For many of us, winter represents a slowing down of things. The days are shorter, suddenly you’re less inclined to go to the gym after work. Vacations have settled for the most part, and energies are redirected towards class or work or whatever it is you do.
It can also kind of suck.
Why is it that our moods are affected by this change of season? What is it about humans that makes us so sensitive to these changes? Does this have an evolutionary benefit? What if we get too sad?
To think about why the human mood (in general) changes during the season, we must first think about what mood is. Where did mood come from? One of the earliest forms of “mood,” is hunger. When in a hungry mood, even the most primitive animals will change their behaviour, and begin food-seeking behaviours. Their cytoplasmic cilia might undulate towards a chemical stimulus. They may swim to a shallower depth towards the scent of a school of fish. If you are a hunter, and encounter a bear in the woods, hope that it’s not hungry. It may not eat you. If it’s looking for a meal? Good luck! The point is the moods, in animals, represent a set of behaviours suited to a particular circumstance.
Does this apply to humans? Of course. We gorge the cupboards when we’re hungry. On a macro level, countries and nations suffering from famine and starvation have orders-of-magnitude more unrest and civil war than their well-fed counterparts.
While hunger is a relatively easy “mood” to understand the benefits of, the behaviours and utility provided by more traditional moods like happiness, sadness, and anger, are more subtle, yet equally significant.
Anger can be considered synonymous with threat. People who are angry often feel threatened, and many of the behaviours associated with anger are involved with defense and mitigating a threat. Yelling, like the growling bear, is making yourself “big,” to intimidate an enemy. Elevated heart rate (tachycardia) occurs when you’re angry, in case the most extreme manifestation of anger, violence, is necessary. Sadness can be a little less clear. After all, what could be the evolutionary benefit of something often so painful?
Sadness is afforded power by virtue of the pain it causes. If we are sad about something, our brains want us to avoid that same circumstance from happening again. Losing a job, a messy break up, losing a loved one, these are all circumstances that our brain is telling us we should avoid again, and our behaviours begin to modify in hopes to avoid triggering the sadness again. If you’ve lost your job because you continually showed up late to work, the sadness afforded by the job loss may motivate you to be on time for the train more often in the future. While wallowing over a messy break up, you may find yourself reflecting on the relationship in search of “what went wrong,” and using this information to improve your relationships in the future.
The pain caused by the loss of a loved one is a little more nuanced. What change could sadness drive? There are a few answers. Historically, most deaths werepreventable, and the result of a sabretooth tiger attack, or tribal warfare. Sorrow caused by deaths in these circumstances were clearly cause people to be more weary of protecting against tigers, and may either question the benefit of their war or double down and fight even harder. Today, many deaths have a component of lifestyle contributions, and grief after a loved ones death from lung cancer, who smoked, may cause us to question our own habits. The point is, even grief, sadness, and sorrow drive change, and have clear utility on an evolutionary, population level.
So what happens when you get too much of this? Well, depression, for one. A disruption of the normal mood cycle, by any number of factors, can contribute to the development of depression. In the case of anger and happiness, they can contribute to the development of mania. And the fact is, all of us are vulnerable to alterations in our moods when the environment changes, even if it doesn’t represent a frank depressive or manic episode. One of these factors is the season, as we discussed above. For most of us, it’s just the way things are. For some of us, it’s the winter blues. In extreme cases, it’s seasonal affective disorder (SAD).
What is SAD? How is it caused? What about the seasons impacts our moods? Can we use this information to inform SAD treatment? Tune in to part 2 to see!
Dr. Travis Barron is a resident physician in Toronto, Ontario.
The ability to read minds is a superpower often portrayed in many forms of popular media. The idea of being able to understand our peers, down to the most minute detail, is both seductive and a credence to our innate desire to understand one another. It is our perception, of the understanding of others’ minds, that we use to shape our views of the world. Mount Rushmore, in the United States, for example, only holds meaning because of our collected understanding of the grandeur of the monument, and an appreciation of what/who we gaze upon.
All humans sort of read minds – it’s called intuition. Based on the feelings, actions and behaviours of another person, someone with well practiced intuition can often tell when something is wrong, or when someone is excited. Believe it or not, these functions are encoded directly into our brain, in an area called the posterior superior temporal sulcus, an area dedicated to recognizing facial expression. The ability “read ones feelings” is so integral to our survival as a social species in fact, that many animals exhibit this level of intuition, dogs being the most obvious example. Have you ever had your pet dog come and comfort you on a difficult day? Ever have your German Shepherd start barking at a stranger when you start to look alarmed and panicked? Ultimately, this phenomenon comes from a profound ability to react to subtle nonverbal communication, like facial expression and body position, on a seconds’ notice.
People have different degrees of intuition. For some people, they are able to “read a room” without ever having met anyone in it. For others, they have a difficult time guessing a loved ones’ thoughts, despite their best effort. There are likely genetic and environmental reasons for this, although they are not well-defined.
Someone practicing as a psychic shows a high level of human intuition and understanding of the human experience, for example. By reading your face, body language, reaction to their readings, and with a little context, they are often able to provide spookily relevant advice to you about, for example, the death of a loved one.
Anxiety and mind reading
A psychic is a great example of a person using an innate ability to their advantage for their profession. Not always, however, does strong intuition on the feelings of others provide us an advantage. Many people with an anxious disposition find themselves hyper-aware of situations, and consequently, it can become overwhelming. Seeing a young group of teenagers for example might set off the anxious persons “spidey sense” and prevent them from walking by the group, whereas someone else may find themselves less preoccupied by this group of people.
An anxious person may also find themselves taking too much responsibility for keeping the flow or a party, group, or conversation comfortable, because they are more sensitive to the various social cues sent out by the attendees. An anxious person would be the first to recognize when Tim was getting bored or when Siobhan is feeling uncomfortable. They might be the first to recognize when dad has had too much, or when the hostess is getting tired. Obviously, having some degree of this behaviour shows high social intelligence. If you find yourself being unable to enjoy your own birthday party for the same reason, it might fall under the umbrella of a disorder.
Cognitive mind reading and depression
“Everyone hates me.”
“My friends think I’m boring.”
“I know everyone is looking at the weight I put on when I go to work.”
“I give a bad first impression.”
“They all think my clothes is lame.”
One of the most common forms of pathological mind reading, is cognitive mind reading. See the examples above. We have all, probably, had a thought at least something like that at some point in the past. We might even be having those thoughts now.
The above examples represent cognitive mind reading, a phenomenon common to many forms of depression. Cognitive mind reading involves someone often making a negative assumption about someone’s thoughts, as it relates to themselves, out of keeping with reality. “Everyone hates me,” for example. Everyone does not hate you. Most people on the street don’t know you! These thoughts are actually a reflection of a depressive process.
When you become depressed, you put on some “gray-coloured glasses.” What this means is you often view things in a more negative light. The skies are grayer, video games are less fun. And seem esteem deflates. The social intuition discussed at the beginning of this post is no exception. When you’re depressed, this part pf your brain becomes hijacked, and all of a sudden, you may find yourself thinking that the world is thinking a lot more negative of you, even though it isn’t. In reality, those negative mind reading assumptions (where you believe that all of the negative things you worry people are saying about you are true) are a reflection of your brain being depressed. When you’re depressed, your brain colours everything gray. It sucks!
But it’s not all doom and gloom. Cognitive mind reading is one of the most common forms of cognitive distortions seen in depression, and physicians and therapists are well positioned to help you handle this. One of the first steps to this is understanding what cognitive mind reading is, why it’s happening, and importantly, that it’s very common in situations like your own. You’re not going crazy.
And not everybody hates your jacket.
While cognitive mind reading is extraordinarily common, with many depressed and non-depressed people experiencing some degree of this on any given day, thought reading is relatively rare.
Thought reading is a delusion, and is actually one of the more classic features of a
psychotic (not psychic) illness called schizophrenia. When someone is experiencing thought reading, they literally believe that they are privy to the thoughts of others. I can literally hear your thoughts. This can be differentiated from cognitive mind reading in a few different ways.
Someone with thought reading may (though not necessarily) literally hear the thoughts as a form of auditory hallucination.
When you ask someone with cognitive mind reading to explain how they know “Yousef hates me,” they will usually give a lot of evidence, as if building an overwhelming court case. “Look at the way he did this… look at this behaviour… and I just know he does because this… he hugged me last and it seemed uncomfortable…” Someone experiencing thought reading will often reply, “I can hear their thoughts.”
The clinical picture is wildly different in both (though there are of course borderline cases). Thought reading is accompanied by psychosis. Cognitive mind reading is accompanied by anxiety and depression.
An important note here is that cognitive mind reading usually upsets the person and causes them problems. Thought reading has a variety of much more extreme reactions attached to it.
A twenty two year old male presents to the unit acutely psychotic and paranoid. During the course of the admission, he is very aggressive, and damages much of the furniture on the wards in a psychotically driven rage. When he’s better treated, you speak to him, and he discussed that he read the thoughts of the female nurses, and they all thought he was disgusting, which angered him.
A thirty year old male tells you about the microchip he had implanted so he can now read minds. He plans to kick some ass on the stock market with this new information. You diagnose him with a grandiose delusion.
If you are worried you have some form of mind reading, it’s most likely some degree of cognitive mind reading. If you’re concerned, see your doctor. They might help!
Dr. Travis Barron is a resident physician in Toronto, Canada.
“Hey, would you like to come catch some lunch with us? There’s this new Mexican place around the corner.”
“No thank you, I have a lot of work to do, I’m going to stay here and catch up on some documentation, next time though!”
“Alright, have a good lunch.”
I quietly closed my office door and flushed pink with embarrassment. I hope that was convincing. I reached for my battered book-bag, and pulled out the two slices of toast and the bag of almonds I had laying around the apartment that morning. My chopped up frozen peas and corn were still frozen.
It tasted a little like cardboard, but it was OK. As I sat eating, I couldn’t help but think about other social events I had to come up with some elaborate excuse to avoid, because I was broke. Beyond broke. I recalled the Tim Horton’s server earlier that week, who stood by annoyed as she counted out my forty nickles – or I thought it was forty. I was five cents short; luckily the annoyed customer behind me overheard and threw a dime down on the table, a little in kindness, but also to help get the line moving, I thought.
That was three days ago. I haven’t been able to afford a coffee all week.
It gets more difficult some days, particularly when tempted with succulent chicken polo frito I know I can’t have. I looked down at my jeans, which I had worn every day this week. They looked shabby and I saw a small yellow dot of something – mustard? – on one pocket. I tried to brush the spot off but it only smeared the yellow-goo deeper into the fabric. I felt the seam of the jeans, gently rubbing the pale, white thread I could tell was going to give out, at some point. Hopefully they last until my birthday… I only owned two pairs of pants that fit me you see, and one was in the wash.
And the drier was broke.
This scene may seem vivid, I hope it is. These events don’t begin to touch on the poverty many residents of the world, country, and Toronto face on a daily basis. I have a relatively safe apartment in a decent neighbourhood, and most months I can afford to get a transit pass.
This story is also about me, and it’s not where I expected to end up as a doctor. So what gives?
For those of you who have read this blog for some time, you will know that I am something called a resident physician. Residents are kind of primordial doctors, having finished medical school, and now completing a program in the specialized area of medicine they will eventually work in for the rest of their life.
Becoming a resident, and a doctor, takes many things. It takes academic rigour, professionalism, dedication, and mental toughness. It also takes a tremendous amount of money.
To enter medical school, you need an undergraduate degree. For most people in Canada, those degrees, four years in duration, can cost anywhere from $10 000 to $50 000, depending on the school you attend. Most young people in Canada don’t have this kind of money just sitting around, and ultimately the vast majority of university students depend on one of two sources of funding – student loans, or help from their parents. Leaving conversations about how the education system is designed to discriminate against the poor aside, I’ll mention here that I was one of the more fortunate undergraduate students at Memorial University, and only graduated with about $15 000 in student loan debt.
In the fourth year of my BSc (Hons) in Cell and Molecular Biology, I began applying to medical schools – at about $700/$800 per application. Those of you who know anything about medical school admissions knows that you don’t want to “hang your hat” on one school, it’s not unlike the lottery. Keeping this in mind, I ultimately opted to apply to seven medical schools, which stung my pockets, but felt necessary at the time.
I was ultimately offered two interviews, one of them here in Ontario, and after some reflection and my acceptance, I found out I was going to medical school! In Windsor, Ontario.
Most Canadians mistakenly associate things like $25 000 a year education to places like the United States. Not so, for medical school. I was dismayed to realize my tuition would be that, and more per year, considering the various $1000 “enrollment fees” and the “one time $800 course fees,” for the odd mandatory skill seminar put off by the school. I did the math, and yes, this was going to cost me $100 000. And I was going to pay interest on that money, as well as my $15 000 student loan, every single day, until the time I graduate. (As an additional fuck-you from my medical school, they went on to increase the cost of tuition every single year I was in medical school; my fourth year, initially supposed to be $21 000, the cheapest year since it was essentially six-months in duration, costed $26 000 by the time for me to pay).
Now of course, as anyone with student loans will attest to, the cost of education is hell of a lot more than tuition. There are textbook costs, transit passes, rent, groceries. All of these things costed money, and since I was going to school 3000 km away from my nearest relative, I had nobody to lean on.
It’s here my trajectory deflected from my colleagues. You see, not everyone enters medical school as equals. The vast majority of my colleagues received significant financial help during medical school from their families. Most people in medicine you see, have doctors for parents, many have a trust fund. A quick Google search can shed light on the tremendous problems of socieoeconomic skewing in medical school classes – it seems like hiring and accepting people from penthouse suites doesn’t increase physician availability in the projects (no s*** guys I could have told you that)!
This is also the case in all education programs, where some students have it better than others, but when you’re surrounded by people without student loans, travelling across the world on the odd weekend, you feel it a bit more. Everything I paid for in medical school was on my back, and it still is.
And I’ll be the first to admit it. I had housing costs, groceries, living expenses. I also enjoyed myself during medical school, not excessively, but in an effort to feel like a part of my class. It was difficult, living in Ontario, and being the only person not travelling to Europe over the summer. It hurt wearing shabby mall-bought clothes among my peers when most of them shopped at expensive outlets.
I eventually finished medical school, and it was finally time for a pay day.
I also fell in love.
I ended up being accepted into a residency program at the University of Toronto, and I moved to the city to be with my partner. She had just finished a different academic program herself, and we had very little money. We accepted the cheapest apartment we could find that had access to the subway. You see, with both my partner and myself working in health care, we worked 12 hour days, if not longer, and a two-hour-each-direction transit ride was not an option. We found something that was a 45 minute transit ride away from our work, 700sqft, at $1800 a month. Yes, that’s obscene. It’s also the reality in Toronto.
The Canada Mortgage and Housing Corporation estimates that housing becomes “unaffordable” when it takes up more than 30% of your income. Many people in Toronto are in an unaffordable housing situation, myself included. This rent costs about 52% of my income per month.
Now I know what you’re saying. “That’s not a lot of money for a doctor.” It is for a resident. My resident salary in Ontario is $58 000, before taxes.
And before my $1200 of student loan INTEREST payments a month (barf).
And before groceries.
And before cell phone.
And before my transit pass.
At the end of the day, it’s really not a whole lot of money. There’s often a month where I have no transit pass for the first few weeks, and I count dimes I have left around the house in hopes of getting on. A few times, I’ve had to sneak onto the bus. Often the bills go unpaid. Don’t ask me about my VISA.
All of that to say, I’m hurting, and a lot of young professionals in this country and city are as well. It’s atrocious that medical schools, or any school, can gouge you for money they know is going to sit on your student loans – I’ve paid enough interest to my bank at this point I could have almost paid off a quarter of my debt. It’s disgusting that the government of Ontario does not account for the school of residency when determining salary – you make the same in Thunder Bay, with a significantly lower cost of living, than you do in Toronto, the most expensive city in the country.
So what’s it like living like a doctor near the poverty line? Just ask me.
It was happening again. These damn asthma attacks. My shortness of breath was getting worse, and I was bent over breathing to try and get a sufficient breath.
“I think I need to go to the hospital.”
An ambulance costed $75… I checked my Uber app – declined. “Please update payment method.” Fuck.
I got in the subway, wickedly coughing, and then transferred to a bus, which I took to the hospital. I was somewhat blue by the time I got there, and they admitted me right away. They prescribed some puffers, and told me to take my allergy pills.
The following day, I went to the pharmacy with my two puffer prescriptions. I left the allergy pills in the aisle – $15 for ten pills? Not happening.
“Alright, that will be $15.”
“I thought my insurance plan covered the drug costs?”
“It does, but for this medication, there’s a co-pay.”
“I’ll only take the one then.”
Dr. Travis Barron is a resident physician in Toronto, Canada.
I recently had a patient who was diagnosed with pneumonia. We had been treating with antibiotics, as well as some temporary puffers, for symptom relief. Unfortunately the puffers did not suffice, and the antibiotics had not acted quickly enough. One evening, after he finished dinner, this gentleman began experiencing shortness of breath. He was concerned, and called an ambulance, who took him to the hospital.
On arrival to the emergency room he was offloaded from the ambulance and given some oxygen, which helped him immensely. His breathing actually settled relatively quickly and he was able to breath without the oxygen mask. The emergency room physician (ERP) took this opportunity to get a more wholesome history from him.
“Do you smoke?”
“Not for the last few years.”
“Do you take any medications?”
“Just the puffers and antibiotic my doctor had prescribed.”
“Very good. Do you have any medical illnesses?”
The patient paused for a moment to think. He had been through this rodeo before, for other medical problems. He was wondering whether or not to mention to the doctor a previous diagnosis of bipolar disorder.
In the past, he had told physicians and paramedics about this diagnosis to underwhelming results. Instantly, the affect of the providers would change. Suddenly, his credibility was drawn into question. Where before he was allowed to speak and describe his story without interruptions, he was now met with requests to, “slow down.” The questions like, “are you feeling like yourself right now?” seemed to bother him the most.
This ERP on this particular day however seemed professional enough, and the patient wanted to be as transparent and honest as possible, so that his medical care could be the most informed it could be.
“I’ve been diagnosed with bipolar disorder, though I’m not on any medications, and I don’t know that I agree with the diagnosis.”
The silence was deafening, although it only lasted a second. The physician quickly regained her composure and started down another line of questioning.
“Have you used any drugs recently?”
“Do you smoke?”
“I already told you I didn’t.”
“Are you manic right now?”
He tried his best not to role his eyes.
“I feel perfectly fine, I’m sleeping eight hours a night.”
“Are you having thoughts of violence or suicide?”
He looked at her sternly and decided not to answer this question – he was here, after all, for pneumonia. No razor blades had been held at any wrist.
The conversation continued and eventually the physician left to order some investigations. Various nurses were in and out of his hospital room, all of whom seemed to suddenly have a lot less to say.
The patients condition improved, and he was eventually discharged on a low dose steroid for a few days to aid in his recovery.
“I don’t think I’ll take this tonight but I’ll take it in the morning.”
It was the ERP’s turn to role her eyes. The patient felt obligated to explain himself.
“If I do have bipolar disorder, the absolute last thing I want to do is take a steroid tonight, be awake the whole night, and have an episode.”
“Alright, see ya,” the doctor said as she left the room.
Now I had heard this story from the patient second hand of course, and I’m sure the dialogue wasn’t exactly as I have described above. But there are some things that are certainly true. This man was extremely aware of the prejudice he received, by virtue of the (unconfirmed) diagnosis he carries, and suffered because of it. He felt insulted, degraded, and less than human.
Great way to make people want to seek treatment for mental illness, eh?
There were a few things that bothered me about the story, the least of which was this physician’s skill in assessing mental illness. For the record, you could ask a naked man screaming about Jesus on top of a Walmart, who hasn’t slept in eight days, “are you manic right now?” and I would be shocked if they said yes. To those of us in the field, we recognize the mental status exam and the whole picture as key instruments leading to diagnosis. Personally, I don’t see the utility in asking seemingly well and euthymic (normal emotion) people what they think of their mental status, irrespective of their diagnoses, when they are seeking help for an unrelated medical problem.
Bipolar people get pneumonia too, y’know.
The physician’s apparent novice skill in this field isn’t why I chose to write this post – it’s the prejudice that came attached. Because this man had a diagnosis of mental illness in the past, and one of the “scarier” ones, his credibility was immediately drawn into question. Are you sure you didn’t accidentally take a bunch of cocaine before you arrived here? Are you positive you don’t want to blow your brains out after you leave here?
That’s not to say that this information doesn’t matter, because it does. On a professional level, whenever I assess someone with mental illness that may put them at risk, I’m always on the look out for any red flags or warning signs.
I’m also sure to treat the patients like humans.
Medicolegally, I understand the need. “Oh Doctor, you didn’t ask about suicide when you assessed Mr. so and so five months ago? And why is that? He did have bipolar disorder, after all.” And Im not saying theese questions shouldn’t be asked. How you go about it however, is another story.
Do any of you have real life examples or prejudice inflicted upon you, or a friend as a result of mental illness? Without going into too much personal detail, share below!
Dr. Travis Barron is a resident physician in Toronto, Canada.
Often times, late at night, I find myself reflecting. Reflecting on life, myself, all I have become, and all I have lost. Growing up, I didn’t have the most friends, but I could always count on my brain. Looking at where I am now in life, is a tremendous source of pride. I was the first in my family to attend post-secondary education, and the first physician as well. In many ways, to my family, I’m seen as a stepping stone for the Barron clan to exit from rural poverty.
That doesn’t mean there aren’t some regrets.
One thing I reflect on often, is faith. Growing up, the church was a huge part of my life. I ached to attend Sunday mass, and volunteered as an altar boy at the first chance I had. At my parish, Confirmation was typically reserved for 12 and 13 year old children. With special permission from the priest, I was allowed to be confirmed at age 8. And I came in top of my class. One of the highlights of this part of my life was when the priest at my church – Holy Trinity Parish, sharing a name with my elementary and high schools, Holy Trinity Elementary and High School – asked my mother and I to be the parish’s representatives at a special visit by the Archbishop of Canada, to the largest Catholic church in St. John’s, the Basilica (as a side note, on that day, I tripped on my way into the pew, and muttered, ‘Jesus, Mary, and Joseph!’ under my breath; my mother made sure I heard it later!).
As these things go, you get older, and you try your best, in many ways, to differentiate yourself from your family. Religion took a smaller role in my teenage life, although it remained important to me. Friends and school and manhood became my primary concerns.
Eventually, I attended post-secondary university at the Memorial University of Newfoundland, majoring in Biochemistry and then switching to Cell and Molecular Biology. That was followed by medical school, in Windsor, Ontario, and eventually residency in Toronto, where I am today.
When I moved to Windsor, a sense of community was lacking. What was this foreign place, so very different from my home? People avoided eye contact in the street, there were no friendly greetings or short conversations with the server at Tim Horton’s. And I missed that. So, I went to the nearest place I could think of, to help bring back that sense of community. I went to church.
A church service is a church service and in many ways the mass at Our Lady of Assumption in Windsor (the oldest church in Canada west of Montreal, now tragically shuttered and closed down), and I felt at home. Though the parishoners and the priest were different, the prayers remained the same, and in some ways I was at peace.
After my second service at Assumption Parish, I began to worry. Something wasn’t feeling right, and it took me a while to realize what it was. I stopped going to the church and looked elsewhere for community. If anyone out there has gone to medical school, you’ll know that my only option was the medical community, a sort of cult, comprised of medical students, residents, and doctors, and where the conversation invariably turns to the latest asthma medication or multiple sclerosis study.
Eventually, it came to me. I had lost faith.
Putting in to words what this meant to me is difficult. If any of you have faith, you know what I mean. God and Jesus were in many ways part of my own being, and the Catholic faith was for me the compass by which I navigated the world. Religion, to my perennially teased and tortured by my classmates in grade school soul, was for many years my anchor. And here I was, drifting off to sea.
I struggled with this for some time and eventually religion moved from my mind. I immersed myself deeper in medicine, and intentionally avoided any religious themed discussions, out of fear it would rip my being in two. To add some context, I’ve been in post-secondary education for eleven years at this point. Eleven years of fanatic education, of evolution, world religions, the big bang, science, and medicine. Eleven years of learning men (and women) are the masters of this world and that it is ours to discover. God, in fact, was only ever mentioned in discussions surrounding the unreasonableness of a Jehovah’s Witness refusing a blood donation. The problems caused by belief in Allah during Ramadan for kids with nutritional disorders. Never did that lens turn inwards, never was the question asked about our relationship with God.
That’s not to say I’m the only religious person that attended medical school, I know I wasn’t. I have friends and colleagues that were and continue to be active in the church. Me, I was Captain Scott, frozen in the Antarctic ice lost and without hope of rescue.
But like Captain Scott, there was hope. Although he died, Captain Scott is famous for the journals he comprised while he and his crew used pick axes to try and cut their boat free of his frozen water coffin. Of course this was a failed venture, and not until a subsequent Antarctic expedition during which his remains were discovered were his journal entries found and disseminated. And what was found was remarkable. These men, faced with their inevitable death, had been singing. They were in good spirits and they sat and played cards and ate breakfast. They joined together in prayer. They had faith, and the spirit lived on.
“God help us, we can’t keep up this pulling, that is certain. Amongst ourselves we are unendingly cheerful, but what each man feels in his heart I can only guess.”
― Robert Falcon Scott, Scott’s Last Expedition: The Journals
I am not an Antarctic expeditionist, but like Captain Scott, my spirit lived on. The Holy Spirit? Maybe. I’m not going to call myself divine. Like an ember on the floor of a seemingly dead fire, I would soon realize my faith could again burn bright.
I was at a low point of my life in the third year of medical school, and I was wondering whether the choices I had made were truly the right ones. I felt like most of my friendships in Ontario were superficial, and that most of my friendships in Newfoundland were decaying. In many ways, I felt caught between two worlds and two provinces, not dissimilar to how I felt being caught between religion and medicine.
So naturally, I went to church.
And I went again.
And eventually the happiness I once had from sermon returned, and I found myself at peace. What had changed, I asked myself. I was still a physician-to-be, I still felt trapped in mainland Canada. Simply put, I had faith.
To this day I continue to struggle. Struggle with thinking about the impacts of evolution on the development of our planet and climate, and reconciling that with the Catholic calendar. Struggle with thinking about life saving blood transfusion and a deeply held belief having ones blood other than your own is a sin. Struggle with my obligations as a doctor to discuss treatments that in many ways go against the very fabric of Catholicism. Sometimes, it isn’t easy.
But I have faith. I have faith that both my lives and both sets of beliefs can co-exist peacefully. Faith that it will all work out. Faith that as a doctor who has tried to do nothing more than elevate his family and extended family out of poverty, and to help the sick and diseased and unwell and disadvantaged, there is a place for me in Heaven.
Some days are easier than others; today is a good day. I’ll continue to toe the line and think and reflect and consider what it means to be a Catholic in 2019. And in the end, I’ll always know, both things can be true. They have to be.
Editor’s note: There are many faiths in the world and I don’t think asking which faith is, “correct,” is a helpful question. What matters to me is that people feel at peace with themselves and their choices. Maybe that means Catholicism, Islam, Hinduism, or Environmentalism. However you identify, there are bound to be conflicts between your faith and what the modern world asks of you. The purpose of this post is to describe my own struggles in reconciling these two ideas.
Dr. Travis Barron is a resident physician in Toronto, Canada.
I recently met a patient in my family medicine clinic, a 28 year old gentleman who had immigrated to Canada as a young child. This man had experienced numerous struggles in his life, from escaping relative slavery in central Africa, to coming to Canada, achieving a professional education, and eventually got a job as an X-ray technician. That was, until recently.
For the last two years, the gentleman, “A”, had been struggling with depression and alcohol use, following the death of his mother. “A”‘s drinking quickly escalated over time, which worsened his depression, which caused him to drink more, and so on. “A” had disclosed these problems to his previous family doctor, who stressed the importance of alcohol cessation, and prescribed a medication.
As these things can sometimes go, “A” was not able to abstain from alcohol, and unsurprisingly (given the ongoing, heavy substance use), they found the medications ineffective for depression and stopped taking them.
“A” eventually ended up back in his previous physician’s office for a separate issue, and the physician decided to check on his mood. It quickly became apparent “A” had continued to drink, and was severely depressed. He was now off of work and almost entirely socially isolated. “A”‘s physician spoke to him about suicide, and it became apparent that “A” had recently attempted suicide via overdose. He was, “disappointed,” the attempt was not successful.
Because of this, “A”‘s doctor had recommended they go to an emergency department to be seen urgently by a physician. “A” had some friends that had previously been through the emergency psychiatry experience, and told his physician there was, “no way,” they would go through that.
The physician, in keeping with her professional and moral duties, issued a form 1; what is a form 1? In Ontario, a form 1 is a form issued by a physician when they have concerns regarding your safety, due to mental health. The form allows you to be apprehended and brought into a psychiatric hospital for assessment.
“A” was picked up by police and they drove him to the hospital. In hospital, they were admitted to the emergency department, and given a glorified, locked, jail cell to stay in. His clothes were taken and they were under constant observation by a security guard outside of the hospital room (cell) door.
After 48 hours, “A” was discharged, and had been lost to follow up for over the last year, until I had met them, again for a separate issue.
“Are you having thoughts of attempting suicide?”
“I need you to be honest with me here, I’m very concerned.”
“A” was not fine. In fact, it soon came out that, yet again, “A” had covertly attempted suicide. He was actively planning another attempt, and had begun to set his affairs in order, as though he would soon be dead.
I issued a form 1.
Why does it matter that the psych wards are full?
“A” was very unwell, and to this day I don’t know how he is doing. After I submitted the form 1, they refused to return to my office. Let me begin by saying, this is the least favourite part about my job. On a personal philosophy level, I do not believe that physicians, or anyone, has the rite to tell people how to feel and what to believe. I also know when to recognize severe, serious depression, that may be treatable, which puts ones life at risk. This was the case with “A”, and I can sleep easy tonight knowing that I did not abuse my government-given powers to take away someone’s liberty.
But this didn’t need to happen.
Far in the past, or in some parts of the United States (if you have money), there is a mythical beast called the elective psychiatric admission. This is exactly what it sounds like – elective, meaning not mandatory. Examples of elective psychiatric admissions include people with a moderate depression, people with severe anxiety, or someone in the need of a mood stabilizer or antipsychotic titration. Useful stuff, no? The philosophy behind elective psychiatric admissions is that we tackle a problem before it gets to serious. You want to treat someone when they are climbing the stairs, not jumping off the balcony.
Unfortunately, I am sad to say that in my short psychiatric career, I could count the number of elective psychiatric admissions I’ve facilitated on one hand. Two fingers, to be exact. And that’s not to say I haven’t met people who may benefit from such an admission – I meet people like that at least once a week. But the reality is, because psychiatric hospitals are overcrowded, there is only room for emergency admissions. These are your form 1’s, the acutely suicidal, the emaciated psychosis.
Of course those people (emergent patients) need hospital, and indeed they need hospital more than an elective patient, by it’s very nature. But that doesn’t mean elective patients don’t need admission, as well. Inevitably, people who may benefit from an elective psychiatric admission are discharged home. Many of those people appropriately improve on an outpatient regimen, but not everyone – some people get worse. Way worse. So much worse, in fact, that they shortly come in need of an emergent psychiatric admission.
You can see how the cycle continues. As long as we deny inpatient treatment to people who are at anything but absolute crisis mode, people will become sicker, and further overcrowd the hospitals. Think of the bipolar man in need of a lithium titration who instead stops his medication and has a severe manic episode. He thinks he can fly, jumps off a building, and breaks both legs.
What about the effect on emergency rooms?
If there is any area of medicine and mental health who sees first-hand the effects of overcrowded, full psychiatric hospitals, it is emergency departments. As emergent psychiatric patients are felt to need admission, a back log is created when the psych wards are full. This results in psychiatric patients being housed, long term in the emergency department, hopefully awaiting some attrition from the wards.
I don’t know that you have ever been in an emergency department, but they aren’t pleasant. The psych beds in the emergency, even less so. They usually float somewhere between jail cell and operating room sterility. Not only is this an abuse of vulnerable people in need of help, but this causes further problems. Physicians are able to dedicate less and less time to each patient, as the mental health population of the emergency grows, which is a recipe for disaster. There are reasons there are nursing ratios on psych wards, because vulnerable people with mental health problems need support. This isn’t the case in emergency departments, and people often go neglected and ignored. Most importantly, it often escalates them with respect to agitation, and suddenly you’re in the position of having to inject someone against their will to keep the overcrowded jail emergency from exploding.
Similar experiences to this are why “A” was so reluctant to go to a hospital and seek help. And because of that, he’s lost to the system. I hope he isn’t dead. I’ve done everything I could to reach out, and now, only time will tell how that story ends.
What I do know, is that psych wards are full, and it matters.
Editor’s note: This post is awfully critical of a lot. If there is one thing I am not critical of, it is the excellent work of my emergency medicine colleagues, who often find themselves overstretched as they save lives, due to poor government planning.
I am extremely critical of the dehumanizing psychiatric rooms so common in our emergency departments, and stand by my description of them as jail cells.
Dr. Travis Barron is a resident physician in Toronto, Canada.
Mental illnesses are complex, and are extremely variable in their presentation. In a woman, depression often comes out as tearfulness. In a man, the same depression might cause uncontrollable anger. To aid in the diagnosis of mental illness, physicians and mental health professionals rely on patterns, or rules-of-thumb, to aid their clinical skills. People tend to fall into patterns, or groups, though this isn’t always the case. The following describes four common subgroups of OCD, but rest assured these descriptions will not perfectly capture everyone suffering from the illness.
“He is a 18 year old male with daily, intense suicidal ideation. We’ve placed him on a form 1 and he’s in the emergency waiting for you.”
Early on in my career as a psychiatry resident, I met a young man, just graduated from high school at one of the hospitals I was working in. I was working in the Psychiatric Emergency Service (PES) at the time, and had been asked to see the man by an Emergency Medicine colleague.
As these things go, you don’t always get the most information. Really all I knew about this person was that he was eighteen, was going to university for engineering, and had daily, intense suicidal thoughts.
As I walked down the hallway to meet him, I considered a differential in my head. Could it be depression? Psychosis? Had a manic depressive fallen into my lap? Or a personality disorder, perhaps?
“Hi, my name is Dr. Barron, I’m one of the psychiatry residents.”
“Hi I’m Sam, nice to meet you.”
“Nice to meet you as well. My emergency medicine colleague asked me to speak with you, is that OK?”
“Yes of course.”
“Let’s start with your understanding of why you are here in hospital.”
We began speaking, and very quickly it became apparent that Sam was not depressed. He wasn’t psychotic. He definitely wan’t manic. I couldn’t even get a whiff of a personality disorder off of him. What the hell was going on?
I didn’t know it yet, but what I was seeing was a common manifestation of OCD, called intrusive thoughts. These thoughts are intense, and are very bothersome to the person. Some classic examples include:
Suicidal thoughts (killing yourself)
Violent thoughts (killing a random person or a family member)
Sexual thoughts (homosexual behaviours if you are heterosexual, heterosexual behaviours if you are homosexual, or pedophilia)
Blasphemous thoughts (against your own religion*)
An important point here is that blasphemous thoughts typically only occur when someone cares about being blasphemous i.e. it would not be considered a blasphemous thought to pee on a church if you didn’t care about peeing on churches.
So wait. Suicidal thoughts can be intrusive? How is that different that a regular suicidal thought? Well, in intrusive thought predominant OCD, the thoughts are egodystonic, meaning they are in direct conflict with that persons values. In other words, a person with intrusive thought predominant OCD does not want to kill themselves, hurt someone, abuse a child, or disrespect a religion. In fact, they are often extremely disturbed by these thoughts.
Another important point to remember is that all forms of OCD have some level of intrusive thought based symptoms, however, the intrusive thoughts are not the predominant feature.
In contamination based OCD, intrusive thoughts of contamination cause extremely debilitating compulsions, focused around cleanliness, which tend to be the primary feature.
In doubt based OCD, compulsory checking tends to be the predominant feature.
In numeracy/symmetry based OCD, extreme cognitive rigidity and intolerance, as well as compulsions, tend to be the predominant feature.
“So doctor, what do you think is wrong with me?”
“Well, this sounds like OCD, a treatable illness. This doesn’t mean you have to kill yourself, or hurt anyone. These thoughts you are having don’t represent anything about who you are, or anything bad about you. In fact, the fact you’re so bothered by them shows how much you value human life. We’re going to help you.”
These are real examples of OCD at it’s strongest. Fortunately, most of the people in the above example recovered reasonably well. Why share this? OCD remains one of the most under-recognized mental illnesses, and hopefully this helps dispel some of the myths.
Sitting in the doctor’s office, I hear the words. They leave her mouth like an anvil and slam upon the floor, the noise made by each previous contact making the next syllable more impossible to hear.
“You have depression.”
I leave my body and float out of the chair. I’m outside the hospital, gazing down on all that was. I’m flying further, and further, overcoming the very curvature of the world, and then I see it. My future, everything that will become of me, and all that was, laid before my very eyes.
My first sense is loss. Loss of mystery, of individuality, and most importantly, of choice.
My head is spinning. I’m falling, crashing through the sky. I miss the chair and my body and drown below into the depths of hell. I’m confronted by all that has ever scared me, a violent torture to my all-seeing soul.
I’m fired, divorced, my family has shunned me. Strangers spit on me, I’m left to rot. Slowly I decay into nothingness until the coolest realization, as I’m forced to linger while all I once loved is forgotten to me.
My heart skips a beat and I’m back in the chair. The doctor is still talking, I realize to myself. I haven’t heard a damn thing she’s said to me in the last five minutes. I hope it wasn’t important.
“The important thing is that there is hope, treatment, and I am going to help you.”
I stumble home from the office, dreading the moment I finally stop. When my footsteps no longer crowd my ears, I’m left with my thoughts. Depression. What does this mean?
It takes a while, but my life takes a surprising fork as I journey on the path to recovery. I actually get better. I’m working again, and somehow, my relationships are more fulfilling. It’s a Saturday, and I want to go to the park. Why? Just because. It’s a refreshing release, to finally do something because.
On Monday, I’m back in her office. She’s asking me questions and I can’t stop thinking about this chair.
“How are you feeling?”
I speak for a while and we exchange pleasantries. She’s happy to hear I’m doing well. In a way, it feels surreal. The doctor catches my smile and asks me what’s up, and I give a small chuckle.
“Last time I was here, I thought I was drowning.”
Editor’s note: The above is a fictional piece I wrote, as inspired by a recent conversation I had with a patient regarding the meaning of a diagnosis. They had felt a diagnosis made a lot of assumptions about them, and what their future looked like. They were glad to be proven wrong.
Dr. Travis Barron is a resident physician in Toronto, Canada.
Editor’s note: It is with great sadness I address, in today’s blog, the recent mass shootings in the United States. I think most of us are speechless and unable to really come up with words to describe how we feel about these events. I know I find myself at a complete loss for words. Eventually, I’ll write something on why a lot of these horrible events happen in the first place, but for now, here’s something relatively small and I think achievable, that we can do abut it.
The most shocking thing to me, regarding the news of two mass shootings out of the United States, is how little it seemed to affect me. Dozens. Dozens of corpses, strewn across a parking lot, live on CNN.
I finished my coffee and sneaked an extra piece of bacon.
This would be the story of the day. Live! Delivered straight to my door. The regular C-list Sunday content was quickly scrapped out of the way, and before you knew it, faces more typically seen on a Tuesday night at prime time were popping up on my screen.
Man, the bacon was good today.
Before lunch, I knew everything about Texas. The weapon, the number of casualties, the broken social policies responsible for the slaughter before my eyes, how much Trump was responsible. I was eating it up, my brain piecing it together, piece by piece.
I wonder if the orange juice has pulp?
By dinner, it was slowing down. Every detail that could seemingly be milked from the day was in the public arena, for Republican and Democrat to fight over like two wild dogs. And then it happened. The second shooting. This time, I did have some shock. This was, even to me, the most faithful detached news-connoisseur.
I found myself wondering, was this a coincidence? And of course I already knew the answer. Of course this was no coincidence. Coincidences don’t exist in this universe of mind and want and lust and need.
What I was seeing, in collective horror with much of the continent I am sure, was unquestionably in part a result of imitation. We see it all the time. Terrorist attacks in clusters, mass shootings in clusters, suicides in clusters. We know this phenomenon exists yet we do nothing to stop it.
Columbine is where this began – the reasons on why these young men have turned so violent aside, had you ever heard of a school shooting in such detail before that tragedy? Every excruciating detail, parading word for word out of the mouth of children for our viewing pleasure, on live television. It was simultaneously awful, incomprehensible, and world-changing. For Columbine would usher in the age of school shootings, each one more gruesome than the next, and each time we would ask why, while the news coverage has only grown greater.
The pictures from the Ohio shooting were scrolling before me. The body count continued to climb. I found myself wondering if this day would finally move the powers-that-be in the United States Congress to do something material on gun control. I was also dreaming of living in isolation in the pacific on my imaginary private yacht.
There was pulp. Love it.
The news media were on their feet today, and presumably using the vigour gained through covering the Texas massacre, the details on the Ohio case were public before everyone knew it. They began spitting demographic details out about him, though I did notice one thing missing.
I took some solace in this. Maybe they’re finally beginning to get it. Maybe they realize that prime time production level, all-day coverage of terrorism and mass murder, inspires some other troubled young men that this is their chance. Maybe there was some appreciation that these young, troubled men need a voice, and that the media has given them one?
There are blueberry muffins in the freezer, I remember.
I will not give CNN too much credit. It was Prime Minsiter Jacinda Ardern who stood in front of the world and announced she would not utter the name of the person responsible from her own mass tragedy in New Zealand.
Though we have come a long way. I you ever want to be disturbed, Google “CNN Iraq war coverage,” and try not to throw up. No, you’re not watching a sequel to “Top Gun.”
Dr. Travis Barron is a resident physician in Toronto, Canada.
“I’m never trying this again, it was awful. I thought you said this thing was supposed to make me feel better?”
“I’m sorry that happened to you. As we discussed, some side effects like nausea and headache are quite common when you start–“
“Start?! I took this thing for four whole days, doctor. I need a different pill. Will my depression and anxiety every go away?”
Medication selection can be a painful time for patients. As with our diagnoses, often times there is trial and error in selecting the right medication that works for you. When it gets to the fourth, fifth, and sixth medications in some cases, it can be demoralizing, not only to the struggling person, but to their doctor. The fact is the science isn’t the most clear to the researchers in the laboratory, let alone a doctor in the office, and for that reason arriving at a suitable psychiatric treatment regimen can take some time.
Don’t despair – the medications work! Not only often, but usually. I see and help people recover every single day in my office, and it can be refreshing. However, that’s not always the case. Sometimes, struggling lasts a little longer than we would like it to. Sometimes, people lose faith in the system and look elsewhere for help. These cases can be tough; but there’s an upside! In my opinion, the majority of these treatment failures are actually preventable. So what am I talking about?
There are many reasons a particular medication regimen does not work. First and foremost, the most common reason I see, as described in the example above, is a misunderstanding of the expectations of an antidepressant or anti-anxiety medication.
Anti-depressants take time to work.
The textbooks would tell you that you need six weeks at a suitable dose to have a full effect. What does this mean? Here’s an example;
The dose this person required was 100mg, and not until 100mg was achieved for six weeks do we see full effect.
What if 100mg isn’t enough? Well, a further increase may be required. The maximum recommended dose of sertraline is 200mg. You and your doctor may ultimately try a 100mg dose for a few weeks, decide it is sub therapeutic, and titrate further. Yes, this means we can be talking week 15, 16 in some case. But remember – this is for full effect. In reality, a skilled clinician and a patient can often tell after the first four weeks of a treatment whether there may be a significant benefit from a particular medication. That’s what the doctor’s are for!
Side effects are expected and will happen.
And they aren’t permanent. Like anything, your body takes time to adjust to anti-depressants and anti-anxiety medications. In fact, the presence of side effects shows that the medications are getting to the brain and having some kind of effect! It’s important to appreciate that this is a normal part of the journey, not only with starting, but with significant dose increases.
Side effects suck and the last thing your doctor wants to do is make you feel worse – like all things in mental health, trust me, it’s an investment! Side effects like nausea and headache and anxiety tend to go away after the first half week-full week of therapy (yes, anti-depressants and anti-anxiety medications can cause transient anxiety – it’s your brain adjusting to the changes). Doctor’s are also all about safety, and don’t worry, the side effects are reversible with dose decrease.
What is considered a true treatment failure?
Part of my job when you come see me for a mental health problem is to take a detailed medication history; people have often tried multiple medications over time, and if something hasn’t worked in the past, it’s unlikely to help in the future. But what constitutes “doesn’t work?”
Not the above example. For a course of an SSRI to be considered a treatment failure, you need to have completed at least six weeks on an appropriate dose of that medication. A rough estimate of an “appropriate dose” is half the maximum dose.
The moral of the story? The medications work, they take time, and they can be a nuisance. Careful time, understanding, and collaboration with your physician is the best way to work through a mental health disturbance. With patience, I promise we’ll help you.
Dr. Travis Barron is a resident physician in Toronto, Canada.