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Editor's note: This article was originally published on August 19, 2016 and has since been updated. PDF version.

What factors predispose patients to TRD and what treatment strategies achieve response? Find out here, with a bonus case vignette.

6 Signs Your Patient Is at Risk for Treatment-Resistant Depression

“Got a challenging case-a patient for whom the diagnosis is unclear or uncertain? Want a diagnostic opinion?

If so, we invite you to submit a brief description of key clinical details (no more than 800 words) plus a description of why you find the case to be diagnostically challenging.

Michael First, MD-nationally recognized expert on psychiatric diagnosis and assessment issues will review those details and offer insights on select cases.

Dr First, Professor of Clinical Psychiatry at Columbia University, is the Editorial and Coding Consultant for DSM-5, Chief Technical and Editorial Consultant on the WHO’s ICD-11 Revision project, an external consultant to the NIMH’s RDoC (Research Domain Criteria) Project and author of a number of books about psychiatric diagnosis, including the DSM-5 Handbook of Differential Diagnosis.”

Only submissions from mental health professionals will be considered. Please include your name and degree with your case along with an e-mail address in case Dr. First needs to contact you for additional information. To help preserve confidentiality, if your case is selected for publication in 

AMENDMENT TO OUR INVITATION: If you are a nurse or nurse practitioner, you may send your case to editor@psychiatrictimes.com for consideration. -The Editors

Got a challenging case-a patient for whom the diagnosis is unclear or uncertain? Want a diagnostic opinion? This is a call for cases. Michael First, MD-a nationally recognized expert on psychiatric diagnosis and assessment issues-will review details and offer insights on select cases.

Call for Challenging Cases

A 30-year old woman with a history of moderate depression presents to your clinic after completing a pregnancy test at home, which was positive. This patient is excited to be pregnant, albeit surprised. She is currently on sertraline, and has been stable on this for many years.

She has a prior history of moderate depression, and during her last episode 2 years ago, she experienced some passive suicidal thoughts, but has never had a suicide attempt. She is concerned about the possible effects of her medication on the fetus, and is very insistent that she would like to stop her medication as soon as possible.  What should you do?

 Any or all of the above except (B) would be reasonable options to discuss with this patient.

Perinatal patients offer a uniquely appropriate population for a truly integrative approach, in that utilizing complementary and alternative therapies to augment the efficacy of a patient’s current treatments can be an effective way to reduce fetal/infant exposure to a psychotropic. To our knowledge, there are no contraindications to adding any of the recommended modalities to currently available medications.

The literature supports a number of integrative treatment approaches for perinatal MDD. Exercise and yoga have good evidence to support their use, and there is encouraging research supporting mindfulness and massage as well. These stress-reducing and skill-building approaches hold particular promise because the skills acquired could enhance parenting, bonding, and childhood development. In addition, based on good evidence for improving overall pregnancy outcomes, it is worth recommending both group visits and supplementation with omega-3 fatty acids, even though the evidence for efficacy in perinatal depression is still mixed.

Perinatal Depression: An Evidence-Based Review of Integrative Treatment

Your patient is excited to be pregnant. She is currently on sertraline, and has been stable on this for many years. She is very insistent that she would like to stop her medication. What should you do?

Mini Quiz: Perinatal Depression

The lady doth protest too much, methinks.

Dr. R is a psychiatrist who has been in private practice for 15 years in a large urban city in the Northeast.

 His practice consists mostly of psychodynamic psychotherapy with some minor medication management. The majority of his patients are self-pay.

Ms. B is an attractive, very intelligent 36-year-old single woman whom Dr. R has been treating for about 6 months for what initially appeared to be an adjustment disorder with depressed mood resulting from an unfortunate career reversal. Most of the sessions have revolved around Ms. B’s feelings of betrayal and embitterment regarding the loss of her academic post in the music department of a large university in the Midwest, where she previously lived. Ms. B insists that a student had falsely accused her of improper sexual advances and that because of department politics, she was forced to resign a year ago. At the time Ms. B says she was a promising concert violinist and music scholar.

Ms. B is distraught that after having graduated from a famous conservatory the only job she has been able to obtain is directing the music program at a local private school. She is enraged that circumstances have reduced her to such a lowly position. Dr. R is well aware of the literature on adjustment disorder and that these patients have an elevated risk of suicide.

The central theme that has emerged in therapy is Ms. B’s loss of reputation and honor and her extreme resentment regarding the unfairness of academia. She vehemently blames the Chair of the department for not defending her against what she perceives as ridiculous allegations from a student who did not get the grade he wanted in her music theory class. She voices revenge fantasies but states that she “would never act on them as I am beyond such primitive reactions; that is why I am in therapy.” As the therapy proceeds, the psychiatrist begins to doubt Ms. B’s account of her recent events and even questions her history as a musician. His psychodynamic formulation is now moving toward a narcissistic personality disorder or even, at times, delusions of grandeur suggesting a bipolar diagnosis.

Repeated efforts using a variety of psychotherapeutic techniques to explore Ms. B’s family of origin or to enable her to describe the emotional effects of the professional upheaval are met with accusations that Dr. R is calling her a liar and a renewed preoccupation-even obsession-with her stolen fame. Ms. B rebuffs any reinterpretation of her experience with the response that “you must have read all about this when I was humiliated in the newspapers; of course it happened exactly as I told you.”

Dr. R is becoming increasingly skeptical of Ms. B’s personal narrative and frustrated with her resistance. He is a regular reader of several major newspapers and a music aficionado yet cannot recall ever reading anything about Ms. B. After much struggling with his own sense of psychoanalytic boundaries, Dr. R finally decides to try to substantiate at least the basic details of Ms. B’s story. He fears that unless he can obtain some reliable independent report about her past he will be unable to constructively help her build a future.

Dr. R believes that the most efficient means of accessing such information would be through the Internet, where he can run a targeted search using the facts as he knows them from the therapy. Dr. R has not kept up much with digital professionalism. He is aware of colleagues who are on Facebook and some who advertise their services on the Internet. He knows that a few even regularly provide psychiatric commentary in blogs. “Googling” a patient does not seem much different from the old-fashioned obtaining of collateral information, but he is unsure of the legal or even ethical ramifications of using the Internet to gather such information. He calls an old friend who was his psychology professor in college and who now teaches ethics at a local college for advice.

Assume you are the psychology professor. What do you tell Dr. R about the ethics of “Googling” Ms. B?

 Go ahead and Google; the Internet is public domain, and there is no ethical or legal problem with accessing the information.

 Do not Google the patient; it is a violation of HIPAA, which protects the electronic exchange of individually identifiable information.

 Don’t Google the patient; it is a breach of the patient’s trust in the therapeutic alliance.

 Don’t Google the patient; instead go to the public library and search the major newspapers from the city where Ms. B purports the events occurred.

2 The professor tells Dr. R there is no ethical reason he cannot Google the patient. Dr. R then asks if he should obtain informed consent from the patient to conduct the search.

 No, don’t tell her. This undermines the entire psychological purpose of the activity and its ethical justification to find out the truth, so you could help her in therapy.

 No, don’t ask her permission, but you can tell Ms. B later that you conducted a search to be better able to understand and work with her in therapy.

 Yes, ask her permission out of respect for her privacy.

Yes, ask her permission and suggest that you do the search together in your office during a session.

3 The professor tells you not only is it ethically permissible to Google Ms. B but that you actually have an ethical obligation to conduct the search in order to provide appropriate care. Does Dr. R really have an ethical duty to Google Ms. B, and if so, what is its nature?

Yes, Dr. R has a duty to overcome his own negative counter-transference toward the patient so that he can form a therapeutic relationship.

 No, Dr. R does not have an ethical obligation to Google the patient because doing so is a breach of physician-patient confidentiality.

 No, Dr. R has an obligation to work within the psychodynamic frame to empathically understand and effectively treat the patient.

 Yes, if Dr. R does not review information accessible to him that could potentially prevent harm to the patient, and if she attempts suicide, he will not have done his duty to protect her and could be held legally liable.

Dr. R decides to Google Ms. B because he fears that unless he knows what really happened to her, her enraged desperation may result in her harming herself or someone else. He finds a few stories in the city newspaper as well as a brief statement from the university about the incident. From these communications, Dr. R learns that Ms. B was not only charged with allegations of sexual impropriety with a student, but the charges were actually substantiated and she was given a choice to resign or to be terminated. She is described as an instructor in the department and a substitute violinist in the local symphony-hardly the irreproachable luminary of classical music she portrayed herself to be in therapy.

4 Now that Dr. R has this information, what should he do with it?

 At the next session, Dr. R should tell Ms. B that he Googled her and would like to discuss what he found so that they can engage in more productive work about her real problems.

 At the next session, Dr. R should tell Ms. B that he Googled her and that she has a right to know what he learned, so she can make an informed decision about whether to continue in therapy.

 At the next session, Dr. R should not tell Ms. B that he Googled her but should begin shifting the therapeutic approach from adjustment disorder to narcissistic personality disorder.

 At the next session, Dr. R should not tell Ms. B that he Googled her; instead he should say that he had read about her in a newspaper at the time of the incident but recalled the details differently and could they discuss the discrepancies as a means of moving her toward insight.

Ethics consultations often involve a number of different and often conflicting ethical concerns and questions. Please vote for your choices-and post your comments below. I’ll offer a discussion of your comments and commentary about the ethical concerns and questions this case raises in a coming issue of Psychiatric Times.

Dr. Geppert is Professor of Psychiatry and Director of Ethics Education, University of New Mexico School of Medicine; and Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System, Albuquerque, NM. She reports no conflicts of interest concerning the subject matter of this article. 

“Googling” a patient does not seem much different from the old-fashioned obtaining of collateral information, but the ramifications may be far more than you bargain for.

To Google or Not to Google? This Is the Question

There are three witnesses, the Spirit, the water, and the blood, and these three agree.

, readers were asked to assume the role of an ethics consultant called emergently to the bedside of Mr M, a patient in critical need of a blood transfusion. Mr M had accepted several transfusions earlier in the hospitalization but now says he is a Jehovah’s Witness and allowed the transfusions only because he thought he was receiving his own blood. An advance directive cannot be found, nor next of kin. The emergency contact is a girlfriend, S, who told the attending she thought Mr M was “crazy” and advocated strongly for the transfusion.

The attending has concerns the patient lacks the decision-making capacity to refuse and could even be suicidal. The consulting psychiatrist believes the patient is alternating between delirium and lucidity and is not suicidal but frustrated with his medical situation. The attending is anxiously awaiting your arrival to resolve the dilemma.

Before you can begin to offer ethically justifiable recommendations, you must work through the answers to 4 key questions.

 Ethics consultations often involve a number of different and often conflicting ethical concerns and questions. As the ethics consultant, which of the following do you think is the central ethics issue in this case?

 If the patient has decision-making capacity, he has the right to refuse a blood transfusion.

 It is unclear whether the patient has a surrogate who is able and willing to make decisions that respect his wishes and values.

 Since the attending has the ability to save the patient, she also has the duty to do so since she does not believe he has capacity.

 The team believes the patient is incapable because he is refusing the clinically indicated medical treatment.

Option A is certainly true. Courts have upheld the right of adult patients with decision-making capacity to refuse a blood transfusion based on religious beliefs.

 (The same is not true for children.) But the psychiatrist is equivocal about the patient’s capacity secondary to his fluctuating mental status.

If this is true, then B-identifying a surrogate-is crucial. But is this really an ethics question? Or is it part of the fact pattern we need to gather in doing the consultation?

The primary team has identified S-a girlfriend whose status as a surrogate would be highly dependent on state law. Often, overworked intensive care and medical teams understandably cast about for anyone to help make urgent medical decisions, and they frequently do not have the knowledge to identify the ethically appropriate decision maker. This is a good place to involve social workers in an attempt to locate an advance directive. If one is not available-which is the situation for about 75% of American patients

-try to contact any family members, who would be the designated surrogates in most state hierarchies of priority.

The attending is morally distressed because of all the uncertainty. Acting on a default ethical and legal position many physicians assume, she believes she has an obligation to save Mr M’s life (option C). The attending considered the implied or presumed consent, often employed in emergencies when there is no time and no voice for the patient.

 Except that the attending recognizes-and herein lies the source of her distress-that if Mr M is capable and this is his real faith position, then she should respect the patient’s beliefs, even if it means he dies.

Option D is true more often than not. Scholarship and experience suggest that clinicians are far more likely to question capacity or determine a patient is incapable when he or she refuses medical and psychiatric treatment or asks to leave the hospital against medical advice.

2 If the psychiatrist determines that the patient lacks decision-making capacity and the team cannot identify another surrogate decision maker, can S act on Mr M’s behalf?

 Yes, because she is acting out of his best interests to save his life.

No, because she is not making the decision according to the patient’s preferences and values as she is required to do as a surrogate.

 No, because only an individual who shares Mr M’s Jehovah’s Witness beliefs can be asked to make a decision based on religious grounds.

 Yes, because there is no advance directive and so the surrogate has to make the decision she believes Mr M would make if he could think clearly.

A expresses what many health care professionals-and even laypersons who do not share the patient’s beliefs-may secretly think should happen. From the comment S made to the attending, it seems pretty clear she shares this perspective. Often exasperated practitioners would point out that S would be acting in Mr M’s broad best interest of continued physical life, while detached ethicists will opine Mr M’s higher spiritual values are being discounted.

When confronted with this understandable lack of understanding, I try to remind myself and my fellow clinicians that all of us have beliefs and values that another individual could feel are irrational or-put more kindly-that are at least not worth dying for. Option C suggests that only a person who shares Mr M’s faith tradition should make the decision about blood transfusions. This is why members of the local congregation-whether it is Jehovah’s Witness5 or any other religious tradition with strong and distinctive beliefs and practices-will frequently be present at the bedside of a fellow believer to ensure the patient’s rights and wishes are honored. But while shared belief systems probably make difficult decisions such as refusing a transfusion more ego-syntonic, respecting only the patient’s beliefs is ethically considered necessary.

Option B is correct in that any surrogate with integrity who recognizes that his or her legal and ethical duty is to “substitute” the patient’s “judgment” were he able to exercise it could make the decision about transfusion. If S truly turns out to be the only person in Mr M’s life who can act on his behalf, it would not be her girlfriend status but her inability to respect what are supposed to be his beliefs and preferences that would disqualify her.

D uncovers yet another layer of uncertainty. Do we really know if Mr M is a Jehovah’s Witness who actively practices his faith? Many persons for whom religious beliefs are very important in medical decision-making carry with them documents, symbols, or alerts indicating their faith stance. Mr M did not have any testimony to his beliefs in his belongings, nor had he mentioned his religious objection to transfusions at any time earlier in his hospitalization. But is that sufficient proof to violate a person’s most sacred commitments or conversely to risk their life?

3 One of the most important things to do as either an ethics or psychiatric consultant when a patient refuses a treatment-especially one that is lifesaving-is to try and understand why he is refusing. Which of these rationales do you find most plausible?

 Mr M is expressing his autonomy in the only way open to him in circumstances where he feels he is not respected and has little control.

 Mr M really believed that he was receiving an autologous transfusion and that his religious beliefs permitted him to accept his own blood.

 Mr M is not truly a Jehovah’s Witness but is refusing the transfusion as a way of indirectly killing himself without the psychiatrist being able to legally intervene.

Mr M did not really have decision-making capacity when he initially accepted the transfusions.

The psychiatrist can be of great assistance to both the ethics consultant and the attending physician through empathic validation of what Mr M is trying to communicate through his refusal. Option A is likely at least part of the story. Mr M had just endured several attempts at an ultimately failed bone marrow aspiration, and no one can tell him what is wrong after days of tests, except that he might have cancer-which to him, as to many patients, is a death sentence he would rather carry out himself. Fortunately, at the time of the consult he is not asking to leave the hospital against medical advice, but if the current crisis is not resolved, that might be his next step.

Even though the psychiatrist does not think option C is accurate (Mr M not being suicidal), he will have to decide whether Mr M can really be allowed to go home in his physically ill and mentally disturbed state.

To answer B will require a knowledgeable chaplain or a call to a representative of the Jehovah’s Witnesses. Mainline members of the religion in the US do not accept autologous blood transfusions because “Witnesses believe that blood removed from the body should be disposed of, so they do not accept autotransfusion of predeposited blood.”

 This returns us to the question of Mr M’s faith.

Option D raises even more doubts regarding Mr M’s authentic views about blood transfusions. Ethics and psychiatric consultants frequently find that the informed consent process was less than adequate, and given the severity of Mr M’s anemia (even after transfusion of 2 units of packed red blood cells, his hemoglobin and hematocrit are 7 g/dL and 20%, respectively) and other medical conditions, it is not hard to see how he could have been delirious from hypoxia when he consented to the previous transfusions in the ICU.

 The attending is asking for your recommendations regarding whether to transfuse the patient. Which of these responses would you give?

 Transfuse Mr M so that his delirium can resolve and he can make an informed and reasoned decision regarding the transfusion.

 Recognize S as the authorized decision maker and follow her wishes and transfuse Mr M.

Respect Mr M’s beliefs as a capable adult who can legally refuse a blood transfusion on legal grounds.

 Obtain the agreement of a second attending physician and transfuse the patient using emergency consent.

As in so much of medicine and psychiatry, the ethics consultant must now make a recommendation with serious consequences with incomplete information. Option A is ethically attractive to physicians because it appears to permit the attending to both save the patient’s life and respect his beliefs. But as in Question 2, this fails to respect the salience of religious commitment in a person’s life and choices or that for such an individual, there could be spiritual and even psychosocial repercussions from transfusion more unbearable than death.

Option B returns to the dubious role of girlfriend S-not only in Mr M’s daily existence but more significantly in his spiritual life. We have no idea of the nature, length, or depth of the relationship between the two and whether S can really meet the bar of surrogacy to even know which direction Mr M would choose in this impasse. We must have a healthy skepticism that for motives of good or ill, she does not share his religion but wants to keep sharing his life.

Option C is the most ethically justifiable course if there is surety that Mr M is capable and a devout Jehovah’s Witness. Yet if he is either incapable or not a believer, then the choice risks his death without a legally authorized surrogate or a higher spiritual warrant.

D is a version of A but may make the attending feel less burdened because she has the concurrence of a colleague. This is the “2 physician rule,” which is the law in many states and also included in many hospital policies for decision-making in an emergent situation when the patient has neither capacity nor a surrogate. The research shows that physicians make these emergency decisions according to medical rationales that express our own medical culture and values-meaning in general that Mr M gets the transfusion.

Astute readers may wonder why neither the psychiatric consultant nor the attending physician has considered perhaps the optimal resolution of the conflict to be the use of alternative blood products and methods, which would be acceptable to a Jehovah’s Witness and which have reasonable outcomes.

 This would enable both ethical values posed at the beginning of this commentary to be upheld. Ethical dilemmas are about choices not between right and wrong, which would be straightforward rules or law-but between right and righter or wrong and wronger, the varied valences of human moral action. The job of the consultant is to remind and help stakeholders find that even in the most desperate of moral conflicts we must strive to follow the maxim of the late Mr Spock’s “there are always options.”

 Barron CH. Blood transfusions, Jehovah’s Witnesses and the American Patients’ Rights Movement. In: Maniatis A, Van der Linden P, Hardy J-F, eds. 

Alternatives to Transfusion in Transfusion Medicine

. 2nd ed. Oxford, UK: Wiley-Blackwell; 2011:531-558.

 Rao JK, Anderson LA, Lin FC, Laux JP. Completion of advance directives among US consumers. 

 Veatch RM. Implied, presumed and waived consent: the relative moral wrongs of under- and over-informing. 

 Ganzini L, Volicer L, Nelson WA, et al. Ten myths about decision-making capacity. 

 Shaner DM, Prema J. Conversation and the Jehovah’s Witness dying from blood loss. 

 Dixon JL, Smalley MG. Jehovah’s Witnesses. The surgical/ethical challenge. 

 White DB, Curtis JR, Lo B, Luce JM. Decisions to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision-makers. 

 Posluszny JA Jr, Napolitano LM. How do we treat life-threatening anemia in a Jehovah’s Witness patient? 

Does this patient have decision making capacity to refuse a blood transfusion that will likely save his life? You are the ethics consultant, and the decision is yours.

Blood, Truth-and the Decision to Transfuse

Mr M is a 56-year-old unmarried man on disability who has a history of a right-sided middle cerebral artery hemorrhagic stroke, hypertension, alcohol use disorder, and prior upper gastrointestinal bleeding secondary to the alcohol use. He presents to the emergency department of a busy academic medical center with severe anemia. His hemoglobin level is 5 g/dL, and his hematocrit is 17%. Mr M is dysarthric from the stroke and so a difficult historian but does report episodes of epistaxis and melena. Review of the medical record does not identify any previous episodes of anemia serious enough to require transfusion.

He is immediately admitted to the ICU, where he provides signature informed consent for a transfusion of 2 units of packed red blood cells. The critical care team begins an extensive workup for the cause of the anemia. Over the next 2 days, the team is unable to establish a definitive diagnosis, and the patient requires another transfusion. His hemoglobin and hematocrit stabilize at 7 g/dL and 20%, respectively. His bleeding continues but has slowed, and he is transferred to the acute medical ward.

A lung lesion is found on a CT scan as well as diffuse lymphadenopathy. The hematology-oncology consultant suspects lymphoma and attempts a bone marrow aspiration and biopsy to make a definitive diagnosis. The procedure is so painful that after several attempts, the patient declines to try again.

Several hours later the daily labs return, and the patient’s red blood cell count is now so low that a transfusion is clinically indicated. The patient refuses and tells the resident physician that he is a Jehovah’s Witness and has religious objections to blood transfusions. He adds, “I was misled about the other transfusions . . . They told me they had transfused my own blood and I believed them, or I would not have let them transfuse me.” The senior resident carefully explains the risk of refusing the transfusion-including death-but the patient makes clear that “I would rather die than be transfused again.”

Dr A, the attending, is called and speaks to the patient at length. During the conversation, she explains that there are concerns he may have cancer. Mr M interrupts her and says, “If I have cancer or have to go through the pain of that bone marrow again, then I would rather just go home and take care of it myself.” When Dr A asks if he is suicidal, he says, “No, not now, but I have a collection of guns at home.”

Dr A is concerned the patient may not have decision-making capacity, especially as he becomes more anemic and frustrated. The attending calls for an urgent psychiatry and ethics consultation. While she waits for the consultants to arrive, she looks in the electronic medical record and the paper chart but cannot find an advance directive. No next of kin is listed, but the emergency contact is a girlfriend, S. Dr A calls S and explains the situation and her concerns. The girlfriend tells the attending, “I don’t care what he says! Transfuse him! He is talking religion, and I think he is crazy.”

The attending is conflicted. She believes that if the patient can be transfused and the workup completed, Mr M can at least have the facts he needs to make an informed decision. But without the transfusion he will die without knowing whether he could be successfully treated. Dr A knows and wants to respect Mr M’s wishes and beliefs, but she is concerned that his inconsistent decisions regarding blood transfusions mean he is not thinking clearly enough to make such a momentous decision.

You are the ethics consultant and arrive within an hour. The psychiatric consultant is finishing with the patient and believes the patient may be experiencing episodes of delirium, especially when he is profoundly anemic, alternating with periods of lucidity and so says he cannot really evaluate the patient’s capacity. The psychiatrist does not think the patient is acutely suicidal but was expressing his fear about the team’s inability to find out what is wrong with him and his anger about the pain and failure of the bone marrow puncture.

Ethics consultations often involve a number of different and often conflicting ethical concerns and questions. Please vote for your choices and post your comments below. A discussion of your comments and commentary about the ethical concerns and questions this case raises will be in a coming issue of 

As the ethics consultant, which of the following do you think is the central ethics issue in this case?

A. If the patient has decision-making capacity, he has the right to refuse a blood transfusion.

B. It is unclear whether the patient has a surrogate who is able and willing to make decisions that respect his wishes and values.

C. Since the attending has the ability to save the patient, she also has the duty to do so since she does not believe he has capacity.

D. The team believes the patient is incapable because he is refusing the clinically indicated medical treatment.
 

If the psychiatrist determines that the patient lacks decision-making capacity and the team cannot identify another surrogate decision maker, can S act on Mr M’s behalf?

A. Yes, because she is acting out of his best interests to save his life.

B. No, because she is not making the decision according to the patient’s preferences and values as she is required to do as a surrogate.

C. No, because only an individual who shares Mr M’s Jehovah’s Witness beliefs can be asked to make a decision based on religious grounds.

D. Yes, because there is no advance directive and so the surrogate has to make the decision she believes Mr M would make if he could think clearly.

One of the most important things to do as either an ethics or psychiatric consultant when a patient refuses a treatment-especially one that is lifesaving-is to try and understand why he is refusing. Which of these rationales do you find most plausible?

A. Mr M is expressing his autonomy in the only way open to him in circumstances where he feels he is not respected and has little control.

B. Mr M really believed that he was receiving an autologous transfusion and that his religious beliefs permitted him to accept his own blood.

C. Mr M is not truly a practicing Jehovah’s Witness but is refusing the transfusion as a way of indirectly killing himself without the psychiatrist being able to legally intervene.

D. Mr M did not really have decision-making capacity when he initially accepted the transfusions.

The attending is asking for your recommendations regarding whether to transfuse the patient. Which of these responses would you give to Dr A?

A. Transfuse Mr M so that his delirium can resolve and he can make an informed and reasoned decision regarding the transfusion.

B. Recognize S as the authorized decision maker and follow her wishes and transfuse Mr M.

C. Respect Mr M’s beliefs as a capable adult who can legally refuse a blood transfusion on legal grounds.

D. Obtain the agreement of a second attending physician and transfuse the patient using emergency consent.

Dr Geppert is Professor, Department of Psychiatry, and Director of Ethics Education, University of New Mexico School of Medicine in Albuquerque and Chief of Consultation Psychiatry and Ethics at New Mexico Veterans Affairs Health Care System in Albuquerque.

Ethics case quiz: A patient's inconsistent decisions regarding treatment are cause for concern. What to do?

Of Blood and Truth

As Mr B started to scratch himself, his golden glow caught my eye. He scratched more than he spoke-but that does not mean much, for he spoke so little. To psychoanalysts (and there were many around me), scratching meant as much as speech. To a newly minted physician like me, just starting psychiatry residency, scratching carried medical connotations as well as veiled analytic meanings.

I squinted to get a better glimpse of his skin. Was it the warm lighting on the ward, or did he really have a yellow tinge? He seemed unconcerned with the itching-which often accompanies icterus. Rather, he spoke of “indigestion” and pain that interfered with eating.

The departing resident had assured me that Mr B was the perfect patient for someone who was just starting out. He had a classic case of “involutional melancholia.” His stomach pains were “somatic preoccupations.” He could not eat, and he lost weight. He paced at night and fretted all day. His sagging skin attested to his weight loss and intensified the furrows on his face as he frowned.

[[{"type":"media","view_mode":"media_crop","fid":"42826","attributes":{"alt":"Â©CrystalEyeStudio/Shutterstock","class":"media-image media-image-right","id":"media_crop_8926239025277","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5015","media_crop_rotate":"0","media_crop_scale_h":"111","media_crop_scale_w":"175","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â©CrystalEyeStudio/Shutterstock","typeof":"foaf:Image"}}]]Mr B had made no headway through twice-weekly psychotherapy sessions. Months had passed. He could no longer care for himself. No one would say that the sacrosanct psychoanalytic treatment failed-but the “higher-ups” agreed that it was time for a hospital stay and a trial of tricyclics. Should that prove futile, there was always ECT.

Interviewing Mr B was not easy. Establishing rapport was even harder. Open-ended questions, like the ones favored by the analysts, accomplished nothing. Some concrete questions finally did the trick.

When Mr B said that he did not “like” anything anymore, I asked the obvious: “What did your life used to be like?”

“Eat exotic food,” he said. That statement sounded promising and might invite more dialogue.

As a new arrival in New York City, I was awed by the variety of restaurants in the city-much to the amusement of my office mate, a native New Yorker. There were more restaurants on a single Manhattan street than in most American towns. When Mr B answered, “Chinese,” I felt almost as sad as he did. Even in my Midwestern mind, it was strange to think of Chinese takeout as exotic. It seemed that Mr B had led a limited life all along.

With the ice broken, Mr B elaborated on his background. He spoke slowly and without inflection, confiding that he lived life in an orderly and predictable manner. A rental apartment in a clean and safe neighborhood and a steady government job were plenty, he said. He grew up during the Depression, and he had lower expectations than Baby Boomers who came of age in post-war America. He expressed regret about the family he never had, but without seeming embittered. He had lost his wife years earlier and never remarried. Maybe he entered a depression way back then and never came out of it, I wondered. When life became unbearable, he sought psychiatric treatment at a local clinic.

In spite of the intriguing information about his being widowed and living his life alone, my mind kept returning to his scratching and his continuing complaints about stomachache. It was hard to discern if he was “yellow”-for I could not see his sclera from where I sat. Medical school preceptors stressed the importance of inspecting inside the eyelid when looking for icterus. That was not possible for me.

At that time and place, thinking about lessons learned in medical school seemed heretical. At the very least, it was a sign of “resistance.” American Psychiatric Association Medical Director Melvin Sabshin’s historic exhortation, urging psychiatrists to re-embrace medicine, was still a few years away. In the mid-70s, psychiatrists in training were taught to shed the MD identity so that they could embrace their new role as “doctors of the mind.” The process reminded me of a snake shedding its skin.

In medical school, we learned that liver disease could cause neuropsychiatric symptoms. On medical rotations, we routinely encountered patients who drifted in and out of consciousness, before falling into hepatic coma. Long before I saw extrapyramidal syndrome from then-ubiquitous phenothiazines, I encountered an even more ominous movement disorder, “liver flap,” during medical rounds. Worst of all, pathology books warned that pancreatic cancer could present as depression years before physical symptoms-or lab abnormalities-manifest themselves.

The combination of gnawing stomach pain, a vaguely yellow tinge, and non-stop itching-along with depression-could not be ignored, at least not by me. My office mate, an aspiring psychoanalyst (as well as a restaurant aficionado), felt otherwise and chided me to focus on Mr B’s feelings, like a psychiatrist.

Residency was a time to indulge in debates about the soma and the psyche, and to argue about Descartes’ concepts-and whether his ideas about the separation of the body and mind should be resurrected or cast into the embers. Biological psychiatry was still a twinkle in most analysts’ eyes.

To avoid an argument, we came up with a compromise: if the patient’s chart confirmed that his liver enzyme and bilirubin levels were normal, I would put my worries aside. There was one problem: there were no labs in his chart.

So I ordered labs, amylase and all. The results returned with sky-high serum glutamic pyruvic transaminase and bilirubin to match. I called an emergency gastroenterology consult and ordered whatever studies would expedite matters. There were no MRI scans in the 1970s-just upper and lower GI series-so work-ups were faster and more straightforward (albeit less precise). Contrarily, arguments among psychiatrists-to-be could become more embittered, if one fervently “believed” in biology while the other sanctified the psyche.

The gastroenterologists arrived, flipped through the patient’s chart, and promptly summoned the surgeons. Mr B was whisked away to prepare for what we presumed would be lifesaving surgery. I was not sure how much Mr B understood about the tests ordered or the treatments proposed, for the surgeons took charge. I was optimistic, and my optimistic attitude presumably allayed many of his fears.

When the biopsy report confirmed our suspicions, there was a bittersweet sense of satisfaction. Mr B underwent the Whipple procedure-or pancreatoduodenectomy-for pancreatic cancer. I still believed that this diagnosis-and relatively prompt treatment-would give Mr B a new lease on life, or at least more life than he might have had otherwise.

Mr B returned to the psychiatry ward months later, having spent weeks in the intensive care unit and more time on medical-surgical wards. He was barely recognizable on his arrival. His already sagging skin hung from his bones. He lost 75 lb (and much of his insides) from the pancreatoduodenectomy. Mr B and I also lost time together-for I was starting a new rotation.

Before I left, Mr B made a point of telling me how much he wanted to believe that talk therapy would work-and how angry he was that his bubble had burst. He no longer sounded depressed.

It was a spot-on diagnosis-with a horrible outcome. Perhaps the day will come when diagnosing such diseases early offers a survival value-but we don’t know when that day will arrive and we don’t know the specific diagnosis-much less the prognosis-until we attempt to tease out the diagnoses.

As I look back and revisit Mr B’s situation, I ask myself if he would have been better served had the diagnosis been made sooner, before he had grown too ill to appreciate daily life. He might have spent the extra time ruminating about his impending suffering and death-or he might have ordered more of his cherished Chinese food.

Perhaps he would have reconnected with people, activities, or causes that once held meaning for him. Instead, he felt like more of a failure than ever before because he could not find the magical psychodynamic “insight” to stop his depression.

Currently, physicians overall are reevaluating recommendations for supposedly “lifesaving”-but quality-of-life losing-treatments. Psychiatrists increasingly recognize that some psychotherapies are more effective for certain conditions and that not all psychotherapies are created equal.

Ironically, male patients with pancreatic cancer who undergo “curative” surgery have a higher risk of suicide than those who forgo surgery-and men with pancreatic carcinoma have a greater than 10-fold increase in suicide overall.1 As physicians, psychiatrists can weigh these data, when they are available.

We will never know whether Mr B would have opted for surgery had he known then what we know now. We can hypothesize that it was safest for him to return to the psychiatry ward. For all I know, maybe some kind nurse’s aide would have smuggled him some Chinese takeout. Stranger things have been known to happen.

This article was originally posted on 11/02/2015 and has since been updated.

Dr Packer is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine, Bronx, NY. She is also in private practice in New York City.

 Turaga KK, Malafa MP, Jacobsen PB, et al. Suicide in patients with pancreatic cancer. 

Psychiatrists increasingly recognize that not all treatments for depression are created equal-but in this case, an entirely different diagnosis came to light.

The Mind-Body Divide: As Seen Through a Jaundiced Eye

[[{"type":"media","view_mode":"media_crop","fid":"42468","attributes":{"alt":"Â© robtek/shutterstock.com","class":"media-image media-image-right","id":"media_crop_4392161276738","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4605","media_crop_rotate":"0","media_crop_scale_h":"200","media_crop_scale_w":"109","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â© robtek/shutterstock.com","typeof":"foaf:Image"}}]]I have been working with individuals who have succumbed to and recovered from addictive disorders for the better part of 5 decades. It has been an adventure taking me into the realm of human vulnerability, suffering, and resiliency. The journey has also shown me that addicted individuals have many of the same life experiences we all encounter. In the realm of human psychology, we all face issues of survival and getting along with each other. Our common challenges include regulation of our emotions, self-esteem, relationships, and self-care. Put more simply, to study addiction is to study the psychological challenges we all face. In what follows, I offer some vignettes drawn from clinical experience and daily life that allow us to consider some of the lessons learned from addiction.

My patients who have experienced the benefits of 

 have taught me the 2 most important ingredients for their success: show up and hang in there.

To run the risk of sounding corny or simplistic, the 2-part secret is an effective guide to dealing with many of life’s problems, and recovering addicted individuals learn this well. There has been ongoing controversy over the past several decades whether 12-step programs are the preferable approach for addictive disorders. Some of this debate is legitimate and some of it polarized and unfortunate. As with most effective therapeutic regimens, when adhered to the results are beneficial. In Alcoholics Anonymous (AA) and related programs, there is a saying, “More meetings more sobriety; less meetings less sobriety; no meetings no sobriety.” I offer a recent clinical example.

Nancy, a 57-year-old patient whom I hadn’t seen for several years, suddenly called me late one night. It was evident that besides being intoxicated, Nancy was frantic about her condition and its effect on her work and career. She asked for help “getting some rest” and getting detoxified from her heavy reliance on alcohol. I gave her an appointment for the next morning for an evaluation and referral to an appropriate program for detoxification and rehabilitation.

When I first saw her the following morning, I was struck by her haggard appearance and rambling manner-a far cry from the poised, attractive, and well-spoken person I remembered. Although she had abstained from alcohol for 9 years and had participated in regular AA meetings, after a divorce from an abusive husband she had stopped going to meetings and resumed periodic drinking. Over the past couple of years, her alcohol consumption increased and she was now drinking heavily. Initially she was resistant to my suggestion that she be hospitalized but finally agreed to self-commit for detoxification. She called me that evening, more lucid and articulate, and expressed relief to be there and mentioned that she had attended a good AA meeting.

At our family Thanksgiving dinner 6 months earlier, I had shared the 2-part secret to life with 10 of our grandchildren. I told them that I had learned the secret from my patients and that I was thankful that their parents adhered to this idea and always showed up for their children, hanging in, for example, by driving them to athletic and social events. I said how thankful we were for our grandchildren successfully sticking with their academic and athletic activities. I reminded them that all of this was not without disappointments and setbacks, but that they were succeeding by persistence, again emphasizing our gratitude for that. I was pleased several days later when 2 of my children mentioned how impressed the grandchildren were with my Thanksgiving thoughts.

I believed that Nancy’s comment about “a good AA meeting” in the detox program might be a hopeful sign that she would get back to the basics of showing up and hanging in there. She needed the connection with others to correct her tendency to isolate, which was greatly amplified by her drinking. She needed to share her shame and guilt for her relapse, to benefit from a caring and forgiving environment, and to be supported by people who could help her work through her feelings about losing control and loss of self-esteem.

I may seem preachy, but more hopefully, instructive in reminding my patients (and my grandchildren) that success in life requires paying attention to the basics, starting with showing up and hanging in there.

Look both ways before crossing the street

Self-care, which some individuals who are prone to addiction lack, involves basic habits of health and safety. More specifically, it affects how individuals think, feel, and behave around dangerous and risky situations. The rule of crossing the street is a basic one-but it likely goes back further than that. Think of the toddler in the family room who bumps into a coffee table. Most parents know enough to comfort and soothe the child and caution him or her to be careful. However, some parents hit the table and say, “Bad table!” That’s the wrong message. The toddler needs comfort and guidance, not a message that attributes the mishap to external environmental hazards.

Too often careless and dangerous behavior of addicted individuals is simply 

, stimulus seeking, and risk taking, when in fact we fail to consider how such an individual’s guidance systems (technically I refer to it as an ego function/capacity) for self-care and safety are underdeveloped or absent. Patients with addiction disorders think and feel differently in the face of danger, especially those involved with addiction and related behaviors. But these kinds of behavioral lapses and shortcomings are on a continuum for all of us. You need not have an addiction to suffer this kind of lapse. In what follows, I share maddening instances that involved operating an automobile, some of which test the limits of my self-care and safety:

There’s an alley for cars off the parking lot of my office building that leads in and out of the lot. The way out of the alley is a blind corner with no indication of traffic on the exit out of the lot. When I leave, I proceed with extreme caution because anyone driving out of the exit can’t see me. I continue to be dumbfounded by how little attention is exhibited by drivers zipping out of the lot with no thought to caution. It seems to be a clear setup for an accident. I suppose this seems like a minor hazard compared with the wide range of dangers we all encounter on our highways, but it still unnerves me that leaving my office feels like a daily opportunity for a major mishap. Perhaps I fuss too much, but maybe if we all fussed a little more, the world would be a safer place.

Tailgating also puts me and others in jeopardy. I sometimes glibly share my reactions about this with my patients to make a point about safe behaviors. Namely, I say there are 2 types of tailgaters-the mean ones and the oblivious ones. I emphasize the latter, but both greatly aggravate me (usually expressed not so delicately). I lament that there seems to be so little margin for safety with such driving.

But I leave out my own contribution to lapses in judgment when I angrily make some gesture (non-obscene of course) to tailgaters who place me and my passengers in danger. My wife has to remind me, and I have to remind myself, that it is at least as dangerous to react to tailgaters as it is to tailgate.

Working with patients in recovery, I learned to pay close attention to 

 and thoughts as a reaction to my patients’ stories of the dangers and risks associated with their addictions. I echoed those reactions to my patients so that they could appreciate and understand their lack of alarm that so often left them at risk. But, lapses in worry and thought fall on a continuum. The lessons learned by addicted patients in recovery about safe living should instruct us all about the value of caution and worry. When feelings of anxiety and fear are absent, we are often put in harm’s way; when they are extreme, we are paralyzed. The right dose of worry will guide us more than imperil us.

There are far too many disputes and polarizing arguments about the nature and treatment of addictive disorders. The influence of heredity is among the most notable. Scholars, clinicians, and the public debate its influence. Alcoholism is a prime example. Concordance rates for alcoholism among identical twins are 50/50: if one twin suffers from alcoholism, there is a 50% chance that the other twin will have the same disorder. Beyond twin studies, it is less clear how influential heredity is in the development of alcohol dependence.

A grandmother who had consulted me about her daughter’s alcohol misuse and later, her granddaughter’s addiction, wrote to me recently raising the question about heredity in a poignant email:

Not knowing how family mental issues can affect other generations I am sending you a summary of what I know of the families on both sides.

My mother suffered from depression and anxiety the last 35 years of her life. My brother Ted struggled with depression from his early 20s and used anxiety meds as drugs until he was 55, when he committed suicide. I have been treated for depression since 1976. Stewart [my daughter’s son] has been treated for depression but is not in treatment now. And as you know Sharon [my daughter] has dealt with drugs and depression. Thank God it seems that now it is under control. She still sees Dr F. My other daughter is also being treated for depression.

My husband was treated for depression over the last 12 years of his life. His sister’s son who had been on drugs committed suicide when he was 18. His sister’s daughter who is in her 60s was diagnosed as bipolar many years ago. Meredith’s [my granddaughter] uncle committed suicide several years ago. I do not know if drugs were involved or if he had depression. It is so frightening to see Meredith’s drug use and depression.

A reminder that success in life requires paying attention to the basics, starting with showing up and hanging in there.

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