Friday, October 18, 2013

How to Combat Stigma, Part 1

The stigma associated with mental illness is something that leaders of the profession such as Dr. Jeffrey Lieberman, the current American Psychiatric Association president, often point to when fighting back against critics of psychiatry. Dr. Lieberman seems to believe that by moving psychiatry away from Freud's "brilliant fiction" and "into the mainstream of medicine," stigma will decrease and people will be more likely to seek treatment.

I think the truth is much more complicated. I believe that well-intentioned interventions can potentially have the opposite effect and increase stigma. I went to medical school in a city where HIV/AIDS was epidemic, and I was part of a medical student-run group that went to local middle schools to teach about HIV and AIDS. Our goal was not only to increase knowledge about the disease and how to prevent it, but also to decrease the stigma associated with HIV by having HIV-positive speakers meet with the students to share their stories. We also administered a quiz before the teaching and again a few months later, to assess for changes in the students' knowledge and their attitudes toward people with HIV/AIDs. Sadly, while their knowledge increased, their negative perceptions of people with HIV also seemed to increase.

An analogous situation is described by writer Ethan Watters in his 2010 book Crazy Like Us, which he excerpted in a NYTimes Magazine article:
In 1997, Prof. Sheila Mehta from Auburn University - Montgomery in Alabama decided to find out if the “brain disease” narrative had the intended effect. She suspected that the biomedical explanation for mental illness might be influencing our attitudes toward the mentally ill in ways we weren’t conscious of, so she thought up a clever experiment.

In her study, test subjects were led to believe that they were participating in a simple learning task with a partner who was, unbeknownst to them, a confederate in the study. Before the experiment started, the partners exchanged some biographical data, and the confederate informed the test subject that he suffered from a mental illness.

The confederate then stated either that the illness occurred because of “the kind of things that happened to me when I was a kid” or that he had “a disease just like any other, which affected my biochemistry.” (These were termed the “psychosocial” explanation and the “disease” explanation respectively.) The experiment then called for the test subject to teach the confederate a pattern of button presses. When the confederate pushed the wrong button, the only feedback the test subject could give was a “barely discernible” to “somewhat painful” electrical shock.

Analyzing the data, Mehta found a difference between the group of subjects given the psychosocial explanation for their partner’s mental-illness history and those given the brain-disease explanation. Those who believed that their partner suffered a biochemical “disease like any other” increased the severity of the shocks at a faster rate than those who believed they were paired with someone who had a mental disorder caused by an event in the past.
Of course, one study in college students is hardly conclusive, but I have had very many similar experiences with my own patients. Those who were told by previous doctors that they had biochemical issues going on in their brains often lost hope when the biological treatments did not help them feel better. I have had patients tell me that they felt like they were damaged or broken after they were told during psychiatric hospitalizations that they had "bipolar disorder" or "treatment-resistant depression."

I feel that many practicing psychiatrists are starting to come around, and I found hope in an unlikely place: the American Psychiatric Association's YouTube page. In particular, the following clip from this year's APA conference:

Below, I've summarized the responses of those interviewed:
  1. Chester Swett, MD: As public becomes better educated, emotional issues are more accepted as a part of going through life; a certain percentage of people may have more trouble than the average person, and that is when we diagnose anxiety, depression.
  2. Ravi Hariprasad, MD, MPH: Role model treating patients and families without stigma. Set a good example. Stigma is fought on individual one-to-one basis; best help is to help patients break their own stigma against themselves.
  3. Darshan Singh, MD: Help patients learn they are not to be blamed, it is a health issue. There is not one cause, mental illnesses are not like diabetes. People should be encouraged to talk to social workers, nurses, mental health agencies, pastors, etc. to learn that they are not alone in their struggles.
  4. Kerin Orbe, DO: Talk about psychiatry and psychological problems more naturally. Educate community about what mental illness means.
  5. Marcos Liboni: Share advances in psychiatry. Show psychiatry nowadays is very different from the past. Historically, psychiatry was linked to prisoners and torture. Now brain diseases can be treated; psychiatry is a medical specialty not far from medicine. 
  6. Laurie Wells, MD: Mental illness is universal, affects everyone. Treatment is whole treatment of mind and body, not just medication. Serving people we treat with respect and respecting autonomy de-stigmatizes them.
There is certainly a diversity of opinion, and I may not have captured the nuances of what each person was trying to convey. But what stands out to me is that only one of the respondents talked about biological advances in psychiatry, while several emphasized the importance of treating patients with respect and compassion. I think that's a good place to start.

Monday, October 14, 2013

Losing the White Coat Part 1: Medical School

This is part 1 of a series on the evolution of my approach to psychiatry. For background, I recommend reading A Most Influential Professor, which is essentially part 0 of this series.

Just about every medical school has a traditional white coat ceremony, during which the incoming class of medical students get their shiny new white coats that they will then wear throughout the rest of medical school during clinical experiences. At my school, the ceremony came with a recitation of a modified Hippocratic oath, adding to the gravitas of the day and helping us reflect on our future roles as healers and doctors.

The psychiatry faculty and residents at my school made it a point to insist that they were “doctors first." As medical students, we were repeatedly told about the contributions our institution made to modern biological psychiatry, and how it was a bastion of biologically-minded psychiatrists even during the era when psychoanalysts dominated psychiatry.

It was not surprising, then, to see psychiatry attendings walking around the hospital and lecture halls wearing their long white coats. Even the lone psychologist that taught some medical student lectures wore a white coat when he was in the hospital.

However, something always felt amiss with this biomedical aura. The psychiatry attendings were very quick – too quick – to defend the medical-ness of their specialty. I was told on multiple occasions that the arbitrary diagnostic criteria used in the DSM-IV are no different than the cutoffs used to define blood pressure in hypertension or glucose levels in diabetes. However, despite the prominent role the school's psychiatry department made in establishing biological psychiatry, physicians in other specialties there did not seem to respect the psychiatrists very much. The psychiatry interns took care of fewer patients on their Internal Medicine rotations than the medical interns, yet the psychiatry program director always insisted that the psychiatry interns performed just as well as the medicine ones.

As a third year medical student, I did my psychiatry rotation in a publicly-funded mental hospital, wearing my white coat just like the residents and attendings. There certainly were cases in which something clearly biochemical was going on in the brain of my patients, such as when a young man came into the ER hearing voices and feeling very paranoid after using a large amount of cocaine. I got to see antipsychotic medications help some patients with schizophrenia, but only so much, and with obvious side effects. There was clearly a vast gulf in understanding between the psychiatrists and patients, with the psychiatric residents spending minimal amounts of time with their patients and going home by 3pm each day. I was not sure how much wearing a white coat contributed to this distance or if it was mostly due to the culture of the place, but it certainly did not help foster empathy.

There were many other cases that left me feeling uneasy. As a fourth year medical student on the consult service, I accompanied a psychiatry resident when he evaluated a patient for suicidal thoughts. Afterwards, he told the primary team, "Don't worry, he's just a boy borderline." The attitude seemed to be that this patient would not actually harm himself because he was just "being manipulative," or that personality disorders somehow were not real, perhaps because there was nothing "biological" that could be done.

I did have a great experience working with the child psychiatrists at my medical school, who because of their specialty necessarily had to take a more holistic view of things. But even so, they tended to focus on the children as individual entities, without deep thought given to how interactions with parents influenced the children's behaviors.

When I asked the program director about learning psychotherapy as a resident there, I was told by that they don't really teach psychotherapy, because that is not going to be part of the job of a psychiatrist going forward. I would learn enough to know what kind of psychotherapy to refer a patient for, if it were necessary. Talking to the psychiatry residents though, some of them clearly wished that they had more psychotherapy training, so they could be more complete and competent clinicians.

I knew as a medical student that this approach to psychiatry was not for me. I would go elsewhere to continue my training.

Sunday, October 6, 2013

A Psychiatrist's Favorite Breaking Bad Moments

I came upon Breaking Bad very late in the game. I have only been watching for the past few weeks, and I still have 8 episodes left. But since watching Season 2, I have decided it's my favorite show since The Wire. While I'm obviously not unique in feeling that way, I wanted to share some of the things I've enjoyed most about the show, from my perspective as a psychiatrist and doctor.

What impresses me most about Breaking Bad is how it portrayed the interactions of its characters with the healthcare system. Just as The Wire showed how individuals were entangled with dysfunctional inner-city institutions, Breaking Bad showed the absurd hoops people have to jump through for good health care in America. This has been written about extensively elsewhere, but what I found most fascinating and revealing was how the characters – like most people in real life – had no recourse but to work with the system as is, since the system is too colossal for any individual to fight.

Breaking Bad, Anywhere but America Edition

Moreover, every single "medical drama" I have ever seen has made me cringe because they just felt off. The doctors and patients were overly dramatic, acting too angry, or too serious, or too witty. They always brought out the paddles when they were trying to revive someone, even if the patient was in asystole. There were too many aha moments, too many exciting procedures, too little quiet suffering. I could go on forever. Breaking Bad made few of those mistakes and got lots of little details right. In particular, I think that the way the characters reacted to being poked and prodded, the look in their eyes as they had to accept the indignity of using a bedpan or stripping down for a PET/CT, and how the doctors and patients talked to each other, all seemed true to life. After seeing the episode in which Walt and Skyler met his new oncologist Dr. Delcavoli for the first time, I had the unprecedented urge to google the name of the actor who played Dr. Delcavoli to see if he was a doctor in real life.

Other details that I loved about the show:

Walt's Family Dynamics

It was clear to me early on that Walt's father was not around when he was growing up, though the show did not reveal why until late in Season 4. I have witnessed numerous patients who grew up in abusive or neglectful homes, who vow to be better parents to their own children, but then inadvertently create a dysfunctional situation of their own. In Walt's case, his justification for starting a meth lab was so he could provide for his family after his death. He likely grew up poor, so his ideal image of a father was someone who could make sure his family did not have to scrape by. However, in embarking on his quest for money, he deprived Skyler and his son Walter Jr. of his presence, driving him apart from the rest of this family. Thinking that he only had months to live, he never seemed to consider whether his family would prefer to have $700,000 or some meaningful time with him. He tries to make it up to his son later by buying Junior a muscle car, but that's no substitute for being a good parent.

My favorite moment of the entire series came in Season 4, Episode 10, when Walt, after the stress of a huge fight with his partner Jesse, broke down crying in front of Junior, who comforted him and helped him to bed. The next morning, Walt talked about how when he was a child, he saw his own father die from Hungtingon's disease, growing weaker physically and mentally, and how he did not want his son remembering him that way. Junior forcefully told Walt that he had no need to feel ashamed, and that unlike how he had behaved for the past year, at least last night "you were real!"

Hank's Post-Traumatic Stress

After Hank's shootout with Tuco Salamaca and then nearly being killed by a Mexican cartel's IED-planted-in-a-decapitated-head-on-a-tortoise in Season 2, he was clearly suffering from post-traumatic stress. The show did not try to get fancy by showing what was going on inside his head from his point of view, but the viewer can clearly see all the external signs of fear and hyperarousal, whether triggered by intrusive recollections/flashbacks or misinterpreting popping noises at night for gunfire. Then, Hank suffered even more trauma when he survived an attempt by the Salamaca brothers to kill him in Season 3. He grew angry and terse with his wife and nearly withdrew completely from life. Even though his emotional recovery from those traumatic events seemed to happen a bit too smoothly and quickly, it felt true to me that what helped him most was having a purpose in life again when he put his energy into going after Gustavo Fring's meth operation.

Jesse's Misinterpretation of Acceptance

While Jesse was in rehab at the start of Season 3, the show did a good job of illustrating the concept of acceptance when the therapy group leader talked about accidentally killing his own daughter, and how beating himself up for it only led to more drug use. Acceptance, as I understand it, does not mean thinking that something is ok. It's an acknowledgement of fact, that something unpleasant or terrible has happened and that one is imperfect, but also acknowledging that one cannot change the past, but can only control how one acts in the present moment. However, Jesse seemed to interpret acceptance somewhat differently, because after he left rehab, he told Walt that he had learned to accept the fact that "I'm the bad guy." Later in Season 4, after killing a man, Jesse berated the same group leader at a 12-step meeting, asking if he is supposed to accept himself no matter what he does. Given Jesse's emotional turmoil and the extent of his grief and guilt, it is not surprising that this was a difficult concept for him to, well, accept.

Walt's "Fugue State"

In Season 2, Walt went missing from his family because he was stuck in his mobile meth lab out in the desert. Upon hitchhiking back to civilization, he stripped naked in a convenience store and made up a story about being in a fugue state. What I love about this scenario is that it fits my experience (admittedly based on a very small n) that most of the time, when someone is found far from home claiming to have forgotten everything, it's B.S. made up by a somewhat sociopathic person to get out of trouble of some sort. And just like in real life, first Walt was seen by his medical providers, who ordered various tests and called a neurology consult. Then, when no answers were forthcoming, they brought in the shrink. I got a good laugh when Walt told the consulting psychiatrist the truth about how he made up the fugue state after the psychiatrist explained the rules of confidentiality. This, unfortunately, is not something I've had the fortune of seeing yet in real life.

I'm impressed if you've never seen Breaking Bad but managed to read this far. What are you waiting for? In addition to being thrilling entertainment, Breaking Bad is an incisive examination of the follies of our society, with some of the finest acting and thorniest moral questions that I have seen.