Monday, July 29, 2013

Side Effects: A Cure for Stigma and Call to Arms in Psychiatry

It is the rare film that takes something I’m already excited about and makes it even more exciting. But Side Effects achieves this: it is a Da Vinci Code for psychiatry, a whirling adventure that takes the viewer through the psych ER, the clinic and the hospital. I must tip my hat to its director, Steven Soderbergh, for he even made a literature review a thrilling, plot-changing scene. He demonstrates that modern psychiatry has all the ingredients of a high-adrenaline thriller: high stakes (pharmaceutical profits), complex character motivations, and a lot of ambiguity. With beautiful cinematography and masterful use of light and focus, the whole movie looked like an antidepressant commercial.

The thriller genre draws the audience along and succeeds in educating them “by the way.” Viewers see the many faces of modern psychiatry, including everything from pharmacotherapy counseling sessions to electroconvulsive therapy, and the attentive layperson can leave the theater with basic knowledge of depression and SSRIs, along with their side effects and what it’s like to be on them.

Psychiatry is an easy field to oversimplify. But Side Effects avoids both witch hunting psychiatrists and propagandizing SSRIs. Its critique of psychiatry is oblique. In 1975, Milos Forman aimed for psychiatry’s chest and unloaded both barrels with Nurse Ratched in One Flew Over a Cuckoo’s Nest. Side Effects used the facts of modern psychiatry as a mostly accurate (if somewhat exaggerated) background; it is a great film set against the intriguing tapestry that is modern psychiatry.

Side Effects seems to cover all the sticky issues in Psychiatry. Lesser movies would simplify the issues. Side Effects keeps them sticky, and uses the stickiness to make the plot gripping. It is uniquely able to do this because of its genre. In a non-thriller, the good guys and bad guys are usually pretty clear; the viewer’s sympathies rarely shift. In Side Effects, Soderbergh is able to give the viewer sympathy for good and bad psychiatrists, good and bad patients, and everyone in between; it is truly a full-spectrum emotional experience. The viewer gets to feel the deep sadness and isolation of depression, despair of suicidality, shame at having to see a psychiatrist, discomfort at a doctor’s “frivolous” prescription, hope that an antidepressant is actually working, and frustration at intolerable side effects. The viewer sympathizes with the psychiatrist’s guilt from a terrible patient outcome, anger at the malingerer, tiredness from overwork, and stress about finances. The viewer sees even the patient’s partner’s perspective, feeling their frustration and powerlessness.

The film powerfully combats stigma against those with psychiatric illness, and it does so by not combating it. In the late 1980’s, Jay Winsten and the Harvard Alcohol Project convinced popular TV shows (e.g. Cosby, Cheers) to donate several seconds of their scripts to including a “designated driver.” Without much finger-wagging or public education, the concept caught on and dramatically reduced the stigma of arranging to have someone drive you home. Side Effects does a similar thing with psychiatry. It doesn’t do much finger-wagging; it simply shows the pain caused by stigma and judgment and the dark road a depressed patient must walk down. The audience actually feels empathy for someone struggling with depression and the pain of judgment. Such empathy is very difficult to generate, especially for people who are “crazy.”

Despite its being a thriller, the film also touches on the deep philosophical question: who are we? A psychiatric patient is defended from a crime by claiming she was a, “victim of circumstance and biology.” The film asks us all, “Are we all victims of circumstance and biology?” Various high-performing not-mentally-ill characters seek medication to help improve their performance which, as one character explains, makes it, “Easier to be who you are.” Are we truly ourselves only when on our medications? And are medications the only defense we have against sadness and stress? In a poignant scene, a depressed character begins crying at a party. Her friend comes as if to console her, but ends up only offering a drug recommendation. The party guests look on the crying woman with embarrassment, unable to comfort or accept her, and she runs out of the party, ashamed.

The most important theme of the movie, and the crux of the plot, deals with diagnosis. The central tensions of the thriller are the daily questions of the psychiatrist: Who is really sick? Did this pill cause that? What should I, the doctor, do? These everyday uncertainties become matters of life and death, fame and disgrace. In the film, the stakes are very high for knowing if the symptoms are real. This fictional story reminds us that for patients, these are always matters of life and death. A correct diagnosis may well change a patient’s life.

In the film, one of the psychiatrists points out that the cardiologist can see the heart attack coming because he has tests, and then asks, “What test there is for sadness?” I hope that this is the last decade that such a film can be set. “The Sting,” a film set in the 1930’s, shows a central dupe which required the protagonists to delay telegraph information. When I saw it, I smiled at the quaint idea of slow information. I hope that our children can look at Side Effects and remember the quaint time when mental illness could not be diagnosed except by interview.

Sunday, July 21, 2013

Pinching Patients - Pain, Consciousness and Practical Neurology

How to Solve the Problem of Consciousness With Pinching

I’ve just completed two weeks with Neuro Critical Care in the Neurological Intensive Care Unit (NeuroICU) taking care of very sick patients. The NeuroICU, like the hospital in general, is not the sort of place you want to end up in. You get to spend time with us if you’ve had a bleed in your brain, or had a massive stroke, or had severe head trauma. There are many things I could say about my experience, but I will focus here on one that is philosophically relevant.

Depending on what service you happen to be on, you report different things. Surgeons are concerned about bowel stasis after abdominal surgery, so are very interested in things like pooping and passing gas (woe unto you if you forget to report to your team whether your patient pooped since last they saw her). Cardiologists care about heart sounds and psychiatrists care about mood. But what about doctors in the NeuroICU?

Many of our patients had sustained brain injury to the point of being unable to speak. How do you assess whether things are getting worse or getting better in the brain, especially when the patient can’t talk? Do we need to perform an operation, do a procedure, or give another drug? First, we check to see if the patient can move despite not being able to talk. “Mr. Johnson, move your fingers. Mr. Johnson, move your eyes.” But sleeping people also wouldn’t follow commands. What’s the difference between a sleeping person, a comatose person, and a dead person? How can you separate these three? How do you know if “anybody’s in there”?

One of the best (and only) tests we have is response to noxious stimulation. That is, we try to hurt them and see how they respond. Every morning, my job was to approach my comatose patient and, to see how she was progressing, pinch her on each of her extremities. Neurologists, I found, are quite adept at causing pain and I was a quick study. A patient might not respond at all (this is a bad sign). A patient might respond, but do so in a “decerebrate” or “decorticate” fashion, that is, their response is a brain stem or spinal cord reflex and not a conscious decision [1]. In other words, some people will respond to a pinch on the inside of the wrist by pulling in toward the pain rather than away from it. Still further, a person who was particularly awake would make some effort to stop the pain. A patient who tries to bat away the pinch is in relatively good shape.

I’m also reading on the philosophy of mind, and I realized that this crude test is actually an experiment demonstrating several things. Minds (whatever they are ontologically) have various capacities and experiences including sensation, thought and intention. I realized that our pinching test is trying to answer these questions. Is the patient experiencing the sensation of pain? As Stanford pain expert Sean Mackey likes to say, “The strain of pain lies mainly in the brain” (i.e. is the “noxious stimulus” of the pinch making it to the brain and consciousness?). Movement, facial grimacing, or increased heart-rate all suggest the sensation of pain is intact. Is the patient thinking about where the pain is? Does the patient intend to free herself from the pain by movement? If she moves away from the pinch, it would suggest both that she has knowledge about where the pain is coming from and intends to stop the pain. Batting at the pinch indicates higher-order knowledge of location and how to stop it.

The “pinch test” has obvious limitations, the most concerning of which is for patients who are “locked in.” Patients who lose the connection between brain and body will “fail” the pinch test, but may still be entirely conscious. Patients we have declared “vegetables” by our crude tools might actually be awake but unable to communicate. The most intriguing work that I know about in trying to improve these tools is Adrian Owen. He put “vegetables” (patients in “minimally conscious states” and “persistent vegetative states”) into fMRI scanner, a machine that can read where blood is flowing in the brain, and asked them to perform various well-characterized tasks. He would say things like, “If you can hear me, imagine swinging a tennis racket.” In their sample of 50 patients, 5 of them could. But ability to follow a simple command, even in the brain, is far from fully conscious. So he tried to go further. Using this strategy, he asked various yes or no questions, and found that one patient was able to respond correctly to personal information. Owen continues his work in this area and is trying to do the same thing with EEG (which would be much cheaper and more scalable).

Pinching is a pretty crude way to answer the Problem of Consciousness. But it is a strategy in line with the core of medicine that I have long loved: it’s about helping patients. Medicine since the time of Hippocrates has been an empirical profession; at our core, our job as doctors is not to discover answers to the deep questions of nature or philosophy. Doctors qua doctors use whatever science or art we can to help patients. Unfortunately in 2013, the best tool we have to assess consciousness is a well-placed pinch. Would it be nice if there were better tests? Sure. But we've got what we've got and there’re sick people to take care of right now. So let’s get busy.

[1] I think it is a fair question to ask how we know for sure that a “decerebrate” response is truly “unconscious.” I’m skeptical that this has been rigorously tested. As with many things in medicine, there is (necessarily) a lot of tradition. Even things as basic as prognosis are notoriously under-studied and even well-trained physicians are exceptionally poor at prognosticating. I read one study of cardiac arrest victims who were given a “poor” or “grave” prognosis: 21% recovered, 54% were supported and died or had poor recovery and 25% had support withdrawn and died. This suggests that on the order of 5% of the total population died because a doctor said they wouldn’t live.