-based treatment for anxiety and depression. What does manualized mean? Don’t think of a guy on his couch discussing his relationship with his mother; that would be an open-ended psychotherapy, such as psychodynamic therapy. CBT is very specific, with worksheets, homework, and goals that are worked on by you and your therapist over a course of 2-4 months.

tfbCBT relies on a principle – that our thoughts, feelings, and behaviours are all related and that they inform each other. And this relationship is a two way street, Your thoughts inform your actions, and your actions inform your thoughts. Your feelings inform your actions and behaviours, and vice versa. I could go on.

In CBT, you and your therapist will work together to address all three of these elements simultaneously. Thought records and your time with your therapist are used to explore thoughts and feelings, and to understand how behaviours may have an impact on how you feel. Remember the cycle of depression and social avoidance.

tfbtOver time, you and your therapist hope to achieve cognitive restructuring – literally a change in the way you think. Instead of thinking, “I’m too tired for that party,” you might find yourself thinking, “I’m tired and I should go to the party for at least a few minutes – it will probably be fun.” Cognitive restructuring takes time, and considerable investment. It can be considered the “top down approach,” because it focuses on thoughts/the brain/the “top.”

A big – and underappreciated – aspect of CBT is behavioural activation, or the “bottom up approach.” When you’re depressed, and have been withdrawn for some time, it literally becomes difficult to have a positive thought. It also becomes easier to negative thoughts, and you lose enjoyment in things you had previously found enjoyable. This isn’t just partying and socializing, but also things like laundry, and brushing your teeth, things that previously resulted in satisfaction but now seem insurmountable.

tfbbBehavioural activation acknowledges this disconnect and works to encourage people to do things anyway, despite the sense that no enjoyment or satisfaction will be wrought. Behavioural activation “kick starts” our brain, and gives us the ability to feel positive about things again. This can in turn make the cognitive restructuring arm of CBT a little easier, and before you know it, the cycle is working in the opposite direction, and improving your mood.

When I work on behavioural activation with patients, we often start with simple things such as brushing your teeth, or making your bed in the morning. We escalate the therapy progressively, and before you know it, the most out of reach goals are within the patients grasp.

I know when I started my residency, therapy seemed like a bit of an enigma. Now, I have a bit of an understanding, and it has empowered me. I hope I have been able to empower you!

 

Dr. Travis Barron is a resident physician in Toronto, Canada.

 

Language matters – Does everybody have mental illness?

“It’s my OCD.”

“She’s so bipolar.”

“He’s depressed.”

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Does it ever seem like everybody nowadays has some sort of mental illness? Behaviours we find uncomfortable somehow explained by the latest acronym? They all have anxiety. Who doesn’t have depression?

That’s because everyone does have anxiety. Or at least, feelings of anxiety. And the same goes with depression. Anxiety has evolved inside of humans to serve vital functions. To be afraid of the lion stalking in the night. To think that standing precariously on the edge of a cliff might not be a good idea. Today, anxiety makes us on time for work. It helps us meet deadlines. Yes, it sometimes makes us feel uncomfortable, but can you imagine humans, without any anxiety? Not a society I want to live in.

Not everybody has Generalized Anxiety Disorder, or Major Depressive Disorder. These are mental illnesses; they are defined by criteria contained within a manual, the Diagnostic and Statistical Manual V (DSM-5). What makes these disorders different from anxiety, and sadness (colloquially known as depression nowadays)? They are pervasive in people’s lives and cause difficulties in functioning.

Mental health awareness is amazing and the reduce the stigma campaign has done wonders for mental health research and support for those suffering from mental illness. A side effect of this campaign has been the increasing use of psychiatric terminology in common speech, resulting in confusion between what a physician means when they use certain terms, or when a term is used on Instagram. This has always happened – the word “paranoid” being a great example – but we are seeing it happen at an increased rate due to social media.

The message? We all have anxiety, sadness, and rigid behaviours (often misdefined as OCD). It’s normal. Those traits probably make you stronger, to some degree. The presence of those features does not mean you have a mental illness. If you are worried you have a mental illness, you should see your doctor. They can often help.

 

Editor’s note: Mental illness is very real and very debilitating. But the stigma remains. Throughout my career I’ve worked with people from all walks of life, mental health skeptics included, and I’ve come to appreciate that at least some of their frustration comes from the fact that seemingly “normal,” well people are endorsing having mental illness. I think what they are describing is a good example of why language matters, so hopefully this can help!

 

Dr. Travis Barron is a resident physician in Toronto, Canada.

He’s biting again

“Mr. V is biting again.”

“God, what are we going to do with him?”

“I don’t know, but he’s getting too much to manage…”

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Dementia is a debilitating disease. It creeps up slowly, crouches for attack, and seems to suddenly wipe our lives from right beneath our feet.

Many of us have had loved ones stricken by the disease, and have watched in muted horror while the person we knew vanishes, as we wonder, “if it’s this bad for us, what must it be like for them?”

I was working in an emergency department in Ontario, Canada, when a gentleman, Mr. V, was brought in from his place of residence when staff determined he was too agitated for their care. On arrival, he could not speak beyond muttering a few nonsensical words, and would randomly grab at staff as they walked by, seemingly on a completely random basis. The staff at his residence confirmed he had a history of dementia.

These sort of patients are difficult for a variety of reasons. The inability to communicate often results in subtle needs going unmet, leading to aggression. They require a high level of nursing resources to manage. And the fact is, our healthcare systems in Canada (particularly emergency rooms) are not equipped to properly care for people with dementia (in fact, in many ways they are perfectly equipped to exacerbate symptoms of aggression in dementia).

I began to work with Mr. V and I immediately noticed his age – he was in his late fifties. This is a fairly young age to develop dementia and immediately the differential changes. Could he have some rare form of genetic Alzheimer’s, which can affect people at  that age?

The second thing I noticed was has last name, changed for the purposes of this blog. The spelling on the name was immediately suspicious for someone of Sri Lankan descent. I phoned Mr. V’s emergency contact, and my suspicions were confirmed. Mr. V had a long history of alcohol abuse, and had subsequently developed a dementia. He had been various degrees of under-sheltered for the last number of years. He had immigrated to Canada some decades prior, as a refugee. Mr. V was Tamil and had been a victim of unnamed trauma during the Sri Lankan civil war.

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Credit: Alternative Press

I won’t go into details here, but the Sri Lankan civil war (1983-2009) was your typical civil war cocktail of genocide, torture, rape, and any number of unspeakable deeds. The effects of civil war and genocide on the human brain are well documented and not easily conceptualized. Obviously it has a tremendous impact on people, Mr. V being the latest example of a casualty of the war. The United Nations recently reported that one in five individuals in conflict zones suffer from a major mental illness, at any given time.

What struck me about this story was how succinct it was. The clear relationship between this man’s trauma, alcohol use, and dementia. The story isn’t always that clear. But there’s always a story. Next time you meet someone with an alcohol problem, dementia, or any other mental illness, stop and think, there’s more to the story.

 

Editor’s note: What happened to Mr. V? We uncovered an acute medical problem that was easily treated, superimposed on his dementia, and he returned to his baseline after a couple of days of treatment!

 

Dr. Travis Barron is a resident physician in the Department of Psychiatry at the University of Toronto in Toronto, Canada.

 

There’s a microchip in my head

“Hi, welcome to our emergency room, what brings you in today?”

“I need to see a surgeon.”

“And why is that?”

“I need to get the microchips implanted in my brain removed.”

What is the role of a psychiatrist? Depending on who you ask, you’re likely to get many different answers. To help people. To make me feel better. To push pills. Population control. It’s a question I myself have struggled with time and time again throughout my career, and it would be a lie to tell you I knew the answer perfectly. In reality, a psychiatrist wears many hats, and many psychiatrists view their own roles quite differently, which is reflected in how they practice.

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I was a wee-medical student in Ontario, Canada, working in the emergency department one summer. We had a gentleman come in and request to see a surgeon to remove microchips from his brain that he felt were responsible for broadcasting his thoughts to the public.

In Canada, when you go to the emergency department, the first physician to assess you would be an Emergency Medicine physician. The doctor I worked with that day, Dr. S, asked me to go see the gentleman.

When I met him, he was tall, skinny (certainly not emaciated), and appeared a little anxious. He was far from the most distressed patient I had ever met and was not agitated whatsoever. I asked him the usual battery of questions and he denied being suicidal or wanting to harm anyone. He simply kept coming back to these microchips. “When is the surgeon going to come?”

I finished my assessment and thanked the gentleman for his time. I explained to him that in my experience, what he was experiencing could be best explained by a condition called psychosis. And good news! Psychosis is a condition that responds to medicine, and we are able to arrange for him to see a psychiatrist today if he is interested.

“When is the surgeon going to come?”

I excitedly headed towards the nursing station to review with my supervisor, confident that my diagnosis was correct and that my plan was solid.

“So, what do you think?”

“I think the most likely diagnosis is psychosis, probably secondary to schizophrenia based on his presentation.”

“Excellent, I agree. What would you like to do?”

“Well, I think we should consult psychiatry, send some antipsychotic labs, call his fam-“

“Wait a minute. Does he want to see a psychiatrist?”

“No, he thinks he needs to see a surgeon.”

My preceptor smiled and asked for my reasoning for treatment, and I explained that the guy is psychotic, he needs treatment. She disagreed.

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The patient was psychotic, this is true. He was not suicidal, he wasn’t violent. He wasn’t agitated, or emaciated. There was no real visible distress – certainly not close to the amount of distress involuntary admission to hospital and coercive treatment causes. And he didn’t want to see a psychiatrist. At the time, I was somewhat mystified at the idea of not treating someone with such profound symptoms that in all likelihood would have been at least somewhat amenable to treatment. I imagined this guy’s life coming together, all his problems solved with my little pill.

Today, I know better.

People are entitled to believe and feel what they want. I have no right to tell you how to feel or what to believe. Is believing you have microchips in your head so different than believing there is someone in the sky that created the earth in seven days? I’m not sure it is. What my job is, is to intervene at moments of risk. You can believe you have microchips in your head – if that becomes so intolerable you feel like you need to kill yourself, it is my duty to intervene and keep people safe. In the absence of risk, as the old adage goes in Newfoundland, more power to ya.

There is of course the argument about treating psychosis when it begins to impact people’s lives, but does not cause an immediate risk. Someone who gradually becomes homeless over time due to functional problems as a result of psychosis, for example. Think the guy talking to himself on the side of the street. Yes, these people would (likely) benefit from antipsychotic treatment, but only when it comes from their own free will. When medications are forced on people, they quit them the first chance they get.

So what is my job as a psychiatrist? To help. To be available. To sometimes intervene and violate free will when there is a risk of harm to someone. But not to tell you what to think, how to feel, or what to believe. That’s your own choice.

 Editor’s Note: We did of course offer this gentleman ample follow up, and he politely refused everything we had to offer. What we find important here is making this gentleman feel safe when he comes to hospital so that when he does need us, he feels safe to come.

Dr. Travis Barron is a resident physician in the Department of Psychiatry at the University of Toronto in Toronto, Canada.

Mental illnesses are made up (sort of)

You’ve experienced some swelling in your neck for the last three months and decide to see your doctor.

They do a physical exam and run some tests. At the follow up appointment, they give you the absolute last thing you wanted to hear.

“You have lymphoma.”

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When I started medical school, a memorable preceptor told me that I was about to learn an entirely new language. An understanding of that language, she said, would empower me to become a wonderful physician.

Hodgkin’s lymphoma is an example of a disease. What makes a disease? The presence of a clear, well-defined pathological phenomenon. Cancer is not a disease. And neither is lymphoma. Hodgkin’s lymphoma, however, is closer to the mark. Why does this matter? Because a disease is a very specific entity, and one that is by-and-large understood. It’s specificity allows us to target very specific elements of the disease, to develop treatment. There are (almost) no diseases in psychiatry.

Syndromes, or disorders, are clusters of symptoms that tend to appear together and suggest to the observer (usually a physician) the type of problem which may be going on. For example, someone presenting to an emergency department with swollen legs, shortness of breath, and chest pain, likely has heart failure (a syndrome; heart failure with preserved ejection fraction may be the disease). We have many syndromes in psychiatry. Someone presenting with an inability to get out of bed, tearfulness, and suicidal thoughts, may have depression. Someone who hears voices and believes they are being monitored by the CIA may have psychosis.

So why the disconnect? Because the brain is cool.

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The pathophysiology behind heart failure and lymphoma is relatively clear. This is not the case with mental illness. The human brain is extraordinarily complex, and is not easily studied under the microscope, or in labs with rats. It’s an exciting time in psychiatric research, as the human brain is in many ways considered the final frontier of medicine. For patients and individuals, it’s a frustrating time..

This ambiguity has caused us to rely on describing syndromes, as opposed to clear, well-defined diseases, in our practices. Syndromes, or disorders, can be seen all over psychiatry. Major Depressive Disorder. Generalized Anxiety Disorder. And I could go on.

Why is this important? A syndrome can be the result of a variety of things. Someone with chest pain, swollen legs, and shortness of breath, may also be having a heart attack. Someone presenting as depressed might have depression, bipolar disorder, hypothyroidism, or could be having a regular ol’ bad day. This helps explain why some people respond to medications, and why some do not. Why some people get great help from cognitive behavioural therapy, and others find it a waste of time. Since we’re dealing with a mixing pot of a variety of potential explanations, some trial and error is required as you and your doctor arrive at a suitable treatment. I get almost as frustrated as a patient when we are going through treatment and a medication doesn’t work, or a therapy isn’t suitable. It can be demoralizing to everybody involved. What can help is keeping in mind that that mystery and ambiguity is expected, and a completely normal part of moving through the mental health system.

 

Dr. Travis Barron is a resident physician in the Department of Psychiatry at the University of Toronto in Toronto, Canada.

Living on the edge

Bzzzzzzzzzt.

Bzzzzzzzzzt.

Bzzzzzzzzzt.

“Hi there! You have been randomly selected as a winner of our draw! All we need is your credit card number-”

“For fuck sakes.”

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Have you ever answered a robocall at four in the morning? You hear the ungodly buzzing of your device – turned on vibrate, so as “not to wake anyone” – and you’re sure it must be a family member in crisis, or a work email that can’t be missed. Instead, you are greeted by the disorienting sound of a fog horn and the robotic voice of the latest phishing scam as they tell you, “the Captain’s calling!,” and start wooing you with free cruise trips, with one catch. They need your social insurance number.

Fat chance.

The next day, you’re at work. You laugh with your colleagues about the Captain, and you realize the same thing happened to all of them as well, at some point. There’s a certain comradery in the shared psychological torture.  That night you can’t get to sleep, and you wonder, “why am I so damn restless?!”

Hopefully, this exact scenario hasn’t happened to you, but I’d be willing to bet you have answered a phone call in bed at all sorts of hours in the morning. It’s a habit many (and probably most) of us do in our technologically driven society. While most of us realize that getting up numerous times a night isn’t allowing for the most restful sleep, many people often do not realize the deeper psychological consequences of bad phone hygiene.

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In broad strokes, anxiety can be defined as a, “fear of uncertainty.” Which makes sense. Anxiety can be accompanied by several symptoms – concentration difficulties, fatigue, irritability, restlessness, and muscle tension. These symptoms are caused by an increase in the part of our nervous system that controls adrenaline, called our sympathetic nervous system. This is the part of the nervous system that allows us to react to uncertainty. In prehistoric times, the benefit from these functions is obvious. You want to be angry, on edge, and have tight muscles (and definitely do not want to be asleep) when the sabretooth tiger is attacking you. Today, these symptoms often cause us discomfort.

Smart phones are wonderful things. They allow access to hordes of information at any given time, and have allowed us to connect with each other on an unprecedented level. They have also allowed us to, unlike ever before, take work home to an entirely different degree. The expectation in many offices today is that emails should be answered immediately, regardless of the time of day (and even if you’re on vacation). In other words, smart phones, while wonderful, represent the endless possibility of something significant happening – a family death, a big deal, the Captain – at any given time, which requires our response. And we sleep with it. Ew.

Our smart phone addiction has contributed to a baseline feeling of uncertainty that in many of us turns on the adrenaline nervous system, and causes us the symptoms of anxiety. Bad phone hygiene, such as sleeping with your phone, and not setting limits insofar as when you will answer your phone, contributes greatly to the symptoms of anxiety, not just on the night of that inappropriate call, but for many nights to come.

 

 

Dr. Travis Barron is a resident physician in the Department of Psychiatry at the University of Toronto in Toronto, Canada.