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.

man pushing hospital bed
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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.

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
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“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.