J. Wesley Boyd, MD, PhD

Celeste, one of my patients, a woman in her mid-30s, unexpectedly had a seizure, fell, and hit her head while at work. She was rushed to a nearby emergency department (ED) where results of laboratory work, an EEG, and an MRI confirmed that she had had a seizure but did not show a cause. The ED physician concluded that the presumptive cause of her seizure was the 150 mg of bupropion (Wellbutrin, Zyban) I had prescribed for her 3 weeks earlier to augment the 40 mg of fluoxetine (Prozac, Sarafem) she had been taking for years for depression (even though some research shows that the risks of seizure from bupropion are overstated). A week later, a neurologist concurred with the findings. Although like most psychiatrists I fear provoking a seizure in any patient I treat, to my utter surprise, this seizure has been one of the best things that has ever happened to Celeste.

Celeste initially came to me a year and a half earlier with what she called a lifelong history of depression (and no significant medical history, including no history of seizures). She had had years of psychotherapy, on and off for 2 decades, and had tried several courses of antidepressants. For the past 7 years or so, she had been taking fluoxetine, which buoyed her just enough to persevere in a life she described as meaningless and filled with apathy, guilt, and shame.

Celeste’s guilt and shame dates back to her childhood. When she was 5 years old, her father died suddenly from a ruptured brain aneurysm. Starting that day and for years afterward, Celeste’s mother told her and her siblings that they were responsible for their father’s death because they had “demanded” that he take them to the county fair the day he died. If they had not “forced” their father to take them to the fair, Celeste’s mother said, their father would not have died.

Children, just like the rest of us, often do not or cannot parse what they hear, and Celeste believed her mother. From that day on, she has been convinced that she killed her father. And because she killed him and left her mother a widow, Celeste vowed silently to herself that she would forsake her own needs and pleasures so she could take care of her mother.

Celeste was a good student and won several academic awards in high school. Even so, she stayed close to home and attended a college far less demanding and prestigious than others she might have attended.

She has since had a string of jobs with a fair amount of responsibility. However, she never feels that she does a good job or contributes much, despite objective evidence to the contrary, such as superlative evaluations and offers of promotion.

Throughout our time together before the seizure, Celeste kept herself hidden from her friends and colleagues. She would fend off any questions of a personal nature and conceal as much of her personal life as possible. She especially avoided talking about her depression, which she felt was a direct result of her shame and guilt for killing her father.

Although Celeste long ago devoted herself to caring for her mother, she can never please her mother. Indeed, her mother constantly harangues and berates Celeste for not being smart, for never having moved out of the house, for never having married, and for never having accomplished much at any of her various jobs. Despite this overt criticism, Celeste’s mother seems secretly pleased that Celeste has forsaken everything else in life to remain close to her. (Celeste’s mother has never accompanied her to any of our therapy sessions.)

Until we began meeting, Celeste bore the feelings of shame and guilt alone. The isolation she felt no doubt made whatever she was feeling that much worse. Everything changed once Celeste had the seizure. Just after her seizure, with one of her coworkers at her side, Celeste told the ED physician that she was taking fluoxetine and bupropion. With that statement, the secret of her depression was out.

Celeste called me from the ED to tell me what had happened. I felt responsible for her seizure and terrible for her-even though I had told her of the risks of starting combination therapy with bupropion. I also wondered whether word would get out around work about her medication use and depression. It is one thing to reveal one’s secrets willingly and another entirely when one is exposed because of external circumstance.

Before our next appointment, I felt a mixture of sadness, guilt, and fear. I worried that even though Celeste had come to respect me, she might harbor anger toward me (and might possibly sue me) or more generally that she would no longer trust my judgment and would no longer want to be treated by me. As I opened the door to my waiting area, Celeste smiled and looked happy. She quickly told me that she harbored no anger toward me and laughed at the prospect of filing any kind of complaint against me. She shocked me when she said that one day after she experienced the seizure, she had never felt better.

As we talked, I came to see that she was not exaggerating. I wondered at first if the seizure had had some effect on her brain, the way electroconvulsive therapy does, and whether the neurological effects of the seizure accounted for her mood change. “Forced normalization” in this fashion certainly may have contributed to her improvement.

I found out that another element had also played a role in her improvement. After Celeste’s seizure, word quickly spread not only of her seizure but also of the fact that she was being treated for depression. Instead of the negative backlash she had feared, just the opposite occurred. Colleagues began sharing their own struggles with depression or their histories of taking psychiatric medications. As a result, she has begun to feel far less like the freak she thought she was and now feels much more normal.

The seizure liberated her from her need to keep her depression secret, and the result has been a tremendous lightening of her mood. Celeste still has a deep-seated belief in her own culpability in her father’s death, and dispelling that myth has been one of the foci of our therapeutic work. Although consciously she can say that, of course, she is not responsible for her father’s death, extracting that belief from the recesses of her inner psyche is not so easy and will not happen quickly. But over time and through therapy, she is starting to believe what she already knows.

Articles

Celeste, one of my patients, a woman in her mid-30s, unexpectedly had a seizure, fell, and hit her head while at work. She was rushed to a nearby emergency department (ED) where results of laboratory work, an EEG, and an MRI confirmed that she had had a seizure but did not show a cause.

An Unusual Side Effect

Dr Rick Miller, a 35-year-old internist, was just trying to be polite when he nearly ended his medical career.

Dr Miller was referred to me from a detoxification unit at a local hospital. He had been admitted a week earlier because of his oxycodone use, which developed over a 2-year period and culminated with a habit that required 600 to 800 mg of the drug daily. Dr Miller had been writing prescriptions for himself in his wife's name and using her driver's license (which he had stolen) to fill the prescriptions.

His oxycodone abuse came to an abrupt halt when he was arrested at a pharmacy. Within a few hours, he had surrendered his DEA license, stopped practicing medicine, and entered an inpatient detoxification unit. He stayed in the facility for 7 days-a short amount of time given the extent and severity of his opiate dependence-and was discharged with a prescription for paroxetine.

As part of his discharge, Dr Miller signed a 5-year chemical dependency monitoring contract with Physicians Health Services (PHS) that mandated regular check-ins with one of its associate directors, frequent and random urine drug screens, psychotherapy with a therapist of his choice (namely myself), and regular attendance at Alcoholics Anonymous meetings. Dr Miller and I have been working together for the past 7 years.

Despite feeling both depressed and shaky on his hospital discharge, Dr Miller maintained complete abstinence from opiates and other substances of abuse (with the exception of a glass of champagne at a wedding 2 years into his contract and another a year later while vacationing with friends at the beach) and came regularly to our therapy meetings. He discontinued paroxetine after about 6 months, and he resumed part-time work in a private practice group setting about a year later. Unlike before his arrest, he now genuinely seemed to enjoy his work.

Dr Miller worked hard in therapy, struggling to understand his past and its role in his substance abuse. He told me whenever he was tempted to use opiates: once a patient thrust a bottle of oxycodone toward him, telling him that he did not want it; another time a colleague handed him a bottle of hydrocodone and asked him to dispose of it. In both instances, he abstained. Because of confessions like this-as well as my general sense of how he was doing- I always felt that Dr Miller was being honest with me and was doing well in sobriety and otherwise.

I was surprised, therefore, when 3 years into our work together I received a call from a PHS associate director telling me that Dr Miller had tested positive for morphine. He also asked me whether I knew anything about this. I told him that I thought Dr Miller was doing well and that I could not explain the positive result. I hastened to add, though, that I realized I could be fooled.

When we hung up, I called Dr Miller and told him what I had just heard. He assured me he had not relapsed but could not explain the positive test result. I believed him, but in the face of the test I had some small level of doubt. We agreed to meet the next day.

When we met, Dr Miller said that since we had spoken the day before, he remembered that he had not eaten breakfast the morning before his last urine test. When he arrived in the office that day, the nurses offered him some Sociable poppy seed crackers. He ate the first cracker out of politeness. He liked it a lot, he added, and realizing his hunger, he ate half the box before heading off to his urine test. Maybe the poppy seeds in the crackers were the source of the positive test results, he surmised.

I wanted to believe him, but over the years I had seen some smart physicians who had relapsed despite intensive therapy and monitoring, so I had my suspicions. Dr Miller said he told his story to the associate director and was waiting to hear back from him. If PHS were to decide he had violated the terms of his contract, they would report the relapse to the Board of Registration in Medicine, which would jeopardize his license.

Several days passed before we heard back from PHS. When the associate director called, he told us that he was initially skeptical of Dr Miller's Sociable cracker explanation. In fact, he was so skeptical that he ate a handful of the crackers and then tested himself. He tested negative.

The following day, the associate director ate a whole box of the crackers on an empty stomach and, voilà, the test came back positive for morphine! This test satisfied him that Dr Miller was telling the truth and had not, in fact, relapsed. Case closed.

Five years later, Dr Miller continues to practice medicine well and without incident. PHS now has written into its chemical dependency contract that clients should not ingest a variety of substances that might yield false positive test results, including poppy seed crackers.

Sometimes, indeed, it's best not to be too sociable.

Dr Boyd is a lecturer in the department of psychiatry at Harvard Medical School and attending psychiatrist at Cambridge Health Alliance. He recently became an associate director at Physicians Health Services and reports no conflicts of interest regarding the subject matter of this article.

Hydrocodone (Vicodin)  
Oxycodone (OxyContin)  
Paroxetine (Paxil)

You are surprised when a patient of yours, a physician recovering from a substance abuse problem, tests positive for morphine. Do you believe his explanation of a false-positive result?

Sometimes It’s Better Not to Be Sociable

Those who suffer from mental illness smoke cigarettes at astoundingly high rates compared to those without some form of mental illness. We have published data showing that between 50% and 80% of those suffering from a major mental illness (such as major depression, bipolar disorder, generalized anxiety disorder and schizophrenia, among others) smoke, whereas less than 40% of those who have never had mental illness smoke (Lasser et al., 2000). In all, people with mental illness consume 44% of all cigarettes in the United States, an exceedingly high figure that might surprise even the most sanguine mental health care professional.

This statistic bears within it numerous individual stories of pain and suffering. Consider the case of one of our patients, whose woeful story no doubt mirrors that of many others we treat who suffer with chronic mental illness:

"Mario" started hearing voices over a decade ago after experimenting with LSD, developing a prolonged psychosis that required several extended stays in psychiatric hospitals with a diagnosis of chronic paranoid schizophrenia. At 35 years old, Mario is perpetually disheveled, with a starry look in his eyes. Mario receives $650 per month from Social Security for disability and, except for his occasional brief forays into the working world (which usually end when voices tell him to quit or when he decides that his bosses are conspiring against him), has no other income. He spends $350 on rent for a subsidized apartment in western Massachusetts and about $50 per month on food beyond what his food stamps will pay.

Like so many others with chronic mental illness, at two packs per day and about $4 per pack, the rest of Mario's money -- roughly $240 per month, nearly 37% of his total monthly income -- goes to cigarettes. Since virtually all of Mario's income comes from the government, in a more cynical moment we might think that he is little more than a bagman whose job is to deliver government money to Big Tobacco.

What will become of Mario in 30 years, almost $100,000 in cigarettes later? Perhaps, like one 65-year-old patient with schizophrenia we met, as a result of smoking-related damage to his respiratory tract, Mario will become an "aspiration risk," unable to prevent food from passing down his trachea into his lungs. And maybe, like this patient, Mario will develop repeated pneumonias, will require frequent ventilation support in the intensive care unit and eventually will need a feeding tube placed directly into his stomach to prevent further pneumonias, costing our health care system thousands of dollars.

Or, perhaps like another 65-year-old patient with schizophrenia we have encountered, Mario will develop a massive lung cancer that, because of his psychosis, he will refuse to have treated.

Tobacco hits the mentally ill especially hard. Roughly one-third of all smokers will die early because of their habit (American Lung Association, 2001). Living with lung cancer or emphysema is hard enough, but imagine trying to make decisions about treatment options or end-of-life issues in the midst of a dark depression or active psychosis. Those with mental illness are often the least capable of coping with the devastating medical illnesses caused by smoking.

Various groups use the association between mental illness and smoking to their advantage. Psychiatric units that allow smoking are generally much more popular among patients than smoke-free units and thus generate more revenue. Many of these psychiatric units further use smoking to their advantage by offering cigarette privileges as rewards for good behavior. At one local unit, patients who break minor rules (such as yelling or refusing to participate in groups) are not allowed to go on the next scheduled smoke break. (At that unit, there were six such breaks throughout the day.) Those patients who are assaultive or require restraints are not allowed to smoke for 24 hours.

The tobacco industry also uses the association between mental illness and cigarette smoking to its advantage. R.J. Reynolds Tobacco Co. noted the perception among smokers that tobacco "helps perk you up" and "helps you think out problems," as well as providing "anxiety relief," and helping people "gain self-control," "calm down" and "cope with stress" (Nordine, 1981, as cited in Lasser et al., 2000). (Recent studies have shown that the opposite is true and that smoking often precedes the onset of mental illness.) 

Could the tobacco industry be unaware that advertising that highlights the youthful, healthy effects of smoking might be particularly appealing to those with mental illness? After all, the Marlboro Man is the epitome of calm self-assuredness. He does not appear to be anxious, depressed or hallucinating -- though we might wonder if he gets a bit sad riding all alone. Have all of his cowboy buddies passed on to the great prairie in the sky because of their tobacco habits?

Unfortunately, tobacco does not deliver any mental health benefit. In fact, it directly contributes to depression and anxiety. In addition, its physical effects -- emphysema, cancer and heart disease -- can certainly make a person feel blue. If the tobacco companies have not hesitated to peddle their goods to children and the Third World, why should we presume they do not also target those with mental illness -- the group that comprises 44% of their market? 

What should we do with this information? First, we need to pressure tobacco companies not to mislead their customers by falsely promoting their products as avatars of health. Those with mental illness probably have a more difficult time than most sorting out the specious claims and implications of tobacco advertising. Second, physicians need to target their patients with mental illness for smoking-cessation efforts. People with mental illness are able to quit smoking, despite some attitudes to the contrary. Third, parents should be alert to the smoking habits of their children -- a child who begins smoking may be at increased risk for mental health problems (including substance abuse) and warrants close observation. Fourth, we need to advocate raising taxes on tobacco. Studies have shown that increased cigarette taxes cut cigarette consumption by teenagers. Perhaps the same would be true for the chronically mentally ill, many of whom, like Mario, have very limited incomes. Fifth, we should pressure our legislators to expand Medicaid coverage (which is the only insurance many with mental illness have) to include smoking-cessation counseling and medications. Finally, we ought to work to ensure that all of the money that states receive in settlements from Big Tobacco be earmarked for tobacco control. Some of this money should be devoted specifically to smoking-cessation and tobacco education efforts aimed at the mentally ill.

We must do all we can to protect everyone, especially our patients who are among our society's most vulnerable, from the devastating effects of tobacco.

American Lung Association (2001), Quitting smoking: Why should cigarette smokers think about quitting? Available at: www.lungusa.org/tobacco/quitting_smoke.html. Accessed Aug. 30.
 

Lasser K, Boyd JW, Woolhandler S et al. (2000), Smoking and mental illness. A population-based prevalence study. JAMA 284(20):2606-2610.

Between 50% and 80% of people with mental disorders smoke cigarettes. Are the tobacco companies targeting this population, and are mental health care facilities promoting the use of tobacco? What are psychiatrists' responsibilities in the overall health of their patient?

Tobacco Madness

Nonprofit health maintenance organizations (HMOs) state that their goal is to serve the public, whereas the main goal of for-profit HMOs is profit generation. One might assume, therefore, that the operating procedures of these two types of HMOs would be different from one another. A recent experience of mine, however, suggests otherwise.

I routinely take calls at one of the psychiatric hospitals in the area. Although I am not a child psychiatrist, I am occasionally called to the child psychiatric unit to admit a new patient or in the case of emergencies.

I had just arrived at the hospital on a Friday evening when I was called to the child psych unit. A child who'd been admitted to the unit five days earlier had been told that he was going to be discharged and was "balking."

When I arrived on the unit I found out that "balking," in fact, meant screaming at the top of his lungs, crying, banging his head on the wall and swearing that he was going to jump out of the car on the way home and try to kill himself. He also screamed that even if he did make it home in one piece, he'd burn down his apartment and kill his whole family in the process.

"We can't discharge this kid like this," I said. "That would be crazy. I've admitted many kids to this unit who look better than this when they're admitted."

The nurse in charge looked relieved. "Thank you," she said. "That's exactly how I feel."

Since discharging anyone from a psychiatric unit late on Friday is generally a bad idea, I asked how it was that this discharge had been planned.

I was told that the discharge had not been planned, but that the well-established nonprofit HMO's psychiatrist who would be responsible for this child's outpatient care-and had not yet seen this child-called and told the psychiatrist in charge of the unit (who had already gone home for the day) to discharge the boy. The unit psychiatrist then called the unit and told the nursing staff to discharge him per the nonprofit HMO's request.

As I discussed the situation with the nursing staff on the unit, they told me that the same thing had happened with this boy one week earlier. They said that as he was being dragged out of the unit the previous Friday, he had vowed that he'd be back within three days because of multiple suicidal threats. When he managed to jump out of a moving car two days later, suffering minor injuries, his promise was fulfilled.

I was incredulous. We called the boy's mother to tell her that we would not discharge her son this weekend.

"But the [HMO] psychiatrist just told me that I'd have to pay $1,000 a day to keep my son in the hospital over the weekend, and I don't have that kind of money," she said. "I need to come get him."

"I'll take responsibility for this decision," I said.

"I can't take the chance that they'll charge me for the weekend. I'm coming to get him," she said.

She called a half hour later, crying, and told us that her car had broken down on the way to the hospital. In desperation she had spoken with the HMO psychiatrist who again told her she'd be responsible for the bill over the weekend if her son weren't discharged. What about the broken car? The patient's mother said she'd been told to have her son sent home in a cab.

"A cab?" I was stunned. A kid who had jumped out of a car five days earlier and who was swearing that he'd jump out of a car on the way home? A kid who was going to burn down his house? Discharge him at all-much less in a cab? I felt like I'd entered a fun house.

I told the mother, the patient and the nursing staff that no matter what the HMO said, this boy was not going to be discharged while I was on duty. I asked the mother who the HMO psychiatrist was and told her I'd speak with him myself. When she told me his name, my heart sank. It was a psychiatrist I knew, who most people found caring and competent, a devoted father to his own children. 

I called this psychiatrist at home, told him what I'd heard, what I'd seen, and said that the boy was going to stay in the hospital. Without accusing him directly, I simply said that I expected that his mother would not be threatened with having to pay her son's hospital bill.

In his defense, this psychiatrist said that he feared this boy was becoming institutionalized. An institutionalized patient is managed care's biggest fear because an HMO depends on healthy patients, who do not utilize the services it (theoretically) offers, to remain financially solvent. Institutionalized patients are costly "utilizers."

"This boy may be becoming institutionalized, but wishing otherwise isn't going to change how he is right now," I said.

As I hung up the phone, I wondered, "Whose side are we on?" As psychiatrists, we actually work 

the health of our patients when we succumb to the pressures our institutions place on us-when we start believing that working for the financial health of our institutions is our primary goal.

Whether "for-profit" or "nonprofit," HMO bureaucrats and administrators be damned, let us focus on caring for our patients and working toward their health. Doing anything else jeopardizes us all. 

J. Wesley Boyd, MD, PhD

Articles

An Unusual Side Effect

Sometimes It’s Better Not to Be Sociable

Tobacco Madness

Commentary: Whose Side Are We On?