Category: Medicine

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Consult-Liaison Education Medicine Public health psychiatry Reading

What is Mental Health? (01)

To try to answer the perennial question I ask myself (“what am I doing?”), I recently read this 2015 article, What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey.

As a psychiatrist1, do I treat mental illness? What is mental illness? What is mental health?

The paper comments on the ambiguity in the definition of “mental health”:

Mental health can be defined as the absence of mental disease or it can be defined as a state of being that also includes the biological, psychological or social factors which contribute to an individual’s mental state and ability to function within the environment.

Upon reading this I recognized that I define “mental health” according to the second definition, “a state of being…”. This also explains why I internally bristle when people say “mental health” when they actually mean “mental illness”. (Example: The Lancet Commission on ending stigma and discrimination in mental health.)

Figure 2B, the Two Continua Model, resonates with me:

There are people with diagnoses of significant mental illnesses who have “high mental health”. (If we’re going to be picky about words, I’m not sure that I like grading mental health as “high” or “low”. Maybe “well” versus “unwell”? It is more common to hear “I’m physically doing well,” rather than “My physical health is high.”)

Consider the person with a diagnosis of schizophrenia who has been hospitalized multiple times in the past. However, now they go about their lives and only make contact with their healthcare team every few months for routine check-ins.2

Then there are people with no diagnosable mental illness who have “low mental health”. Consider the many people who felt psychologically unwell during the Covid pandemic.

I started doodling to try to determine where psychiatry should intervene along the axes of mental illness and mental wellness:

I have yet to come up with any convincing answers. This doodling did offer clarity, though:

My professional interest has been the diagnosing and treatment of (often severe) mental illness. There are many reasons for this. One compelling reason is that the severity of symptoms makes it unmistakable that professional intervention is warranted.3

Only after years had passed did I recognize that this worldview is why I chafed at some requests patients brought to me early in my career. I once went through an entire diagnostic interview with a guy who worked as a game designer. Nothing came up; according to the Two Continua Model, he had neither a mental illness nor low mental health. Only at the end did he reveal why he had sought care from a psychiatrist: “My girlfriend takes Prozac and it made her more creative. I thought that if I take Prozac, that might make me creative, too, which can help me with my work.”

My goal was to diagnose and treat a mental illness. His goal was mental enhancement.

Are these two goals mutually exclusive? I don’t think so, though I want to noodle on this more.

The history of psychiatry holds these two goals in tension, too: On one end are the state psychiatric hospitals (also called asylums) where some people with severe symptoms (or not) were held (warehoused?) prior to the elimination of these institutions. On the other end are the psychoanalysts, where the typical patient was “a college-educated, upper-middle class professional who paid for service out of pocket.”

More to follow as I continue to wonder what I am doing.

  1. It was never part of The Plan to become a psychiatrist. This is part of the reason why I ask myself the perennial question, “What am I doing?”
  2. When asked, “What is your best life?”, no one responds, “I want to spend as many precious moments of my existence in hospitals and clinics.”
  3. A choice quote from the paper that highlights why I personally like clarity about where professional intervention is warranted: “Lots of things can cause people problems—poverty, vices, social injustice, stupidity—a definition of health should not end up defining these as medical problems.”
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Medicine Observations

H/ours Lost.

Most people in ten countries lost an hour of time between yesterday and today in the name of Daylight Saving. (Nearly 30 nations in the Northern Hemisphere will lose an hour by the end of March.)

Among the many who woke up at a later clock time today are the seven million or so Americans who have dementia. They opened their eyes and their gazes passed over the clocks in their worlds. The faces of those with dementia may have matched the faces of analog clocks: Flat, blank, lacking emotion.

There were fewer sparks of electricity this morning in these brains speckled with scar tissue. Amyloid plaques and tau tangles are the remnants of neurons that once vibrated with vitality. The hues of their hair have faded to gray; the gray matter of their brains continues to disappear.

When they looked at their cell phones, they may have forgotten that their phones automatically adjusted the time at 2:00am. The steps of logic are missing from these brains; the staircases of reasoning have crumbled. When someone mentioned “Daylight Saving”, they sprang forward with their praxis memory, similar to “muscle memory”: They can no longer explain the steps to search the internet on their phone, but their fingers reflexively swipe and type.

Their aged fingers tapped out the word “time”, trusting that Google would orient them to this moment.

Except their query was unsuccessful. With the decay of the gray matter in their brains, their abilities to give and hold attention, to notice details, have also deteriorated. Their single word question didn’t go to Google; it went into a text message:

Time

And then again, since Google did not respond:

Time

Daylight Saving Time may have stolen one hour of our time, but dementia has stolen hours and ours from us.

Categories
Blogosphere Medicine Systems

Brain Snacks.

It’s a short post this week, though the links will take you to nutritious brain snacks (or hors d’oeuvres, if you identify as classy):

24 Hours in an Invisible Pandemic. This is an excellent example of data visualization about the experience of loneliness in the US.

26.2 to Life. This documentary is about the San Quentin Marathon. The athletes are inmates at the San Quentin prison. The course is 105 laps around the prison yard. (The virtual premiere is this weekend.)

30 Days of Healthcare. Dr. Glaucomflecken’s series of short videos about the US health care system is accurate, devastating, and, when it can be, amusing.

We Are Not Just Polarized. We Are Traumatized. This long essay is provocative, thoughtful, and worth the time to read. (Side commentary: The term “trauma response” is a relatively new phrase and, as far as I know, isn’t rooted in robust psychological or biological principles. I worry that the usage of “trauma response” may also dilute the experiences of people who meet formal criteria for the diagnosis of PTSD.)

Categories
Consult-Liaison Medicine

Analysis of How a Baseball Team Responded to Alcohol Misuse.

Three glasses of alcohol with ice cubes in the foreground.

Related to my ongoing efforts to be a better spouse by learning more about baseball: On August 1, 2023, New York Yankees pitcher Domingo Germán was reportedly intoxicated from alcohol and ended up “flipping over a couch and smashing a TV” in the team clubhouse.

The New York Post further reported that he

was held in a sauna as the team tried to get him to sweat out the alcohol.

He was then placed in a team nap room as team security watched over him, but it’s uncertain when he left Yankee Stadium.

The Post also reported: “Witnesses determined that Germán was under the influence of alcohol and did not appear in control of his emotions.”

Germán ultimately “[sought] treatment for alcohol abuse”. Other outlets reported that he voluntarily went to residential treatment and will not play for the Yankees for the rest of the season.

Let’s discuss.

Humans do not “sweat out” alcohol. We each have an amazing organ called the liver, which is the primary organ that metabolizes alcohol. Enzymes in liver cells break down the alcohol so it is no longer toxic. (… though some groups, like some East Asians, may have a bum version of this enzyme, called aldehyde dehydrogenase.) Though skin is the largest organ we have, it does nothing to make alcohol leave the body faster.

Note that even pro-sauna sites discourage people from using saunas to sober up.

Putting Germán in a sauna could not help him get sober faster.

Livers work at their own steady pace to clear alcohol. The enzymes that break down alcohol do so in a “linear” fashion, meaning that the same amount of alcohol leaves the body over time. It doesn’t matter how much alcohol is in the body.

In the United States, the legal blood alcohol level is 0.08%, which means there are 0.08 grams of alcohol in 100 milliliters of blood. Because decimals require more precious brain power, we can convert that to 80 milligrams per deciliter of blood. And we’ll abbreviate that even more and just use the number 80 when talking about blood alcohol concentration.

Because livers break down alcohol in a linear fashion, we can talk about blood alcohol concentrations decreasing by a fixed number per hour. While in training, jaded and cynical health care professionals taught us that anyone who comes into the emergency department intoxicated with alcohol has an alcohol problem.

“Their blood alcohol level will drop 30 points an hour,” they said. This means that if someone came in with a blood alcohol concentration of 200, their blood alcohol level would drop to zero in about seven hours.

This rate is likely an overestimate. While it is true that people who routinely drink large amounts of alcohol will have livers that will metabolize alcohol faster (because, remember, your amazing liver is looking out for you and wants to get that toxin out of your system as soon as possible), most livers aren’t breaking down alcohol at 30 points an hour. This paper suggests that most people metabolize alcohol anywhere between 8 and 32 points an hour.

Putting Germán in the nap room did not help his liver work faster, but at least gave his liver a quiet space to do its amazing work.

No one is “in control” of their emotions. Emotions happen. They often give us valuable information about ourselves and the world around us. We are more likely to have some control over our behaviors. There seems to be a conflation of “emotions” and “behaviors” in baseball (see “Mariners’ Jarred Kelenic breaks his foot kicking a water cooler, makes emotional apology to team“.) They’re not the same thing. You may feel anger at someone, yet restrain yourself from punching them. Or frustration with yourself, but not drink alcohol or kick something.

Dr. Viktor Frankl shared wisdom about this:

“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”

Sure, emotions might cram into that space between stimulus and response, but a gap can appear where we can choose what behavior to do next.

“Voluntary” entry into residential treatment for alcohol misuse doesn’t mean there wasn’t coercion. Indeed, people may not be forced into rehab, but there might be conditions (e.g., if you don’t go into rehab, we’re kicking you off the team; or “interventions”, as John Mulaney described in his stand up special). To be clear, I have no idea what happened: Maybe there wasn’t any coercion at all. The timing just seems… curious.

If Germán actually entered treatment on the day reported, that’s remarkable (though not surprising): For people or corporations with gobs of money, you can pay for quick access. For people who don’t have money, it often takes weeks or months to enter residential treatment for substance use.

This was perhaps the most jarring aspect of the story for me: Where were the doctors? Sports teams have psychologists, physicians, and other health care professionals. Did they not know about his reported intoxication and behavior? Any one of them could have stopped the nonsense of sauna “treatment” and promoted rest, hydration, eating, etc. If they knew and didn’t do anything, that’s worrisome: What got in the way?

If they didn’t know, I’m not sure if that points to problematic team dynamics or stigma. Alcohol misuse and alcohol withdrawal can cause literal disease and death. Did the team want to hide Germán’s substance use from the team doctors? Did team members simply not recognize that alcohol misuse is a health problem that responds to psychological and health interventions? Did the team health care professionals view alcohol misuse as outside of their purview?

Although deaths from opioids (especially fentanyl) are getting a lot of attention these days, way more people suffer injuries and die from causes related to alcohol. I hope that Domingo Germán and anyone else who has alcohol overtaking their lives will receive useful support and won’t be relegated to saunas and other bunk interventions.

Categories
Lessons Medicine Nonfiction

Treatment Options.

Reading this essay, A Major Problem With Compulsory Mental Health Care Is the Medication, made me think of the following anecdote. I’ll say more about compulsory mental health care (also called involuntary psychiatric treatment) and involuntary medications in a separate post.

Long time readers (from 2004—close to 20 years ago! thanks for spending decades with me!) will recall a physician I dubbed the Special Attending. (In this post from 2019 I identify him by his first name, Matthew.) I am certain that I wrote about the following anecdote at the time it happened; I was upset and distressed. The Special Attending was not a desirable flavor of “special” at this point. Frankly, I believed he was unnecessarily cruel and unfeeling.

I was an intern on the general medicine service. The patient was an elderly, frail woman with multiple medical conditions. She looked and sounded ill; the numbers from her blood and imaging studies confirmed her health was deteriorating.

The senior resident, the other intern, and the medical students all expressed concern about her viability. She looked miserable; she told us with her weak voice that she felt exhausted and uncomfortable. Why are we still poking and prodding her? we wondered. What are we doing?

“We should put her on comfort care,” someone offered. This quickly became the team consensus. We all knew the adage: Cure sometimes, relieve often, comfort always. With confidence that bloomed from the shallow earth of inexperience, we believed that none of our interventions would cure her. The pathway to relief, from our distressed perspective, was only through comfort care.

We—probably me, since this was my patient—proposed this plan with certainty to the Special Attending.

“No,” he replied. It wasn’t that he uttered only one syllable and nothing more. He was frowning. Though I had only worked with him for a few days, it was clear that he was radiating disappointment and disapproval.

Maybe it was me; maybe it was someone else with more courage who finally sliced into the uneasy silence by asking, “Why?”

Because we haven’t tried everything yet, he tersely answered, making no eye contact with any of us. There are still things we could do.

After rounds, we grumbled as a team. “Why is he making us do this?” we whined. “We’re the ones who have to tell her about next steps and do all the things. She’s not going to want this. She’s already suffering so much.”

See, the thing is, we couldn’t tolerate her suffering. We couldn’t bear to witness the deterioration of her body. We didn’t want to try another thing that would fail and prolong our mutual suffering. And what better way to help us escape than by limiting options and withdrawing?

So what does this anecdote have to do with involuntary psychiatric treatment?

My own view is that involuntary psychiatric treatment (inclusive of detention and medications) is a bad outcome. It means that multiple systems failed. The Big We either did not intervene earlier or care to intervene sooner. The Big We didn’t create or maintain enough options to avert this undesired result.

(To be clear: I have provided involuntary psychiatric treatment. It’s not an option I ever want to choose. I never feel great about it.)

We must create as many options as possible for people to receive care and treatment. We must tell people about these options and eliminate barriers so people can access them with ease. When you’re already feeling terrible, the last thing you want to do is climb uphill to knock on doors that won’t open.

It’s hard to witness suffering, but dealing with our discomfort is a problem for us to solve. For those who are suffering, they should not have to solve our discomfort, too.

In retrospect, I wish the Special Attending had explicitly talked with the team about our distress from witnessing the woman’s suffering. It doesn’t have to be a “processing” conversation or “touchy feely”. It could have been something like, “It’s hard to witness someone who is really sick. Our job, though, is to think of and share all treatment ideas with patients. They trust us to help them, so we must try. We can’t give up and look away, though, just because it’s hard for us. We are talking about this woman’s life.”

In the end, we talked with the woman about another treatment plan. She agreed to it. It didn’t help. And that’s when the Special Attending said, “Now we can talk with her about comfort care.”