The Face and the Person

I carry the plenum of proof, and everything else, in my face.

Walt Whitman, Leaves of Grass

The importance of the face in human interactions from the day we are born
cannot be overstated.

Infants, even if they are blind, communicate their feelings to
their parents in large part through facial expressions. For children and adults, so much of what we comprehend about people’s feelings
involves interpreting a glance, a smirk, or raised eyebrows. And there has been research suggesting that our own facial expressions can affect how we feel — what is called the “facial feedback hypothesis.”

I didn’t fully understand the importance of facial communication, though,
until I met patients with illnesses — such as

Parkinson’s Disease
 (PD),

depression
, and

schizophrenia
 — that drastically alter a person’s ability to express thoughts and feelings
through small movements of facial muscles. When meeting patients afflicted in this manner, I don’t know how
they receive my questions or explanations. I don’t know if they’re upset. I
can’t tell what they’re going to say next. The emotionless face, so empty
and devoid of character, can be frightening; a person
seemingly unaffected by emotion is capable of almost anything. Of course, these
patients experience emotions of all kinds. Their faces just don’t exhibit
them.

Leon Kass writes in Toward a More Natural Science about the
importance of emotions expressed through the face, for instance in blushing. This can help us to think about patients with
limited facial communication.

Blushing, like many facial expressions, “is not under our control.” Moreover, blushing is the “involuntary outward bodily manifestation of a very
complex psychophysical phenomenon.” Mental states induce blushing: shyness,
modesty, embarrassment, shame. Many of us blush when we’ve done something
wrong, know we’ve done something wrong, and are scolded for doing so. It is,
in certain respects, a public proclamation of shame. Similarly, the
furrowing of the brow, a smile, and a frown are also public manifestations of
mental states. All
this indicates that we are social beings and cognizant of those
around us. To wit, Kass argues that blushing requires a notion of the self,
a concern of how one appears to others, and an “awareness that one is on
display.”

The same is not always true about every facial expression, but
it is certainly applicable in most circumstances. When we laugh at someone
else’s joke, or cry when wronged in some way, we can do so alone. But more
frequently we do so in front of others and in response to others. In the
case of crying, we may try to be alone when we sob because we are concerned
about appearing fragile or weak. With smiling or laughing, we are
recognizing that someone else said something funny. These are social
reactions that require cognizance or acknowledgement of other human beings, and many of our facial expressions take place within the context of
social relationships. “The face,” Kass writes, “is not only the organ of
self-expression and self-presentation, the source of our voice and
transmitter of our moods; it also contains the chief organs for beholding
other selves.”

Because of the significance of the face in our social interactions, it is
“most highly regarded, both in the sense of most looked at and in
the sense of most esteemed.” Attention, wanted and unwanted, centers on the
face. Yes, some superficial aspects of ourselves can reveal much
beneath the surface: our deepest worries, fears, and joys. Such an
understanding ought to give us new appreciation for the kinds of
difficulties patients without facial expressions confront. They are
handicapped in their interactions with others. They inadvertently block a
vital mode of communication. They cannot indicate how they feel without
using words. As physicians we treat the symptomatic aspects of diseases
like Parkinson’s, but we cannot change someone’s face; even while patients
are on their PD medications, their facial deficits persist. It is one of
those debilitating aspects of illness that one can easily forget when thinking about people who suffer from these illnesses but that one cannot ignore when facing them in person.

Should Computers Replace Physicians?

In 2012, at the Health Innovation Summit in San Francisco, Vinod Khosla, Sun Microsystems co-founder and venture capitalist, declared: “Health care is like witchcraft and just based on
tradition.” Biased and fallible physicians, he continued, don’t use enough science or data — and thus machines will someday rightly replace 80 percent of doctors. Earlier that same year, Khosla had penned an article for TechCrunch in which he had made a similar point.
With the capacity to store and analyze every single biological detail, computers would soon outperform human doctors. He writes, “there are three thousand or more metabolic pathways, I was once told, in the human body and they
impact each other in very complex ways. These tasks are perfect for a computer to model as ‘systems biology’ researchers are trying to do.” In Khosla’s
vision of the future, by around 2022 he expects he will “be able to ask Siri’s great great grandchild (Version 9.0?) for an opinion far more accurate than the one I get
today from the average physician.” In May 2014,

Khosla reiterated his assertion that computers will replace most doctors
. “Humans are not good when 500 variables affect a disease. We can handle three to five to seven, maybe,” he said. “We are guided too much by opinions, not by
statistical science.”

The dream of replacing doctors with advanced artificial intelligence is unsurprising, as talk of robots replacing human workers in various fields — from eldercare to taxi driving — has become common. But is Vinod Khosla right about medicine? Will we soon
walk into clinics and be seen by robot diagnosticians who will cull our health information, evaluate our symptoms, and prescribe a treatment? Whether or not the technology will exist is difficult to predict, but we are certainly on our way there. The IBM
supercomputer Watson is already being used in some hospitals to help diagnose cancer and recommend treatment, which it does by sifting through millions of patient records and producing treatment options based on previous outcomes. Analysts at Memorial Sloan Kettering Cancer Center are training Watson “to extract and interpret
physician notes, lab results, and clinical research.” All this is awe-inspiring. Let us generously assume, then, for a moment, that the technology for Khosla’s future will be
available and that all knowledge about and treatment options for medical problems will be readily analyzable by a computer within the next decade or so. If this is the future, why
shouldn’t physicians be replaced?

There are several errors in Khosla’s way of thinking about this issue. First of all, modern health care is not “like witchcraft.” Academic
physicians, for example, use evidence-based medicine whenever it is available.
And when it isn’t, then they try to reason through a problem using what biologists know about disease presentation, physiology, and pharmacology.

Moreover, Khosla mischaracterizes the doctor-patient interaction. For Khosla, a visit to the doctor involves “friendly banter” and questions about symptoms. The
doctor then assesses these symptoms, “hunts around … for clues as to their source, provides the diagnosis, writes a prescription, and sends you off.” In Khosla’s estimation the entire
visit “should take no more than 15 minutes and usually takes probably less than that.” But the kind of visit Khosla writes about is an urgent care visit wherein quick and minor issues are addressed: strep throat or a small laceration requiring a
stitch or two. Yes, these visits can take fifteen minutes, but so much of medicine does not involve these brief interactions. Consider the diabetic
patient who has poorly controlled blood sugars, putting her at risk for stroke, heart attack, peripheral nerve destruction, and kidney failure, but who hasn’t
been taking her medications. Or consider a patient addicted to cigarettes or on the verge of alcoholism. Consider the patient with Parkinson’s disease who wonders how this new diagnosis
will affect his life. And what about the worried parents who want antibiotics for their child even though their child has a viral infection and not a
bacterial infection? I can go on and on with scenarios like these, which occur hourly, if not daily, in nearly every medical specialty. In fact,
fifteen-minute visits are the exception to the kind of medicine most physicians need to practice. One cannot convince an alcoholic to give up alcohol, get
a diabetic patient to take her medications, or teach a Spanish-speaking patient to take his pills correctly in fifteen minutes. In addition, all this is impossible without “friendly banter.”

As Dr. Danielle Ofri, an associate professor of medicine at the New York University School of Medicine,

wrote in a New York Times blog post, compliance with blood pressure medications or diabetic medications is extremely difficult, involving multiple factors:

Besides obtaining five prescriptions and getting to the pharmacy to fill them (and that’s assuming no hassles with the insurance company, and that the
patient actually has insurance), the patient would also be expected to cut down on salt and fat at each meal, exercise three or four times per week, make
it to doctors’ appointments, get blood tests before each appointment, check blood sugar, get flu shots — on top of remembering to take the morning pills
and then the evening pills each and every day.

Added up, that’s more than 3,000 behaviors to attend to, each year, to be truly adherent to all of the
doctor’s recommendations.

Because of the difficulties involved in getting a patient to comply with a complex treatment plan, Dr. John Steiner argues in an article in the Annals of Internal Medicine that in
order to be effective we must address individual, social, and environmental factors:

Counseling with a trusted clinician needs to be complemented by outreach interventions and removal of structural and organizational barriers. …[F]ront-line clinicians, interdisciplinary teams, organizational leaders, and policymakers will need to coordinate efforts in
ways that exemplify the underlying principles of health care reform.

Therefore, the interaction between physician and patient cannot be dispensed with in fifteen minutes. No, the relationship involves, at minimum, a
negotiation between what the doctor thinks is right and what the patient is capable of and wants. To use the example of the diabetic patient, perhaps the
first step is to get the patient to give up soda for water, which will help lower blood sugars, or to start walking instead of driving, or taking the
stairs instead of the elevator. We make small suggestions and patients make small compromises in order to change for the better — a negotiation that helps
patients improve in a way that is admittedly slow, but necessarily slow. This requires the kind of give-and-take that we naturally have in relationships with other people, but not with computers.

This kind of interaction also necessitates trust — trust regarding illicit drugs, alcohol, tobacco, and sexual activity, all of which can contribute to or
cause certain medical problems. And a computer may ask the questions but cannot earn a patient’s confidence. After all, these kinds of secrets can only be
exchanged between two human beings. David Eagleman, a neuroscientist at the Baylor College of Medicine, writes in his book Incognito that when we reveal a secret, we almost always feel that “the receiver of the secrets
has to be human.” He wonders why, for example, “telling a wall, a lizard or a goat your secrets is much less satisfying.” As patients, we long for that human reception
and understanding that a physician can provide and use to our advantage in coming up with a diagnosis.

Khosla neglects other elements of medical care, too. Implicit in his comments is the idea that the
patient is a consumer and the doctor a salesman. In this setting, the patient buys health in the same way that he or she buys corn on the cob. One doesn’t need friendly banter or a packet of paperwork to get the best corn, only a short visit to the
grocery store.

And yet, issues of health are far more serious than buying produce. Let’s take the example of a mother who brings her child in for ADHD medication, a
scenario I’ve seen multiple times. “My child has ADHD,” she says. “He needs Ritalin to help his symptoms.” In a consumer-provider scenario, the doctor gives the
mother Ritalin. This is what she wants; she is paying for the visit; the customer is king. But someone must explain to the mother what ADHD
is and whether her child actually has this disorder. There must be a conversation about the diagnosis, the medication, and its side effects, because the consequences of these are lifelong. Machines would have to be more than just clerks. In many instances, they would have to convince the parent that, perhaps, her child does not have
ADHD; that she should hold off on medications and schedule a follow-up to see how the child is doing. Because the exchange of goods in
medicine is so unique, consequential, and rife with emotion, it is not just a consumer-cashier relationship. Thus computers, no matter how
efficient, are ill-fitted to this task.

Khosla also misunderstands certain treatments, which are directly based on human interactions. Take psychiatry for example. We know that

cognitive behavioral therapy and medication combined are the best treatment for a disease like depression
. And cognitive behavioral therapy has at its core the relationship between the
psychiatrist or therapist and the patient, who together work through a depressed patient’s illness during therapy sessions. In cognitive behavioral therapy, private
aspects of life are discussed and comfort is offered — human expressions and emotions are critical for this mode of treatment.


To be sure, Khosla is right about quite a lot. Yes, technology ought to make certain aspects of the patient visit more efficient. Our vital signs may one day easily be taken with the help of our mobile phones, as he suggests, which
would save time checking in to a clinic and could help give physicians constant and accurate measurements of blood pressure in hypertensive patients or EKG
recordings in patients with heart disease. Technology of this sort could also indicate when an emergency is happening or how a patient ought to alter medication
doses.
Furthermore, Khosla correctly identifies some of the limitations of human physicians: “We cannot expect our doctor to be able to remember everything from medical
school twenty years ago or memorize the whole Physicians Desk Reference (PDR) and to know everything from the latest research, and so on and so forth.”
True, the amount of information accumulated by modern medical research is beyond the capability of any human being to know, and doctors do make mistakes because they forget or are not up on the latest research. In a 2002 study in the Journal of Neurology, Neurosurgery and Psychiatry, investigators found that 15 percent of patients with a diagnosis of Parkinson’s disease do not
necessarily fulfill criteria for the disease and 20 percent of patients with Parkinson’s disease who have already seen medical providers have not been diagnosed.
These are large percentages that have profound implications for people’s lives. And this is exactly why physicians must use technologies like Watson to do a
better job, not necessarily abdicate the job altogether. Most of us already carry smartphones or tablets on rounds, to look up disease processes or confirm
our choice of antibiotic.
Lastly, Khosla wisely points out that physician bias can negatively affect a patient’s treatment. As he writes, “a physician’s bias makes all these
personal decisions for patients in a majority of the cases without the patient (or sometimes even the physician) realizing what ‘preferences’ are being
incorporated into their recommendations. The situation gets worse the less educated or economically less well-off the patient is, such as in developing
countries, in my estimation.” Undoubtedly, this dilemma is real. I have spent many of my posts on this blog writing about the issue of remaining unbiased or level-headed in the face of difficult patient interactions.
study published in Obesity in 2013 found that physicians “demonstrated less emotional rapport with overweight and obese patients … than for normal weight patients,” which may
“weaken the patient-physician relationship, diminish patients’ adherence to recommendations, and decrease the effectiveness of behavior change counseling.”
And

as Tara Parker-Pope remarks in the New York Times
, “studies show that patients are far more likely to follow a doctor’s advice and to have a better health outcome when they believe their doctor empathizes
with their plight.” If bias exists in lieu of empathy, it makes sense that patients have worse outcomes. What makes doctors most valuable,
their humanity, can have negative consequences.
But people can learn from studies, alter their behavior, and remain human. Computers or robots can learn from studies and alter their behavior, but they will
always be robots. They will never earn the trust of the chronically ill drug addict. They will never be able to negotiate with the most difficult patients
who demand specific treatments but may not be entirely sure why. An ideal system would not be one built solely on fallible human doctors but one
in which new tools significantly augment human physicians’ skill and knowledge. A measured combination of these will put all the information at a doctor’s
fingertips while keeping the art of medicine alive.

Three Years Left to Live

What would you do if you only had three years left to live? I remember, in middle school, discussing a version of this question with my friends. Sometimes we
presented each other with a timeline of three weeks, sometimes just three days, but the scenarios all had similar preconditions: you have no obligations and
it doesn’t matter if you spend all your money. Our answers were all similar. We proposed travelling to exotic places, tasting unusual foods, and performing
daredevil tricks like bungee jumping or skydiving. Indeed, the question did not really concern death’s imminence. It was more about what one would do with
a lot of money and a limited amount of time. We were so young, we didn’t fully grasp that such a situation could ever truly exist.

It began with a fall. The patient, a fifty-eight-year-old woman, was not usually clumsy. She kept everything neat around the house and remained active,
walking daily with her husband and their dog. She brushed it off as an aberration. Then, she fell again the next week; a third time the week after. The
falls slowly became more frequent. Once she began to experience clumsiness in the right arm as well, she and her husband agreed something was not right —
it was time for a visit to the doctor. Her doctor diagnosed her with ALS.

Amyotrophic Lateral Sclerosis
(ALS), also known as Lou Gehrig’s disease, begins for most people like it did for this patient. It starts so subtly that it is almost impossible to
diagnose when symptoms first appear. Neuroscientists and neurologists know very little about what causes the disease but its effects are well-understood.
It leads to slow and progressive death of motor neurons (nervous system cells that carry signals which allow our muscles to contract) in the anterior horn cell body, a portion of the spinal cord containing the origins of motor
neurons. In fact, peripheral nerves from the spinal cord innervating muscles (often referred to as lower motor neurons) and central nerves from the brain which send signals to the spinal cord (upper motor neurons) both die off, causing two different sets of
symptoms. The loss of lower motor neurons leads to muscle atrophy: the muscles look smaller, are weaker, and have diminished reflexes when a neurologist
uses a reflex hammer. The loss of upper motor neurons exaggerates reflexes and causes
uncontrollable muscle firing, leading to muscle stiffness and spasms. Very few diseases combine these symptoms; polio and ALS are two of them. Because of this, whenever a neurologist finds upper and lower
motor neuron symptoms in the same patient, he or she immediately considers ALS as a possible diagnosis.

ALS spares certain functions, though. Patients retain bowel and bladder control, tactile sensation, and eye movements. Additionally, cognitive abilities are
frequently untouched. Unlike in Alzheimer’s disease, where patients are not fully cognizant
of their march toward death, ALS patients know all too well what is happening. ALS drags the helpless patient, with no ability to kick or scream,
toward his or her end. There is no therapy to reverse ALS. Treatment involves medication for depression, muscle spasms, and anxiety. Riluzole, an NMDA
inhibitor, may extend life by a short period of time.

Patients eventually require a tracheotomy, a surgical windpipe for a breathing tube, and a ventilator as
respiratory failure ensues. The example of Stephen Hawking, the famous physicist who has lived with the disease for more than a half century, is an extreme outlier: the median survival time with ALS is just three years from the onset of clinical symptoms. About 80 percent of people with ALS die within five years of their diagnosis.

Our patient wanted a second opinion about her diagnosis from an academic physician at a large medical center, which is what brought her to the office. She
stoically retold her story to us and further described her symptoms. Her motions were so clumsy and uncoordinated that she could no longer sew as efficiently as
she used to. She fumbled when turning a doorknob, inserting a key into a lock or using a spatula. Walking was a struggle, too — she leaned on her husband to
avoid falling.

After a thorough physical exam, the second opinion offered by the attending physician merely confirmed the first opinion the patient had received. She had upper and lower motor
neuron symptoms and no evidence of any other cause for them besides ALS. There, in the office with her husband, she began to sob. At fifty-eight years old and a few years left before retirement, she was going to die. Her husband teared up, too, and sat with his arm around her. We
responded with silence, perhaps the best response to such tragic news. After about thirty seconds, she looked up at us, bleary-eyed, and asked what would
now happen. Physical therapy, riluzole, antidepressants — yes, she would start all of these. But I’m not sure that’s what she really wanted to know. What
should she, a wife and mother of three with a newborn grandchild, do with her last three years?



Images via Shutterstock

Practicing Medicine Turns One

As I look back on the first year of this blog and reflect on my four years of medical school, I am amazed at how much I have learned and how much
I have seen. All of it has informed what I have written about here on Practicing Medicine. And many of the issues I have raised remain vital to my experience within the hospital.
Medicine forces physicians to ask questions; questions beyond which IV fluids to give or which antibiotic to use. Medicine demands that we ask the same
questions that any student of human history might ask: What makes us human? What is so humorous about human suffering and pain? Why
do we become numb to human forms of sufferingWhat is the process by which we die? And is it dignified?

How should we view the place of the mentally ill in our society
?

I have also made other, perhaps less broad and less grand, attempts at explicating the practice of medicine. My first post explained why I decided to blog and the awkward place
of medical students within the medical field. This piece
discussed the potent smells of the hospital — they are unavoidable and yet we adjust to them. Stepping into the ED for the very first time, I
explained how a trauma code works and the horrors that
trauma patients face. The kidney-failure patient also faces difficulties,
but they are of a chronic nature due to dialysis, a miracle of modern science with its own drawbacks.

I compared
George Orwell’s experiences in a French hospital in the early twentieth century to my own experiences in a hospital in the early twenty-first; yes, there are major differences, but there are also similarities. This is a pragmatic post on how we ought to think about
scientific studies and evidence-based medicine. I have written about depression and schizophrenia. And, in a more recent post that would have
pleased me greatly as a younger reader, I wrote about Sir Arthur Conan Doyle’s eponymous detective, Sherlock Holmes — it turns out his methods are relevant to physicians today.

Over the next year I hope to continue to write about the big questions and bring up others in relation to what I see and do. I also have a few bigger writing projects in the works, which I will mention here on the blog. If you have suggestions or
comments, please feel free to send them my way. My e-mail address and Twitter handle can be found at the right.

Denying and Romanticizing Mental Illness

Reactions to mental illnesses or disorders vary. (I wrote about some of them
in a 2012 essay in
the pages of The New Atlantis
.) I’ve noticed, however, that some of
the responses among physicians differ from their reactions to other medical
pathologies. There are several reasons why this might be the case, having to do
with the fact that psychiatric pathology is far more difficult to comprehend
and thus more easily misunderstood than the pathology of other diseases we
usually associate only with the body, such as cancer or pneumonia.

Image via Shutterstock

Unlike bodily illnesses, mental disorders primarily affect patients’
emotions and actions. As a consequence, our implicitly held beliefs about human
behavior, especially our views of free will, can color how we react to people
suffering from mental illness. A strong belief in free will helps validate a
sense of justice and morality: generally speaking, people choose their actions
and are thus responsible for them. So if a person with a psychiatric diagnosis
commits suicide, kills another person, or runs onto a highway screaming at
imaginary beings, it is easiest to hold the person morally responsible if we
believe he acted freely. Or, in the case of suicide, we might say that the
person “should have done” this or that to make life better: he should have seen
a psychiatrist, or he should have realized how wonderful his life was. We want
to hold the person responsible for his actions rather than deal with an illness
that so often makes people completely irrational and incapable of choosing
their actions.

Additionally, the fact that most medical pathology is visible to us makes it
simpler to understand. In the emergency room we easily see the
effects of a chopped-off leg
. We can feel
a large spleen
, hear an irregular heartbeat, or view an abnormal lab
finding. Psychiatric pathology, however, is not palpable in the same way. With
schizophrenic patients, for example, we cannot see the beings they see. We do
not inhabit the world they inhabit. Nor can we easily visualize their brain
chemistry. It is as if we are looking for the culprit in a pitch-black world.

With these difficulties in understanding psychiatric disease, some
physicians, patients and observers dismiss mental illness as a product of the
weak-willed or obstreperous. Or they romanticize it, focusing on the
interesting and provocative aspects of mental illness. These are minority
views, but they are not without influence — which is unfortunate, because if
they are followed, they can lead us to deny treatment to those who need it.

Dr. Robert Youngson, a British doctor-turned-author,
is an instructive example of someone espousing dangerous views of this sort. In
his 1999 book, The
Madness of Prince Hamlet and Other Extraordinary States of Mind
, he
writes:

Doctors and lay people talk, quite casually, of ‘mental
illness,’ the implication being that conditions like schizophrenia are much the
same as conditions like tuberculosis or meningitis. In fact, they are not.
Mental disorders have hardly anything in common with organic physical
disease…. The observable changes occurring in the body — including the brain —
in the course of organic disease are called pathology. So far as current
research can demonstrate, there are no corresponding organic changes causing
schizophrenia.

Dr. Youngson goes on to assert that we classify schizophrenia as an illness
in order to maintain a society of “normal” people. He claims that British
psychiatrists “carry out a tidying-up function much more closely equated with
that of the police and the judiciary than with that of the medical profession.”
Then he asks, disturbingly, whether there is “really any difference between
what happened in Russia, when political dissidents were deemed to be mad and
were incarcerated in mental hospitals, and what happens in Britain and America
when people who do not conform to current social mores are legally certified
and locked up.”

For support of his position, Dr. Youngson refers the reader to the work of the
late Thomas Szasz, who,
as a professor of psychiatry at the State University of New York Upstate
Medical University at Syracuse, New York, published a number of controversial
books arguing that mental illness is a myth. The status quo of medical practice
that considers mental conditions like schizophrenia as illnesses, Dr. Youngson
writes, is a “convenient fiction about a state of the mind.” (A critical essay
about Dr. Szasz appeared
in The New Atlantis
in 2006.)

But Dr. Youngson’s premise, that schizophrenic patients lack cerebral
pathology, is wrong. We know, for example, that patients with schizophrenia
have a disruption in certain neurotransmitters in their brains. Dopamine is
increased in patients with schizophrenia, and this possibly relates to the
effects of genetic alterations. There are specific (and multiple) gene
variants associated
with this disease. Furthermore, medications do sometimes
work, as I explained in another
recent post
. They inhibit dopamine’s actions on certain receptors in the
brain and, despite their side effects, can rid patients of awful and
belligerent visions and voices. If there were truly no pathology, why would
blocking receptors work? If there were truly no pathology, why would there be
significant elevations of certain neurotransmitters? There is indeed pathology
here — Youngson apparently just chooses to ignore it because it contradicts his
preferred explanations.

Dr. Paul McHugh, a
professor of psychiatry at Johns Hopkins University School of Medicine, wrote
about this particular topic in a 1995
issue of The American Scholar
. He argues that “the context of a life
should not be confused with the cause of all mental disorders or made the sole
focus of therapeutic attention as though guidance were always synonymous with
cure.” Unfortunately, “the assumption that something must have happened
if a mental disorder is present has provided an entry for zealots and
charlatans into psychiatry.” If we believe that mental disorders like
schizophrenia or depression are always rooted in life experiences and never in physical
pathology, we can easily misunderstand patients, their families, and the
possibilities for therapies. Not only is Dr. Youngson’s view wrong; it is injurious
to those whom it is meant to help.

Dr. McHugh also addresses the romanticization of depression in a 2005 Commentary
essay
(which I quoted in another
recent post
). McHugh reviews Andrew Solomon’s book The
Noonday Demon: An Atlas of Depression
(2001), in which Solomon writes
about his own experiences with depression. Solomon, McHugh argues, romanticizes
depression by making it seem mysterious like sex and curable most effectively
by a sheer act of will. Similar to Dr. Youngson, Solomon mischaracterizes a
terrible sickness. As McHugh writes,

the particular disorder at issue here is a disease,
an affliction that disrupts a natural function of emotional control. This
disease, like other diseases both physical and mental, renders the afflicted
person impaired in ways that are essentially the same from case to case….
[Depression] is not a you but an it, a thing unto itself and not
just the dark side of human emotion.

Again, depression, like schizophrenia, clearly involves pathologies in the
brain. It is a real disease that tears apart human lives.

What’s so striking about these cases is that those who are denying or
romanticizing mental illnesses are familiar with the diseases. Surely, Dr.
Youngson saw schizophrenics in his family practice. Solomon experienced
depression himself. And Dr. Szasz also saw patients with these disorders.
Seeing or experiencing the illness, then, is not enough to understand it. An
understanding of disorders of the mind requires that we not only learn about
symptoms, social context, and pharmacology, but also that we understand the
underlying pathology.

In the Clutches of Depression

Oh, that this too, too sullied flesh would melt,

Thaw, and resolve itself into a dew,

Or that the Everlasting had not fixed

His canon ’gainst self-slaughter! O God, God!

How weary, stale, flat, and unprofitable

Seem to me all the uses of this world!

Fie on ’t, ah fie! ’Tis an unweeded garden

That grows to seed. Things rank and gross in nature

Possess it merely. That it should come to this.

Hamlet

I need not speak to him to know he is not well. A simple glance tells me all. The patient’s unshaven face wears no smile and, at once, no frown. His vapid gaze
lingers longer than it should on various objects or people or nothing at all. The slippers, pajama pants, and torn t-shirt express the disposition of their
owner, unkempt and exhausted. His visage is neither pale nor tan nor some variation on one of these — it is like a bare tree on a late and chilly fall day.
His brow barely responds even when he speaks and his susurrant replies to our questions are scarcely audible over the ambient sounds in the room. In
conversation he rests his hands on his knees, palms up as if hoping to receive something to make this all end. I can only claim that he exists in physical
form.

We, the psychiatry team, confronted in this patient a true disease of the mind; unchecked and unmitigated depression, eating away at the soul and
destroying its possessor. One doesn’t require the Diagnostic and Statistical Manual of Mental Disorders
(DSM) of the American Psychiatric Association to diagnose this young father with depression. But if we wanted to, we could look through it for criteria on diagnosis and treatment of this disease. A
diagnosis of Major Depressive Disorder requires five of nine specific symptoms,
which include depressed mood, decreased pleasure, change in appetite, change in sleep, and others, present nearly every day for more than two weeks. This
makes the diagnosis “official,” though the definition and the name of the diagnosis lack the descriptive power to characterize its severity (and perhaps also a crispness that one wants out of any definition). Algis Valiunas, a
fellow at the Ethics and Public Policy Center and a contributing editor to this journal, points this out in a wonderful 2007 essay in The New Atlantis, “Melancholy’s Whole Physician.” He writes that the term “depression” was “never appropriately ferocious to begin with, suggesting a mere dip in the road rather than the sulfurous sinkhole that engulfs you and all
you love and sends you into infernal freefall like the host of wicked angels, plummeting in terror with no end in sight, no hope of seeing the beautiful
face of God again.”

Still, we’ve chosen “depression” as the name for it and unfortunately this gives a false sense of innocuousness to the whole experience. We also, frankly,
overuse the term which may contribute to that perception. Whenever we feel down or something hasn’t gone our way we claim depression, as if getting a flat
tire marks a trough in our lives. But to see someone truly depressed gives new meaning to the word.

There was no triggering factor for this particular patient. He had dealt with depression his whole life. He never attempted suicide but his illness waxed
and waned, sometimes waxing so powerfully that he could not work, love, or live outside of the pseudo-security of a dark room under his blanket.

Nobody is sure about the exact pathophysiology of depression, but physicians suspect it has to do with an imbalance of neurotransmitters, small molecules that
bind receptors in the brain affecting happiness, sadness, and desire. Specifically, depressed patients often lack the neurotransmitter called serotonin, which functions in many different biological activities including vomiting, memory, blood
pressure, pain, and others. Therefore, psychiatrists often begin treating depression with an SSRI (Selective Serotonin Reuptake Inhibitor) as well as
cognitive behavioral therapy, which in combination are better than either alone. SSRIs work by preventing neurons from absorbing serotonin after they have transmitted a neural impulse, which allows serotonin to remain active for a longer period of time. And there is a

60–70 percent response rate
to initial therapy with antidepressants. Other medications can be tried if these fail, including multiple SSRIs, tricyclic antidepressants, monoamine oxidase inhibitors, and others.

After seeing multiple psychiatrists the patient had unsuccessfully tried many of these medications. Dr. Paul McHugh, former psychiatrist-in-chief at Johns Hopkins Hospital, describes the
kind of hopelessness a patient like this feels when confronted with depression in a wonderful essay for Commentary Magazine. (A collection of his essays can be found in The Mind Has Mountains, a fascinating
collection reviewed here in The New Atlantis). “You cannot choose for
or against this disease. It chooses you, just as does epilepsy, cancer, or heart disease. It turns you into a stereotyped copy of every other person
afflicted with it. You are not in charge of it, you are not to blame for it, and you can do little about it except seek the help that may enable you to
escape its clutches.” When the medical help fails as it had for this patient, imagine the tightening of clutches, the sheer hopelessness compounded with
the underlying pathology.

Image via Shutterstock

The next option for this patient was Electroconvulsive Therapy (ECT). This is
an effective last-ditch possibility for some patients with intractable depression as well as some patients with schizophrenia. (I will write about a schizophrenic patient in the next
couple of posts.) The side effects of ECT include some ephemeral cognitive decline and memory loss. Anesthesiologists sedate the patient and the psychiatrist
hooks the patient up to a machine and sends a series of electrical waves through the patient’s brain. The response to this therapy, which is relatively
safe despite the possible conception of it as some barbaric torture method, depends on the individual. Some patients respond and feel better after one
treatment. Others may need multiple treatments. Psychiatrists don’t fully understand why this works. Also, ECT does not always permanently fix depression; it often merely
gives a brief respite, sometimes half a year, before the disease comes roaring back.

And this persistence of disease leads to even more problems, as Valiunas explains in his essay — it actually causes anatomical changes that further
exacerbate depression, a vicious cycle. Examples of changes include destruction of glia, which supply
nutrients to neurons and clean up their garbage, and atrophy of the hippocampus
and amygdala, parts of the brain involved in memory and emotion.
This, of course, is why
treatment of depression is so important and it explains why this disease, as Dr. McHugh points out, is not due to some “great personal or moral flaw, one
that can be corrected if only [patients] would not let their emotions run amok.” No, the disease is very real and vicious.

I don’t know if ECT ever worked for this particular patient because, as seems to be so common a trope in this blog, I left the psychiatry service before I
got to see the procedure performed on him. But I cross my fingers that when I run into him again I won’t recognize him at all.