When I Believe That Life Can Never Hold….

Every once in a great while, I hear a former student say he or she is trying to “channel” a favorite teacher, usually when the days are a chore to get through or a major challenge to professional identity or some other sorrow is afoot. I do the same. I had a favorite teacher too. Occasionally I try to channel Dr. Jenny Lind Porter, my literature professor at Huston-Tillotson College (now Huston-Tillotson University) back in the day. She wrote a volume of poetry called “The Lantern of Diogenes and Other Poems” [1]. Today the selection is:

When I Believe That Life Can Never Hold….

When I believe that life can never hold

That which is longed for, when I’m growing old,

Then once again I’ll seek that dreaming bow’r,

Lost from the wheel of life, the twilight hour,

Stand in the deepening shadows, as before,

Look to my valley, where the canyon floor

Lies dark with the purple of the mountains.

Soft comes the faint splashing of the fountains:

Peace is my master. There’s my gnarled oak,

Round which I ran on Mercury’s feet and spoke

To all of nature’s children. No one heard

Except a bright-eyed, solitary bird.

O Cardinal, can’st thou recall to me

That song, echoed in childhood’s ecstasy?

I’ve always been a gunslinger, restless and edgy. I don’t remember songs and bowers, but I prefer to believe they exist. On the other hand, peace is always her master. For many of us, Dr. Porter was and is our bright-eyed, solitary bird, singing the song of faith, not just in ourselves but in whatever lies beyond the sky.

1. Porter, J.L., The Lantern of Diogenes and Other Poems1954, San Antonio: The Naylor Company Book Publishers.

Which Medical Specialist Should Discuss Death with Patients? Is That the Right Question?

I recently saw the Boston Globe report saying that physicians have received “remarkably little instruction on how to discuss death” with their patients (at link http://www.boston.com/lifestyle/health/articles/2011/07/24/at_mass_general_palliative_care_changes_patients_lives/?page=full) [1]. It’s led to the rise of palliative care as a subspecialty in the development of teams to “live with serious illness–and cope with its toughest decisions.” Palliative care programs grew from 658 of 2,489 US hospitals to the current 1,500 according to figures from the Center to Advance Palliative Care.

One our talented resident physicians gave a presentation at our weekly case conference about how to give patients difficult news utilizing the SPIKES protocol [2]. You can find the video presentation by the University of Iowa’s own Dr. Marcy Rosenbaum on how to put SPIKES into practice, including a little role-playing exercise, on this blog site and at the site where the video originated, the Iowa Geriatric Education Center, the link for which is also above under the Humanism in Medicine menu heading. NOTE: if the IGEC site link doesn’.t work, see below). It doesn’t make difficult conversations about death and dying and other jugular issues with patients any easier.

But it’s a place to start. There’s a whole lot more to SPIKES (an acronym of the 6 steps of an ideal interview for giving bad news to a patient) than just the steps:

Setting up the interview

Evaluating the Perception of the patient regarding his/her illness

Getting the patient’s Invitation to disclose bad news

Sharing the doctor’s Knowledge (bad news) with the patient

Evaluating and Empathizing with the patient’s emotional response

Strategy for dealing with the patient’s diagnosis, and summary of encounter

Probably the most difficult step is empathizing, strange as that sounds. Another study the resident presented outline the difficulty in doing research on communication skills training for physicians, noting that this really didn’t significantly change the patient’s anxiety level after medical consultation [3].

Is the goal to eliminate anxiety–or sit in the chair and share it with the patient? And will there ever be enough Palliative Care subspecialists to assume this role? I think once upon a time there was a special group of medical professionals who carried this burden. We called them “doctors.”

1. Burge, K. (2011) “A better kind of care.” The Boston Globe.

2. Baile, W. F., R. Buckman, et al. (2000). “SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer.” The oncologist 5(4): 302-311.

3. Lienard, A., I. Merckaert, et al. (2006). “Factors that influence cancer patients’ anxiety following a medical consultation: impact of a communication skills training programme for physicians.” Annals of oncology : official journal of the European Society for Medical Oncology / ESMO 17(9): 1450-1458.

Melatonin to Prevent Delirium?

I laughed when somebody in our administrative office sent me an email link to a case report on how melatonin might treat delirium. But then I ran across the randomized placebo-controlled trial published recently in the International Journal of Geriatric Psychiatry [1]. Out of 145 patients aged 65 year or over, 72 were randomly assigned to get either 0.5mg of melatonin or placebo at night for 14 days or until discharged from hospital. Melatonin was associated with a lower risk of delirium (about 12%) than placebo (31%). The results were adjusted for dementia and other comorbidities. The conclusion was that low dose melatonin given nightly to older patients admitted to hospital may prevent delirium.

It sounds like the holy grail. There have been a few studies using antipsychotics, both conventional and atypical to test the hypothesis that this class of drugs might prevent delirium, mostly with mixed results. The downside of antipsychotics are the many side effects, including cardiac arrhythmias which could be potentially lethal, neuroleptic malignant syndrome, extreme restlessness known as akathisia, parkinsonism, and various dystonic reactions to name a few. If you want to treat with intravenous antipsychotic, like Haloperidol, most hospital protocols require the patient to have cardiac monitoring.

On the other hand, melatonin is a pineal gland hormone that our bodies naturally produce and which regulates the sleep/wake cycle, which is often disrupted in delirium. The authors cite background literature showing urinary levels of melatonin metabolites are normal in patients without delirium high in those with hypoactive delirium, and low in those with hyperactive delirium. This led some researchers to guess that delirium may be related to abnormal tryptophan metabolism. Giving melatonin supplements, according to some researchers, might reduce delirium by “decreasing the breakdown of both tryptophan and serotonin through negative feedback.”

The Confusion Assessment Method (CAM) was used to screen for delirium, a well-validated, sensitive and specific instrument developed by Dr. Sharon Inouye [2]. Overall, melatonin was well-tolerated. It didn’t decrease delirium severity, length of hospital stay, restraint or sedative use, or mortality once delirium had already got started, emphasizing the critical role of prevention.

The limitation of the study is small sample size. Strengths were that it was randomized, double-blinded, and placebo-controlled as well as using well-validated rating tools.

1. Al-Aama, T., C. Brymer, et al. (2011). “Melatonin decreases delirium in elderly patients: A randomized, placebo-controlled trial.” International Journal of Geriatric Psychiatry 26(7): 687-694.

2. Inouye, S. K., C. H. van Dyck, et al. (1990). “Clarifying confusion: the confusion assessment method. A new method for detection of delirium.” Ann Intern Med 113(12): 941-948.

Delirium Management in Community-Based Palliative Care (or Delirium Masquerading as Pain), an Annotated Video

This very interesting and rather long (about and hour) video details management of delirium in the cancer patient. The physician, Dr. Ted Braun with the Calgary Health Region and University of Calgary Division of Palliative Medicine,  giving the presentation discusses common problems in recognizing delirium, one of them being the fluctuating nature of the syndrome. The patient can appear to be very calm and superficially organized only hours or less after presenting with visual and other types of hallucinations, disorganized and even violent behavior, and this is very distressing to caregivers and physicians. I see this every day in the general hospital in patients who are suffering from a variety of medical problems, not only cancer.

Frequently, one of the causes of delirium (often there are many medical causes) is toxicity from a variety of medications, which can include opioid analgesics and sedative-hypnotics. The technique of switching opioids or rotating them, is not invariably effective at reversing the delirium. I think the presenter’s suggestion that delirium often masquerades as increasing pain is so familiar because I see it all the time. I would add that delirium is an astonishing mimic of almost any primary psychiatric illness as well. Behaviorally, it can resemble psychosis, depression, anxiety, mania, and more.

He mentions hypoactive delirium, both by description and by name. It’s the most common motoric subtype of delirium, has the worst prognosis, and tends to get the least attention because the patients don’t raise a ruckus with the nurses or other caregivers. They just lie there and don’t complain–but are most likely cognitively disorganized, quietly hallucinating, and often described as apathetic or depressed. I like Dr. Braun’s interpretation of a term we often use about this, which is “pleasantly confused”. Because patients with hypoactive and hyperactive delirium are both very distressed, “pleasantly confused” he says it really means “the patient is confused and we’re pleasant about it”.

When Dr. Braun describes the DSM-IV diagnostic criteria for delirium, please cut him a break. The term “perceptual disturbances” is misspelled as “perpetual disturbances” on his slide. The ironic thing is that delirium, once it appears may become persistent and indeed, the most unfortunate sufferers may develop a perpetual delirious state.

I have a problem with Dr. Braun’s identification of the Mini-Mental State Examination (MMSE) as a good screening test for delirium. It probably isn’t although some form of cognitive test is necessary to inform the results of what is a good detection instrument, one example of which is the Confusion Assessment Method (CAM) [2, 3]. Recall as well that the MMSE is not free. It’s copyrighted by Psychological Resources (PAR), Inc. I’ve posted enough about that. Remember the fate of the Sweet 16? Type in “Sweet 16” in the search box on this blog site and see what I mean.

I also doubt that Haloperidol would be classifiable as “anticholinergic” as Dr. Braun claims. In fact, we use Haloperidol to treat the hallucinations, fragmented delusions, and agitation caused by delirium in order to alleviate distress and manage disruptive behavior that interferes with treating the underlying medical emergencies that cause delirium. Further, we anticholinergic drugs such as Benztropine Mesylate (Cogentin) to treat the side effects of drugs like Haloperidol.

I also think you have to be very cautious about using benzodiazepines in the delirious patient. Although Dr. Braun seems to advocate the use of Midazolam, there is still good sense in trying to reserve the use of benzodiazepines for those who are in alcohol or sedative-hypnotic withdrawal. And it has been shown that benzodiazepines are an independent predictor of delirium in the ICU [1]. Notice I didn’t say it would never be correct to use benzodiazepine to get severe agitation under control. We sometimes find it necessary to use both Haloperidol and a benzodiazepine together to protect the patient and others from harm as quickly and as safely as we can.

1. Pandharipande, P., et al., Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology, 2006. 104(1): p. 21-6.

2. Inouye, S.K., et al., Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med, 1990. 113(12): p. 941-8.

3. Wong, C.L., et al., Does this patient have delirium?: value of bedside instruments. JAMA, 2010. 304(7): p. 779-86.

British Book Review of Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry Edited by Yours Truly and Dr. Robert G. Robinson, M.D. at the University of Iowa

Book Review: Psychosomatic Medicine eds Amos & Robinson in The British Journal of Psychiatry

I just thought I ‘d share the first book review I’ve seen about Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry edited by me and my colleague, Dr. Robert G. Robinson, MD. The book was a labor of love and the credit for this favorable review goes to the contributors. Heaven knows what we can change.

Thanks, Bob.

Cross, S. (2011). “Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry.” The British Journal of Psychiatry 199(1): 79-a-80.

Amos, J. J., M.D., and R. G. Robinson, M.D., Eds. (2010). Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry. New York City, Cambridge University Press.

Serotonin Syndrome Educational Module at the NMS Information Service Web Site


Dr. Rosebush has a very nice review about Serotonin Syndrome at the link above, which is on the web site for the Neuroleptic Malignant Syndrome Information Service (NMSIS) at http://www.nmsis.org/. The one drug I often think of when trying to puzzle through complicated serotonin syndrome cases is Tramadol (Ultram), an opioid-like analgesic that can cause serotonin syndrome by itself and there may be more of a risk when combined with serotonergic antidepressants.

Not all experts recommend tapering and discontinuing sertonergic antidepressants before starting the antibiotic Linezolid, which is a monoamine oxidase inhibitor (MAOI). Some recommend watchful waiting [1].

The differential diagnosis for serotonin syndrome is NMS and there’s  a nice table outlining the differences and similarities. There’s also a little quiz at the end. Enjoy!

1. Sola, C. L., J. M. Bostwick, et al. (2006). “Anticipating Potential Linezolid-SSRI Interactions in the General Hospital Setting: An MAOI in Disguise.” Mayo Clinic Proceedings 81(3): 330-334.

New Psychosomatic Medicine Subspecialties?

Leonard Tow Humanism in Medicine Award Day

I really enjoyed the comments from Dr. Wood (see home page) posted on July 19, 2011. His suggestion about making a new sub-specialty within Psychosomatic Medicine called “vascular psychiatry” reminded me of an outstanding paper by a giant in Psychosomatic Medicine, Dr. Thomas N. Wise, MD. The title is “The Journey to Sub-specialization in Psychosomatic Medicine (or Consultation Psychiatry): A United States Experience” [1]. Most of my remarks in response to Dr. Woods’ question will be keyed to Dr. Wise’s paper.

Just to recap Dr. Wood:

Ever give thoughts about a new field within PSM?..i would call it vascular psychiatry, a field which would open up the practice to all those things cardiovascular for our field, such as VaD, vascular depression, expert in cardiac consultations (ex post MI depression), carrying our stethoscopes again listening to heart sounds, bruits. Working with cardiac prevention to prevent dementia, treating hyperlipidemia,htn, diabetes..I think it would open up psychiatry immensely..

Dr. Wise begins his paper with a chronology of how Psychosomatic Medicine itself came to be approved as a subspecialty. In fact, when the application was first presented in 1992, it was turned down. Among the reasons was the fear by the American Psychiatric Association (APA) that “psychiatry would become composed of subspecialties that would balkanize the general field of psychiatry, as had happened in internal medicine with its many sub-specialties.”  For that and other concerns, the American Board of Psychiatry and Neurology (ABPN) turned down the application.

About 9 or so years later, the Academy of Psychosomatic Medicine (APM) reapplied and ran into resistance again from the APA and the Council of Medical Education. Eventually, after “continuing arguments” by consultation-liaison psychiatrists, the APA approved subspecialization in June of 2001.

The next step was to present the proposal to the ABPN, which meant meeting 15 criteria, one of which was that the proposal had to be submitted by a professional organization. This turned out to be the APM. Among the arguments that had to be made was that general psychiatrists did not have the required specific expertise to work in the intensive care units and did not have enough time to work as consultants in the general hospital. There had to be 500 practitioners within the field at the time of the proposal, the distribution had to be throughout the U.S.A. and there had to be continuous growth in the field during the previous decade.

Further, there had to be national societies and individuals who seek sub-specialty certification who are board certified in general psychiatry as well. Additional criteria in the list of 15 included but were not limited to:

1. More than 25 specialty training programs or fellowships one year in length.

2. More than 20 graduates per year and objective evidence of need.

The American Board of Medical Board of Medical Specialties (ABMS) also had requirements, including the requirement the new subspecialty have “a name, a purpose and specific professional and scientific status, such as population of patients with a specified body of knowledge and skills by the practitioners.” There also must be a scientific body of knowledge more detailed than the general or parent specialty and  the existence of groups of practicing sub-specialists with professional societies, textbooks and journals active in medical school and hospital departments.

Tired yet? There’s more.

It turns out that a jugular issue was what we were going to call ourselves. Names were offered and rejected including “Medical Psychiatry”, “Psychiatry in the Medically Ill”, and “Medical-Surgical Psychiatry.” The ABPN finally settled on “Psychosomatic Medicine” and many practitioners find it difficult to say. I don’t know if anyone ever suggested “Psychosomaticism.” Dr. Wood has a name already for the proposed new subspecialty, “Vascular Psychiatry.”

A colleague who for now shall remain nameless until he gives me permission to attribute the upcoming quote offered this tongue in cheek definition of another name for the specialty I sometimes hear, “Psychosomatic Psychiatry”: “The empirical use of numerous off-label medications through non-approved routes of administration to treat the confused, agitated, or unconscious hospital inpatient and the anxious inpatient physician.” Thanks, JB; I’ve been keeping that until I could  find just the right place to use it!

Dr. Wise goes on to say that “Clearly, there will never be enough sub-specialists in consultation-liaison psychiatry to see all such consultations…” I think I would extend that by quoting George W. Henry, the author of what is often said to be the first article on consultation psychiatry:

Relegating this work entirely to specialists is futile for it is doubtful whether there will ever be a sufficient number of psychiatrists to respond to all the requests for consultations. There is, therefore, no alternative to educating other physicians in the elements of psychiatric methods[2].

As we all know, Psychosomatic Medicine was given subspecialty approval finally and the  first certification examination was held in 2005. I was among the first wave of those certified.

This post would not be complete without mentioning what the new Maintenance of Certification (MOC) program does to make recertification more challenging in medicine and psychiatry subspecialties. By far the Performance in Practice (PIP) module requirements make this a an expensive, time and labor-intensive project over every 10 year period of MOC. In order to sit for the MOC cognitive examination, every diplomate needs to understand the duty oto collect not only continuing medical education and self-assessment modules, but clinical and patient and peer review modules of the PIP. There will be an audit of 5% of diplomates at MOC examination times. Please see my latest posts about the Maintenance of Certification and Performance in Practice by just plugging those terms into the search box. One of the nice additions to the MOC program is the Continuous Pathway to Lifelong Learning Program (CPLLP). It will help psychiatrists track their MOC activities (the Physician Folio system) so that we always know what we need to collect to stay certified in our profession. The CPLLP will also charge an annual fee of $175 to cover the cost of collecting and storing data that will help document that modules are being completed toward maintaining certification and will also cover the cost of one MOC cognitive examination in a 10 year period. However, if you have more than one subspecialty certification, you’ll still have to pay the examination fee for the additional exams, and that could add up to a substantial sum because one can cost $1500.

I admire and support Dr. Wood and other dedicated, enthusiastic Psychosomatic Medicine practitioners out there who want to extend the field and make collaboration with our colleagues in medicine and surgery as broad and deep as we can in the service of providing the highest quality care to our patients which is supported by evidence-based research.

You might want to talk to Dr. Wise first, though. Don’t mention my name.

1. Wise, T. N. (2003). “The journey to subspecialization in psychosomatic medicine (or consultation liaison psychiatry): a United States experience.” Seishin shinkeigaku zasshi = Psychiatria et neurologia Japonica 105(3): 325-330.

2. Henry, G. W. (1929). “SOME MODERN ASPECTS OF PSYCHIATRY IN GENERAL HOSPITAL PRACTICE.” Am J Psychiatry 86(3): 481-499.