From the Editor
She presents with suicidal thoughts and had a challenging course with COVID-19.
She could be a patient in your afternoon clinic. In fact, she was seen and treated at Massachusetts General Hospital. And her case was discussed at psychiatry grand rounds, and then written up for The New England Journal of Medicine.
In our first selection, Dr. Carol S. North (of the University of Texas Southwestern) and her co-authors consider this patient’s story. They detail her history and course in hospital. They also note the complexities: “This case highlights the importance of attending to the intricate, multilevel, systemic factors that affect the mental health experience and clinical presentation of patients, especially among patients such as this one, who identified as Latina.”
Dr. David Goldbloom (of the University of Toronto) joins me for a Quick Takes podcast interview. We discuss his new book about innovations in mental health care. “I wrote the book because like so many people who work in our profession, so many people who are on the receiving end of care, and for the families who support those individuals, there is a shared sense that the status quo isn’t good enough.”
In the third selection, Dr. Kaylynn Purdy (of the University of Alberta), a resident of neurology, writes about her brother and his illness in the pages of the CMAJ. He develops schizophrenia and becomes homeless in Vancouver. She talks about his life and death. “When you meet somebody living on the streets, remember my brother.”
Selection 1: “Case 28-2021: A 37-Year-Old Woman with Covid-19 and Suicidal Ideation”
Carol S. North, Emily M. Sorg, SooJeong Youn, and Jacqueline T. Chu
The New England Journal of Medicine, 16 September 2021
A 37-year-old woman was admitted to this hospital because of fever, shortness of breath, and suicidal ideation in March 2020, during the pandemic of coronavirus disease 2019 (Covid-19).
Ten days before this admission, fever, fatigue, sore throat, cough, and myalgias developed. The symptoms did not abate after the patient took aspirin and acetaminophen. Five days before this admission, she sought evaluation at the urgent care clinic of this hospital because Covid-19 had been diagnosed in two coworkers. A test for Covid-19 was not performed because of limited test availability; tests for influenza A and B viruses and respiratory syncytial virus were not performed because of a statewide shortage of nasopharyngeal swabs. The patient was instructed to quarantine at home.
So begins a clinical case by North et al.
“In addition, the patient reported a 1-week history of new, recurring nightmares in which she would see herself playing with her own severed body parts; these nightmares occurred more frequently during periods of high fever. She intermittently had the sensation that someone was in the room with her while she was awake, even though she was aware that she was alone. She disclosed that, on the previous day, she had had new suicidal ideation associated with fear of transmitting SARS-CoV-2 to her family and that she had taken five aspirin–paracetamol–caffeine pills at once. There had been no history of suicidal ideation or attempt, self-harm, or homicidal ideation.”
They note a psychiatric history: “The patient had a history of depression and panic attacks when she was a teenager and had been treated for less than 1 year with a medication that she could not recall; the symptoms had resolved by 19 years of age, and there had been no mental health follow-up.”
The case presentation goes on to mention both physical and psychiatric symptoms and signs. And there is, yes, a positive swab. But as her suicidal thoughts linger, they weigh a psychiatric presentation complicating her course.
Major depressive disorder. “At this point in the patient’s history, it is not possible to diagnose major depressive disorder, although her presentation has several features suggestive of this diagnosis, including depressed mood, anhedonia, sleep disturbance, psychomotor retardation, loss of energy, anorexia, feelings of worthlessness (feeling like a burden to her family and having a fear of infecting them), and thoughts of suicide. However, this patient’s symptoms had been present for only 5 days, and several of her symptoms could be related to medical illness…”
Post-traumatic stress disorder. “Literature regarding post-traumatic stress disorder (PTSD) related to the Covid-19 pandemic is accruing rapidly, but this diagnosis is not plausible in this case, given that the DSM-5 criteria for a diagnosis of PTSD exclude naturally occurring illness, such as viral infection, from the definition of trauma.”
Adjustment disorder. “A diagnosis of adjustment disorder would require determination that the distress is out of proportion to the severity or intensity of the stressor. Given this patient’s personal risk as an essential worker and her understandable concerns about potentially catastrophic or fatal viral exposure to herself and her family members during the Covid-19 pandemic, application of this diagnosis would not be warranted.”
The authors argue that she doesn’t have a diagnosis. “This patient is having understandable psychosocial distress in the context of a serious medical illness during the Covid-19 pandemic.”
“When a patient has suicidal symptoms, it is important to rule out the possibility of an active psychiatric disorder that requires identification and professional care. This patient had no history of suicidal symptoms but had reportedly been treated for depression and panic attacks as a teenager, without known recurrence of psychiatric difficulties. Thus, her current psychiatric situation appears to have developed suddenly in the context of her SARS-CoV-2 illness within the larger pandemic and its social effects.”
They note her background in terms of understanding her journey: “The patient identified as a Latina woman who prioritized her sense of self as a mother,living with her husband, mother-in-law, and children, including a child who has a pulmonary disease, in a crowded, urban home. They live in a neighborhood that is predominantly Latinx, with high rates of Covid-19–related infections and deaths and a high level of concern related to the virus. At the time of this patient’s admission, information that was accessible to the patient with regard to the virus, symptoms, and progression of the disease was lacking, possibly owing to the fact that she spoke predominantly Spanish, and this lack of information increased the fear about the virus and the uncertainty that comes with having contracted it. She depended on her work in food production for her family’s financial stability,and therefore, even though she wanted to stay home for fear of infection and to protect her family, she felt obligated to work.”
A few thoughts:
- This is an interesting case discussion.
- The authors emphasize the cultural context. “If we were to think about the patient’s symptoms in a vacuum and focus only on the presenting suicidal ideation, we would miss the myriad contextual factors that led to this Latina mother’s despair and presentation. Only when we evaluate all the available data can we determine and assess the best course of action and treatment for this patient and all patients who present for care.” Nice.
- It’s great to see such a case presentation in The New England Journal of Medicine.
- The discussion is very timely and relevant. Will a future case presentation explore “long” COVID?
- How did things work out for this patient? After discharge, she follows up:“she reported ongoing resolution of psychological symptoms, with no recurrence of suicidal thoughts.”
The full NEJM paper can be found here:
Selection 2: “What all physicians need to know about innovations in mental health care”
Quick Takes, 22 September 2021
Mental health care is difficult to access – and the quality of care is often uneven. In this episode of Quick Takes, I speak with Dr. David Goldbloom, Senior Medical Advisor at CAMH and a professor at the University of Toronto. Dr. Goldbloom (a returning guest) has just written We Can Do Better: Urgent Innovations to Improve Mental Health Access and Care. We speak about the book – and his optimism.
I highlight from the discussion:
On the UK’s IAPT
“Perhaps the biggest revolution in the provision of psychological services, probably anywhere, has been the development of the improving access to psychological therapies. In the U.K., where now a million people a year are being assessed for that service and about 600,000 a year are being treated, and that’s on the public purse… with a level of accountability to the public who’s paying for it. That is really, in my view, unprecedented in health care. We have outcomes in the IAPT initiative in the U.K. on 98.5% of encounters. Try to imagine that for any problem anywhere in health care in Canada.”
On innovation and the need to communicate
“People often have trouble communicating a big message, and honestly, one of the reasons I wrote the book was trying to communicate that message to the general public, to policymakers, to patients and families, to make people aware of things, because in a vast country like ours, what’s happening in Nova Scotia may be unknown in Manitoba and vice versa. So we need to do an unrelenting job of communicating this kind of information as widely as possible.”
On changes to psychiatry over his career
“I’ve seen, particularly among young psychiatrists, a renewed commitment to working with severely mentally ill individuals. And that’s a welcome shift. I think that I’ve seen in our own institution increased enthusiasm for being in the trenches of emergency room work and inpatient care. I’ve seen a shift in kind of accountability to patients and to families, and that’s a welcome thing. And obviously, the stigma around mental illness, while not gone, has diminished compared to when I started out. So it’s part of the public conversation as well as the private conversation.”
(The above answers were edited for length.)
The podcast can be found here, and is just over 24 minutes long:
And a previous Reading featured a lengthy excerpt from his book:
Selection 3: “My brother”
CMAJ, 13 September 2021
My oldest brother, Blake, was six years my senior. Despite our age difference, he never made me feel like his annoying little sister. He taught me how to tie my shoes when I was four and to play basketball in our driveway, how to fight properly should I ever need it, and even how to string together rhymes to make my own raps. He always had a knack for fashion and whenever I wore something that he bought me I would get compliments. He was also my cheerleader. When I graduated from high school, Blake’s shout — “Go, Little Kaykay!” — echoed off the walls and was the loudest in the massive auditorium. He truly was the best big brother a little sister could ask for.
At 18, Blake moved to Vancouver, a big move for a kid who grew up in a small town in the Kootenays, but he loved the city life and his job installing marble countertops. At 24, he returned to school to pursue a business degree. Near the end of his first semester, he developed psychosis.
Blake was eventually diagnosed with schizophrenia after being admitted to a locked psychiatric unit.
So begins a paper by Dr. Purdy.
She notes his recovery after the hospitalization, with him working as a landscaper, and time home over Christmas.
But things change several months later: “The Blake I knew was gone. His delusions had taken over his mind and body. He bounced in and out of hospital. Our family lost contact with him for days, sometimes weeks, at a time. Not long afterward he was homeless, living on the streets of Vancouver.”
His illness is worsened by substance. “Using substances became Blake’s way of quieting the storm inside his mind. As his schizophrenia progressed, so too did his addictions, creating a downward-spiralling cycle where each worsened the other.”
She also notes her own feelings, perhaps including guilt. “I was a medical student, and my brother was sleeping outside with stolen hospital blankets. Blake became a secret that I carried with me. I worried that if people knew my brother was homeless, I would be viewed as flawed or ‘not cut out’ to be a doctor. While Blake walked the streets in Vancouver, I walked the halls of hospitals, trying to become the successful doctor I was supposed to be. I wished I could trade it all to have my brother back.”
Unfortunately, he dies of an overdose of fentanyl-contaminated methamphetamines. He was just 34.
She closes with a call to action: “I am a doctor, with the skills to save lives, yet I couldn’t save my own brother. If death was the outcome for Blake — a person with a whole family behind him, working daily to help him — how is there any hope for people who don’t have that support? To change the outcome for people like Blake — homeless, addicted and struggling with mental illness — it will take more than just a few caring individuals; it will take every member of society doing everything in their power.”
A few thoughts:
- This is a moving essay – personal and well written.
- It was tough to read. (A comment I have made before about such papers.)
- It’s never easy to deal with the challenges of major mental illness in a loved one, but do such experiences make us better physicians?
The full CMAJ paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.