every doctor needs to know about . . .

Suicide.

I'm in the last few days of my psych rotation and I realized I can't finish without saying something about suicide. I've switched to a different unit, where there is much less psychosis, and much more suicidality and substance use. Here are some quick facts about suicide:

• 9th leading cause of death in the US (30,000 people per year).
• 3rd leading cause of death in individuals 15-24, accounting for 13% of deaths in this age group (following accidents, 46%; and homicides, 15%)
• 95% of people who commit suicide have an existing psychiatric diagnosis.

Many of the patients I have seen recently were admitted to the hospital because they were having suicidal thoughts, or because they had attempted to take their own life. A couple of my patients have walked across the Aurora Bridge and thought seriously of jumping. The Aurora Bridge is shown in the picture and is about a 1/2 mile from our apartment - I ran across it today. It is the second most common site for suicide attempts in North America (the Golden Gate is first).

Like every Catholic kid, I was taught that suicide is the worst sin a person can commit since there is no opportunity to ask forgiveness. I remember it being presented as a choice people make, akin to stealing or adultery. But like everything in life, it's much more complicated. One of my patients (who had paced across the bridge) did incredibly well during his hospitalization. His depression was treated, he participated in therapeutic groups, he sobered up, and he was discharged into an inpatient alcohol treatment program. Unfortunately, there is no evidence that inpatient treatment actually prevents suicide, and studies have shown that psychiatrists can't predict which individuals with suicidal ideation will go on to attempt. Thus, although it is one of the most common problems seen in psychiatry and primary care, it remains one of the most baffling. Every depressed patient should be asked about suicide, and every doctor should know the right questions to ask.

some northern exposure

This weekend I got a break from the psych wards with two friends and we climbed Mount Daniel in the Central Cascades. Nothing too tricky in terms of the climb, but spectacular views and we barely beat the weather that came in the night after we summited. When you get a clear day like this in the Cascades it's something special.
The picture above gives you some northern exposure (find out why this is a cheesy pun below). You can see to Canada, including Mt. Baker over my right shoulder and Glacier Peak over my left. The picture below is taken looking south, with Mt. Rainier beyond the lakes in the distance.
This might have been the last trip of it's kind this summer, as fall has unofficially arrived in Seattle. It's crisp and rainy, and it's almost time to turn on the heat in the building.

One other bonus of this trip is that in order to get to the trailhead, you have to drive through Roslyn, WA, which as it turns out is where Northern Exposure (the tv show) was filmed. We ate at The Brick, a great bar in town and stopped by the local brewery. Worth the trip even if you can't do the climb.

Yes, they still do that . . . . and it works

This morning I went with one of my patients for his ECT, or electroconvulsive therapy. Yes, it is probably what you're thinking it is, though it may not look like what you imagine. So what is it? Most simply, it is when a patient's brain receives a series of electronic pulses which cause a seizure, and for unknown reasons, that seizure causes changes in the brain which are known to be effective for certain psychiatric conditions. In fact, studies have shown that it is the most effective treatment for refractory (meaning not responsive to other treatment) depression.

Here's what happens: the patient goes down to the anesthesia recovery room where they get an iv and have their vital signs monitored. A series of sensors which monitor brain electrical activity are put on the patient's head (EEG), and an adhesive pad is put on their temple. The anesthesiologist administers one drug for pain, another to make the patient unconscious, and the third to paralyze him. At this point the patient cannot breathe on his own and has to be "bagged". The psychiatrist, who has already adjusted the settings of the device which supplies the shock, then pushes a button and the shock begins. The patient then has a seizure, which since he is paralyzed, is seen primarily on the readout on the EEG, but can also be seen by sustained contractions of some facial muscles and neck. The seizure lasts from 25 to 90 seconds and the "quality" of the seizure correlates with the success of the treatment. After a few minutes, the patient awakens, remembers nothing, and suffers no ill effects aside from a temporary difficulty with memory acquisition.

How ECT works is not known exactly, but as it was explained to me, there are two main theories. The first is that the brain is like the heart, and like cardiac myocytes, neurons work in synchronous electrical harmony which can sometimes become out of sync. Like shocking a heart beating arrythmically, "shocking" the brain may re-synchronize neuronal electrical activity (an oversimplification of course). The second theory is that the increase in some neurotransmitters which is clearly seen after the seizure is responsible for the therapeutic effect. Regardless, it is well recognized that ECT is the best treatment for depression and is an excellent option for some chronic, severely depressed patients.

You'll no doubt be happy to know that ECT these days is never performed against the patient's will and doesn't resemble what you remember from One Flew Over The Cuckoos Nest. But it can be an excellent choice for some patients and it still done every day at Harborview.

From the roof

I took this picture today from the roof of our building because the weather has been nearly perfect for the past few days, and as you can see, there's quite a view. Unfortunately, we rarely go up on the roof since it's not meant for people to hang out on. This is looking south from our neighborhood (Queen Anne) toward downtown. If you look closely behind the skyscrapers, you can see the edges of Mt Rainier, about 80 miles away.

Of interest

1. Check out pandora.com. It's a great free website which lets you create your own radio station based on music you like. You enter an artist or song, and then it chooses other songs for you based on similar tonal patterns or other musical themes. You rate each song as it comes up, and it chooses new songs based on that history. It's wild.

2. The Seattle PI reported today that Darrel Everybodytalksabout (real name, I swear), a death row inmate here in WA who was convicted of murder, had his conviction unanimously overturned by the state supreme court. Why do I mention this? Because when Diana was a senior at UW, she tutored him at the King County Jail and he always insisted he was innocent. Incidentally, he was a "transient" at the time of his arrest. Click here to read the story.

A moment on my soapbox, if you will

One of the principal goals for the psychiatry clerkship is to learn how to interview patients with mental illness. It's difficult to ask someone if they are hallucinating or if they are thinking about killing themself. How do you ask those questions when someone thinks your Ed Norton?

For those of you who don't know (or don't remember), I worked for one year at a daytime homeless shelter in Tacoma, WA called Nativity House. Before I started, my biggest fear was working with the mentally ill - I thought of them as unpredictable at best, and violent at worst. I had no idea how I was supposed to talk to them. What I soon realized is that you talk to them like everyone else. Being a medical student on psychiatry isn't really that different from being a volunteer at Nativity House, only now I have to ask a whole new set of questions: do you see things other people don't? do you have any thoughts about hurting yourself? what's your mood like today? I ask in the same way I'd ask about someone's chest pain, because like chest pain, hallucinations and suicidal thoughts are symptoms of a medical problem.

The mentally ill fall into a problematic gap in our society. Unlike other people with serious, disabling, even life-threatening illness, they usually don't come to the doctor on their own. They often have to be brought to the hospital by ambulance or police car. Many people with mental illness, especially the homeless, have active delusions or hallucinations or they may have serious communication or social problems, yet to a certain extent, they are "functional". They find their way to shelters at night, to kitchens for meals, and navigate major cities and transportation systems. Could they find a job? Some could and many do, but the people I knew at Nativity House who were chronically unemployed I couldn't imagine anyone hiring. The problem is that most of the people with what I would call sub-acute mental illness won't go see a doctor, either out of fear, distrust, or most likely, they wouldn't know how. Many of them try to treat the voices, the fear, or the anxiety they experience with drugs. At this point, what most people see from the window of their bus or SUV is a drunk lunatic who probably smells and should just get a job.

It's ironic that many people don't consider mental illness in the same way as diabetes, heart disease, or other medical conditions. There is often just as much of a genetic component to mental illnesses as for other illnesses. It seems like common sense, but nobody chooses to have schizophrenia, or to get manic or be depressed.

You'll hear very few medical students say they want to go into psychiatry. Statistically, less than 2% of my medical school class will choose psychiatry as their specialty. I'm not sure why, but it just doesn't seem as doctorly to folks - they'd rather suture something. Even now, maybe some of you are wondering (be honest, even worrying?) if I'm interested in psychiatry. But I'm not going to tell you - I'd rather you just get used to the idea.

This is your brain on drugs

(A cautionary note: this post is not G-rated)

Friday night I was in the Psychiatric Emergency Room when I looked up at the patient list and saw that one of my former patients was waiting on the medicine side of the ER. The attending physician and I went to see him, and found him strapped to a stretcher in the hallway, talking to somebody who was not there. When he saw me coming, I heard him say incredulously with bug eyes, "Is that Ed Norton?". When I introduced myself, he told me I was in that Fight Club movie and addressed me as Ed Norton. Instead of answering our questions, he rambled non-sensically about "trying to kill the terrorists" and said he saw Satan. He would yell incoherently, then lower his voice and speak in very serious tones about the "international allegionary network". He was constantly moving. While we were trying to assess his mental status ("do you know where you are?", "do you have any thoughts of hurting yourself?", etc.), another man was lying on a stretcher restrained about 10 feet down the hall. He was actively lurching against his restraints, shaking the stretcher and yelling incoherently when when suddenly heard him shout, "somebody better put my dick in restraints!" I hid my laughter behind my clipboard, but our patient didn't care; he was talking to an unseen figure down the hall.

The problem with patients like these is you don't know if they are psychotic because of mental illness, because they are drunk and/or high, or both. Interviewing a patient, there's no way to tell. The truth is, in the setting of acute psychosis like this one, it doesn't really matter because you do the same thing. Ideally, erratic patients are put in restraints, sedated with medication, and have their urine sampled. In reality, they don't get sedated and thrash around in their restraints, left alone with their hallucinations. This is because the county has certified professionals who are authorized to involuntarily admit someone to the hospital, and if you treat the symptoms for which a patient would be committed (like homicidal behavior) then there's no basis for admission. In our patient's case, I brought him as much water as he would drink and eventually we got a urine sample, which was positive for numerous drugs. That'll do it. Does he also have schizophrenia? Quite possibly. After some antipsychotic medication, he was eventually dicharged to the street.