My last previous post has got me thinking: what exactly is a ‘nervous breakdown’.  I muddled through five years of medical school without the curiousness to find this out, and still don’t know exactly.  The term certainly has no precise psychiatric or psychopathological use.  The Oxford English dictionary defines nervous breakdown as: ‘noun a period of mental illness resulting from severe depression or stress’ which could mean just about anything.  It also begs* us to consider the nature of ‘mental illness’ which is a difficult question in itself.  Always available to shine light were once darkness reigned, my favourite book, Campbell’s Psychiatric Dictionary allows us:

 

breakdown,nervous A popular, inexact term for the appearance of neurotic or psychotic symptoms of enough severity to impair significantly the person’s ability to cope with demands of his or her current life.  The term implies a relatively sudden onset of disability and/or readily discernible fall from a previously maintained level of performance of adaptation. 

 

Good enough for Robert Campbell, M.D. good enough for me.  Why it’s under ‘breakdown, nervous’ rather than ‘nervous breakdown’ is something I may ask him if ever we meet. As a bogus pseudo-medical term it has much company;  ‘critical but stable’ is a particular favourite of mine in this regard.  The use of nervous breakdown is euphemistic and perhaps its use widespread because of a desire to root something as frightening and unknowable as mental illness in something physical and accessible - ’nerves’. 

*You’ll note that I did not use the phrasing ‘begs the question’ here.  My usage of this phrase has been thrown into confusion following being introduced to the website www.begthequestion.info

Several newspapers including The Guardian and The Irish Independent have reported have reported over the past few days that an Air Canada 767 bound for London Heathrow had to divert to Dublin Shannon following one of the co-pilots suffering from ‘nervous breakdown’. 

The Irish Independent reports that the co-pilot had been ‘acting in a peculiar manner and was talking loudly to himself’ during the transatlantic crossing and the crew had become concerned.  From The Guardian we learn that he was restrained after yelling and "invoking God" while at the controls of the plane.  The Guardian continues by quoting one of the passengers on board, who said that the co-pilot was carried into the cabin with his hands and ankles cuffed after being restrained by, amongst others, an off-duty Canadian soldier.  He was subsequently handcuffed to a seat as his captain requested permission to land from Irish air traffic authorities.

I read of what sound like quite severe psychotic symptoms: ‘His voice was clear, he didn’t sound like he was drunk or anything, but he was swearing and asking for God. He specifically said he wants to talk to God’. When the plane landed in Dublin, he was met by a medical team who assessed him at the scene before transferring him to a psychiatric unit in Ennis.  

It’s hard to imagine a more difficult situation for any of the people involved in this incident.  It must have been terrifying for the passengers on board the aircraft as well as extremely distressing for the crew to have to restrain one of their colleagues. We should reserve some of our sympathy for the co-pilot too.  A previously high functioning individual, when he recovers he will have to come to terms with what has happened as well as facing the end of his flying career.  

A search of the Canadian Civil Aviation authority website suggests that anyone with a history of psychotic illness is not permitted to fly aircraft. It is therefore likely that this is a first presentation of psychiatric illness for this pilot, or possibly he has in some way concealed any problems he has had in order to maintain his chosen career ultimately putting passengers at risk. 

A recent article in the New Scientist is about antidepressant use amongst pilots.  It tells us that most aviation authorities do not allow pilots on antidepressants to fly.  The Australian Civil Aviation Authority is one of the few that do and a study there suggested that pilots on antidepressants were not at greater risk of accidents.  It also suggests that banning pilots from flying who are taking antidepressants may actually increase accidents by discouraging depressed pilots from seeking treatment.  Perhaps this pilot did not seek help until it was too late with very nearly devastating consequences. 

Despite being very famous, Heath Ledger had somehow passed me by until a few weeks ago when I watched ‘Monster’s Ball’ and ‘Brokeback Mountain’ within a few weeks of each other.  It seems likely that his death was caused by an overdose of sleeping pills, either mistakenly or intentionally.  As a psychiatrist I was struck by something Ledger said in his last interview with Sarah Lyall, published in the Observer.

‘Last week, I probably slept an average of two hours a night,’ he said. ‘I couldn’t stop thinking. My body was exhausted and my mind was still going.’ One night, he took an Ambien sleeping pill, which didn’t work. He took a second one and fell into a stupor, only to wake up an hour later, his mind still racing

Obviously there’s not much to go on here, but I wonder if Ledger is suffering from hypomania, although I note that there is no mention of elevated mood in the article.  It is also worthy of note that Ledger had been flying between Manhattan and the UK, as he had been filming ‘The Imaginarium of Doctor Parnassus’ in London.  According to NICE guidelines, if a person has a predisposition towards bipolar disorder, relapses can be triggered by ‘night flying and flying across time zones, and routinely working excessively long hours, particularly for patients with a history of relapse related to poor sleep hygiene or irregular lifestyle’

There’s also been press speculation about Hedger’s history of drug use.  In 2006 he was the victim of a paparazzi sting operation during which time he was filmed admitting to smoking ‘five joints a day for twenty years’; in the background of the film were unidentified persons snorting what is presumably cocaine.  At the time the tape was not shown due to legal threats, but now Ledger is dead no such restriction aside, of course, from decency. 

I’ve just finished watching Michael Moore’s new film ‘Sicko‘, a polemic against the American health care system and a paean to  socialized medicine.  I was a big fan of Michael Moore’s first film ‘Roger and Me‘, an exploration of the impact of the closing of a General Motors plan in his home town of Flint, but less keen on his subsequent two.  This reservation less concerns less Moore’s choice of subject matter, but more his poorly constructed arguments and tendency to widen his attack into broad swipe at the
right wing.

With this film he keep his focus and it’s devastating.  Moore visits American citizens denied vital medical care due to their lack of health insurance; he interviews people who had health insurance but found their insurers unwilling to cover their bills and most shockingly reports on a child that died having was taken to a hospital not covered by her insurers and denied care there; she arrested on arrival at the approved facility.

Having set out his stall Moore visits the alternatives: the UK, France and finally Cuba. Moore’s view of the NHS is somewhat rose-tinted; he does not devote a single second to the problems with the model, instead choosing to interview a wealthy young GP and extrapolating.  However it was a pleasure to see someone being positive about our way and made me realise that, despite its faults, we are lucky to have universal healthcare here.  The irrepressible Tony Benn gets a look in too, opining how democracy empowers people and that the way of emasculating the poor is to keep them sick and demoralised; demoralised people don’t vote.  Benn imagines a time when the poor will mobilize and tell their governments what they really want.

Much like the French often do.  Moore interviews a group of Americans in Paris, some of whom seem simply unable to believe their luck at being able to access the services the French government provides.  Finally, having heard about the high standard of health care afforded to the detainees at Guantanamo Bay, the film closes with Moore’s visit to Cuba, taking along volunteers from 9/11’s ground zero who are suffering from respiratory problems but denied healthcare by the US government because they were not under its employ at the time of the attack.  The Cuban doctors provide the American citizens tests not available to them in the USA. Cuba’s health system costs just $251 per citizen, but Moore claims that the average life expectancy is higher than the USA.  This part of the film is particularly poignant.

I highly recommend this film, but left it wanting more.  It’s hard to know if Moore really cares about the state of his nation’s health, or whether this is just for him a new avenue to make further attacks on right wing politics in the USA.  Sometimes I feel that he’s playing around at the edges,  when what we really need from him is a magnum opus: a dissection how to correct what is sick at the heart of American society, whilst celebrating it’s strengths.  Or perhaps there can be no unravelling;  America is so successful precisely because of its devotion to commerce and people are attracted to the country precisely because its toleration of inequality is what allows people to make and keep such enormous amount of money there.  With right wing politics dominating American for the past thirty years, we can but hope for a change with this new presidental election.

Someone called Cliff Arnall has come up with a equation for the most depressing day of the year.  It goes like this:

1/8W+(D-d) 3/8xTQ MxNA.

Where W is weather, D is debt - minus the money (d) due on January’s pay day - and T is the time since Christmas.
Q is the period since the failure to quit a bad habit, M stands for general motivational levels and NA is the need to take action and do something about it.

I was rather amused by this the first time I read about it.  The Guardian had an article all about the best songs to listen to on the most miserable day of the year.  But it’s all bollocks, so much so that it is worthy of a diatribe from Bad Scientist writer Ben Goldacre, who appears to be a longtime adversary of Mr Arnall.  The same story was wheeled out in 2005 and 2006
The Samitarians got sucked this time and have launched Beat Blue Monday as a money earning drive, allegedly with Mr Arnall and a PR company taking their cut.

So when is the most depressing day of the year? If we assume that people who commit suicide are a reliable indicator of misery, then these two papers are relevant:

The Office of National Statistics have published a cheerful paper entitled Mortality from suicide and drug-related poisoning by day of the week in England and Wales, 1993–2002 An increased proportion of suicides occurred on Mondays, while the single day on which the largest number of suicides occurred was 1st January 2000, a Saturday.  The increased numbers of deaths would on a Monday and especially on 1st January would suggest a theory that people are more suicidal with the move into a new time period.

More light is shed by another interesting article which considers the frequency of suicide by day, day of the week, month, and lunar phase by studying suicide occurrence among residents of Sacramento County, CA, during the period from 1925 to 1983. It found suicide occurrence varying substantially by time of day, with the fewest suicide deaths occurred during the early morning hours. Suicides occurred most frequently on Monday for both males and females and for most age groups. Furthermore, variation by month followed no consistent pattern by gender, age, years of the study. Suicide occurrence did not vary by lunar phase.

There aren’t so many werewolves after all.

I’m revising for MRCpsych papers 1 and 2 this week and have been listening to the psychiatry podcasts that are available online.

The best is the British Journal of Psychiatry podcast available from the Royal College of psychiatry website.  TV doctor Raj Persaud is the host and discusses papers in the most recent journal with their authors.  There are two podcasts available - one is for the ‘public’ and the other a longer CPD version.  The discussion is usually rather matey (about 50% of the authors work at the IoP and would be known to Dr Persaud), but Dr Persaud does often put his guests on the spot by challenging them with possible alternative interpretations for their results.  Highly recommended.

The American Journal of Psychiatry also provides a lacklustre podcast or, as they call it, ‘audio digest‘.  I have never managed to get through an entire episode as its format involves a monotonic American reading out an abbreviated AJP papers.  Unlike the BJP there is no illuminating discussion.  The Mindhacks blog describes it as being ‘like an excessively thorough lecture given by a voice synthesiser’, which is a nice summary.

Also featuring Dr Persaud, but aimed at the general public is the BBC’s ‘All in the Mind‘.  This has more of a magazine format, but is often very interesting, and does not shy away from controversial topics.  All the episodes from the series broadcast since 2005 are available to ‘listen again’. on the BBC’s All in the Mind webpage.

The Institute of Psychiatry also offers podcasts.  Their website says that they wish to put online all the public lectures and debates at the institute.  These are a mixed bag, but included in amongst them are recordings of Maudsley debates going back some time as well as lectures on a wide variety of other topics.  A sort of lucky dip by the looks of things…

Bad Science blogger Ben Goldacre has started podcasting.  It’s a fledgling initiative, judging by there only being one download available, but it’s pretty interesting, and I hope adds more soon.

The ‘My Three Shrinks’ podcast is by blogger ‘Shrink Rap‘ and friends.  I’ve not listened to this yet, but it looks informal and interesting.  There are 42 downloads available

Another podcast I’ve not yet listened to are psychiatry podcasts by the Peerview Press.  Here’s a link to their stuff on podcastdirectory.com

If you are aware of any worthy psychiatry podcasts not on this list, please let me know.

Naomi Klein’s new book ‘The Shock Doctrine’ has an interesting chapter on the techniques of Dr Ewen Cameron, Scottish born US psychiatrist and former head of the American and World Psychiatric associations.

The essential thesis of Klein’s book is that since the end of WWII America’s ‘free market’ policies have come to dominate the world through the exploitation of peoples and countries in the midst of upheaval. At these chaotic junctures, wide ranging reforms which benefit the elite at the expense of the poor are much less likely to be opposed. The new economic order established is massively lucrative for a few but is ruinous for the majority of the population, who are in many cases prevented from protesting either by a repressive state machine (Chile 1973) or by their preoccupation with another incident (UK post Falklands conflict).

Klein draws a parallel between the intentions of interrogation – to breakdown and remake a person – with that of ‘Shock and Awe’ style regime change – to overwhelm and remake a country. In the opening chapter of her book she tells of patients who had gone to Dr Cameron for treatment for relatively minor psychiatric complaints and were subsequently used, without their permission, in experiments that Cameron was being paid to do by the CIA in order to glean information about how to control the human mind.

Descriptions of Cameron’s techniques make alarming reading. Cameron is reported as contending that by way of an array of shocks inflicted on patients he could unmake and erase faulty minds believing that the only way to teach patients new healthy behaviours was to get inside their minds and ‘break up old pathological patterns’. The first step in this was ‘depatterning’, for which the goal was to return the mind to a state as if it were a blank sheet of paper. To achieve this Cameron used a device called, after its inventors, the ‘Page-Russell’ – an ECT device that administered six shocks rather than the usual one. Page and Russell recommended that their machine be used on patients no more than four times – that is up to 24 shocks per patient. Cameron used it on patient twice a day for thirty days – 360 shocks per patient.

Cameron also disorientated his patients with a variety of drugs including chlorpromazine, hallucinogens and barbiturates, LSD and PCP. Alongside memory – which he aimed to banjax with ECT – he felt that our sense of self is maintained by continuous sensory input. With this in mind he aimed to further dent the his patients’ defences by converting the old stables behind the hospital and creating isolation boxes. Cameron kept some of his patient in these boxes for weeks. To make patient lose their sense of time, Cameron had the kitchens mix up the times and sequences in which meals were delivered.

Once complete depatterning had been achieved, the ‘psychic driving’ – rebuilding personalities on a ‘blank slate’ – could being. In scenes which must have been reiniscent of ‘A Brave New World’ tape recorded messages were played to patients, often for days at an end. These messages, it was believed, would be absorbed by the patients and lead to behaviour change.

It didn’t end there. Cameron also kept some patients in a ‘sleep room’ where a patient would be kept in a heavily sedated state for twenty to twenty-four hours a day for fifteen to thirty days. Klein notes that there are several indications that Cameron was aware that he was simulating torture conditions, not least when in 1955 he openly compared his patients to POWs facing interrogation.

In 1988 the CIA were subject to a freedom of information act request and reluctantly produced the ‘Kubark Counterintellegence Interrogation’ manual. This is a 128 page manual for the ‘interrogation of resistant sources’. Klein notes that it had Ewen Cameron’s ‘marks all over it’.

 During the NHS’s first 50 years the organisation saw enormous advances in the application of technology to healthcare.  During the 1940’s a physician’s medicine cabinet was virtually bare and the only imaging available was X-ray; even the humble mobile phone was the stuff of science fiction.  Over the same period computers went from being primitive calculators, contained in specially cooled rooms and running off punch cards, to being highly portable and with incredible processing power.  Some research is moving so fast that futuristic techniques are close to being available now, whilst ideas that appear highly theoretical today will, in coming years, become increasingly practical.

Nanotechnology and Nanorobots

Nanotechnology is a field which covers the control of matter on the atomic and molecular scale.  Its name is derived from the scale at which this work is conducted – that of the nanometer.  The allied field of Nanomedicine covers its medical applications and this is already becoming one of the biggest industries in the world with 2004 sales reaching $6.8 billion.  The field has its own journal ‘Nanomedicine’and the October 2007 issue discusses such issues as using nanotubes to fight bacteria and nanoparticles for cancer diagnosis and therapeutics. Further from practical use are ‘Nanorobotics’ the technology of creating machines or robots on a nanometer scale.  Expectations for this are high; Robert Freitas, senior research fellow at the Institute for Molecular Manufacturing in California, describes its development as one of humanities ‘greatest and most noble enterprises’.  Once introduced to the body these ‘nanomachines’ will be able to repair cellular structures, isolate cancer cells on an individual basis, and deliver drugs directly to appropriate receptors.  If all the possibilities for this technology are realised nanotechnology may even make possible indefinite lifespans for humans. 

Genetics and pharmaceuticals

When Dr Francis Collins of the Human Genome Research Institute, published in the New England Journal of Medicine that the Human Genome Project provided an audacious tool to ‘uncover the hereditary factors to virtually every disease’ it was hard not to be impressed.  With advanced genetic testing we will be able to pinpoint the cause of a disease so exactly that any condition will be considered an individual event and will have an individually tailored treatment. A unique DNA signature for each patient will enable identification of disease susceptibility, and optimal drug, vaccine or gene therapy treatment.  There is enormous genetic variability between individuals, leading to a corresponding variability in responses of patients to modern medical treatments.  In the future, instead of wasting time on trial-and-error treatment, physicians will be able to use a genetic test to identify patients with the potential to respond to a drug. 

It may also be possible to combine genetic treatments with other technologies; Professor Sikora, a leading cancer researcher in Hammersmith hospital, suggests that susceptible people may be able to be implanted with a ‘gene chip’ which would detect the earliest signs of genetic mutations that produce cancer.  A patient could check themselves up with a home computer and which could then contact the GP by email to arrange an appointment if something is amiss.

Sensors

Sensors are all around us, and we are used to them being in our homes, cars, security systems, and household appliances. In the future, sensors will be embedded in walls and ceilings of our homes and workplaces, or woven into clothing, and will monitor our health. People are already planning for this: in an issue of the BMJ devoted to technology, Charles Wilson, Director of the Institute of the Future, predicted that "inpatients may be implanted with tiny sensors as part of the admission process, and throughout the patient’s hospital stay the chip will provide values instantaneously for laboratory tests." Remote transmission of pulse rate and blood pressure from the homes of patients with chronic illnesses is already possible.  Close to hitting the market are devices that sense hypoglycaemia in diabetic patients and can differentiate between the odours produced by ear, nose and throat infections.  This latter technology has further applications in infection control as in future hospital lobbies could be vented with air monitors that detect and report any visitor who might transmit airborne infection.

Robots in Surgery

Robots used in surgery have potential advantages of precision and miniaturization as well as articulation beyond normal manipulation and when it comes to their use, the future may be sooner than we may think.  Researchers in the University of Nebraska have developed a machine about the size of a tube of lipstick which is able to drive around a patient’s  body and act as the eyes and hands of a surgeon who could be many miles away.  ‘We think this is going to replace open surgery’ says Dr Dmitry Oleynikov, a specialist in minimally invasive surgery who heads the team, who further speculates that such machines could be used to treat patients on a battlefield or even in space.  Nearer to home London doctors have begun pioneering the first fully robotic heart catheter ablation and angioplasty.  With this technique the cardiologist sits at a console outside the operating theatre and uses a joystick or mouse to guide the magnets. They can also preprogramme the computer so the entire operation is automatic. 

Bionics

From the Cybermen in Doctor Who to the Borg in Star Trek, lovers of science fiction will be well acquainted with alien races who are part machine.  Fortunately such technology is now being developed by the forces of good and has already found some impressive applications.  The case of Mr Nagle from Massachusetts has been published in Nature and the results have been spectacular.  Mr Nagle was left paraplegic following a knife attack.  Now he’s been fitted with a 4mm-square chip or ‘Braingate’ that reads signals in the primary motor cortex of his brain and this has been allowing him to open emails, play computer games and operate a prosthetic limb.  ‘After my injury I was depressed for two years’ he said . ‘It’s been three years now, and this BrainGate has been unbelievable’. 

The possibilites of such cyborg technologies appear almost limitless.  As well as providing prosthetic limbs for accident victims, or restoring sight to the blind, within our lifetimes we could be seeing applications with the intent of enhancing the human body beyond its natural capabilities.  Imagine for instance putting on a prosthetic suit and running from London to Manchester; or implants that could make you see clearly at night. 

The Challenges of Technology

Over coming decades it is a certainty that technology will play an increasing role in the provision of healthcare.  Is it possible, that with its advance the doctor will become obsolete?  Or will we find that patients need our help more than ever to provide a human face, a friendly smile and a guiding hand? More concerning, is that given the budget difficulties of the NHS today, will it just be the rich who will benefit from the changes to come, or will we all be able to look forward to an era of amazing technological possibilities?