Getting SAD in the winter – Why do we have emotions?

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It creeps up on you in the mornings.

First, it’s the cold.

Then the dark.

And finally, the snow.

Winter is here.

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.

sliced burger on white paper plate — Photo by TheFacesISeek (Saptarshi) on Pexels.com

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 were preventable, 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.

All the different kinds of mind reading – does it exist?

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.

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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

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“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.

Thought reading

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

the hanged man card — Photo by Lucas Pezeta on Pexels.com

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.

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.

***

man in blue and brown plaid dress shirt touching his hair — Photo by Nathan Cowley on Pexels.com

“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.

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.

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.

***

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.

Is electrocompulsive therapy inhumane?

“Open your mouth?”

“What’s that?”

“To keep you from biting your tongue.”

“No! No!”

It’s a Friday night in 1975. You decide to hit up the cinema and see the latest Jack Nicholson flick that’s been pegged as Absolutely Maddening! One Flew Over the Cuckoo’s Nest, based on the 1962 book written by Ken Kesey, went on to become one of the most popular and absolutely terrifying psychological thrillers of it’s time.

It’s also caused significant damage to the field of psychiatry that remains felt today.

ofc — Credit: One Flew Over the Cuckoo’s Nest

There are a number of disconcerting features of the movie, with inpatients being locked in straight jackets and handcuffs serving as just one example (this never actually happened except in certain cases of very dangerous, high-risk people, which I agree is still inhumane; it’s not practiced whatsoever any longer). One of the most significant and gruesome scenes featured in the movie is a scene featuring electrocompulsive therapy (ECT).

The main character Randle McMurphy is played by Jack Nicholson. In the scene, Nicholson is brought into a room by security, and is met by another twelve men, who proceed to man-handle him onto a stretcher. They paint him with “conductive,” and shove a mouth guard in his mouth. They proceed to shock him, featuring loud screams, huge convulsions, and best of all, all while he is still completely awake. Gruesome. But come on.

ECT remains a procedure of mystery in the public realm and sadly that has resulted in people disproportionately and incorrectly being informed on the nature of ECT by modern media. In the 1970’s, at a time when media was limited to movies, and television, productions like One Flew Over had a tremendous impact that still hurts the field of psychiatry, and most importantly, patients.

What am I talking about?

two woman sitting on bench near the table — Photo by rawpixel.com on Pexels.com

“My recommendation is a short course of elctrocompulsive therapy, also known as ECT.”

“No, no way I want that. I don’t want to be electrocuted man.”

“In my experience, ECT is the treatment that would work best for your condition.”

“There’s no God damn way.”

ECT remains today one of the most under-utilized therapies in medicine. That’s because ECT actually has a tremendous amount of evidence for a number of different psychiatric disorders, and in many cases, works significantly better than medications. Yet due to patient and provider stigma, ECT is often left aside because people “don’t feel comfortable” with it. Movies like One Flew Over popularized what can only be described as torture in the movie, and called it ECT, which is actually an extremely safe and effective procedure.

What are some advantages of ECT?

Electrocompulsive therapy is unique in it’s ability to treat a number of different illnesses. I have routinely used ECT to treat depression, depression with psychosis, mania, and behavioural/psychiatric symptoms of dementia.
ECT is the most effective treatment for unipolar depression (also known as Major Depressive Disorder). Remission rates have been estimated as high as 90%.
ECT is the most effective treatment for bipolar depression and mania. Remission rates have been recorded as high as 80%.
ECT, in many cases, works more quickly than medications.
ECT is safe in pregnancy whereas many psychiatric medications for bipolar disorder are not.
No medication side effects.
ECT is performed under anaesthetic.
ECT is performed with muscle relaxants; usually, the only convulsion seen happens in the big toe.
ECT is one of the only treatments approved for suicidality.

What are some disadvantages of ECT?

ECT requires a hospital, an anaesthesiologist, and a psychiatrist to administer. This costs money and resources (arguably, the cost saved by the quick and larger effect mitigates this).
ECT does have some side effects, most notoriously memory and thinking problems on the day of the treatments (a typical course involves three treatments a week for a month, and then tapering that down).
ECT can require maintenance treatments once a month for a few years or longer after you complete the acute course.

The conclusion? ECT remains one of the most effective and safest treatments in medicine. It has the ability to help people, and I’ve seen it. What’s inhumane is how little access there is to this treatment around the country.

Editor’s note: Working in Toronto, ECT was a relatively accessible service. I’ve worked at three hospitals, at least, with the ability to do ECT. This is not the case everywhere. I’ve worked in centres acorss the country where there is no access to ECT, and sick, unwell people, who deserve to have this excellent treatment, are left to go and suffer without. Improving ECT access and education is part of ending the stigma!

Stay tuned for “How does ECT work?”

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

Mental illness exists for a reason (part 4)

Thanks for reading and keeping up with this series – Mental illness exists for a reason! In part 1, part 2, and part 3, we discussed the evidence for genetic control of behaviour in primates, and found that variability within a species’ genome allows that species to be adaptable. Humans are an example of a species with a variation in genes within their genome, allowing us to become one of the most successful species on the planet! We discussed that because of this variability, some of us succeed in cities, rural areas, at high elevations, or thrive working underground. It also means that not all of us will succeed – at least in every environment.

So how do we guide treatment and recovery, with this understanding of mental illness?

three toddler eating on white table — Photo by Naomi Shi on Pexels.com

When I was in grade school, as there tends to be, there was always the one problem child. Teachers would scorn this child, parents would be caught whispering about the kid in hushed after-dinner conversations as they dispersed the latest rumors coming from the school. This child had bad grades, would act out in class, and was the regular example of how not to act when your parents warned you about the repercussions not studying. “Do you want to end up like Johnny? No future?!” You could say that in the eyes of the masses, this child was struggling.

Johnny felt he was struggling too. He didn’t seem to jive with the classroom environment. He had a lot of pent-up energy he felt he had nothing to do with. He intended well, but ultimately was ambivalent regarding his grades. ‘What will I ever need that for, anyway?”

I eventually moved on from grade school, and high school, and university, and medical school. Years later, on a short trip home to Newfoundland, I saw Johnny in the supermarket, He was with his beautiful family, and had three kids. We got to talking and it turned out he entered trade school after high school, was at work a few years later, and now actually owned a home. The thing that stuck out the most was he was glowing. Absolutely glowing., I couldn’t help but feel, this guys got it all figured out.

But Johnny was struggling. So what happened?

Not everybody will thrive everywhere. I could think of lots of examples from my office, but I thought that this example was more down to earth and a great example of how things are not always as they seem.

Johnny was never meant to sit in a classroom, and was intended to use his hands. When given the wide open expanse of a work day and a welders hat, he found his niche, and owned it. The reality is, the filtration system this is our school system didn’t work for him, and he struggled.

The conclusion? Sometimes, a change in environment is the most important intervention when you are struggling with a mental illness. If you live away from your family and friends, and are struggling, my pill will have limited benefit. Until jobs can stop requiring people to work 50, 60 hours a week for next-to=nothing, people will suffer.

Editor’s note: As if it wasn’t complicated enough, I’ll add an asterisk! Often times, when you are in the throes of a mental illness, your judgement can be distorted. In general, I recommend people do not make life-altering decisions while severely unwell. A discussion with your doctor on how to best approach this scenario is my recommendation.

Not all mental illness is a result of person-environment incompatibility. There are true, organic mental illnesses out there. Often times, a combination of medication, therapy, and life changes, is required.

I would like to credit Dr. Albert Wong at the Centre for Addiction and Mental Health for inspiring most of the content of parts 1-3 of this blog series.

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

Mental illness exists for a reason (part 3)

In part 1 of Mental illness exists for a reason, we discussed the evidence behind genetic control of temperament in two different primate species, Chimpanzees and Bonobos.

In part 2, we discussed how having a variation of behaviours within a species makes that species adaptable to a broad range of environments. Voles were a great case study on how polymorphic genes lead to a variety of behaviours within a species, allowing voles to thrive in a wide range of habitats on the planet.

In part 3, we will be discussing the role of the gene we have been examining, vasopressin 1a receptor, in human behaviour, and extrapolating from that why mental illness may exist.

adult biology chemical chemist — Photo by Pixabay on Pexels.com

Humans are not voles. Before we get started, I want to reiterate that there are thousands of genes which interact to have an effect on human behaviour. No one gene is responsible for the beauty that is the human mind. When we examine human behaviours in studies, like the one I will be discussing today, we are observing trends in behaviour, and not absolute rules. Remember, personality is thought to be at most 50% genetic, and each one of those thousand genes are in direct interaction with each other, and our ever changing environment, at any given moment, to produce the “climate” of traits that becomes our personality.

So what’s the deal with vasopressin 1a receptor? What is it anyway?

In the human body, brain function is dependent on something called neurotransmission. In a nut shell, neurotransmission is when two different nerve cells, called neurons, communicate with each other. Neurons are constantly communicating with each other at any given time to produce consciousness, vision, hearing, touch, and just about any neurological function you can imagine.

41592_2018_268_Figa_HTML — Credit: Nature

How does neurotransmission occur? Through chemicals called neurotransmitters. In a neuron “discussion,” the first neuron sends a neurotransmitter to the second neuron. There is a receptor on the second/receiving neuron that picks up the message. Vasopressin 1a is this kind of receptor. Depending on the shape or form of the receptor, different things will happen to the second/receiving neuron. This is how variation in the receptor produces variation in effects!

Why is this important? Vasopressin 1a receptor has been implicated in pair bonding behaviours, across a wide range of species, including humans, chimpanzees, bonobos, and voles. Consistently, a “longer” form of the gene has been associated with increased pair bonding and less aggressive behaviours. Think the lazy, horny Bonobo and the monogamous Prarie Vole’s. And some humans.

A group at John Hopkins set out in the mid-2000’s to investigate the role of vasopressin 1a receptor in humans. You can read their study here. To summarize, the group found that a number of variations of the vasopressin 1a receptor exist in humans. That makes this a polymorpic gene. As expected, certain forms of the gene correlated with certain behaviours in humans. Longer forms of the gene were associated with increased pair bonding, as determined by a questionnaire. Amazingly, not only did carriers of the longer gene tend to report happier marriages, their partners did as well. Carriers of the shorter gene were unhappier in their marriages on average and were considerably more likely to have had a threatened divorce within the last year.

So why can’t we all be married, well fed, and happy?

buildings near body of water at night — Photo by James Wheeler on Pexels.com

Like the Prarie Vole, humans live in a wide variety of environments. This is different than Chimpanzee’s and Bonobo’s, who are really good at living in the kinds of places they live, but not great at living elsewhere. Humans live in mountains, on swamps, the plains, the coasts. There’s hardly a terrestrial environment on this planet that we haven’t conquered. The point? Humans have had to be extremely adaptable to achieve this level of success across the wide range of environments we inhabit. This doesn’t only apply to geography. The massive differences between an urban metropolis and a rural village cannot be understated. The variation in cultures across the West and East is difficult to appreciate. These differences in the societies in which we lives requires a broad range of behaviours to be within our species to succeed. We need people who thrive in a big city, among thousands of their peers, in cramped, noisy, stimulating environments. Without them, the economic engines of our nations would collapse. We need people that can’t stand the city, who need wide, open expanses, and tranquility to survive. Without them we wouldn’t be able to feed the masses. The point is that variation in our personalities allows some of us to succeed, and to excel, so that society and the species may go on.

But that doesn’t mean we are all meant to succeed. Or rather, that we are all meant to succeed in every environment.

Variation means exactly that – variety. For every person that thrives in a city there’s another who suffers. Sometimes, there is a fundamental mismatch between our personality, and our environment. Try as you may, a monogamous Vole ain’t gonna do well at a polygamous Vole frat party. A Bonobo chimp would be dead meat caught in a Chimpanzee civil war.

These mismatches occur in humans as well; sometimes, we may call that mismatch, a mental illness.

Join me in part 4 for a discussion of how we can use our understanding of why mental illnesses may exist to help guide treatment and recovery!

Editor’s note: I do not want to diminish the role of, “nurture,” in the nature vs nurture argument. By no means in personality 100% genetic (most studies show it’s around 50%)! This blog simply looks at the genetic side of things.

I would like to credit Dr. Albert Wong at the Centre for Addiction and Mental Health for inspiring most of the content of this blog post.

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

Were we meant to be alone?

“Ha, that’s fun!” he said to himself as he looked into the camera, jovially laughing as he honked his air horn at the nonexistent mice he thought may be living in his shelter.

Meanwhile, the audience, myself included, were simply marveling at the extent this man’s beard had grown while he spent two months entirely ALONE in the Mongolian wilderness.

If you’re not sure what I’m walking about, I’m referring to The History Channel’s amazing new show, Alone. In a nutshell, the show takes ten survival experts and drops them off in the remote wilderness, entirely alone. They give them a camera to film themselves and a wireless phone to call into the crew and, “tap out.” How do you win? Last the longest.

The effect of the show is remarkable; very quickly you can observe the mood fluctuations among the participants. Careful, calm experts quickly see the onset of sometimes game-ending impulsivity. Suspicion and paranoia often sets in at the later stages, not unlike the collective psychosis shared by the cast of “Lost.”

It’s impossible to watch the show and not wonder, were we meant to be alone?

The effects of loneliness on the human mind are well documented. Loneliness can both contribute to and perpetuate a depressive episode, and loneliness is one of the number one risk factors for suicide. In Borderline Personality Disorder, one of the key features is an inability to be alone. This manifests as a fear of abandonment/intense interpersonal relationships, difficulties defining your own individual identity, and impulsivity.

portrait filter grandfather — Photo by Serkan Göktay on Pexels.com

The effects of loneliness on dementia risk is one of the most astonishing revelations as we reflect on the effect of isolation on the human brain. Studies have shown that elders who endorsed feeling lonely had a 1.64 higher likelihood (that’s 164%!) of developing dementia than their non-lonely peers. Sadly, millions of older seniors in the developed world interact with absolutely nobody up to six days a week. How does loneliness affect the elderly brain? You can read my article on sleep hygiene and brain functioning here – the punchline is that our brain needs to be used to stay healthy. “If you don’t use it, you lose it.” Our brains are designed to be in relative constant conversation and use, and when people become socially isolated for two long, the brain literally starts to degrade.

What may be more surprising is the effect of loneliness on our physical health. Some studies have shown that loneliness has the same effect on cardiac health as smoking fifteen cigarettes a day! Finally, the effects of loneliness on mortality has been estimated at increasing your risk of death by 29%.

The average family size two centuries ago was 20-30. It wouldn’t be uncommon for that many people to share a small residence. While I am not recommending a return to this social structure, the effects of the decreasing family size in western society cannot be ignored. In more recent times, families that often had 10-12 member (it was not uncommon to have 7-8 children per family). Today, the average household in Canada, and much of the west, is four people and change.

family of four walking at the street — Photo by Emma Bauso on Pexels.com

As our family sizes decrease, so do our supports. The increasing emphasis in western civilization on individuality and independence has caused many of our traditional social safety nets to degrade. It’s no coincidence that children apprehended by child protection do much better, on average, when there is an extended family member able to take custody of the child.

When I think about life-draining, isolating office jobs, I find myself wondering, “who the fuck doesn’t get depressed?” When I think about borderline personality disorder, and see the impulsivity, and mood fluctuations among the Alone contestants, I find myself wondering if I am simply watching the normal reaction to isolation. When I think about dementia and loneliness, I find myself disgusted, at the collective failure of our society to embrace the people who once stood before us.

I don’t think any of us were meant to be alone.

Editor’s note: Am I saying Borderline Personality doesn’t exist? No. It’s real, and can be serious. As with all psychiatric illnesses, social context matters, and people who have Borderline Personality may not necessarily find they would have had the same struggles in social functioning if our social structure was a little different!

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

The first patient I cured

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

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

“You’re telling me…”

action automotive car employee — Photo by Pixabay on Pexels.com

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

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

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

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

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

man pouring water from dipper on blue and grey house — Photo by hitesh choudhary on Pexels.com

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

“that fucking sucks, it does.”

“You’re telling me…”

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

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

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

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

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

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

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

“Good morning doctor.”

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

“I’m great – you were right!”

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

“It’s finally over.”

“The renovations?”

“Yes!”

“I’m so happy for you.”

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

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

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

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