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Monthly Archives: September 2013

Electroconvulsive Therapy (ECT)

At the end of medical school, when it was time to choose my specialty, I was torn between psychiatry and internal medicine.  Psychiatry seemed most suited to my interests and aptitudes.  Focusing on the mind and mental illness bridged my interest in the big questions of human existence and the practice of medicine.  On the other hand, it was hard to see how being a psychiatrist would fit with the vision of being a medical missionary that motivated me to become a doctor in the first place.  I, therefore, chose to receive the broader training that internal medicine would provide.

As an internist, I manage a variety of health issues from gout and hypertension to diabetes and dementia.  But perhaps because of my long-standing interest in psychiatry, treating depression is one of the most absorbing and fulfilling parts of my practice.  It provides the chance to hear people’s stories, to encounter the complex interplay between the mind and the body, and to quite often offer a helpful treatment.  In fact, my experience is that with regular exercise, therapy, medication, or combination thereof, most people successfully recover from depression in a relatively short amount of time.

Unfortunately, there are some patients with depression in whom these initial treatments don’t work.  They require the expertise of a psychiatrist and sometimes the combination of multiple medications.  And even with the best efforts of a skilled psychiatrist, certain people with severe depression fail to respond to medications and therapy.  In such cases of treatment-resistant depression, the sufferer descends into a more miserable and hopeless place.  Lacking the motivation to engage in any activities, they may become bed-bound, so that physical weakness begins to accompany their mental lethargy.  And the mental lethargy can become so profound that a previously sharp-witted person comes to appear like somebody with end-stage Alzheimer’s Disease, unable to retain information or put their thoughts together.  All the while, friends and family watch impotently as their loved one tragically slips away.

In such situations, a treatment called Electroconvulsive Therapy (ECT) can sometimes be quite effective.  The idea of causing somebody to experience seizures by applying electricity to their brain evokes an understandably negative reaction.  But before quickly dismissing it as barbaric or inhumane it is important to consider the awful, hopeless situations in which ECT is applied and the transforming results it can provide.

In his book, How We Age, geriatric psychiatrist Marc Agronin presents a case from his practice that provides a good deal of insight into ECT.  Over a year’s time, a Cuban man named Leonardo had seen his “once bright, loving mother Rosa turn cold, confused, and compulsively agitated.”  She was “full of mental confusion, irritability, anxiety, odors of incontinence, and fits of crying and panic that quickly gave way to screaming, kicking, and flailing at any attempts to redirect or soothe her. “  Agronin describes the “almost violent grief” that overtook Rosa’s husband Alberto as his witnessed his wife’s decline.  When Alberto spoke, “his entire body seemed to convulse with each phrase, and he vacillated between expressing devastation over the loss of his partner and exaltation over his enduring love for her.  His face would twist and spasm as he coughed and choked on his words of concern:  ‘She . . . needs more. . . help. . . now!’   Agronin writes that “I always knew when they arrived for appointments because I could hear Rosa’s yelps grow increasingly louder as they approached the door of my office.”  At home, “peaceful hours for Alberto with his wife alternated with crises:  She fell; she hit him; she urinated on the living room floor.”  When Rosa was ultimately transferred to a nursing home, “every effort to care for her was met with fits of panic and screaming.”  Agronin tried to address Rosa’s destructive behavior with medications, but each one he tried had produced intolerable side effects.  He writes,

“I tried every psychopharmacologic trick in my bag, to but to no avail.  In concert with her internist and neurologist, I ran every possible diagnostic test, hoping that I was missing some hidden organic cause.  Nothing revealed itself and nothing worked.  Alberto and Leonardo were initially patient with my attempts at treatment, but with time they lost faith.  Eventually, I too lost faith in my ability to understand and heal her condition.  It would have been easiest to simply call in hospice and wash my hands of the case, but something in me resisted.”

After much discussion with Leondardo and Alberto, Agronin decided to hospitalize Rosa and try ECT.  Agronin writes that

“despite many misconceptions about ECT, it is actually one of the safest and most effective treatments for severe depression, even in older individuals.  A course of ECT typically involves eight to twelve sessions spaced out over several weeks.  During each session the individual is briefly anesthetized and paralyzed with medications and then administered an electric shock to the forehead to induced a seizure.  We still have no idea how ECT changes brain chemistry to improve depression and other mood disorders, but its effects are impressive.  Nevertheless, it’s usually a treatment of last resort.  ECT is used even more rarely to treat agitation associated with dementia, but with Rosa I felt we had run out of choices other than massive doses of sedating medications.  . . . Over the course of three weeks Rosa received 8 rounds of ECT.  Her memory impairment held steady, and she seemed to tolerate ECT well for the first two weeks, but without response.  During the third week, however, Rosa’s storm began to subside as she grew quieter and less frenetic. . . Actually, the treatment worked beyond our wildest expectations, and a completely different woman emerged from the hospital.  She was generally calm, pleasant, and cooperative.  I could actually have a conversation with her.”

Her husband Alberto and son Leonardo were overjoyed by the change.  To them, “Rosa, even in her relatively severe state of cognitive impairment, seemed like a rose.  It was as if an exile had returned, changed from the experience and not quite the same person, but good enough.”

The story of the surgeon and author Sherwin Nuland provides another revealing look into ECT.  In a fascinating, inspiring TED talk linked here Nuland describes suffering from a depression so severe and resistant to medication that during his hospitalization, psychiatrists came close to performing a lobotomy.  At that point in the 1970s, ECT had fallen out of favor, and it was only because a resident-in-training advocated for its use in Nuland’s case that he received it.  As Nuland shares in his lecture, ECT worked and he was able to ultimately go back to being a productive surgeon and later a writer who won the National Book Award.  I highly recommend watching the video.

 
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Posted by on September 14, 2013 in Uncategorized

 

Opening Ourselves to Others’ Stories

In her essay, Uncovering the Ethics of Suffering, Maj-Britt Raholm applies Hans-Georg Gadamer’s hermeneutical approach to the health care professional’s task of ethically responding to suffering.  Gadamer pointed out that humans are situated within traditions formed by family, society, and state.  The prejudices or traditions in which we are thrown are the means through which we encounter the world.  They constitute the “historically effected consciousness” with which we liveAs Raholm writes, “What we hear depends on the kind of questions we ask from our vantage point in history.” Each individual has a unique horizon, which Gadamer defines as “the range of vision that includes everything that can be seen from a particular vantage point.”

“A fusion of horizons” (Horizontverschmelzung) occurs “when our horizon of historical meanings and assumptions fuses with the horizon within which the narrative is placed.” Raholm applies the idea of Horizontverschmelzung to the clinician’s work of understanding their patients’ stories.  Health care professionals encounter patients through certain orientating preconceptions or prejudices.  Indeed, as Gadamer would remind us, these preconceptions are a necessary port of entry.  They help form the reason that the doctor or nurse attends to the patient in the first place.  But to understand their patient’s situation, health care practitioners must allow their preconceptions to be challenged, humbly opening themselves to realities they might not expect or anticipate.

Geriatric psychiatrist Marc Agronin illustrates this process in a story from his book How We Age.  He describes meeting a ninety-three year woman shortly after the death of her husband of seventy-three years.  Agronin writes, “I was overwhelmed by the thought of her loss and wanted to offer some words of comfort.  I leaned in close and spoke, ‘I’m so sorry.  What has it been like for you losing your husband after so many years of marriage?’  She paused for a moment and then replied, ‘Heaven.’  I flinched for a moment, hoping that I had misheard her.  Seeing my bewilderment and understanding immediately the irony of the response, she smiled at me and proceeded to describe how she had endured decades in an unhappy marriage, with a gruff, verbally abusive man. . . In my misguided empathy, I had committed what William James described as the psychologist’s fallacy—assuming incorrectly to know what someone else is experiencing.”  Agronin approached his patient with certain preconceptions about what she must be feeling as a new widow.  His presumption that she would be sorrowful served as a useful initial guide for their interaction. But Agronin listened openly enough to have his prejudice challenged and replaced by the different reality he received.

 
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Posted by on September 13, 2013 in Uncategorized

 

Sharing Bad News

My wife recently read me her journal entry from the day our younger son turned two years old.  She had written quizzically that he had still not spoken any words despite a good deal of speech therapy.  For months previous to that birthday, he had also been engaging in repetitive, obsessive behaviors.  He walked circuits around the couch with total concentration, oblivious to the rest of his surroundings.  If you were in his way or tried to engage him in another activity, he became upset and screamed for what seemed like an endless amount of time.  In fact, interacting with him began to appear impossible.  The beautiful boy we adored shrank more and more into his own isolated, small world.  It was as if somebody was taking him away from us.

I remember when another person raised the idea that he might have autism.  At first, it did not seem like this condition could apply to our boy.  My image of autism was a child who could not be affectionate, who rocked uncontrollably.  But our little guy did not shrink away from hugs and did not perform any unusual activities with his body.

Still, something was clearly wrong.  When he was two and a half years old, we were able to get him an appointment with a pediatric neurologist.  I wondered if the doctor would be able to make much sense of his behavior in just one appointment.  Shortly after the physician entered the exam room, our older son began trying to take over the appointment with disruptive behavior and I took him out to the car to find a toy to distract him.  When I returned to the room and asked my wife what I’d missed she appeared shell-shocked.  She mumbled “autism” and when I looked to the neurologist he concurred confidently that this was the diagnosis.

My immediate question was what his future would hold.  Would he ever be ever able to live independently, to take care of himself?  The doctor told us it was too early to tell.  We were given a referral to an autism center and scheduled some blood tests and a brain MRI.  And then we left.  Completely numb.  I went back to work, seeing my patients scheduled for the afternoon and visiting somebody in the hospital I sent to the emergency room that morning.

I try to remember how I felt that day when I deliver bad news to a patient.  There is vast divide between the physician sharing a hard reality and the person receiving it.  As much as the doctor works to imagine what it must be like, he or she is not the one whose life is changing.  The physician moves on to the next patient, while the patient now lives in a new world.

 
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Posted by on September 10, 2013 in Uncategorized

 

Narrative versus Principle-Based Bioethics

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The field of bioethics addresses moral questions in the areas of medical practice and policy, as well the life sciences. Although there are many different methods of approaching bioethical issues, two in particular are currently very influential and often thought to be in tension.  The first, often called principlism, looks to certain basic principles as its central guide.  These principles of autonomy, non-maleficence, beneficence, and justice are held to be objective and universal, the set of norms that all morally serious persons share.  A course of action is morally justified if it is consistent with the principles.  The work of ethical decision-making consists in bringing these principles to bear on the particular situation at hand.   The principles are weighed, tested, and revised in response to the specific context involved.

 

While principlism has long dominated the bioethical landscape, in the last twenty years, an increasing number of theorists have turned their attention to alternative approaches.  One such alternative approach is narrative ethics, which incorporates narrative concepts and methodologies drawn from literary criticism and philosophy.  According to bioethicist Joan McCarthy, narrative ethics holds that “every moral situation is unique and unrepeatable and its meaning cannot be fully captured by appealing to universal principles.  In any given health care situation, any decision or course of action is justified in terms of its fit with the individual life story of the patient,” not with how closely it follows universal moral principles.  The objective of narrative ethics is “not necessarily to unify moral beliefs and commitments, but to open up dialogue, challenge received views and norms, and explore tensions between individual and shared meanings.”

 

McCarthy sees principlism and narrative ethics as each having their own respective strengths.  Principlism “provides a clear method and vocabulary for identifying ethical concerns in health care situations and for negotiating moral ideas and arguments.” It is also a “particularly useful means of drawing the parameters of moral relationships between strangers.” Since “the four principles are considered to be binding on all moral persons irrespective of culture or creed,” principlism is “a particularly important tool for legislators and public policy makers, whose task is to regulate the conduct of various individuals, groups, and institutions with different backgrounds and agendas.” “The strength of narrative ethics, on the other hand, is that it provides a method and vocabulary for interpreting and respecting the unique and personal stories of individuals.”

 

In considering McCarthy’s descriptions and analysis of principlism and narrative ethics, it seems to me that the two theories function as complementary partners in the process of ethical decision-making.  Narrative ethics acts as a check on the tendency of principlism to lose sight of the particularities of the stories involved in a moral situation.  In applying moral principles to a situation it is crucial that we have an accurate portrayal of the stories that constitute that situation.  We must have a correct diagnosis (the story) before we can apply the cure (the moral principles).  Arriving at such an accurate portrayal is more challenging, painstaking work than some ethicists applying principles to a situation might at first appreciate.  Rather than a god’s-eyed view of the situation, a tapestry of narratives is sometimes the most we can expect to obtain. 

 

But the stories that make up a moral situation do not themselves supply the values and principles that guide moral action.  For example, McCarthy describes how a narrative approach has “contributed to discussion and debate in relation to end of life decisions.” The U.S. Council on Ethical and Judicial Affairs suggests when making decisions for an incompetent patients, one the decision-maker’s tasks is to consider “how the patient constructed his or her identity or life-story.” In this way, the surrogate decision-maker can act in a way that continues the patient’s life-story “in a manner that is meaningful and consistent with the patient’s self-conception.” Here it seems to me the principle of autonomy is being implicitly applied.  That a person constructed a certain identify or life-story does not bind the surrogate decision-maker to make a decision in continuity with that life-story.  The surrogate decision-maker’s values might conflict with the patient’s, leading to a decision that is contrary to the patient’s will.  For example, a surrogate decision-maker who values the continuation of life at all costs might disagree with the living will of a patient who opposes any “heroic measures.”  It is principle of autonomy—respecting the patient’s agency—that instructs the surrogate decision –maker to nevertheless act in continuity with the patient’s life-story.

 

Narrative ethicists might respond that we do not need values or principles to guide moral decision-making.  Even without reference to any moral principles, sharing and hearing the stories that constitute a moral situation enriches our understanding and generates a better appreciation of the courses of action we might take.  But what is the use of arriving at a better understanding of our moral options unless there is some real moral standard to which we want our choices to conform?    While “opening up dialogue, challenging received views and norms, and exploring tensions between individual and shared meanings” are intrinsically valuable activities, aren’t they ultimately driven by question, “what is the truly right thing to do?”  To answer that question, we need criteria or principles for what constitutes right action.  Positing, as some narrative ethicists seem to do, that “right action is what best fits the story” is smuggling in such a moral principle.

Even as I don’t see narrative ethics as supplanting the principle-based approach to bioethics, it nonetheless is making important contributions to the field and to health care in general.  Here is an interesting article about the movement.

 

 
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Posted by on September 5, 2013 in Uncategorized

 

The Complex Problem of Obesity

mid section view of a man sitting on a bench in a park

Obesity and the struggle to lose weight are among the most challenging issues I encounter in my medical practice.  At first glance, the problem and solution seem rather straightforward.  As New York mayor Michael Bloomberg recently put it, “If you want to lose weight, don’t eat.  This is not medicine, it’s thermodynamics.  If you take in more than you use, you store it.”

But as somebody who regularly works with people battling obesity, I can attest that Bloomberg’s words do not come close to capturing the complex realities overweight individuals face. For example, I sometimes see patients with severe autoimmune or psychiatric conditions who must take medications like corticosteroids and antipsychotics that stimulate  their appetite and cause significant weight gain.  Even more often I work with people whose life situations do not permit regular exercise or a consistently healthy diet.  Think of the single mother working long hours who must get her children out to school in the morning and cook and care for them at night.  For her to find the time to regularly exercise and make nutritious meals is a real challenge.  And this does not even take into account factors like how well she is sleeping or what is going on in her life.  As David Berreby points out,

“sleeplessness and stress have been linked to disturbances in the effects of leptin, the hormone that tells the brain that the body has had enough to eat.”

Berreby’s fascinating piece The Obesity Era considers the

“troublesome fact , reported in 2010 by the biostatistician David B Allison and his co-authors at the University of Alabama in Birmingham: over the past 20 years or more, as the American people were getting fatter, so were America’s marmosets. As were laboratory macaques, chimpanzees, vervet monkeys and mice, as well as domestic dogs, domestic cats, and domestic and feral rats from both rural and urban areas. In fact, the researchers examined records on those eight species and found that average weight for every one had increased. The marmosets gained an average of nine per cent per decade. Lab mice gained about 11 per cent per decade. Chimps, for some reason, are doing especially badly: their average body weight had risen 35 per cent per decade. Allison, who had been hearing about an unexplained rise in the average weight of lab animals, was nonetheless surprised by the consistency across so many species.

How do we explain the increase in obesity across species?  Berreby writes that

it isn’t hard to imagine that people who are eating more themselves are giving more to their spoiled pets, or leaving sweeter, fattier garbage for street cats and rodents. But such results don’t explain why the weight gain is also occurring in species that human beings don’t pamper, such as animals in labs, whose diets are strictly controlled. In fact, lab animals’ lives are so precisely watched and measured that the researchers can rule out accidental human influence: records show those creatures gained weight over decades without any significant change in their diet or activities. Obviously, if animals are getting heavier along with us, it can’t just be that they’re eating more Snickers bars and driving to work most days. On the contrary, the trend suggests some widely shared cause, beyond the control of individuals, which is contributing to obesity across many species.

Some proposed causes for the obesity epidemic include changes in the bacteria in our gut, viruses, industrial chemicals, heating and air conditioning, and light exposure.  Regarding our gut bacteria,

a study in humans by Ruchi Mathur and colleagues at the Cedars-Sinai Medical Center in Los Angeles, published in the Journal of Clinical Endocrinology and Metabolism earlier this year, found that those who were overweight were more likely than others to have elevated populations of a gut microorganisms called Methanobrevibacter smithii. The researchers speculated that these organisms might in fact be especially good at digesting food, yielding up more nutrients and thus contributing to weight gain.

Evidence for a possible viral culprit is suggested by the fact that

a virus called Ad-36, known for causing eye and respiratory infections in people, also has the curious property of causing weight gain in chickens, rats, mice and monkeys. Of course, it would be unethical to test for this effect on humans, but it is now known that antibodies to the virus are found in a much higher percentage of obese people than in people of normal weight. A research review by Tomohide Yamada and colleagues at the University of Tokyo in Japan, published last year in the journal PLoS One, found that people who had been infected with Ad-36 had significantly higher BMI than those who hadn’t.

I find the possible role of air conditioning and heaters in our obesity epidemic to be especially interesting. Berreby writes that

there is a ‘thermoneutral zone’ in which a human body can maintain its normal internal temperature without expending energy. Outside this zone, when it’s hot enough to make you sweat or cold enough to make you shiver, the body has to expend energy to maintain homeostasis. Temperatures above and below the neutral zone have been shown to cause both humans and animals to burn fat, and hotter conditions also have an indirect effect: they make people eat less. A restaurant on a warm day whose air conditioning breaks down will see a sharp decline in sales (yes, someone did a study). Perhaps we are getting fatter in part because our heaters and air conditioners are keeping us in the thermoneutral zone.

Our increased exposure to light is another interesting potential factor in why we’re getting bigger. Berreby points to a 2010 in the Proceedings of the National Academy of Sciences reporting that mice exposed to extra light put on nearly 50 per cent more weight than mice fed the same diet who lived on a normal night-day cycle of alternating light and dark.  Some scientists theorize that this effect occurs by light at night robbing mice (and humans) of natural cues about when they are supposed (and not supposed) to eat.  

I recommend Berreby’s entire piece.  It resonates with my experience that treating obesity is tremendously challenging and complex work.

 
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Posted by on September 2, 2013 in Uncategorized

 

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I’ll Be Back

I’m on vacation for a few days in a cabin without WiFi, so there will be no new posts until Monday night

 
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Posted by on September 1, 2013 in Uncategorized

 
 
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