WHOLE LIFE EXPO 2002
Toronto – Metro Toronto Convention Centre, Nov. 22-23, 2002
Robert Sealey, BSc, CA spoke about Finding Care for Depression
Saturday, November 23
Stage One (NW Corner of Exhibit Hall)
One Patient’s Search for Quality Mental Health Care
The author, a prosumer, trusted an expert psychiatrist to diagnose and
treat his mood disorder. The ‘expert’ relied on quick and easy short cuts.
The author got worse. Wanting to restore normal brain function, the author
searched for quality mental health care. He studied the best and worst practices
of psychiatry and recovered using restorative orthomolecular medicine. He
wrote the SEAR series of layman’s guides to help patients, families and caregivers.
Seven years ago, my life was shredded by misdiagnosis and mistreatment when
I was a trusting outpatient of a large hospital. My curiosity never died.
I kept asking: How can I find quality care? Can I recover and keep well?
Why did my psychiatrist, a published mood disorder expert, rely on short
cuts? Was I a bad patient who deserved nihilism? As a former business fraud
investigator, I knew it would take time to learn the truth.
By 1995, I had been depressed off and on for twenty-eight years. I consulted
with several health professionals, tried their methods but did not recover.
Deteriorating and desperate, I was referred to the department of psychiatry
at a large teaching hospital. I trusted my psychiatrist and cooperated, politely.
I complied and took my medications - SSRIs, a MAOI, benzo’s and lithium,
first alone and then in combinations. They did not help. My symptoms of depression
and anxiety continued. The medications caused side effects like brain fog
and akathesia, disrupted sleep, escalated anxiety, reduced sexuality, induced
migraines and triggered hypomania.
It seemed odd that I had symptoms of depression but anti-depressants and
other meds made me worse. My psychiatrist, a bright and well-diploma’d expert,
smiled but did not take patient or family medical or mental histories, did
not do mental status exams, did not do diagnostic tests, did not get informed
consent, did not warn about side effects, did not recommend therapy; did
not monitor lithium blood levels or kidney functions; did not make a differential
diagnosis, and did not educate me about my diagnosis, explain possible treatments
or review my prognosis. Two years later, I analyzed my medical file and realized
that 13 standard of care procedures were omitted. Why was my mental health
care substandard? Could I find quality care and get well?
In 1996 I started IDP, an Independent Depression Project. While researching
and writing Depression Survivor’s Kit and Finding Care for Depression, I
interviewed 150 depression survivors and family members. Apparently their
doctors did not offer quality care either. Three interviewees killed themselves
after misdiagnoses and mistreatments.
In a 2002 editorial, geriatric psychiatrist Dr. Ken Shulman offered a clue.
He referred to the tradition of nihilism in psychiatry. Could that tradition
explain my skimpy medical file, the missing patient and family, medical and
mental histories, the lack of mental status exams, the missing diagnostic
tests, the misdiagnosis and the absence of supervisor notes?
Webster’s dictionary defines nihilism three ways: (1) belief in nothing,
(2) extreme skepticism and (3) the rejection of customary beliefs. A healthy
level of skepticism can open our minds to better ways of doing things. For
instance, a skeptical psychiatrist might question short cuts and improve
the quality of care. However, a psychiatrist who omits the standard of care
procedures can misdiagnose, mistreat and damage a sick patient.
Dr. Shulman’s editorial also mentioned the clinical practice guidelines.
Written as a consensus of experts, the guidelines recommend a systematic
approach to patient care: taking histories, doing medical tests, assessing
mental status, making a differential diagnosis and offering effective treatments.
A competent clinician will consider, discuss, do and document standard procedures,
investigate the root cause(s) of symptoms and recommend appropriate treatments.
An experienced clinician will adjust the care to suit each patient.
In 1999, when he was a chief psychiatrist, Dr. Shulman explained that his
psychiatrists were expected to read, study, learn and apply practice guidelines.
Surely a skeptical psychiatrist would not ignore professional practice guidelines
and watch sick patients deteriorate. Surely not often, but that’s what happened
to me.
Substandard care is not recommended in the guidelines. However, the nihilistic
tradition of psychiatry may lie dormant in the collective unconscious. I
wondered if researchers who see evidence of substandard psychiatry ever report
the short cuts and recommend quality care.
Dr. S. Green and Dr. S. Bloch, authors of ‘Working in a Flawed Mental Health
Care System: An Ethical Challenge,’ reported that too many psychiatrists
“participate in a system known to have deleterious effects”, “harm patients”
and “withhold information.” According to that article, short-cutting may
be efficient, but too much ‘efficiency’ is unethical.
Dr. E. Plakun, author of ‘A Psychodynamic Perspective on Treatment-Refractory
Mood Disorders’ in stated that “half of mood-disordered patients fail to
respond adequately to biological treatment[s]. Only a minority of patients
recover fully with medications”. The article outlined steps for a clinician
to consider if a depressed patient does not recover. Psychiatrists can apply
their medical skills and their specialist training rather than watch a sick
patient get worse. The author warned about “frustration and despair induced
by the treatment-refractory patients” and that the “prescribers may unwittingly
respond . . . with withdrawal or a sadistic counter transference response”.
Dr. C. Blanco et. al, authors of ‘Trends in the Treatment of Bipolar Disorder
by Outpatient Psychiatrists’ reported that “pharmacological treatment of
bipolar disorder still departs substantially from the . . . published guidelines.”
Researchers found that: (1) “One-third of the patient visits to office-based
psychiatric practices . . . did not include the prescription of a mood stabilizer.”
(2) “There is a substantial discrepancy between evidenced-based treatments
and routine clinical practice. (3) Therapeutic monitoring of serum lithium
levels . . . were not conducted in 36.5% of the sample.” The poor treatment
of bipolar disorder by outpatient psychiatrists means that manic-depressive
patients and families have to work hard to find quality care.
The prevalence of mental disorders combined with healthcare cutbacks may
explain why some psychiatrists short cut standard practices. If an over-worked
doctor believes that practice guidelines are meaningless, he may watch sick
patients deteriorate, ignore standard procedures, omit diagnostic tests and
withhold treatments. Patients of a short-cutting psychiatrist may not get
accurate diagnoses or proper care. Patients and families can study the practice
guidelines to learn how ethical psychiatrists diagnose accurately and treat
effectively.
Might there be a restorative approach to mental healthcare? When interviewed
in 2001, psychiatrist Dr. N. Hermann questioned the guidelines. No doubt
he applies them selectively. His 2002 article identified high homocystine
(HCY) levels as a medical condition that can affect brain function. He explained
that diagnosis involves blood tests and treatments can include supplements
with vitamins B6, B12 and folic acid.
In April, 2002, Dr. John Hoffer, a Montreal internist, spoke at Nutritional
Medicine Today in Vancouver. When researching the care of dialysis patients,
he compared the results of treatments provided by two hospitals. Dialysis
patients who received adequate nutritional supplements maintained normal
homocystine levels. Other patients who received insufficient supplements
developed high homocystine conditions and risked serious cardiovascular complications.
Other orthomolecular physicians spoke at the 2002 conference. Dr. Abram Hoffer
who helped to develop the principle of orthomolecular medicine, reviewed
his research, progress and success, since the 1950’s, treating schizophrenia
with supplements of niacin and ascorbic acid, vital amines B-3 and C. After
they recover, the majority of Dr. Hoffer’s patients can live well, work and
pay taxes. Some of his patients continue taking low doses of synthetic antipsychotic
medications but they have few adverse effects on minimal meds. Dr. David
Horrobin reviewed his research and clinical trials which support adding essential
fatty acids to the orthomolecular regimen for schizophrenia.
Other clinicians explained how they fine-tune regimens of natural supplements
such as vitamins, trace minerals, amino acids, energy and enzyme co-factors
and essential fatty acids. After making a differential diagnosis and taking
into account the principle of biochemical individuality, orthomolecular physicians
recommend restorative protocols for depression, bipolar, schizophrenia, autism,
attention deficits and other mental disorders. A conventional doctor would
describe this as bio-logical medicine. Restorative orthomolecular medicine
is an effective alternative to substandard short cuts.
Concerned patients may want to learn about their illness before asking a
physician to use restorative methods. Bibliotherapy can help. Rather than
trust a do-nothing psychiatrist, patients can read guide books, scan medical
journals, search the Internet, ask about prescription medications, study
the practice guidelines of psychiatry and learn about the standard of care
procedures for accurate diagnosis and effective treatments.
When I needed help to recover from a misdiagnosed and mistreated bipolar
mood disorder with anxiety and migraines, I trusted my life to substandard
care. Of course I had a mental disorder but my expert’s nihilism was not
my fault. Maybe my illness kept me at arm’s length from a therapeutic alliance.
Wanting to recover, I used self-help tools and found quality care. My progress
report, a layman’s ‘anecdote’, can help other patients, families and caregivers.
After noticing that physicians did not answer my all questions, I turned
to bibliotherapy. I read books by four types of authors: (1) conventional
psychiatrists and psychologists, (2) patients, consumers and survivors, (3)
health professionals vulnerable to depression and (4) orthomolecular physicians.
The books answered my questions and taught me how mood disorders and mental
conditions are diagnosed and treated; how people feel about their symptoms
and live with brain disorders, what treatments involve side effects and that
ethical health professionals use standards of practice to guide their care,
orthomolecular doctors recommend restorative treatments and effective care
can help patients recover.
To learn from a consensus of experts, I studied the practice guidelines of
psychiatry, US and Canadian. Written for patients as well as health professionals,
the guidelines taught me that ethical doctors take medical and mental histories,
ask about family members, use mental status exams and medical tests to make
a differential diagnosis, obtain informed consent, monitor medications, explain
the diagnosis, treatments, progress and prognosis, counsel the patient and
educate the family. A basic awareness of the guidelines helped me find competent
health professionals and cooperate with diagnosis and treatments.
I applied the advice of health professional authors who consider, discuss,
do and document standard of care procedures and recommend restorative treatments.
I found research reports that explain how gingko biloba can help with depression
and anxiety. The right dose worked well for me. I learned which vitamins,
minerals, amino acids, energy and enzyme co-factors nourish my brain, which
diets suit my metabolism and how the principle of biochemical individuality
means that a patient may need a customized restorative regimen of medications
and supplements. With restorative treatments, I soon recovered. Stable since
1996, I can live and work.
Although I recovered from depression and stabilized a bipolar II mood disorder,
my curiosity continued. I interviewed patients who recovered and patients
who got worse. I attended medical conferences and support groups. I learned
that healthy skepticism can be useful but patients who trust their lives
to nihilistic short cuts do so at their peril. While recovering, I read and
researched, investigated substandard care, developed and wrote tips, tools
and teaching tales for laymen.
I founded and coordinate the FOR•OM network. Friends of Restorative Orthomolecular
Medicine share progress reports and success stories to educate the public
and support recovery work.
Bibliotherapy, the clinical practice guidelines and restorative orthomolecular
medicine can help a patient find quality care and keep well, even after years
of substandard psychiatry.
References
Blanco, C, MD, PhD, et al. (2002) Trends in the Treatment of Bipolar Disorder by Outpatient Psychiatrists. American Journal of Psychiatry 159: 1005-1010.
Green, Stephen, MD, MA & Bloch, S, MD, PhD. (2001) Working in a Flawed Mental Health Care System: An Ethical Challenge. American Journal of Psychiatry 158: 1378-1383.
Hermann, N, MD, FRCPC. Cognitive Pharmacotherapy of Alzheimer’s Disease and Other Dementias. The Canadian Journal of Psychiatry 47(8): 715-722.
Hoffer, Abram, PhD, MD, FRCP(C). (1998) Vitamin B3 and Schizophrenia: Discovery,
Recovery, Controversy, Kingston, Canada: Quarry Press.
McIntyre, J, MD, Chair. (1996) Practice Guidelines, American Psychiatric Association, Washington, DC.
Plakun, E, MD. (2002) A Psychodynamic Perspective on Treatment-Refractory Mood Disorders. Psychiatric Times, XIX (10).
Sealey, Robert. (2001) Finding Care for Depression, Mental Episodes &
Brain Disorders. North York, Canada: SEAR Publications.
Shulman, K, MD, SM, FRCPC. (2002) Geriatric Psychiatry: Complex Challenges, Promising Treatments, The Canadian Journal of Psychiatry, 47(8): 713-714.
Shulman, K, MD, SM, FRCP(C). Tohen, M and Kutcher, S, eds. (1996) Mood Disorders
Across the Life Span. Toronto: John Wiley & Sons Inc.
Webster’s Dictionary. (1984) Boston, MA: Houghton Mifflin Company.
About the author -
Robert Sealey has a BSc from the University of Toronto with courses in biological
and medical sciences and psychology. He practices as an accountant, consultant,
author and self-publisher in North York, Ontario, Canada.
Bob wrote the SEAR Series of layman’s guide books to help patients and families.
find quality care. The series includes the Depression Survivor’s Kit, Finding
Care for Depression and the 90 Day Plan for Finding Quality Care.
These layman’s guides are available from www.searpubl.ca
and the Cdn. Schizophrenia Foundation. The Mood Disorders Assoc. of Ontario,
the Cdn. Mental Health Assoc. and the Toronto Public Library have reference
copies.
Robert Sealey, BSc, CA
SEAR Publications
291 Princess Ave.
North York, ON M2N 3S3
(416) 221-1300
www.searpubl.ca
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