Depression: B\
\\TIIO’\\
Schism \I.
D’G()STI’\O.
in Contemporary
Psychiatry
\I.D.
The author describes an experience in his own family involving the initial unsuccessful treatment of a depressed patient. The patient failed to respond to psychotherapeutic and drug treatment on an outpatient basis
and
improved
in three
hospitals;
dramatically
and remained stresses the
without importance
mind
various
about
after
in a fourth a series
hospital of ECT
he treatments
depressive .cvmptoms. The author of psychiatrists keeping an open
treatment
approaches.
A MANIFESTATION of the state of any relatively inexact science, there exists in psychiatry a variety of treatments for almost every known disorder. Depression is, of course, no exception; one can suppose that until more exacting standards are developed there is merit in the competition of various approaches with, presumably, the more successful treatments eventually prevailing and the less successful methods falling by the wayside. The problem, however, is much more complex, and such optimism may not be wholly warranted. For one thing, the various schools of thought are not in the habit of comparing their treatment approaches objectively with any other. Problems ofdefinition arise, and there are senious difficulties associated with trying to get everyone to agree on a terminology, especially when one is speaking of depression. Certainly a question like “Have you even felt depressed?” would elicit an affirmative response from almost everyone. It is with this in mind that since the time of Hippocrates, and probably earlier, physicians have attempted to organize apparently related symptoms into syndromes and, where possible, into specific disease entities, the goal being the development ofthe most pansimonious form of therapy. Unfortunately, in the mid-l970s we are still unable to agree on whether depression is a disease, a scapegoat phenomenon, a problem in living, a conditioned response to a series of more or less accidental environmental contingencies, an overly insightful existential awareness of the futility of man’s struggle against the inevitability of death, or all of the above. The following is the history of a depression of the socalled involutional type and the efforts of one family to do something about it. Despite the limitations of the single case history presentation, I feel this case may merit AS
Dr. D’Agostino Stnitch School and Director. Health Center.
is Assistant of Medicine, Children’s Hines, III.
Professor of Psychiatry, Loyola University 2160 S. First Ave., Maywood, III. 60153, Inpatient Service, John J. Madden Mental
reporting since it illustrates not only the variety of mental health services and techniques available to a consuming public but also the reaction of one professional who, at the beginning of his training, was able to experience on a very personal level the schism in points of view in contemporary psychiatry. I am the professional; the patient is my father.
THE
PROBI.EM
I was 24 years old and had just graduated from medical school. My father was as I had always known himlow-keyed, sociable, more than a little pleased at his only son’s graduation to doctorhood. He was also near the bottom of my list of potential mental patients-much too steady, too reliable, no history of anything save essential hypertension diagnosed a year earlier and well-controlled on a fixed combination drug ofO. I mg of reserpine, 25 mg of hydralazine hydrochloride, and 15 mg of hydrochlorothiazide (Ser-Ap-Es). Seven days after graduating I left my home state to do a one-year internship. Sometime during that 12-month period a radical change occunred in my father’s state of mind. His appearance had changed dramatically. He was 52 but looked 70; he had lost over 20 pounds and was anxious and agitated. He would ruminate oven what he felt were occasions of bad judgment on his part. Worst of all, he could barely get himself to work in the morning. He “knew” he wasn’t doing hisjob properly and felt his employer was keeping him on only because the others in his department were covering for his ineptitude. He would awaken early in the morning and debate with himself (and my mother) over how he was to face another day on thejob. Believing that his performance on thejob was his problem, my mother called his employer. She was even more perplexed when she was told he was functioning as well as even, although he seemed worried and less interested in the social aspects of his work. In addition, he seemed more self-centered than I’d ever known him. He talked only of himself, his failures, and his bleak future. Friends and relatives would come over to cheer him up and leave many hours later, frustrated by what seemed his unreasonableness and inability to make a decision. Normally compulsive, he became a caricature in the extreme. When I finally decided that some kind of treatment was definitely indicated, he would not hear of it. Angry at what I felt was an incessant repetition of the same issues with no conclusions, I found more and more reasons not to visit my parents. I had my own patients to worry about and did not need another. Moreover, I knew
Am
J Psychiatry
/32.6,
June
1975
629
SCHISM
IN CONTEMPORARY
PSYCHIATRY
that he would probably be a miserable candidate for psychotherapy. After an abortive attempt at office psychotherapy, hospitalization was recommended. We sought admission to what I felt was the best available psychiatric hospital. As it turned out, however, there were no beds available at the time and an alternate was suggested. Since a crisis of sorts had developed by this time, I thought it wise to take what was available; the altemnate institution had been well recommended. From my point of view as both a first-year resident and a consumer of psychiatric services, the experience proved a little puzzling.
HOSPITAL
A
After much hassling, my father and I arrived at the hospital. He was seen by a psychiatrist who seemed to agree that he needed hospitalization. However, in speaking to me afterward, he expressed an opinion that the process had been going on and/or developing for many years. I was distressed that somehow I had not been able to see it since I thought the illness had developed during my one-year absence. My comments to that effect didn’t seem to change anything, but I was hopeful that now some meaningful treatment might occur. The hospitalization lasted only eight days. The final diagnosis was “chronic brain syndrome” and the reason for discharge at that time was “patient refuses psychotherapy. Even more painful was the recommendation resulting from the inpatient evaluation-custodial-type came at home (i.e., no more employment, at least not what he had been doing, early retirement [age 53], and application for Social Security benefits as a means of support). The psychiatrist’s fee for this evaluation was by far the most expensive item during the course of the entire illness, considering the length of the hospitalization. “
HOSPITAL
B
Even I could realize that something wasn’t night at hospital A. My father’s condition had stabilized somewhere around absolute zero and the agitation and ruminations continued. Meanwhile, beds became available at the hospital originally chosen. Like hospital A, hospital B was generally known for its use of a model similar to the one used at the institution where I was serving my nesidency (many of our faculty also served on the faculty of the training program at hospital B). I can vividly remember my feelings of shame and nagging responsibility as my father was admitted for the second time to a mental hospital. After 10 months of a psychiatric residency, I was well aware of the importance of intrafamilial dynamics in the etiology of mental illness and resolved that somehow this treatment was going to go forward. I would do my best not to let anxiety, guilt, shame, or resistance get in the way. The psychiatrist during this hospitalization seemed to
630
Am J Psychiatry
132:6,
June
/975
have a much better idea of what my father was dealing with, and from the kinds ofthings my father talked about during visits I surmised that his psychiatrist was devoting considerable time and energies to helping him cope with his illness. I agreed with his techniques, which involved a combination of medication and psychotherapy - exactly what I was involved in with my own patients, depressed on otherwise. But there was to be another problem ---my mother. Despite the efforts of his physician, my father was not impressed. In fact, he felt he was being “tortured.” He would impart these impressions daily to my impatient mother who, after my father had been hospitalized for two months, was beginning to feel that the illness would never end. She also became paranoid about the psychiatnist, who would say very little when she called him to get information on how things were progressing, obviously giving her a chance to say what was on her mind. Since I was using essentially the same techniques with my patients, I had little difficulty understanding the rationale. With my mother it was quite another stony, and feeling put off, she finally agreed with my father that hospitalization was not the way to go and took him home over my objections. This action filled me with despair, both because I felt that without treatment this could go on indefinitely and because it had become plain that my father was not a “good” treatment case, i.e., not psychologically minded, and my mother was being uncooperative.
At this point it appeared that we would now carry out essentially the recommendation of the psychiatrist from hospital A. Social Security benefits were applied for and received and the family seemed to accept the inevitability ofcaning for a casualty from life. Only his incessant complaints and disturbing agitation forced us into trying once more to get treatment. During one ofher phone conversations with the psychiatrist from hospital B, my mother was told that illnesses of this type often lasted as long as two years. During a visit she met one patient, about my father’s age, who had been in the hospital for over a year. The cost of such a stint with no guarantees of success had something to do with why my mother was inclined to go along with my father’s complaints about the hospital.
HOSPITAL
C
I thought that a different approach might be helpful. Hospital C was a publicly supported institution of good reputation staffed with personnel inclined toward avantgarde psychiatric treatment. It was less expensive than hospital A or B and was strongly influenced by principles growing out of the community mental health movement. My own residency program, although strongly psychoanalytic, had taken a number of significant steps in the direction of a more community-oriented approach to mental health services. Our faculty contained several dynamic proponents of the community approach who felt that mental health was not so much an individual as a
ANTHONY
group phenomenon. By this time I was a second-year resident. It was a struggle, but we arrived at the appointed time. We were met by an intake team consisting of a psychiatnc resident, a social worker, and (I believe) a psychiatric nurse. Father was interviewed by the psychiatrist, my mother and I were interviewed by the others. By this time, I had the story down pat, feeling that my father’s emotional condition was appalling; however, my father was well dressed, sitting up, and minimizing his problems. After the interviews the team conferred and gave a verdict: day hospital. I was disappointed but tried not to show it. My mother’s disappointment was obvious. It had taken several hours of hassling to get him out of the house and into the car for the appointment; could we do it five days a week? Would the family be cooperative? The team had mentioned that if he was not “motivated” he could not be helped. Although my father had agreed reluctantly to start the following day, when the time came he wasn’t motivated; he never went to the day hospital. His symptoms continued. By this time, my mother and I were not getting along too well. After all, I was studying to be a psychiatrist and should be able to do something for my own father. I tried to explain that these things took time, pointing out that she had an excellent doctor at hospital B and had pulled Father out prematurely. We returned to hospital B, and after another month the same problems were there, with no improvement.
HOSPITAl.
I)
Finally, my mother took matters into her own hands. Living in a small, lower-middle-class suburb, she took Father to see a psychiatrist practicing in the town. He saw Father for a few minutes and recommended hospitalization and electroconvulsive therapy. He even went so fan as to suggest that my father’s antihypertensive drug might have been implicated in his illness. By this time, my mother and I were speaking again. Since I had been less than helpful up to this point, I kept out of the way. Nevertheless, I had read Hollingshead and Redlich and knew that the less affluent often got more cursory “medical” (by implication, less effective) treatment. I would like to mention something about ECT at this juncture. My training up to this point had led me to believe that electroconvulsive therapy was a thing of the past and was still used only by people who didn’t know that the millenium had arrived. Psychotherapy and “therapeutic community” were in; ECT was definitely out. Of about 100 admissions to our unit during my first year of residency, only one patient (mine) received ECT, and the treatments had to be stopped after three sessions because the patient was a black man and the staff wondered whether I wasn’t simply torturing an already sufficiently oppressed citizen. The patient, hospitalized for seven months, was both schizophrenic and depressed; after three ECT sessions, he felt better and went home.
M. D’AGOSTINO
Nevertheless, convinced that there is no room for ECT in a therapeutic milieu, I wondered if it wasn’t true that I had viewed the patient as a lesser human, deserving of such tortures. Four months later I was acquiescing to my own father being so treated, with the sanction of my unenlightened mother, in a hospital of marginal repute. Six weeks later my father was again working, and if the word “cure” can ever be used in psychiatry, it could be used in his case. He saw his psychiatrist only once afterward and the long nightmare was over-no insight, no awareness, no motivation to get well. There remains no evidence ofdepression or any other illness.
1)ISC
USS
ION
One hears a good deal these days about the relevance of the so-called medical model” in psychiatry. As a practicing psychiatrist-psychotherapist, I have on many occasions had reason to question the usefulness of much psychiatric nosology. Nevertheless, one must wonder why it is that techniques of psychiatric treatment with rather obvious usefulness can be allowed to go unused and untaught. For some reason, ifone attempts to understand a patient’s sufferings in psychodynamic terms this somehow precludes using medical therapies, although the converse also often applies. ECT was not merely untaught during my residency training, it was actually disparaged and looked upon as an assault on one’s patient for which the good psychiatrist should feel guilty and mitiate in himselfsome powerful soul searching. In psychiatry the “good” patient is one who understands the origins of his illness, not, as in the rest of medicine, one who thrives on the therapy ofhis physician. Those who do improve on somatic therapies like ECT are said to be guiltladen people who want to be assaulted to expiate their guilt. Diagnosis is also grist for the therapeutic homogenizer. The impression is that all people develop mental illnesses for basically the same reasons; therefore, the treatment of mental illnesses involves variations on the same basic techniques. Some psychiatrists treat all patients on the couch. In these cases the determination of whether on not a patient is suitable for such treatment rests on how psychologically minded a patient is rather than on whether the process is suitable for verbal psychotherapy. In these cases also the diagnostic process attends primarily to the relationships between mental structures (i.e., id, ego, superego) on the affects, rather than to the descriptive, syndrome-oniented, or disease model, as if disease in the medical sense does not exist in psychiatry. On the other hand, we have all been critical of the converse approach: the psychiatrist who electrifies and/or drugs any and all patients who present themselves for treatment, whether they suffer from schizophrenia, de“
iAfter
receiving
ECT,
my
father
was
also
taken
off
his
sive medication. Reserpine depletes brain norepinephnine cause depression. It is not known whether the withdrawal contributed to my father’s recovery.
AmJ
Psychiatry
132.6,June
/975
antihypertenand may of reserpine
631
ECT
FOR
CHRONIC
PAIN
pnession, homosexuality, or marital maladjustment. These physicians seem to equate “different” with “sick,” and no doubt serious injustices in the form of insensitive treatment, forced confinement, and the nefarious “labeling” have occurred. Nevertheless, and this is especially true in many state-operated and community facilities today, it is as if mental illness, as illness, does not exist, and use of medical therapies such as ECT is disparaged and simply not available to patients. Diagnosis is deemed irrelevant just at a time when logic dictates that it is more important than it has ever been. From the point of view of the layman, who comprises the majority of patients, the schism that I have described can only appear as further evidence that psychiatrists have little to contribute to the well-being of society. The pernicious consequences of one’s choice of treatment were highlighted several years ago when a high government official was denied a chance for even higher office by virtue of the treatment he had accepted for an alleged depressive episode. Because he had received ECT, his fitness for high office was suddenly in question. Had he had the same symptoms but been treated with psychotherapy, plus or minus medication, his chances might have been different. Unfortunately, too many psychia-
Electroconvulsive BY
MICHEL
R.
Therapy MANDEL,
for Chronic
THE MOST DIFFICULT patients to treat in medical practice are those who present with pain problems requiring a subtle differentiation between predominantly physiologic pain and psychogenic pain. The histories of these patients often read like odysseys, with multiple hospitalizations, clinical procedures, and physician contact. Engel (I) has described this group of patients as “pain prone.” Frequently they are not psychologically oriented people, in fact, just the opposite, and they often reject attempts to obtain psychiatric consultation. It has been AMONG
AmJ
Psychiatry
COMMENT
In this presentation of the history of my father’s mental illness and my family’s attempts to get treatment, an effort has been made to highlight the consequences of the obvious lack of communication among various schools of psychiatry. It has not been my intention to denigrate anyone’s approach but rather to point out that we have much to learn from one another in dealing with the problems our patients present to us.
Associated
with
Depression
M.D.
Electroconvulsive therapy alleviated the symptoms of f our out ofsix patients sufferingfrom chronic pain and f rom depression as measured by the Hamilton Depression Rating Scale. All ofthe patients had been unsuccessfully treated with tricyclic antidepressant medication. The author suggests that ECT may be the treatment ofchoiceforsomepatients with this combination of symptoms.
632
Pain
tnists trained to believe that ECT has few indications and then only for the “very ill” are unable or unwilling to properly inform a public which still looks upon ECT as a form of electrical purgatory or last-ditch radical treatment for the virtually hopeless. In my own training I can vividly recall looking for an appropriate candidate for ECT only to have every candidate rejected as “not that ill.” I am certain that had my father been admitted to my residency training program, he would not have been considered ill enough to receive ECT. Even if he had been so considered, the issue would never have been raised out of deference to me.
132:6,June
1975
shown that the presentation of the painful symptom is influenced by the patient’s individual personality and other variables, including cultural background, suggestability, and various types of stress (2). Theme is often a strong suggestion that this group of patients has long-term psychological difficulties (3). Various contributing factors maintain the symptom complex in chronic pain syndrome, including malingering, hypochondriasis, and conversion reaction (I, 4, 5). Several authors have shown that depression can also play an important role in pain and that affective disorders sometimes accompany other diagnoses such as conversion reaction ( 1 4). Ziegler and associates (6) reviewed the cases of 100 randomly chosen patients with a ,
Dr. Mandel is Assistant in Psychiatry, tal, Fruit St., Boston, Mass. 02114, and chiatry, Harvard Medical School. The author wishes to thank Alan ett, M.D., and Gerald 1. Klerman, the preparation of this paper.
Massachusetts Instructor,
General Department
Hospiof Psy-
J. Gelenberg, M.D., Thomas P. HackM.D., for their valuable assistance in
\\TIIO’\\
Schism \I.
D’G()STI’\O.
in Contemporary
Psychiatry
\I.D.
The author describes an experience in his own family involving the initial unsuccessful treatment of a depressed patient. The patient failed to respond to psychotherapeutic and drug treatment on an outpatient basis
and
improved
in three
hospitals;
dramatically
and remained stresses the
without importance
mind
various
about
after
in a fourth a series
hospital of ECT
he treatments
depressive .cvmptoms. The author of psychiatrists keeping an open
treatment
approaches.
A MANIFESTATION of the state of any relatively inexact science, there exists in psychiatry a variety of treatments for almost every known disorder. Depression is, of course, no exception; one can suppose that until more exacting standards are developed there is merit in the competition of various approaches with, presumably, the more successful treatments eventually prevailing and the less successful methods falling by the wayside. The problem, however, is much more complex, and such optimism may not be wholly warranted. For one thing, the various schools of thought are not in the habit of comparing their treatment approaches objectively with any other. Problems ofdefinition arise, and there are senious difficulties associated with trying to get everyone to agree on a terminology, especially when one is speaking of depression. Certainly a question like “Have you even felt depressed?” would elicit an affirmative response from almost everyone. It is with this in mind that since the time of Hippocrates, and probably earlier, physicians have attempted to organize apparently related symptoms into syndromes and, where possible, into specific disease entities, the goal being the development ofthe most pansimonious form of therapy. Unfortunately, in the mid-l970s we are still unable to agree on whether depression is a disease, a scapegoat phenomenon, a problem in living, a conditioned response to a series of more or less accidental environmental contingencies, an overly insightful existential awareness of the futility of man’s struggle against the inevitability of death, or all of the above. The following is the history of a depression of the socalled involutional type and the efforts of one family to do something about it. Despite the limitations of the single case history presentation, I feel this case may merit AS
Dr. D’Agostino Stnitch School and Director. Health Center.
is Assistant of Medicine, Children’s Hines, III.
Professor of Psychiatry, Loyola University 2160 S. First Ave., Maywood, III. 60153, Inpatient Service, John J. Madden Mental
reporting since it illustrates not only the variety of mental health services and techniques available to a consuming public but also the reaction of one professional who, at the beginning of his training, was able to experience on a very personal level the schism in points of view in contemporary psychiatry. I am the professional; the patient is my father.
THE
PROBI.EM
I was 24 years old and had just graduated from medical school. My father was as I had always known himlow-keyed, sociable, more than a little pleased at his only son’s graduation to doctorhood. He was also near the bottom of my list of potential mental patients-much too steady, too reliable, no history of anything save essential hypertension diagnosed a year earlier and well-controlled on a fixed combination drug ofO. I mg of reserpine, 25 mg of hydralazine hydrochloride, and 15 mg of hydrochlorothiazide (Ser-Ap-Es). Seven days after graduating I left my home state to do a one-year internship. Sometime during that 12-month period a radical change occunred in my father’s state of mind. His appearance had changed dramatically. He was 52 but looked 70; he had lost over 20 pounds and was anxious and agitated. He would ruminate oven what he felt were occasions of bad judgment on his part. Worst of all, he could barely get himself to work in the morning. He “knew” he wasn’t doing hisjob properly and felt his employer was keeping him on only because the others in his department were covering for his ineptitude. He would awaken early in the morning and debate with himself (and my mother) over how he was to face another day on thejob. Believing that his performance on thejob was his problem, my mother called his employer. She was even more perplexed when she was told he was functioning as well as even, although he seemed worried and less interested in the social aspects of his work. In addition, he seemed more self-centered than I’d ever known him. He talked only of himself, his failures, and his bleak future. Friends and relatives would come over to cheer him up and leave many hours later, frustrated by what seemed his unreasonableness and inability to make a decision. Normally compulsive, he became a caricature in the extreme. When I finally decided that some kind of treatment was definitely indicated, he would not hear of it. Angry at what I felt was an incessant repetition of the same issues with no conclusions, I found more and more reasons not to visit my parents. I had my own patients to worry about and did not need another. Moreover, I knew
Am
J Psychiatry
/32.6,
June
1975
629
SCHISM
IN CONTEMPORARY
PSYCHIATRY
that he would probably be a miserable candidate for psychotherapy. After an abortive attempt at office psychotherapy, hospitalization was recommended. We sought admission to what I felt was the best available psychiatric hospital. As it turned out, however, there were no beds available at the time and an alternate was suggested. Since a crisis of sorts had developed by this time, I thought it wise to take what was available; the altemnate institution had been well recommended. From my point of view as both a first-year resident and a consumer of psychiatric services, the experience proved a little puzzling.
HOSPITAL
A
After much hassling, my father and I arrived at the hospital. He was seen by a psychiatrist who seemed to agree that he needed hospitalization. However, in speaking to me afterward, he expressed an opinion that the process had been going on and/or developing for many years. I was distressed that somehow I had not been able to see it since I thought the illness had developed during my one-year absence. My comments to that effect didn’t seem to change anything, but I was hopeful that now some meaningful treatment might occur. The hospitalization lasted only eight days. The final diagnosis was “chronic brain syndrome” and the reason for discharge at that time was “patient refuses psychotherapy. Even more painful was the recommendation resulting from the inpatient evaluation-custodial-type came at home (i.e., no more employment, at least not what he had been doing, early retirement [age 53], and application for Social Security benefits as a means of support). The psychiatrist’s fee for this evaluation was by far the most expensive item during the course of the entire illness, considering the length of the hospitalization. “
HOSPITAL
B
Even I could realize that something wasn’t night at hospital A. My father’s condition had stabilized somewhere around absolute zero and the agitation and ruminations continued. Meanwhile, beds became available at the hospital originally chosen. Like hospital A, hospital B was generally known for its use of a model similar to the one used at the institution where I was serving my nesidency (many of our faculty also served on the faculty of the training program at hospital B). I can vividly remember my feelings of shame and nagging responsibility as my father was admitted for the second time to a mental hospital. After 10 months of a psychiatric residency, I was well aware of the importance of intrafamilial dynamics in the etiology of mental illness and resolved that somehow this treatment was going to go forward. I would do my best not to let anxiety, guilt, shame, or resistance get in the way. The psychiatrist during this hospitalization seemed to
630
Am J Psychiatry
132:6,
June
/975
have a much better idea of what my father was dealing with, and from the kinds ofthings my father talked about during visits I surmised that his psychiatrist was devoting considerable time and energies to helping him cope with his illness. I agreed with his techniques, which involved a combination of medication and psychotherapy - exactly what I was involved in with my own patients, depressed on otherwise. But there was to be another problem ---my mother. Despite the efforts of his physician, my father was not impressed. In fact, he felt he was being “tortured.” He would impart these impressions daily to my impatient mother who, after my father had been hospitalized for two months, was beginning to feel that the illness would never end. She also became paranoid about the psychiatnist, who would say very little when she called him to get information on how things were progressing, obviously giving her a chance to say what was on her mind. Since I was using essentially the same techniques with my patients, I had little difficulty understanding the rationale. With my mother it was quite another stony, and feeling put off, she finally agreed with my father that hospitalization was not the way to go and took him home over my objections. This action filled me with despair, both because I felt that without treatment this could go on indefinitely and because it had become plain that my father was not a “good” treatment case, i.e., not psychologically minded, and my mother was being uncooperative.
At this point it appeared that we would now carry out essentially the recommendation of the psychiatrist from hospital A. Social Security benefits were applied for and received and the family seemed to accept the inevitability ofcaning for a casualty from life. Only his incessant complaints and disturbing agitation forced us into trying once more to get treatment. During one ofher phone conversations with the psychiatrist from hospital B, my mother was told that illnesses of this type often lasted as long as two years. During a visit she met one patient, about my father’s age, who had been in the hospital for over a year. The cost of such a stint with no guarantees of success had something to do with why my mother was inclined to go along with my father’s complaints about the hospital.
HOSPITAL
C
I thought that a different approach might be helpful. Hospital C was a publicly supported institution of good reputation staffed with personnel inclined toward avantgarde psychiatric treatment. It was less expensive than hospital A or B and was strongly influenced by principles growing out of the community mental health movement. My own residency program, although strongly psychoanalytic, had taken a number of significant steps in the direction of a more community-oriented approach to mental health services. Our faculty contained several dynamic proponents of the community approach who felt that mental health was not so much an individual as a
ANTHONY
group phenomenon. By this time I was a second-year resident. It was a struggle, but we arrived at the appointed time. We were met by an intake team consisting of a psychiatnc resident, a social worker, and (I believe) a psychiatric nurse. Father was interviewed by the psychiatrist, my mother and I were interviewed by the others. By this time, I had the story down pat, feeling that my father’s emotional condition was appalling; however, my father was well dressed, sitting up, and minimizing his problems. After the interviews the team conferred and gave a verdict: day hospital. I was disappointed but tried not to show it. My mother’s disappointment was obvious. It had taken several hours of hassling to get him out of the house and into the car for the appointment; could we do it five days a week? Would the family be cooperative? The team had mentioned that if he was not “motivated” he could not be helped. Although my father had agreed reluctantly to start the following day, when the time came he wasn’t motivated; he never went to the day hospital. His symptoms continued. By this time, my mother and I were not getting along too well. After all, I was studying to be a psychiatrist and should be able to do something for my own father. I tried to explain that these things took time, pointing out that she had an excellent doctor at hospital B and had pulled Father out prematurely. We returned to hospital B, and after another month the same problems were there, with no improvement.
HOSPITAl.
I)
Finally, my mother took matters into her own hands. Living in a small, lower-middle-class suburb, she took Father to see a psychiatrist practicing in the town. He saw Father for a few minutes and recommended hospitalization and electroconvulsive therapy. He even went so fan as to suggest that my father’s antihypertensive drug might have been implicated in his illness. By this time, my mother and I were speaking again. Since I had been less than helpful up to this point, I kept out of the way. Nevertheless, I had read Hollingshead and Redlich and knew that the less affluent often got more cursory “medical” (by implication, less effective) treatment. I would like to mention something about ECT at this juncture. My training up to this point had led me to believe that electroconvulsive therapy was a thing of the past and was still used only by people who didn’t know that the millenium had arrived. Psychotherapy and “therapeutic community” were in; ECT was definitely out. Of about 100 admissions to our unit during my first year of residency, only one patient (mine) received ECT, and the treatments had to be stopped after three sessions because the patient was a black man and the staff wondered whether I wasn’t simply torturing an already sufficiently oppressed citizen. The patient, hospitalized for seven months, was both schizophrenic and depressed; after three ECT sessions, he felt better and went home.
M. D’AGOSTINO
Nevertheless, convinced that there is no room for ECT in a therapeutic milieu, I wondered if it wasn’t true that I had viewed the patient as a lesser human, deserving of such tortures. Four months later I was acquiescing to my own father being so treated, with the sanction of my unenlightened mother, in a hospital of marginal repute. Six weeks later my father was again working, and if the word “cure” can ever be used in psychiatry, it could be used in his case. He saw his psychiatrist only once afterward and the long nightmare was over-no insight, no awareness, no motivation to get well. There remains no evidence ofdepression or any other illness.
1)ISC
USS
ION
One hears a good deal these days about the relevance of the so-called medical model” in psychiatry. As a practicing psychiatrist-psychotherapist, I have on many occasions had reason to question the usefulness of much psychiatric nosology. Nevertheless, one must wonder why it is that techniques of psychiatric treatment with rather obvious usefulness can be allowed to go unused and untaught. For some reason, ifone attempts to understand a patient’s sufferings in psychodynamic terms this somehow precludes using medical therapies, although the converse also often applies. ECT was not merely untaught during my residency training, it was actually disparaged and looked upon as an assault on one’s patient for which the good psychiatrist should feel guilty and mitiate in himselfsome powerful soul searching. In psychiatry the “good” patient is one who understands the origins of his illness, not, as in the rest of medicine, one who thrives on the therapy ofhis physician. Those who do improve on somatic therapies like ECT are said to be guiltladen people who want to be assaulted to expiate their guilt. Diagnosis is also grist for the therapeutic homogenizer. The impression is that all people develop mental illnesses for basically the same reasons; therefore, the treatment of mental illnesses involves variations on the same basic techniques. Some psychiatrists treat all patients on the couch. In these cases the determination of whether on not a patient is suitable for such treatment rests on how psychologically minded a patient is rather than on whether the process is suitable for verbal psychotherapy. In these cases also the diagnostic process attends primarily to the relationships between mental structures (i.e., id, ego, superego) on the affects, rather than to the descriptive, syndrome-oniented, or disease model, as if disease in the medical sense does not exist in psychiatry. On the other hand, we have all been critical of the converse approach: the psychiatrist who electrifies and/or drugs any and all patients who present themselves for treatment, whether they suffer from schizophrenia, de“
iAfter
receiving
ECT,
my
father
was
also
taken
off
his
sive medication. Reserpine depletes brain norepinephnine cause depression. It is not known whether the withdrawal contributed to my father’s recovery.
AmJ
Psychiatry
132.6,June
/975
antihypertenand may of reserpine
631
ECT
FOR
CHRONIC
PAIN
pnession, homosexuality, or marital maladjustment. These physicians seem to equate “different” with “sick,” and no doubt serious injustices in the form of insensitive treatment, forced confinement, and the nefarious “labeling” have occurred. Nevertheless, and this is especially true in many state-operated and community facilities today, it is as if mental illness, as illness, does not exist, and use of medical therapies such as ECT is disparaged and simply not available to patients. Diagnosis is deemed irrelevant just at a time when logic dictates that it is more important than it has ever been. From the point of view of the layman, who comprises the majority of patients, the schism that I have described can only appear as further evidence that psychiatrists have little to contribute to the well-being of society. The pernicious consequences of one’s choice of treatment were highlighted several years ago when a high government official was denied a chance for even higher office by virtue of the treatment he had accepted for an alleged depressive episode. Because he had received ECT, his fitness for high office was suddenly in question. Had he had the same symptoms but been treated with psychotherapy, plus or minus medication, his chances might have been different. Unfortunately, too many psychia-
Electroconvulsive BY
MICHEL
R.
Therapy MANDEL,
for Chronic
THE MOST DIFFICULT patients to treat in medical practice are those who present with pain problems requiring a subtle differentiation between predominantly physiologic pain and psychogenic pain. The histories of these patients often read like odysseys, with multiple hospitalizations, clinical procedures, and physician contact. Engel (I) has described this group of patients as “pain prone.” Frequently they are not psychologically oriented people, in fact, just the opposite, and they often reject attempts to obtain psychiatric consultation. It has been AMONG
AmJ
Psychiatry
COMMENT
In this presentation of the history of my father’s mental illness and my family’s attempts to get treatment, an effort has been made to highlight the consequences of the obvious lack of communication among various schools of psychiatry. It has not been my intention to denigrate anyone’s approach but rather to point out that we have much to learn from one another in dealing with the problems our patients present to us.
Associated
with
Depression
M.D.
Electroconvulsive therapy alleviated the symptoms of f our out ofsix patients sufferingfrom chronic pain and f rom depression as measured by the Hamilton Depression Rating Scale. All ofthe patients had been unsuccessfully treated with tricyclic antidepressant medication. The author suggests that ECT may be the treatment ofchoiceforsomepatients with this combination of symptoms.
632
Pain
tnists trained to believe that ECT has few indications and then only for the “very ill” are unable or unwilling to properly inform a public which still looks upon ECT as a form of electrical purgatory or last-ditch radical treatment for the virtually hopeless. In my own training I can vividly recall looking for an appropriate candidate for ECT only to have every candidate rejected as “not that ill.” I am certain that had my father been admitted to my residency training program, he would not have been considered ill enough to receive ECT. Even if he had been so considered, the issue would never have been raised out of deference to me.
132:6,June
1975
shown that the presentation of the painful symptom is influenced by the patient’s individual personality and other variables, including cultural background, suggestability, and various types of stress (2). Theme is often a strong suggestion that this group of patients has long-term psychological difficulties (3). Various contributing factors maintain the symptom complex in chronic pain syndrome, including malingering, hypochondriasis, and conversion reaction (I, 4, 5). Several authors have shown that depression can also play an important role in pain and that affective disorders sometimes accompany other diagnoses such as conversion reaction ( 1 4). Ziegler and associates (6) reviewed the cases of 100 randomly chosen patients with a ,
Dr. Mandel is Assistant in Psychiatry, tal, Fruit St., Boston, Mass. 02114, and chiatry, Harvard Medical School. The author wishes to thank Alan ett, M.D., and Gerald 1. Klerman, the preparation of this paper.
Massachusetts Instructor,
General Department
Hospiof Psy-
J. Gelenberg, M.D., Thomas P. HackM.D., for their valuable assistance in
