Are you manic right now?

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.

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“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?”

“No.”

“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.

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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.

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Keeping your faith when you’re a doctor

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.

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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.

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Captain Robert Scott

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 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.

The psych wards are full and why that matters

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“I can tell that things have been difficult.”

“That’s life, isn’t it? One thing after another.”

“Are you having thoughts of wanting to be dead?”

“All the time.”

“Are you having thoughts of attempting suicide?”

***

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.

***

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“Are you having thoughts of attempting suicide?”

Silence.

“I need you to be honest with me here, I’m very concerned.”

“I’m fine.”

***

“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.

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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.

The four kinds of OCD – Intrusive thought predominant

From Part 1:

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.

Part 2

Part 3

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Intrusive thought predominant

“Hi Doctor, we have a consult for you,”

“Go ahead.”

“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.”

***

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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.

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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.

Editor’s note: Read about what OCD isn’t!

Stay tuned for OCD – What to do about it.

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

Of depression

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.

Shootings, imitation, and media responsibility

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.

His name.

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.”

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

The pills aren’t working

“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?”

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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;

Week 1 – Sertraline (Zoloft) 25mg, oral, daily
Week 2 – Sertraline 50mg, oral, daily
Week 3 – Sertraline 75mg oral, daily
Week 4 – Sertraline 100mg, oral, daily


Week 9 – Sertraline 100mg, oral, daily
FULL EFFECT
Week 10 and onwards – Sertraline 100mg, oral, daily

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!

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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.

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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.