From the monthly archives:

May 2008

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“It is not a thing to do while one is not in one’s best mind. Never kill yourself when you are suicidal.”   Edwin Schneidman. Art by Nacho Garcia

Dr. Jack Kevorkian, the assisted suicide proponent, announced in March that he will run for Congress in Michigan’s 9th Congressional District as an independent. Kevorkian was convicted of second-degree murder in 1999. He served eight years of a 10-to-25 year sentence and was released from prison on parole last June. He admitted to helping more than 130 people commit suicide.

A majority of the public supports a legal right to assisted suicide, and there has been much heated debate about this issue. Oregon has even legalized the practice. But many citizens, politicians, and even physicians who support legalized physician-assisted suicide are misguided and uninformed.

Why sick people become suicidal

First, some crucial information on why people with severe, progressive illnesses may want to die. Much research has shown that patients with incurable, terminal illnesses do not usually seek death from physicians. Instead, they seek relief. When these patients are suicidal they are usually depressed.

Depression is a serious and potentially fatal illness

Depression is an illness characterized by persistent, overwhelming sadness and a depressed mood, crying, loss of interest, and insomnia. People with this illness have lost interest in activities and interests they formerly enjoyed and are unable to feel pleasure or happiness. Depressed patients are often obsessed with or wish for death.

False beliefs held by physicians, families, and society about suicide.

Family members, friends, and even physicians may accept a suicidal patient’s gloomy assessment as accurate. This is a mistake, even when depression accompanies an incurable medical illness. Whatever the illness associated with depression, the modern treatment of depression with antidepressants is very effective in relieving such patients’ gloom and wish for death. When the depression improves, the wish to die usually goes away. Accepting depression as an “understandable” consequence of a serious illness and not treating it makes no more sense than accepting cancer pain as understandable and not treating it.

What is demoralization?

Demoralization is an abnormal mental state which may accompany depression or a severe illness. Demoralization is a perception that one is unable to cope effectively with severe stress. Features of demoralization are depressed mood, feelings of inadequacy, mistrust, confusion, low self-esteem, hopelessness and helplessness.

Depression and demoralization are similar but not identical. Demoralization may accompany depression or a serious medical illness. However, depression is a more sustained illness which is accompanied by biological changes in the brain and often requires medication for relief.

Demoralization is highly treatable and often responds to supportive psychotherapy, hope, therapeutic optimism, and time. A realistic but hopeful attitude on the part of the doctor can be very helpful in improving demoralization. Even in the face of terminal illness, there is often great benefit in careful explanations of measures which will be taken to combat the disease and provide pain relief and comfort.

Can suicide be rational?

But what about “rational suicide?” The answer is that suicide isn’t rational. Depressed, suicidal patients have lost the ability to concentrate, reason, and perceive their circumstances correctly. Their rationality has been overwhelmed.

Post-mortem “psychological autopsy” research has shown that almost 100% of people who commit suicide suffered from a mental illness, usually depression. Thus, suicide is an act compelled by a treatable mental disorder.

Kevorkian’s victims

Kevorkian’s victims have had a variety of disorders: Alzheimer’s disease, chronic pain, cancer, and other problems. Kevorkian is a pathologist and is not trained in treating the sick. He acted without taking careful histories, doing physical examinations, reviewing medical records, seeking second opinions, or considering alternative therapies.

One of his victims had chronic fatigue syndrome, a disease which is associated with no identifiable physical abnormalities. Another victim he believed had multiple sclerosis, although an autopsy revealed no evidence of the disease. Kevorkian’s victims have all been suicidally depressed and demoralized and so, by definition, were insane and mentally incompetent, by both legal and medical definitions.

Is Kevorkian nuts?

All of which raises the question: is Kevorkian insane? Is killing people under these circumstances a mark of insanity?

According to psychiatrist Dr. Paul McHugh, in a 1997 article in the American Scholar, “The Kevorkian Epidemic,” the answer, at least at that time, was an emphatic yes. Dr. McHugh considered Kevorkian to be “certifiably insane.”

In making this determination, Dr. McHugh asked whether Kevorkian suffered from an abnormal mental condition which made him a danger to others. Again the answer was yes.

According to Dr. McHugh, Kevorkian is motivated by an “overvalued idea.” He has adopted an idea shared by some fellow members of society and transformed it into an overwhelming passion. It rules his life. He is willing to sacrifice everything for it. If he has killed people who were “suffering pain unnecessarily.” he feels free to ignore the law and others opinions or interests. He considers himself “humanitarian” and views all opposition as misguided or evil.

Kevorkian’s mental illness is unlikely to have resolved. Now that he has been released from prison, he says that he won’t assist in any more suicides. But who can take comfort in his reassurances? If he doesn’t help any more sick people kill themselves, it will not be from lack of desire to do so, but from fear of going back to jail.

“Failing upward”

Now that Kevorkian is running for Congress, can he be following that uniquely American trajectory - “failing upward?” In Andrew Ferguson’s memorable essay “McNamara’s Brand,” failing upward refers to America’s curious tolerance, even friendliness, especially in politics, towards those who fail.

Ferguson’s cardinal example of failing upward is the career of Robert McNamara, probably best remembered as President Lyndon Johnson’s Secretary of Defense during the Vietnam War. McNamara consecutively screwed up the Ford Motor Company, the Vietnam War, and the World Bank, with promotions following each disaster.

Ferguson aptly depicts failing upward with the workaday example of the unbearable houseguest:

Imagine a friend who comes to visit. The first night he cooks you dinner and sets fire to the kitchen. The next morning he accidentally electrocutes the cat. He blows his nose in the curtains and never flushes the toilet. He borrows your car and drives through the garage door, then spreads a rare contagion to your kids. By the third day you make the decision: You ask him to move in with you.

Will Kevorkian fail upward?

So now Jack Kevorkian, “Doctor Death,” a convicted murderer, his medical license revoked, certifiably insane, is running for Congress. Sadly, many of us would not be surprised if he were to be elected.

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“That’s great if you’re a rat,” you say, when you find out that an article published last month (Science 319, 385 (2008)) showed that in the brain of the adult rat, Prozac (fluoxetine) restores plasticity, or changeability – the potential to adapt after injury. But there’s more to the story. This finding shows us a possible reason why antidepressants, given for a few months soon after strokes in humans, improve survival and recovery years after the treatments are finished.

Plasticity is a sort of brain rewiring

Plasticity, the ability of the brain to change, adapt, and form new connections, is usually seen only in the immature, developing brain. In the Science journal article, antidepressants induced plasticity, or changeability, which allowed recovery from an experimentally induced brain injury in the rat. Without the drug, recovery did not occur.

Benefits of antidepressants after stroke – improved function

In humans, remarkable benefits have been seen when antidepressants are given after strokes. In a clinical trial (J. of Nerv. & Mental Dis. 191, 645 (2003)), patients in one group were given a 3 month course of antidepressants within a month after a stroke. Patients in the other group were given the same treatment, but the antidepressants were started after more than one month post-stroke, an average of 140 days after the stroke. The early treatment group had a better recovery with respect to self care, mobility, speech, less cognitive impairment, and in other ways. The improved recovery in the early treatment group was maintained for over 2 years.

Another benefit – better survival

In another study (Am. J. Psych. 160, 1823 (2003)), three months of antidepressants after a stroke dramatically reduced death rates for as long as 9 years. Antidepressants or an inert placebo were given to patients within 6 months after a stroke. At the 9 year follow up, 68% of the antidepressant group survived compared to 36% of the placebo patients. This benefit occurred whether patients were depressed or not when they entered the study.

How do the antidepressants cause these effects?

The mechanisms by which antidepressants produce these benefits in stroke patients are unknown. Antidepressants given soon after a stroke may, as in rats, enhance the ability of the brain to recover and adapt. Antidepressants are known to increase the levels of brain growth factors which may enhance the growth and survival of brain cells.

Should antidepressants after stroke be a standard treatment?

Obviously, more research is needed. One could make the case that soon after a stroke, all patients should be put on antidepressants whether or not they are depressed. One class of antidepressants, the selective serotonin uptake inhibitors (SSRIs), can increase the risk of falls, hip fractures, and bleeding. However, the treated patients still had overall improvements in survival and function. So the benefits appear to outweigh the risks.

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Smokers’ Faces

by Brian Carty, MD, MSPH
05-11-2008

-With permission of British Medical Journal

-With permission of British Medical Journal

Hint: the smokers have more wrinkles. There are 9 photos followed by a short article. Guess whether the person in the photo above is a smoker or not, then click here for the answer. Click here to skip the quiz and go directly to the article.

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Medical Image of the Month - Watch Painters

by Brian Carty, MD, MSPH
05-01-2008

http://www.hotmedicalnews.com/images/watchdialpainters_400.jpg

Women painting watch dials with luminous paint containing radioactive radium (c. 1920). By pointing their brushes with their lips, they inadvertently ingested radium. The radium later caused degeneration of the bone of the jaw, bone cancer, and other health problems.

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“Anyone who goes to a psychiatrist
ought to have his head examined.” Samuel Goldwyn

In the 1956 science fiction movie “Invasion of the Body Snatchers,” Miles Bennell is a doctor in a small California town. He is inundated with phone calls from local people who insist that their family members are not the same people anymore, that they have changed in some way. He eventually discovers that the townspeople are being replaced by physically identical alien duplicates.

Like Dr. Bennell’s patients, people with the Capgras syndrome are convinced that something is wrong with those closest to them. The Capgras syndrome is a delusion, or false belief, that significant others, usually a spouse or family members, have been replaced by imposters, exact duplicates.

The disorder was first described by a French psychiatrist in 1923. The Capgras syndrome is often associated with organic brain disease such as dementia, stroke, epilepsy, or traumatic brain injury. The syndrome also occurs without organic brain disease in patients who have psychiatric disorders such as schizophrenia.

Probably all patients with the Capgras syndrome should be evaluated for underlying neurological disease with CT or MRI and other studies. Psychiatric or neurologic diseases associated with the Capgras syndrome should be treated to the extent possible. Antipsychotic drugs may be helpful.

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