One Trusting Patient Questions
the Ethics of Nihilism in Psychiatry
By Robert Sealey, BSc, CA
Key Words
Nihilism, incompetent shortcuts, standard of care, practice guidelines, refractory depressionAbstract
A trusting and cooperative patient, suffering with depression, consulted an expert psychiatrist as an outpatient of a large Toronto teaching hospital. Expecting proper medical care, the patient unknowingly trusted his life to a brainy doctor who practiced nihilism. The expert psychiatrist omitted 13 standard of care procedures, misdiagnosed, mistreated and watched the sick patient get sicker, month after month. Over an 8 month period, the psychiatrist did no mental status exams and no diagnostic tests but prescribed several pills which made the sick patient worse, gave one medication at more than twice the maximum recommended dose, prescribed lithium without blood levels or kidney function tests, repeatedly noted “refractory depression” in the patient’s file and smiled as the sick patient deteriorated. The skimpy medical file provided evidence of substandard shortcuts. When the patient complained to the medical authorities, the system did nothing to help the victim or to protect other patients. The trusting patient questions the ethics of nihilism in psychiatry.--
My symptoms recurred over 28 years: on-again off-again episodes of depression with anxiety, dark thoughts and blue moods interspersed with high-energy phases and irritable outbursts. Periodically, I sought help from physicians, psychologists and psychiatrists. As a trusting and a cooperative patient, I tried pills and therapy but was dismissed, misdiagnosed, mistreated, lied to and laughed at. Maybe that was my fault; maybe health professionals find it hard to care for a sick patient if his depression lingers, unresolved.
Desperate for help, I updated my Bachelor of Science degree (in biological and medical sciences and psychology) by studying self-help books, psychiatry texts and psychology references. Alone with my symptoms, I needed the reassurance that comes from learning how people cope with mental health problems. Even though I had not been well for years, The Depression Workbook: A Guide for Living With Depression and Manic Depression by Mary Ellen Copeland inspired me to learn and renewed my hope for recovery.
My psychiatrist relied on shortcuts
Eventually I read the practice guidelines of psychiatry. They recommend accurate diagnosis and effective treatments. Would any competent psychiatrist shortcut the guidelines by merely labeling a sick patient as refractory, without doing mental status exams, without taking histories, without calling for diagnostic tests, and without recommending appropriate treatments? What sort of doctor would rely on shortcuts? After prescribing antidepressants, tranquilizers, and lithium, what if the patient deteriorates?Prescribing an SSRI to a patient whose depression presents as the most obvious symptom sounds quick and easy. What if that pill makes a sick patient worse? What if a previous doctor had tried that same class of antidepressant but not found it helpful? What if a misdiagnosis leads to a misprescription? For 8 months my psychiatrist increased doses, even trying one pill at more than twice the maximum recommended level. For 8 months, I deteriorated. My doctor prescribed lithium without blood levels or kidney function tests; it made me worse. For months as I got sicker, I thought about suicide – I just wanted the pain to end.
Nobody likes it when a moody patient gets sicker, not the doctor, not the family and certainly not the patient. The system has three labels for the worst cases – refractory depression, treatment resistance and borderline personality.
One day when my regular psychiatrist was away, his colleague did a mental status exam and kindly explained that my SSRI medication was causing hypomania. He recommended reducing the dose. When I phoned the pharmaceutical manufacturer, their neuropsychopharmacologist verified what the company knew - their popular antidepressant had also caused problems for other patients. Extensive reading taught me that when some patients take antidepressants without mood stabilizing medications, they risk hypomania – especially if they are bipolar rather than unipolar depressives. At age 45, I was finally diagnosed with a bipolar II mood disorder, a form of manic depression. For the first time, I had the right medical words to understand myself. I wasn’t mad, sad or bad, just a person with a mood disorder.
I wondered if other patients have serious problems with antidepressants. In February of 2004, the US Federal Drug Administration held public hearings and listened to family members and health professionals. Some shared horror stories about patients who could not tolerate their SSRI antidepressants. For as-yet-unidentified reasons, these pills make some patients worse, and may even cause akathesia. But suicide?
Wondering if my psychiatrist knew about these risks, I studied the literature. A google search on the Internet takes only seconds to find books and articles written by health professionals. It did not take me long to discover that my psychiatrist was a real expert whose 6 articles were published by medical journals in the US, Canada and the UK.
My expert psychiatrist wrote ‘The Clinical Meaning of Refractory Depression’ for the American Journal of Psychiatry in 1991. His article defined “refractory depression” as “primarily involving diagnostic-treatment variables rather than patient variables” and he proposed 6 questions to consider if a sick patient seems “refractory”: (1) Is the diagnosis correct? (2) Is the treatment adequate? (3) Rational stepped-care approach? (4) Outcome measured? (5) Coexisting medical or psychiatric disorder? (6) Factors interfering with treatment? His six questions could assist any psychiatrist to review the diagnosis and treat any ‘refractory’ patient. His article about the refractory depression was even referenced by US and Canadian practice guidelines of psychiatry.
Another of his articles presented the case of a patient who took an antidepressant under medical supervision, but did not recover. During the process of reviewing that patient’s diagnosis, it was discovered that the patient had a brain tumor, a condition for which an antidepressant medication would not be a safe, an effective or an appropriate treatment. Perhaps hoping to educate his colleagues, my psychiatrist wrote about that case for a medical journal – taking care to note the horrific outcome – the deteriorated patient took his own life.
How can we explain what happened when I consulted that very same expert psychiatrist, whose articles, published years before he met me, include the article about “refractory depression” (referenced in US and Cdn practice guidelines); and the article about the patient who killed himself after misdiagnosis and mistreatment? What might cause my expert psychiatrist to do nothing but forget his medical education, reject his clinical training and omit 13 standard of care procedures? See Table 1.
My brainy expert repeatedly noted “refractory depression” in my medical file and kept writing prescriptions. He did not revisit my diagnosis or change the care. While I deteriorated, he shortcut standard of care procedures. For months, he increased the doses and smiled as his pills caused side attacks and toxic effects.
Perhaps it was quicker, easier and therefore more efficient for him to ignore his own advice that a refractory patient needs to be re-diagnosed and then treated properly. Maybe he was too tired or too stressed to bother with the usual routines. Maybe it was faster for him to shortcut the tedious standard of care procedures. Who would know if he did no mental status exams, ordered no differential diagnostic testing, took no medical or mental, no patient or family histories, and never bothered to get the prior medical file from the family doctor who had watched me get worse while taking an SSRI antidepressant– at the same hospital? Why not rely on shortcuts? After all, he was an expert psychiatrist and his patient was obviously a chronic mental defective.
Years after I was misdiagnosed and mistreated, I read a guest editorial in the Canadian Journal of Psychiatry, written by my expert’s superior, the former chief psychiatrist of the large Toronto teaching hospital where I was seen as a trusting and a cooperative patient Dr. Ken Shulman had co-edited Mood Disorders Across the Lifespan, (in which 31 mental health professionals recommend following the practice guidelines of psychiatry when diagnosing and treating young, middle-aged and older patients with mood disorders). In his 2002 CJP editorial, Dr. Shulman referred to the tradition of “nihilism in . . . psychiatry” and reminded readers about the practice guidelines. His hint that some psychiatrists do nothing to restore sick patients inspired me to write ‘One Patient’s Search for Antidotes to Nihilism in Psychiatry’ which was published by the Psychiatric Rehabilitation Journal 2004. I suggested 3 antidotes for patients whose doctors do nothing to diagnose or treat:
(1) bibliotherapy – reading to learn;
(2) the practice guidelines of psychiatry; and
(3) restorative orthomolecular medicine.An orthomolecular recovery
The stigma of a chronic mental illness distances depressives from friends and family just when sick people need care, encouragement and support. Instinctively I sought other people with similar problems, hoping to learn how they got well. At mood disorder association meetings, I met people with diagnoses like depression, manic depression and dysthymia. Most of them were anxious and unsettled, wondering about their symptoms, treatments and prognosis. I felt comfortable with my moody tribe, welcomed and understood. While discussing our problems, we monitored our progress. We compared symptoms, side effects, diagnoses and therapies. Some people did well on high doses of meds, while others, like me, could not tolerate even low doses of our pills. Some talk therapies helped us improve our patterns of thinking, feeling and behaving but it was hard to make progress when we were sick. Once when my expert psychiatrist lectured there, I heard him tell 100 people that he had no problem prescribing antidepressants at higher-than-recommended doses.I started an independent depression project and interviewed more than 150 depressed people and family members, while studying the mental healthcare system and researching books and articles. One woman mentioned orthomolecular medicine. My curiosity was aroused by its fifty-year history of scientific and medical research, the success of orthomolecular medicine and the progress reports of recovered patients. Would ortho-care heal my ailing brain?
Disillusioned after years of failed doctor-patient relationships and determined to avoid shortcuts, I read about orthomolecular doctors who apply the life science of biochemistry to the art of medicine. Thanks to The Way Up From Down, by California psychiatrist Dr. Priscilla Slagle, whose own mood disorder resolved when she tried orthomolecular medicine, I learned how to customize a regimen of nutritional supplements. I had already responded quickly to an extract of the world’s oldest plant, gingko biloba, but some symptoms continued. A basic orthomolecular regimen of vitamins, minerals and amino acids, taken one by one and continued if they helped, soon restored my mental health.
Investigating nihilism and finding more nihilism
Struggling to rebuild my life after years of mood disorder symptoms and the shattering impact of medical incompetence, I thought about what went wrong and wondered if I could help other patients. Writing several polite letters to my former psychiatrist resulted in a call from a policeman who suggested that I not write to the doctor but complain to the College of Physicians and Surgeons of Ontario. Tasked by the Regulated Health Professions Act of Ontario with the legal responsibility for investigating all such reports, the CPSO receives 4,000 complaints every year. The Medical Post and the Toronto Star reported CPSO registrar Dr. Rocco Gerace as saying that his organization refers fewer than 1% of complaints to its Discipline Committee for investigation and hearing. Only 40 of 4,000 cases get properly investigated, heard in public and flagged for incompetence?The complaint process involved allowing the CPSO to get my medical file from the hospital. I also obtained a copy and was shocked to see its skimpy contents. As a former business fraud investigator, I realized that the doctor’s cursory notes and his repeated notation of “refractory depression” while failing to test, diagnose or recommend effective treatments proved that he relied on shortcuts. Even though I reported that my former psychiatrist had omitted 13 standard of care procedures while misdiagnosing and mistreating me until I nearly ended up dead, the CPSO refused to investigate my case, but simply decided that the “care was appropriate”.
I appealed to the Health Professions Appeal and Review Board – twice - and my case became a matter of public record. After my first hearing in 1999, the Board ordered the CPSO to investigate my case and the Board detailed my concerns in the public record. The College reviewed the file and cautioned the psychiatrist to note the patient’s history in future. They failed to listen when I explained that over an 8 month period, the expert had NEVER taken my patient or family medical or mental histories, therefore, he could not note them in my file. I could not see how sloughing off my complaint would protect other patients. Again I asked the CPSO to investigate; again they refused but wrote that I could appeal. At my second hearing in 2002, I presented evidence of incompetent care to the Health Professions Appeal and Review Board. The Board chair smiled. The second Board did nothing to protect patients from shortcuts but did detail my concerns in its public record.
In an apparently unrelated development, before my second HPARB hearing, in 2001 the CPSO elected my former psychiatrist to their medical council and appointed him to their Discipline Committee. Hopefully his five-plus years in that role afford him ample opportunity to investigate medical negligence and witness the damage done when sick patients receive incompetent care.
Case synopsis:
I trusted an expert psychiatrist who shortcut 13 standard of care procedures. Efficient nihilism. Misdiagnosed and mistreated, I deteriorated. When I complained, the CPSO used efficient nihilism to protect him. The doctor denied incompetence but his shortcuts were proven by the skimpy medical file. The CPSO refused to investigate my complaint properly, even after they saw written evidence - in the doctor’s handwriting – which proved that the expert shortcut standard of care procedures, misdiagnosed and mistreated (see Table 1). For 8 months he noted “refractory depression” and prescribed escalating doses of an SSRI and other pills that made me worse.The CPSO and the Health Professions Appeal & Review Board could have respected my concerns, studied the evidence, helped me understand what went wrong, reviewed a selection of patient files and taken action. Instead they did nothing to protect vulnerable patients; they did nothing but protect the psychiatrist; years of their delays and slough-offs wore me down and further victimized me.
Ethics Alert!
What happens when a sick and vulnerable patient gets a referral to an expert psychiatrist in charge of the mood disorder clinic at a large teaching hospital (which has more than 30 psychiatrists on staff)? Can the patient trust such a highly-placed psychiatrist to diagnose accurately and treat effectively? Will that doctor use standard of care procedures consistent with the practice guidelines of psychiatry? Can a new patient expect competence, capabilities, care and ethics? No badge indicates whether a new doctor will be trustworthy, competent, careful or ethical.Every mental patient has brain problems; stating the obvious seems unnecessary. Nevertheless, symptoms of the depleted state called depression, the frantic fear called anxiety and the high-intensity phase called hypomania interfere with normal thinking, feeling and acting. The sick patient is not in his right mind. Vulnerable during episodes, the patient relies on his psychiatrist to diagnose and treat – not any old way, but competently, carefully, safely and effectively. An experienced psychiatrist has at least twelve years of scientific and medical education, clinical training, and experience seeing hundreds, if not thousands of patients.
A competent psychiatrist offers information, help and hope along with quality care so the patient can recover and live well. An ethical brain doctor might start slowly, perhaps with a period of watchful waiting to get to know a new patient; while carefully considering, discussing, doing and documenting standard of care procedures: using differential diagnostic tests to determine the root cause(s) of lingering symptoms; taking patient and family medical and mental histories; explaining the likely diagnosis, discussing the risks and benefits of treatments; getting prior records and informed consent; outlining the prognosis; developing a treatment plan, recommending safe, proven and effective treatments, monitoring suicidal thoughts and watching for problems.
If a doctor misdiagnoses, mistreats and withholds information, makes a sick patient worse, destroys hope of recovery and causes damage which reduces the patient’s quality of life, that doctor practices incompetently, below the standard of care. Substandard shortcuts might cause a patient to suspect something has gone wrong except that the sick patient, distracted by symptoms, has less capacity for analysis and no opportunity to compare his medical file with the practice guidelines. The confidential physician-patient relationship hides the truth from third parties and shields the careless doctor from his superiors.
What patient would know if his doctor relies on shortcuts; smiles insincerely, offers careless platitudes and fails to follow the practice guidelines? What if the college of physicians disrespects a patient’s report of incompetence and does nothing to protect other patients; what if the system uses nihilism to protect a shortcutting doctor? How can we explain a bad case of nihilism in psychiatry? Why would medical monitoring bodies do nothing to properly investigate incompetent shortcuts?
Trust betrayed by medical incompetence points to the antithesis of ethical medicine. Trust betrayed for months by a smiling perpetrator produces the opposite of quality care – how might we explain such aberrant behavior? Incompetence? Neglect? Negligence? Why would the system protect a careless perpetrator who misdiagnoses, mistreats, mismedicates and makes a sick patient worse? Efficient nihilism?
How can a patient cope with substandard care? Proceed with caution: (1) Note your questions and list your concerns. (2) Read the practice guidelines and study books about the best practices. (3) Ask for guideline-quality care.
(4) Request a second opinion. (5) Don’t trust your life to shortcuts. If you suspect incompetence, you can complain but the system may care more about dismissing the matter than assessing the damage and protecting patients.
(6) Refer to the Regulated Health Pro’s Act.
(7) Consult a medical malpractice lawyer.
(8) Ask the College of Physicians to investigate. (9) Expect years of delays; but they will ask to see your medical file. (10) You can ask for a copy of your file. You can compare the file with practice guidelines and medical books.Patients who suffer damage from medical incompetence have a tough time speaking about their horrible experiences and finding anyone to listen to their warnings. However, if we all keep quiet, practitioners of nihilism will continue to shred the lives of vulnerable patients. How can we describe a doctor who does the opposite of helping a patient recover and live well? “Live” written backwards spells “evil”. Too strong a word for anti-healing? Maybe so. Consider the English philosopher Edmund Burke who offered these thought-provoking words, “For evil to triumph, it is sufficient that good men do nothing.”
Table 1. Shortcuts evidenced Nihilism: Thirteen Standard of Care Procedures Not Done, Discussed, or Documented over an Eight Month Period of Care
The psychiatrist noted 9 words per visit: “refractory depression” and the dose of prescription medications. The skimpy medical file proves thirteen shortcuts:
(1) failed to diagnose accurately or treat effectively; noted “refractory depression” in patient’s file – every visit for eight months
(2) no patient or family, medical or mental histories; later, claimed taken (but not typed)
(3) no diagnostic tests (medical, psychological); without testing, could not and did not diagnose
(4) no mental status exams noted
(5) no lithium blood levels; no kidney function tests; no lithium discussion with patient
(6) no patient education; no discussion of treatment plan, options or prognosis
(7) no notes that patient was having suicidal thoughts; which got worse as patient deteriorated
(8) as the patient deteriorated, refused to listen to coping problems, no referral for therapy
(9) watched patient deteriorate; no note of worsening symptoms, no note when patient’s wife, an RN, visited to mention deterioration
(10) no risk benefit discussion when prescribing MAOI and SSRI antidepressants, benzo, lithium; no note of side effects, worsening, kept upping the doses, one to more than twice the max
(11) no informed consent before treatments;
no explanation of diagnosis, treatment plan, risks, options, or patient’s deterioration(12) no notes when patient had problems tolerating prescription medications; month after month, as the patient deteriorated; the psychiatrist smiled and said “You will get well.”
(13) no referral when the expert psychiatrist left the hospital; claimed that a referral was made –10 years later, still not told the patient which psychiatrist took over the patient’s case.
Bibliotherapy
Noticing that years were passing while the system was doing nothing to protect vulnerable patients from negligence and nihilism, the author researched and wrote two books:
Finding Care for Depression, Mental Episodes
& Brain Disorders90-Day Plan for Finding Quality Care.
These books encourage patients to navigate the mental healthcare maze, find quality care and avoid the damage that can result from substandard shortcuts.
References
Bongar, Bruce et al, ed.: Risk Management With Suicidal Patients; Guilford Press, New York, 1998
Copeland, Mary Ellen: The Depression Workbook; A Guide for Living With Depression and Manic Depression; New Harbinger Publications, Oakland, CA, 1992
Guscott R, Grof P: The Clinical Meaning of Refractory Depression: A Review for the Clinician; Am J Psychiatry, 1991; 148: 695-704
Kelley, James, Psychiatric Malpractice: Stories of Patients, Psychiatrists and the Law; Rutgers University Press, New Jersey, 1996
Practice Guidelines for Bipolar Disorder, Major Depressive Disorder; American Psychiatric Association, 1996
Psychopharmacologic Drugs Advisory Committee with the Pediatric Subcommittee
of the Anti-infective Drugs Advisory Committee,
Food and Drug Administration, Maryland, 2004,
401 page transcript of public meetingRubin, S & Zoloth L, ed., Margin of Error: The Ethics of Mistakes in the Practice of Medicine; University Publishing Group, Maryland, 2000
Sealey, Robert: Finding Care for Depression, Mental Episodes & Brain Disorders; Toronto, Sear Publications, 2002
Sealey, Robert: One Patient’s Search for Antidotes to Nihilism in Psychiatry; Psychiatric Rehabilitation Journal, Boston, 2004
Shulman, Kenneth et al, editors: Mood Disorders Across the Life Span; J. Wiley & Sons, Inc., New York, Toronto, 1996
Shulman, Kenneth, editorial, Canadian Journal of Psychiatry, Canadian Psychiatric Assoc.., Ottawa, Oct. 2002
Slagle, Priscilla: The Way Up From Down; St. Martin’s, New York, 1992
The Treatment of Bipolar Disorder:
Review of the Literature, Guidelines, and Options, Cdn Psychiatric Assoc., 1997
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