The depressed may appear like you and me

I received a panic call from Jim, who had been a patient for over ten years.  His 5-year-old daughter had passed out.  Amanda was rushed to the ICU for new onset diabetes.  After stabilization, she was transferred by helicopter to a university hospital for an insulin pump insertion.  He knew that her life, his life, would never be the same.

Two weeks later, I received another call from Jim.  This time, his son had been hospitalized for attempted suicide.  Michael had started college at the age of twelve and was about to graduate at fifteen when he started drinking.  First alcohol.  Then drugs.  His racing thoughts could not be contained.  He would go nights without sleeping.  Once, he had spent all his savings on fake baseball cards.  At fourteen he was an exemplary child.  At fifteen, chaos had taken over.  “Bipolar vs. schizophrenia” echoed in Jim’s ears.

Two months later, after a period of relative quiet, we sat in my office, both exhausted.  His tears bled with each pump of his heart.

What surprised me was his disappointment in Michael.  After all, he understood the lack of insulin production by Amanda’s pancreas, and could see the metallic device to the left of her belly button.  What he couldn’t grasp was why Michael had to act this way?  Jim had spotted Michael’s talents early and had honed his skills.  They had spent hours juggling math together.  They went to sport games.  They had dinner together almost every night.  Jim had been a perfect dad.  Where did he go wrong?

Such is the nature of mental illness.  Grief can hide behind the most seductive face.  Insanity is sheltered behind a handsome smile.  Alcohol may sooth the soaring sirens inside the head until the teenager ends up with his car wrecked.  Depression is masked by lipstick.

Even a caring father like Jim may not realize that the same type of hormone deficiency that is found in diabetes is responsible for his beloved son’s mental illness.  Physical is seen, mental hidden.

I care for a world class model who self mutilates out of severe depression.  She pulls out her hair and has large patches missing, covered with scabs and newly dried blood.  But on the runway, in the store, no one would know.  She is stunning outside, a mess inside.  Yet, when she takes her medicine, she has months of stability and happiness.

Mental illness can be caused by genetics, by lack of chemicals in the brain, by hormonal insufficiencies such as dopamine and serotonin.  There are no broken bones.  There is no metal device.  There is no obvious scar.  The depressed may appear like you and I or even better.  Well intentioned loved ones often hinder the recovery of the ill by not allowing proper diagnosis or treatment.

When severe depression, bipolar disorder, generalized anxiety disorder take hold of a loved one’s life, we need to respect their need for medical evaluation and treatment.  Counseling, diet, exercise, community, spirituality, music and art can all be used as adjunctive therapy.  But just as in severe cases of diabetes, we need to show love and support to the patient and provide medications needed to stabilize missing hormones.

Afshine Ash Emrani is a cardiologist and can be reached at Los Angeles Heart Specialists.

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  • Steven Reidbord MD

    Dr. Emrani’s well-intentioned plea to take depression seriously is marred by several misstatements. Dopamine and serotonin are neurotransmitters, not hormones. It is categorically untrue that “the same type of hormone deficiency that is found in diabetes is responsible for his beloved son’s mental illness.”

    The ultimate cause (etiology) of most mental illness is unknown; there is no evidence of “insufficiency” of dopamine or serotonin, nor “lack of chemicals on the brain.” This is not to diminish the severe toll taken by major depression, bipolar disorder, schizophrenia, and other psychiatric disorders. Yes, they can be hidden, and yes, they should be taken seriously and treated. But the truth is, we don’t don’t why they occur — possibly some as-yet-unknown combination of genetic, epigenetic, and environmental factors. Strained analogies to medical conditions of known etiology serve neither patients nor the general public.

    • Afshine Emrani MD FACC

      Thank you for the clarification, but the article is far from scientific ; it is meant at the public to lift the shame of discussing and treating mental disorder. I am sure you understand.

      • Steven Reidbord MD

        I understand that you meant well, and of course I share your wish to lift the shame of discussing and treating mental disorders. But when a physician describes the causes of illness, the public assumes his statements are based on science. I wonder how you’d feel if I blogged that atrial fibrillation was psychosomatic, or referred vaguely to it being genetic in origin. We psychiatrists are a little sensitive about this, as non-specialists rarely make public declarations about cardiology, endocrinology, or hand surgery, whereas everyone seems to have an opinion about psychiatry. In this case you innocently stepped into a contentious issue in my field, and I felt I had to say something. I nonetheless applaud your sensitivity to emotional issues in your patients, and hope you continue to fight psychiatric stigma.

        • Afshine Emrani MD FACC

          Agreed. Unfortunately, I see and treat more depression and anxiety than any single cardiac condition. I believe many patients either have a fear of seeing a psychiatrist, worried to be labeled crazy, or can not be seen by one as most psychiatrists don’t accept insurance, leaving most patients in the care of their primary care physicians or specialists when they present with surrogate symptoms of chest pain, shortness of breath, palpitations, or dizziness. Thus, the more we raise awareness without being technical, the better.

          • Carolyn Thomas

            “Unfortunately, I see and treat more depression and anxiety than any single cardiac condition.” That’s a remarkable observation coming from a cardiologist! Most research has suggested that psychosocial issues are largely ignored by your colleagues in cardiology (and in other medical specialties as well).

            As Dr. Sharonne Hayes, founder of the Mayo Women’s Heart Clinic, once explained: “Cardiologists may not be comfortable
            with ‘touchy-feely’ stuff. They want to treat lipids and chest pain. And most are not trained to cope with mental health issues.”

            Although it’s always refreshing to see the subject of mental health awareness raised within the medical profession like this, Dr. Reidbord is indeed correct in his comment pointing out the obvious: when people with the letters MD after their names speak, those listening understandably assume that basic science supports every claim.

            More on this at: “When Are Cardiologists Going To Start Talking About Depression?” –

          • Afshine Emrani MD FACC

            Thank you. This is a large part of why I wrote the blog. We need to bring attention to this all encompassing disease state which affects recovery from physical ailments.

        • IFINDITODD

          That is because psychiatrists don’t know anything more than Internists do about mental illness. The model has been to Rx a small set of pills and argue amongst themselves about definitions and categorizations. Or prescribing talk therapy for demented, averbal patients – which I have seen repeatedly.

          Furthermore, I have seen that doctors who treat patients holistically and address the medical issues will end up cleaning up the psych manifestations. (In other words, but getting the diet, exercise and nutrition in place.) It is ALL a system – might show up as fibromyalgia in one person, and psychiatric issues in another.

          Psychiatrist over at Evolutionary Psychiatry Blog talks about this a lot. She and others like her will be the ones to move your field forward. Not the guys arguing over DSM categorizations and over-prescribing SSRIs.

        • guest

          Personally I think that if psychiatrists are going to withdraw from the field of providing treatment to patients who are significantly affected by mental illness (as they do when they decide to maintain cash-only private practices which don’t accept insurance and therefore exclude all but the highest-functioning patients from their care) they probably shouldn’t be outspoken in criticizing the treatment attempts of other medical professionals who are left holding the bag, so to speak.

          • Patient Kit

            Agreed. Access to treatment from a psychiatrist isn’t even on the radar for many Americans, largely because so much of it is cash only. Treatment for mental illness, for many, is a luxury. The inaccessibility of unaffordable cash only mental health care is one reason that I’m skeptical about what would happen if all primary care went direct pay/cash only.

          • guest

            It’s an unfortunate trend, although I can see why many doctors feel that it is unsustainable to allow third-party payors to be involved in their practices, and I support their right to take back some control over their professional lives.
            Where I think psychiatry and direct-pay primary care differ in this paradigm is that it appears that direct-pay PCPs are spending a lot of their extra time and energy looking for ways to make the care they offer more affordable for their patients. The psychiatrists I see who have cash-only private practices seem to spend their extra time and energy…getting massages on their Fridays off, planning to retire at age 60 and being judgmental about other practitioners. It would be nice if they could get involved in offering pro bono care at mental health clinics, or providing consultation services to primary care practices.

          • Steven Reidbord MD

            “Guest”, ever since I arrived here in early March you’ve been on my case. One snide comment after another that direct-pay psychiatrists avoid tough cases, take massages on their Fridays off, and “should not be outspoken” about psychiatric matters. In your fervor to put me down you keep ignoring that I see Medicare patients in addition to direct-pay, currently between 1/4 and 1/3 of my practice. Moreover, some self-pay patients have serious disorders: I’m seeing a new patient on clozapine tomorrow, and have hospitalized two patients with bipolar exacerbations in the past month or two. I don’t know anyone who retires at 60 or takes Fridays off; my direct-pay officemate just retired at 75-plus and worked hard his whole life.

            You support direct-pay practice in primary care, but give me grief about *partly* having one in psychiatry. The logic is exactly the same — same pros and cons. Reasonable people can discuss these real trade-offs, whereas unreasonable people can lob snippy anonymous comments and play to the crowd.

            As for “being judgmental about other practitioners”, I suggest you look in the mirror.

          • Arby

            Meanwhile on other boards, there are those that think psychiatry is the work of the devil, verbally eviscerate psychiatrists for the neurotransmitter myth and couldn’t care less that you are unaffordable because they wish you would all cease to practice.

            Seemly those in your field can’t win regardless. Yet, I think it is more of one side not being able to see the other and that often not practiced phrase of live and let live.

    • querywoman

      Nevertheless, for some of us, there is a strong link between depression and diabetes and, of course, hypothyroidism.
      A hypothyroid patient often develops diabetes also!

  • guest

    It is truly unfortunate that you had that experience. Sadly, most non-psychiatric medical professionals really struggle to recognize signs of mental illness in their patients, as they really have very little training in psychiatry. Frequently, given a situation where a clinician is not familiar with the signs of a specific psychiatric condition, it’s easiest to dismiss those signs as evidence that the patient has a “difficult personality,” and treat them accordingly.

    • querywoman

      Yes, that’s what happened too often in my pre-diabetes years.

  • Arby

    Some people are content not to know the truth and if a well meaning attitude is enough for them, fine. I am not one of them, and believe that it only sets up a greater issue to be dealt with later on.

  • querywoman

    I was dx’d with hypothyroidism at age 17. In my early 20s, I was really depressed in college, that might have had something to do also with serious weight loss.
    I probably began developing diabetes in my early 30s.
    In spite of a really nasty skin disease worsening in my late 40s, my mood is much more stable with better diabetes control, more than it was in my pre-diabetes years.
    I used to take huge amounts of insulin. Now I am on Victoza, along with glimepiride and metformin. My blood sugar doesn’t fluctuate as much on Victoza as it did insulin, do I feel more stable emotionally and physically.

    I ask my friends who are chronically depressed if diabetes runs in their families. It often does.
    The links need to be explored more, and hopefully something done before someone goes all the way into diabetes.

    • Afshine Emrani MD FACC

      Agreed. Thank you for sharing

      • querywoman

        I said something to one of my post-diabetes endos about knowing now that a disastrous thyroid dosage adjustment spun me into a, “subdiabetic state,” in my mid-twenties.
        She replied, “We are learning more about that state all the time.”
        I’ll mention it to my current endo, the guy who put me on Victoza, at my next visit.

  • querywoman

    No, it is not the most scientific article. His wish is social cultural. He is wishing caring parents would understand depression better.

  • Afshine Emrani MD FACC

    Thank you for your kind words. The point of this article was to raise awareness in the public that
    1- Mental disorder, though unseen as compared to a broken bone, is very real and causes serious barriers to a full life;
    2- It is difficult to find a psychiatrist if you cannot afford to pay cash and treatment needs initiation through primary care physicians or specialists who accept insurance;
    3- Caretakers of the mentally ill must allow and encourage patients to obtain care, evaluation and treatment and not obstruct their recovery.

    Once again, although I certainly understand the difference between a hormone and a neurotransmitter, I am more interested in a model that sheds light on the similarities of diabetes and mental disorder so that the public can better understand the need for evaluation and treatment. In other words, just as a diabetic needs the hormone for proper recovery and maintenance, so does the mentally ill need the neurotransmitters.

    The academic discussion, although mentally satisfying for physicians has little value to the public that suffers from mental illness that falls on the lap of MDs other that psychiatrists to treat.

    • Steven Reidbord MD

      Dr. Emrani,

      In this, my last comment on your article, I want to say again that I applaud your concern for the emotional difficulties of medically ill patients. Truly, minds and bodies are all one system. You encounter psychiatric conditions masquerading as cardiac, while we sometimes see medical conditions masquerading as psychiatric. It’s good to be aware, and make others aware, of this.

      I fully agree with your 3 points listed above. Difficulty finding a psychiatrist who accepts insurance wasn’t mentioned in your article, but it’s a real challenge. In 2010, 55% of private, office-based psychiatrists accepted private health insurance, versus 89% of all private and public medical specialists. The reasons are too long to include here; for the most part office-baseed psychiatry parallels (precedes, actually) the same trend now occurring in primary care. KMD has articles nearly daily on direct-pay primary care, and the complexity of that debate applies just as much to psychiatry.

      I’ll end with a request that you reconsider likening mental disorders to diabetes. This oft-cited analogy, and the “chemical imbalance” language that underlies it, has been criticized by patients, mental health professionals, and pundits. Here are some links. Take care.

      • Arby

        I understand that the article pertains to a much bigger issue than what I see as the paternalistic treatment of the public, but for the current discussion I wanted to weigh in to say thank you for sticking up for the truth.

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