UNBROKEN CHAIN

Paul SInger, a psychiatrist, writes an essay about this thoughts when his father, also a psychiatrist closed his office after over 50 years of practice. I worked with both of them while I was at New York Medical College and know them to be outstanding people.

The following is an essay by a psychiatrist about his thoughts when his father, also a psychiatrist closed his office after over 50 years of practice. I worked with both of them while I was at New York Medical College and know them to be outstanding people

Unbroken Chain

After over fifty years of treating patients, my father, a psychiatrist, took down his shingle this week. He picked a day to stop practicing, saw his last few patients, stepped out of his office, closed the door and walked away. In the end, after thousands of forty-five minute sessions of talking, listening and helping, ironically, he said only, “it’s time to stop”. He was leaving behind a lifetime.

He was not turning back, but neither was he turning his back. Not on a half century of patients and their stories. Stories of sadness and of joy. Of wishes and fears. Misery and hope. Suffering and triumph. Bitter stories and sweet ones. Stories of despair and of fulfillment. Of accommodation and rebellion. Freedom and constraint. War stories and stories about making peace. Angry stories, guilty stories, lonely stories, and love stories. But mostly, stories about all the conflict and beauty in between. The stories of our lives.

How does one walk away from the relationships with patients? Patients with whom one has spent years together at sea. Straining, struggling, and delighting in intangible moments of connection that seem to hold much of the meaningfulness? How does one walk away from being immersed, day after day, year after year, in the winding and jagged paths, the various and sorted twists and turns of lives lived. And all of the sorrow, satisfaction, envy, frustration, pride, shame, angst, gratification, regret, and pleasure that comes with. Most of all, how does one walk away from the sheer privilege of sitting down with another human being, and together, trying to untangle it all.

We never know in this work, when a patient walks through the door for the first time, if this will be the one and only session we will have together, or if it will mark the beginning of a relationship that will span a good chunk of a century. Will they be here and gone in a relative instant, or will this person sitting with me today, a stranger, be a person I will come to know in some ways better than my own children and with whom I will grow old together.

One of the patients my father said goodbye to this week has been a patient of his continuously since 1965. When this patient walked in the door of my father’s office for the first time, Lyndon Johnson was president. The US troops were not yet on the ground in Vietnam. The patient, at the time, was in his twenties. He is now in his seventies, a grandfather.

How does the patient walk away from my father? A patient with such bad anxiety that it flirts with psychosis. He is often frightened and is delusional at times. For forty-seven years he has sought relief in my father. He trusts him. He is calmed by him. For the patient, what my father does is “magic”. Sometimes it helps to have magical thinking.

How does one even give up a decades old office phone number? A phone number that has traveled with my father to all of his many offices over the years. A number that I have known since I am a child. In the era before e-mail, websites and texting, it was through that one phone number that a career’s worth of patients reached my father. Originally on rotary phones, dialing it up in times of need, times of crisis, times of everything. It was through that number that my father put food on the table and as patients like to say, “sent his kids to college”. And it was through that number that all of the relationships, over all the years, began. The phone number was, in many ways, a lifeline.

So how does it all come to an end? How does the shingle, dripping with history and still pulsing with life, get put away? Not so easily. Not so fast.

As for the phone number? My father is now having the line installed in his home. He told me, “You never know when someone might want to call”. It strikes me that he is not installing the phone number at his home, but where he lives. He is staying connected. To who he is. To others. To being alive.

As for the patient, what will happen to him? Just as my father was reluctant to leave his patient, the patient, as one might imagine, was reluctant to leave him. As it turns out, my father will transfer the care of his patient to me, and he will now become my patient. Just before the termination of their relationship, after all the years, my father offered some final parting words of comfort to the patient he has known the longest, and with whom he has spent a lifetime. He said, with a knowing smile, “Don’t worry, my son has the magic too”. The words were comforting. To all three of us.

The next generation of talking and listening will carry on. Going forward, there will be more winding and jagged paths, more twists and turns, and more stories to tell, all told, as we move further, along an unbroken chain.

We live within each other. Within each other we live on.

Mark Singer
September 2012

Mark Singer,M.D. is an Assistant Professor of Psychiatry at New York Medical College and has a private practice in New York City and in Valhalla, NY. His email address is marksingermd@gmail.com
Paul Singer,M.D. is Professor Emeritus of Psychiatry at New York Medical College.

Anatomy of a Psychiatric Consultation For Depression

When a psychiatrist does a consultation for depression, many things have to be considered. Ultimately the psychiatrist needs to decide whether to recommend medication, psychotherapy or a combination of both.

THE REFERRAL OR CHOOSING THE PSYCHIATRIST

Let us look at typical situation where a person comes to a psychiatrist for evaluation because of depression. The most common sources of this referral would probably be from one of the following (or a combination )

1- Primary care physician refers the patient
2- A non psychiatrist mental health professional who is treating the patient in psychotherapy refers the patient for medication
3- The patient is self referred either finding the psychiatrist at the recommendation of an acquaintance or the patient finds the psychiatrist through the Internet

The referral might be influenced by finances and by insurance considerations. The patient may be going to a low cost clinic or they may need to find a psychiatrist who is on a particular insurance panel although insurance companies will often allow their subscribers to see an “ out of network” doctor and will cover part of the fee. Many private psychiatrists have either opted out of the Medicare program or are not accepting Medicare patient so this will also have to be determined before choosing the psychiatrist.

The patient calls the psychiatrist and makes the appointment. The initial appointment is usually 45 minutes – 1 hour. It is perfectly appropriate to discuss the fee and any questions about insurance coverage on the phone

THE INITIAL PRESENTATION

The psychiatrist would take a careful history and look at the reason that the patient is coming ( in this case depression ) and examine the development of this symptom and circumstances around it. Similarly the presence of any other symptoms, problems or difficulties would be carefully examined.

After looking at any of the issues which the patient brings up, the psychiatrist would ask about many other symptoms which may not have been mentioned by the patient such as anxiety, phobias, obsessions and compulsions, sleeping difficulties, appetite or eating difficulties, sexual problems, paranoid thoughts, auditory and visual hallucinations, suicidal thoughts and actions, anger, irritability, racing thoughts, grandiose feelings, short term and long term memory problems, confusion, tiredness, excess energy, dreams, nightmares and a bunch of other things. There would be questions about a history of traumatic events, recent loss and grieving as well as any history of substance abuse including alcohol. The psychiatrist would ask about a history of previous treatment for mental disorders and any psychiatric hospitalization. There also would be a review of any family history of psychiatric disorders. Also, not necessarily in this order the psychiatrist would learn about the patient’s interpersonal relationships with the people in his or her life. This would include getting some preliminary understanding of the patient’s childhood and relationship with close family members. It would also be important for the psychiatrist to understand about the existence of any medical problems, previous medical treatment as well as any medication that the patient may be taking .

WHAT CAN THE PSYCHIATRIST CONCLUDE?

Most of the time at the conclusion of the first interview the psychiatrist will have at least a tentative diagnosis related to the depression and any other condition that the patient may have. It may be that the psychiatrist feels that some medical tests are in order such as a test for low thyroid functioning which can cause depression. The psychiatrist may want the patient to have a neurological consultation or even some brain imaging to rule out something like a brain tumor although that would be quite rare. The results of a physical exam and lab tests may be useful in making the diagnosis and in determining which medication can be utilized if that is being recommended. Most of the time a tentative diagnosis and a recommended treatment plan can be instituted before all the results of any requested medical consultation or tests are received.

For the this discussion, let us assume that the patient doesn’t have any other major psychiatric disorder other than a major depression. There is no substance abuse use, schizophrenia or bipolar disorder or underlying medical problems. Let us also assume that at the time of the consultation the patient does not require hospitalization for suicidal or other dangerous behavior including needing treatment for substance abuse. If the patient was having a first major depressive episode or if it were a repeat episode it would mean that he or she were having significantly depressed mood with possible problems in sleep, appetite, concentration as well as diminished interest and pleasure . The patient may be feeling worthless, guilty and having thoughts about death and suicide even if they didn’t have an active plan to kill themselves. There are other symptoms also and they all don’t have to be present. Most likely the patient isn’t functioning well socially or at work . Even if most of these symptoms are not full blown, it has the potential to get worst and the fact that patient has sought out help indicates that he or she is having a difficult time.

ANTIDEPRESSANT MEDICATION

Anti-depressant medication may well be the treatment of choice to alleviate many of these symptoms. It is most likely going to take at least 4 weeks to get a significant improvement if this medication is going to work.
The dosage may have to be adjusted and the patient will have to be monitored for side effects and possible worsening of symptoms including the potential of becoming a serious suicidal threat. In some situations more than one medication may need to be utilized.

PSYCHOLOGICAL FACTORS

Thus far we haven’t factored in how important are the psychological factors in the patient’s life. Self image, personality, realistic issues in the environment, interpersonal conflicts, failure to achieve goals in school, work and in love can all be an important part of the equation. While improvement in the patient’s mood may very well occur with medication, this is no guarantee that these other issues will improve. Therefore psychotherapy should be considered as the main treatment recommendation. It is true that when a depressed mood lifts, a person is often better able to deal with certain problems. But on the other hand a antidepressant is not going to change deep seated neurotic symptoms, self image and serious relationship problems.

COMBINATION OF MEDICATION AND PSYCHOTHERAPY

Even objectively looking at basic depressive symptoms there is a lot of research that shows that some form of psychotherapy with medication is better that either one of these modalities when the problem is depression.

Of course the recommendation for treatment will also have to take into account, the age of the patient, life circumstances, social supports etc. However in most cases a combination of psychotherapy and medication is often the treatment of choice in the above situation. In cases of a recurrent depression, it may be that the person has previously had psychotherapy and a reinstitution of medication is all that is required or that the patient has done well on medication alone in the past.

WHO DOES WHAT ?

Many psychiatrists such as myself do psychotherapy and also can prescribe medication. Ideally many prefer to do both with a patient when it is indicated. Some psychiatrists only do psychopharmacology and would refer the patient to someone who does psychotherapy. If a patient is referred to a psychiatrist by a non-psychiatrist therapist, then the psychiatrist would prescribe the medication and the original therapist would usually continue the psychotherapy. This requires collaborative therapy in which the patient gives permission for communication as needed between the two health professionals. The psychiatrist would have to decide on the frequency of follow-up visits to adjust medication which can usually be done in time limited visits and the two professionals may have to talk periodically to decide if the treatment needs further adjustment. On some occasions, the psychiatrist may feel that the depression does not or may not require medication but rather there should be a trial of therapy first. This means that if there is a non psychiatrist therapist who referred the patient to the psychiatrist, that person would have to be comfortable in continuing the therapy without medication. Medication could always be reconsidered at a later date.

Another variation would be a trial of medication perhaps with continued psychotherapy and then perhaps a trial off the medication as the psychotherapy continues. Sometimes a non-psychiatrist physician will be comfortable in prescribing medication but might periodically want a to consult with a psychiatrist who would see the patient for an occasional visit.

NO SIMPLE ANSWER

It would be nice if there were a simple blood test or MRI to determine the best form of treatment or even a simple test to determine whether psychotherapy will be successful. While psychopharmacology and psychotherapy techniques have come a long way in the past 50 years, there still needs to be good clinical judgment and a working alliance between the patient and any professionals working with them.

Comments are welcome from both mental health professionals as well as patients, potential patients and anyone else.

Public Awareness about the Relationship Between Heart Disease and Depression

A research study which examined the public awareness about the connection between heart disease and depression. This included data on the preferred sources of health information across educational levels.

A few months ago I published a research project in the journal Psychiatric Quarterly (Springer) which examined the public awareness of the connection between depression and physical health: specifically heart disease. It appeared online November 2011 and it will be soon be published in the regular edition of this journal.
The following is an abstract of this article. I welcome any comments or questions.

Public Awareness About the Connection Between Depression and Physical Health: Specifically Heart Disease

Michael Blumenfield, Julianne K. Suojanen, Charlene Weiss

Abstract

The medical community continues to acknowledge a connection between depression and physical health, for example, cardiac disease. This study addresses public awareness about depression’s effects on physical health, the relationship between cardiac disease and depression, and preferred sources of health information, in an effort to inform future health education programs. A survey, administered to 816 adults ages 40-69, focused on public awareness, perception of depression as an illness, its impact on other illnesses such as heart disease, and sources of health information. (1) Eighty-three percent (83%) of respondents felt depression was an illness; (2) a slightly higher percentage (85.8%) felt a mental disorder, like depression, could affect the course of a physical illness; (3) respondents’ awareness of links between depression and cardiac disease ranged from 29.8% (awareness of depression as a risk factor for coronary artery disease) to 31.6% (awareness that depression can increase the risk of having a second heart attack); (4) print media were the most frequently cited sources of health information (22.7%); and (5) more highly educated respondents were more informed about depression than respondents with less education. Although a majority of respondents (1) recognized depression as an illness (2) thought it could complicate recovery from a physical illness, less than a third of them were aware of links between cardiac disease and depression. Demographic groups differed in their preferred sources of health information, especially across educational levels, demonstrating a need for targeted health educational outreach in efforts to reach a variety of populations.

Psychiatric Considerations in Colorado Shooting

This article will discuss psychiatric considerations in the shooting a movie theater in Aurora, Colorado

Early this morning I received phone calls from various news outlets asking me to give an instant psychiatric opinion on the shooting and the shooter of the terrible incident in Colorado. I knew nothing about the incident and could never comment specifically on a person I had not examined and of course couldn’t talk about someone that I did examine.

Could Mental Illness Be Involved?

However, I understands that there is a strong public interest when something like this happens. There is a natural inclination to believe that the shooter must be “crazy”, meaning a person with mental disorder. This is a way of distancing oneself from some abhorrent behavior. The fact is that one in five people do have significant mental problems. But it is also true that people with severe mental illness (usually defined as schizophrenia, often with delusion or severe depression ) are no more likely to show violent behavior than those without these conditions. Such persons should be even less inclined to violence when they have been properly treated. Even when one looks at the relatively small amount of violent behavior seen in people discharged from a psychiatric hospital, it is usually directed at people know to them rather than random violence.

My reading of the scientific literature doesn’t tell us anything about this particular shooter in Colorado. He may very well have been psychotic (out of touch with reality) and have ideas and thoughts which led him to do this act. Whether or not he was psychotic, I am confident if we knew everything about his life experience, inner feelings and thoughts, we would be able to understand his anger or his fantasies which led him to plan and carry out this horrible deed. There is also the possibility that he used alcohol and or drugs which disinhibited him or even made him psychotic. Although his lawyers may very well mount an insanity defense and try to prove that he was under the influence of a mental illness, they will have a difficult task especially since this was obviously planned and deliberately carried out rather than impulsively done. Even if we can understand the psychological determinants of this behavior, it doesn’t at all in any way justify or excuse it.

Columbine and Other School Shootings

People will no doubt make comparisons with the Columbine High School shooting that by coincidence occurred in nearby Littleton, Colorado. There also were several other similar type school shootings in recent memory. The U.S. Secret Service conducted a comprehensive study of the attackers and the circumstances involved in 37 incidents of targeted school violence that occurred between 1974 and 2000.. They concluded that a history of having been the subject of a mental health evaluations, diagnosed with a mental disorder or involved in substance abuse did not appear to be prevalent among the attackers, however, most of the attackers showed some history of suicidal attempts or thoughts, or a history of feeling extreme depression or desperation. Most of the attackers felt bullied, persecuted or injured by others prior to the attack.

The Texas Tower Shooter

There also was the well know 1966 case of Charles Whitman, The Texas Tower Shooter. He was a student at the University of Texas in Austin who killed 16 people and injured 32 others before he was killed by the police . It turned out that he had a dysfunctional family, used amphetamines but also was determined to have glioblastoma which is a highly aggressive brain tumor. It was believed that this brain tumor played a role in his actions.

The Traumatic Effects Will Linger

Today’s traumatic event in Colorado is obviously a tragedy for the victims and their families which will never be forgotten by those close to anyone touched by this event. It will cause painful grieving among the families and friends of those who lost their lives. It will also cause Post Traumatic Stress Symptoms in persons who witnessed this event in person as well as many who will be impacted as they follow the story in the media. Young people will be particularly vulnerable as they identify with people like themselves who were looking forward to an enjoyable fantasy movie and instead were confronted with a reality which they could have never imagined.

The Spinoza Problem: A novel by Irvin D. Yalom

This novel by Irvin Yalom follows two characters, Benito Spinoza, a 17th century philosopher who was ex-communicated by his Jewish rabbi and Alfred Rosenberg a 20th century Nazi who was hanged as a war criminal by the Nurenberg trails. While the personal lives and dialog which they had with various people is made up, most of the remaining part of the book is historically correct. The book examines some of Spinoza’s thoughts about God and reglion and how he felt that they were superstitions. It also looks at the deep seated antisemitism that Rosenberg harbored and how that ruled his life and led him to want to be close to Hitler. He was able to relate these two lives by looking at the question which he believes that Rosenberg must have struggle with and that is was to understand how the great German thinkers through the years were able to become fascinated by the writings of Spinoza who clearly was a Jew.

The Spinoza Problem: A Novel: by Irvin D. Yalom–  Irvin Yalom is a prominent psychiatrist who is now Professor Emeritus at Stanford Medical School He is a well published author who is known for his outstanding books on group therapy. He also has written books about case histories and relationships, which have been very well received by the public including Love’s Executioner and Staring At the Sun, which addresses death and dying. In addition he has authored a few novels including When Nietzsche Wept and this latest book published in February 2012, The Spinoza Problem.

This very readable novel will be particularly engrossing to those who have some acquaintance with the philosophy of Spinoza or have chosen to put aside any literal understanding of the bible and question the traditional belief in God. It also will have great appeal to readers who are always drawn to trying to get further insight into how anti-Semitism and Hitler were able to flourish in post World War I Germany leading to the rise of Nazism and World War II.

Yalom acknowledges that he always had been fascinated with Spinoza but could never find a way to write about him since very little was known about his personal and inner life. In the foreword of this book he describes a circumstance, which stimulated an idea, which then allowed him to imagine this novel.

The story starts off by introducing the reader to Baruch Spinoza (nicknamed Benito), a brilliant Talmudic student in Holland and Alfred Rosenberg a student in Germany who runs for President of his College class by making an anti-Semitic speech which gets him called on the carpet by two of the faculty, one of whom is Jewish. Each chapter alternates by following the lives of one of these two young men. Spinoza who lived in the 17th century in Holland becomes ex-communicated by his well-known Rabbi because of his heretic views of the bible and his refusal to accept a belief in God, rejecting both ideas as superstitions. Rosenberg lives in the 20th century and experiences the aftermath of Germany’s humiliating defeat in World War I, becomes a writer and an editor, meets a young Adolph Hitler whom he idolizes and ultimately serves. Although they lived nearly 300 years apart, their connection through Spinoza’s writings resulted in nagging questions which Rosenberg pondered most of his life. These may have unconsciously challenged his deeply held anti-Semitic beliefs. On another level the examination of Spinoza’s deconstruction of a religion based philosophy founded on myths and superstitions highlights the flaws of the deeply held views of Hitler and so many of his followers.

Yalom offers this book as completely factual except for the personal life and inner thoughts of each of the protagonists and the connection that he imagines between the two. There are however some reasons that Yalom has for believing that Rosenberg could have been bothered by the problem that some earlier great German minds valued the writings of “Spinoza the Jew.”   The real lives of both men are well known.  This includes the details of the ex-communication of Spinoza from his Jewish community and the actual writings of Spinoza. Rosenberg’s life and ultimate death by hanging as a war criminal have been well documented and his views were widely disseminated, as he was an editor of a prominent Nazi newspaper as well as holding other important positions under Hitler.

There are records that show that Rosenberg did spend some time hospitalized in a Psychiatric Clinic during his Nazi years. Yalom creates therapy sessions between Rosenberg and a made up German psychiatrist who is not sympathetic to his vision. Yalom obviously does this, as he imagined the method in which he would approach Rosenberg if he were his psychiatrist.

Another made up character is Franco who is depicted as a friend and follower of Spinoza, who believes that Judaism should be changed from the inside rather than completely discarded in place of a new philosophical view of God as Nature, which was Spinoza’s view. This character becomes a Rabbi and plans to leave Europe and come to the New World and found a new religion. In the epilog of the book Yalom suggests that he was making a reference to Mordecai Kaplan a 20th century pioneer of modernized and secularized Judaism known as the Reconstruction movement in the U.S. (although Kaplan’s trajectory was somewhat different than the character in the book).

Also in the epilog of the book Yalom quotes the wisdom that, History is fiction that happens. Fiction is history that might have happened.

This novel successfully weaves the two together in a stimulating, thought provoking and quite enjoyable novel.