Virtual Journal Club--Week of August 29, 2016

Reaching into the archives for a classic critique of our profession--one you may have heard about, but not actually read for yourself, The Myth of Mental Illness, by Thomas Szasz. (American Psychologist, 15: 113-118, 1960.) Szasz delivers a scathing critique of the psychiatry of his day, noting the tendency (which to be honest, still exists today) for us to wish to medicalize deviations from social norms as "illness", when in his view, almost all such problems stem from "... the everyday fact that life for most people is a continuous struggle, not for biological survival, but for a 'place in the sun,' 'peace of mind,' or some other human value." He seems bothered by the lack of pathophysiological lesions, such as found in syphilis, and notes that what is considered as a sign or symptom of psychiatric disorder is to a great extent based in the values and beliefs of the observer. It should be noted that Dr. Szasz is driven very much by an ethical concern regarding involuntary treatment and commitment, and the slippery slope societies find themselves on when they label some beliefs as pathological, and how that might be (and has been) abused by political systems. This comes out strongly, even fifty years later, as Szasz gets the uncommon opportunity to revisit his views in a retrospective second article, The myth of mental illness: 50 years later (The Psychiatrist, 35, 179-182, 2011). "The thesis I had put forward in The Myth of Mental Illness was not a fresh insight, much less a new discovery. It only seemed that way, and seems that way even more so today, because we have replaced the old religious-humanistic perspective on the tragic nature of life with a modern, dehumanised, pseudomedical one." "Formerly, when church and state were allied, people accepted theological justifications for state-sanctioned coercion. Today, when medicine and the state are allied, people accept therapeutic justifications for state-sanctioned coercion. This is how, some 200 years ago, psychiatry became an arm of the coercive apparatus of the state. And this is why today all of medicine threatens to become transformed from personal care into political control."

I also attach a brief response by Dr. Edward Shorter, Still tilting at windmills: Commentary on "The myth of mental illness" (The Psychiatrist, 35, 183-184, 2011), in which he appears to charge Szasz with the perpetuation of stigma against psychiatric illness, and a stubborn refusal to accept physiological facts supporting psychiatric symptoms as brain-based abnormalities.  Nevertheless, one gets the impression that Shorter and Szasz are arguing about two different entities when they term something as illness. After fifty-six years, I suspect that the dialogue will continue for another fifty or so--our DSM is still quite remarkably lacking in pathophysiological correlations, and if anything, the tendency to medicalize psychosocial problems has intensified.  However, I think that we are finally beginning to appreciate that these are not self-contradictory explanations--the arrow of causation clearly points in both directions. For example, Newsweek recently published a synopsis highlighting what many of us see everyday in our patients, and what was in part the topic of last week's papers: the toxic effects of a stressful social environment on brain development.  I think if Szasz had had more evidence for this at hand, he might have been less dualistic in his "mind" vs "brain" ideation.

Google Drive links:  Szasz; Szasz Retrospective; Commentary-Shorter

Virtual Journal Club--Week of August 22

Just published last week in JAMA Archives:

Association of Reports of Childhood Abuse and All-Cause Mortality Rates in Women by Edith Chen, PhD; Nicholas A. Turiano, PhD; Daniel K. Mroczek, PhD; Gregory E. Miller, PhD (JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.1786. Published online August 17, 2016.)
Chen Google drive link

Child Maltreatment as a Root Cause of Mortality Disparities A Call for Rigorous Science to Mobilize Public Investment in Prevention and Treatment by Idan Shalev, PhD; Christine M. Heim, PhD; Jennie G. Noll, PhD (JAMA Psychiatry. Editorial. Published online August 17, 2016.)
Shalev Google drive link

The longer one hangs around psychiatry, the more one notices the pattern that "bad things keep happening to people that have bad things happen to them".  This report quantifies that impression in women (and interestingly, not in men) by linking an increased all-cause mortality with history of child abuse. I've often said that if there is one preventative intervention that would eliminate the need for our services, it would be to abolish all child abuse, particularly sexual abuse. However, since I lack the supreme omnipotence to institute this change, it is important that we acknowledge it as a predisposing factor in many of our patients and do our best to mitigate its long term effects.  The Chen, et al. paper offers some hypotheses regarding the mechanism of this connection, though interestingly, subsequent psychiatric diagnosis is not correlated with the outcome. Is there some hypothesis that seems compelling to you, possibly supported by some other research you've run across?  The Shalev, et al. editorial discusses further, and calls us to consider the needed broader focus on social policies and preventative strategies required to address this meaningfully, if we are to effect changes in these areas.

Virtual Journal Club--Week of August 15

One more post about Resilience this month, because it's not only important to us, but also to our patients. Many of us, along with the vast majority of our patients, count spiritual beliefs and practices among our first line coping strategies when facing crisis or stress. For many, it is also a "maintenance" strategy for daily life. If you look again at the Milestones posted this month, specifically PROF1, thread A, you see that being able to display sensitivity for the different beliefs and points of view of others is basically founded on having a capacity for self-reflection and an awareness of one's own cultural background.

I post a couple of papers for this week which demonstrate the effectiveness of spirituality as a method to increase our own resilience and manage the day-to-day wear and tear of residency. With this I am reminded that (with all due respect to Michael Phelps and Usain Bolt) life is a marathon, not a sprint. It behooves us to exercise self care which is sustainable over the long haul. Consider your own spiritual beliefs and practices--that which connects you with something greater than yourself and which transcends the mundane moments.

Spirituality&Well-being
Burnout&Spirituality

I was struck a couple of years ago by the following Walt Whitman poem. (Yes, it was from my year of binge-watching "Breaking Bad". I confess.) Nonetheless, it is a challenge to us that we might break off now and then from the constant flow of 1s and 0s that make up our daily life to take a moment to reflect on the wonder of it all.

When I heard the learn’d astronomer, 

When the proofs, the figures, were ranged in columns before me, 

When I was shown the charts and diagrams, to add, divide, and measure them, 

When I sitting heard the astronomer where he lectured with much applause in the lecture-room, 

How soon unaccountable I became tired and sick, 

Till rising and gliding out I wander’d off by myself, 

In the mystical moist night-air, and from time to time, 

Look’d up in perfect silence at the stars.

Virtual Journal Club

This is a selection of readings aimed to develop and enhance a Program-wide shared knowledge base in Psychiatry.  I've selected papers from a number of themes:  core clinical knowledge, classic historical writings, interesting new neuroscience, and social and professional issues.  It's my intent that all residents and many faculty would take time to read the "Paper of the Week", and that it might fuel many side conversations. This blog is also a place where you might tune in every week to share an observation or comment about the reading.

Here's how to get the most out of it:
1) Read it! (Sounds almost silly--but I've killed hundreds of trees I'm sure by printing out and filing papers "to look at later". So we've got to start somewhere!)
2) Log it. We remember what we write down. Set up a journal page in New Innovations to track your efforts and thoughts.
3) Discuss it. Enter a comment or question on the blog, or talk it over with your peers during down time.

Here's a set of general questions to use for contemplation or discussion:

Whenever possible, the pdfs will be available on New Innovations under Resources/Readings for the Week.  I am also including links to current months' papers on Google Drive, however, these will not be accessible at Regions Hospital or certain other firewalled sites, such as the VAMC.

Let's give it a try!

Virtual Journal Club--Week of August 8, 2016

The following article has kept popping up on a number of my social media newsfeeds:
What Is Resilience?, by Dr. Jamie Riches.  It is a poignant reminder to me of our vulnerabilities and of a system that both exacerbates those and struggles to respond to prevent these outcomes.

The papers I've linked this week are about this uncomfortable topic.  I chose them, not only because they are recent, timely, and relevant--but because the author of two of them, Dr. Srijen Sen, is someone who trained a few years behind me at the University of Michigan.  Beyond our common training however, we also shared the grief of the death of one of our peers, a mutual friend and co-resident who completed suicide in September, 2004. As our program reeled from the initial shock, we experienced the common questioning that ensued:  "What did we miss? What could I have done? If only I had..."  I think the theme that came out was that we had failed to see his pain because he had taken care to hide it from us, and when that became too difficult, he hid himself from us by progressively isolating and withdrawing. I often tell my depressed patients "Isolation is the Enemy"--and it certainly was in this case, preventing friends from seeing the need as well as curtailing the opportunities for positive connections that might have helped to alleviate his depression.

A Prospective Cohort Study Investigating Factors Associated With Depression During Medical Internship, by Srijan Sen, MD, PhD; Henry R. Kranzler, MD; John H. Krystal, MD; Heather Speller, MD;
Grace Chan, PhD; Joel Gelernter, MD; Constance Guille, MD.  Archives of General Psychiatry, June 2010.

Web-Based Cognitive Behavioral Therapy Intervention for the Prevention of Suicidal Ideation in Medical Interns: A Randomized Clinical Trial, by Constance Guille, MD; Zhuo Zhao, MS; John Krystal, MD; Breck Nichols, MD; Kathleen Brady,MD, PhD; Srijan Sen, MD, PhD. JAMA Psychiatry, November 2015

Dr. Sen, in these two papers, quantifies the burden on medical residents, specifically interns, and then shows on a smaller scale how a brief CBT-based intervention effectively reduces suicidal ideation in a similar group. I also attach a related editorial which makes certain recommendations regarding education, screening, and theatment. However, as I read these side by side with the refrain of Dr. Riches' editorial above--"The work did not stop"--I worry that sometimes we are just slapping band-aids on a deeper problem. I found her words haunting:  "The resilience lecture began to feel less therapeutic [albeit well-intentioned] and more like a venue for perpetuation and exacerbation of a culture that was in itself, the compressive stress. We were being trained like soldiers, in the wake of our fallen comrade, to go out and fight! Be strong! Our strength was being measured by our ability to silently struggle through whatever we were experiencing and get the job done. Admit. Discharge. Admit again. We were being given tools to obviate the natural human state of vulnerability. We were “tasking victims with the burden of prevention.” We were reminded to be proud of our ability to charge on. I ended my commentary by stating that we were using the language of an abusive relationship."

Our work is hard and intense. Our systems, despite our best efforts, are flawed. I think our strongest weapon, though, is healthy, honest, compassionate, respectful, open interpersonal communication. Seek to become good listeners to one another, and be willing to share your own vulnerabilities as well.

Thanks for listening.

Links to Google Drive:
Sen, et al., 2010
Guille, et al., 2015
Goldman, et al., 2015

Virtual Journal Club--Week of August 1, 2016

I encountered this article on Suicide Assessment in the most recent issue of Academic Psychiatry, and thought it was reasonably concise and coherent--especially in the examination of the patient's Risk Status vs. Risk States, as well as the focus on preventative strategies, anticipating changes in circumstances, and documentation. It should serve as a good supplement to what you are already doing in terms of safety assessments. Does it cause you to think about these assessments in any different way? What do you think it might add to that process for you?

Reformulating Suicide Risk Formulation: From Prediction to Prevention, by Anthony R. Pisani, Daniel C. Murrie, & Morton M. Silverman. Academic Psychiatry 40(4): 623-29 (2016) 

Online access: http://link.springer.com/article/10.1007/s40596-015-0434-6

August Milestones of the Month--ICS1 and PROF1

I'm often asked by applicants "What are you looking for in a resident?"  I've answered that in a lot of ways over the past couple of years, but what it really comes down to is that I'm looking for Future Colleagues. I think that that is what the following two sets of Milestones emphasize--the kind of respect, integrity, and teamwork that makes a person someone that you like to work with every day, even in tough times.  And like clinical skills, we aren't born with these qualities 100% developed in us--they grow through experience (and are forged into us through trial). On ICS1 (Interpersonal Communication Skills, in case you were wondering), the emphasis is on our behavior with patients and in teams, whereas PROF1 seems more to emphasize the values and ethics which underlie that behavior. Nevertheless, the two are inextricably related--our behavior toward one another and toward our patients is the visible and observable manifestation of our beliefs and ethical precepts--even, and perhaps especially, when they are different from ourselves, or when we fundamentally disagree about important matters. Consider these things and make it your goal to behave toward one another, toward your teammates, and toward your patients as you yourself hope to be treated.