Neuro Psych

So I haven't posted in a while, but not because I haven't had anything to say. I have spent the last 4 weeks doing inpatient psychiatry at our inner-city hospital. Daily, schizophrenic patients abstaining from their medications would report to the ER or were brought by the police after being found cursing in the street or doing other disorganized behavior. We had a gentleman with multiple personalities, numerous heroin addicts, an anti-social personality, a borderline personality, multiple suicide attempts or gestures, and of course generic psychosis and delirium. I live a very sheltered life, it turns out. I never really realized how well off I am, despite living on a pittance from student loans, until I saw the effects that devastating mental illness had on these folks. You never really think twice about being able to evaluate the world realistically and act accordingly until you meet people who can't. It was disheartening, really, to help bring a schizophrenic patient down from his floridly psychotic state to a less psychotic, but still rather disorganized condition, discharging him, and knowing that in 2 months or less, he would have stopped taking his medication, or not followed up or been lost to follow up, and likely be gracing our ER again.

The downward drift hypothesis of schizophrenia certainly holds true in the city here. This hypothesis posits that schizophrenia is more common among lower income echelons of society, either because of their low income status, or more often because their schizophrenia causes them to lose employement and become a marginalized member of society. Most of our patients drifted from group home to group home, and living intermittently on the street until they were sick enough the police found them and brought them to the hospital. Dante outlined concentric circles in Hell, and presumably there are analagous realms in Heaven, the more exalted of which are occupied by Social Workers. The social workers on 4 West Psychiatry Service found these people homes and case workers who would follow them and ensure, to some degree, that they recieved and took their medication. Their tireless efforts ensure that, at least on discharge, our patients at least had a roof and food.

Depressing as the schizophrenic patients were, the heroin addicts were worse. They would come to the ER either having OD'ed, run out of dope and detoxing, or allegedly wanting to go to rehab, which usually happened mostly on cold nights. If they only wanted a roof, they left AMA (against medical advice) when the weather warmed up, or when their cravings got bad enough, usually after 36 hours or so. The really sad cases were those who wanted, or at least convincingly acted as though they wanted (drug addicts will make you cynical very quickly) to get clean, but would then leave as soon as the craving for heroin overpowered their higher cortical funtion. The ol' limbic system is pretty powerful compared with the puny little cerebral cortex. One trio went so far as to stage a little drug reunion in the parking lot after leaving AMA. Sadly, two of them were at a point when they really could have changed, gotten clean, and moved on in their lives, but instead chose to piss away what little meaningful trappings of life they had left.

I can never practice Psychiatry because there is so much of the patient's social environment that factors into their illness but that lies outside the realm of any intervention I can make. It is arguable that this is true in all medical specialties, but I contend that it is to a lesser extent. So much of psychiatric illness stems from problems in childhood, abuse, poor education, low income, poor housing, poor mobility, poor literacy, poor parenting, that a psychiatrist can only do so much to ameliorate. Combine the underlying socio-economic problem with a pharmacological arsenal that is rather limited, and psychiatric illness becomes a daunting and frustrating thing to manage.

I never fully understood the logic behind giving a patient SSRI #1 v. SSRI #2 , and then why schizophrenic patient Joe took antipsychotic X which we then switched to Y , thinking of perhaps combining with Z and W as well. Perhaps that's my fault as a medical student, but as I have alluded to in other posts, psych meds are difficult to understand because of the combinations of receptors that they interact with, as well as the fact that the underlying disease is very poorly understood from a molecular biological standpoint. Take my patient "Joan", who took: Seroquel (quetiapine, an anti-psychotic with anti-dopamine and anti-serotonin properties), Modafinil (an atypical stimulant type medication whose mechanism is unknown), Celexa (a selective serotonin re-uptake inhibitor (SSRI)), and a few other non-psych meds. It would be extremely challenging, based on the known mechanisms of those drugs, to predict how they will interact with one another, let alone the underlying psychiatric illness, which in this case was a personality disorder more than depression, and thus more likely to be refractory to medication in the first place! (take that, grammar snobs! 'twas a run-on sentence!)

I bid adieu to neurology/psychiatry and will now enter the cut-throat world of surgery (no pun intended). I have the following rotations: pediatrics, pediatric urology, general adult, and orthopedics. At least I will be back in children's hospital which is much nicer than the adult hospital next door. As I know that there are surgeons who read this blog, I will be diplomatic in my analysis of this rotation. I fully expect to be the low man on the totem pole, in this case the little raccoon-man who is parked 2 feet underground holding up the rest of the totem pole so that admiring tourists can gush about the woodwork.