Should Patients Be Allowed to Die From Anorexia? Is a 'Palliative' Approach to Mental Illness Ethical?

Katie Engelhart

New York Times Magazine

Originally posted 3 Jan 24

Here is an excerpt:

He came to think that he had been impelled by a kind of professional hubris — a hubris particular to psychiatrists, who never seemed to acknowledge that some patients just could not get better. That psychiatry had actual therapeutic limits. Yager wanted to find a different path. In academic journals, he came across a small body of literature, mostly theoretical, on the idea of palliative psychiatry. The approach offered a way for him to be with patients without trying to make them better: to not abandon the people who couldn’t seem to be fixed. “I developed this phrase of ‘compassionate witnessing,’” he told me. “That’s what priests did. That’s what physicians did 150 years ago when they didn’t have any tools. They would just sit at the bedside and be with somebody.”

Yager believed that a certain kind of patient — maybe 1 or 2 percent of them — would benefit from entirely letting go of standard recovery-oriented care. Yager would want to know that such a patient had insight into her condition and her options. He would want to know that she had been in treatment in the past, not just once but several times. Still, he would not require her to have tried anything and everything before he brought her into palliative care. Even a very mentally ill person, he thought, was allowed to have ideas about what she could and could not tolerate.

If the patient had a comorbidity, like depression, Yager would want to know that it was being treated. Maybe, for some patients, treating their depression would be enough to let them keep fighting. But he wouldn’t insist that a person be depression-free before she left standard treatment. Not all depression can be cured, and many people are depressed and make decisions for themselves every day. It would be Yager’s job to tease out whether what the patient said she wanted was what she authentically desired, or was instead an expression of pathological despair. Or more: a suicidal yearning. Or something different: a cry for help. That was always part of the job: to root around for authenticity in the morass of a disease.

The info is here.

Some thoughts:

The question of whether patients with anorexia nervosa should be allowed to die from their illness or receive palliative care is a complex and emotionally charged one, lacking easy answers. It delves into the profound depths of autonomy, mental health, and the very meaning of life itself.

The Anorexic's Dilemma:

Anorexia nervosa is a severe eating disorder characterized by a relentless pursuit of thinness and an intense fear of weight gain. It often manifests in severe food restriction, excessive exercise, and distorted body image. This relentless control, however, comes at a devastating cost. Organ failure, malnutrition, and even death can be the tragic consequences of the disease's progression.

Palliative Care: Comfort Not Cure:

Palliative care focuses on symptom management and improving quality of life for individuals with life-threatening illnesses. In the context of anorexia, it would involve addressing physical discomfort, emotional distress, and spiritual concerns, but without actively aiming for weight gain or cure. This raises numerous ethical and practical questions:

• Respecting Autonomy: Does respecting a patient's autonomy mean allowing them to choose a path that may lead to death, even if their decision is influenced by a mental illness?
• The Line Between Choice and Coercion: How do we differentiate between a genuine desire for death and succumbing to the distorted thinking patterns of anorexia?
• Futility vs. Hope: When is treatment considered futile, and when should hope for recovery, however slim, be prioritized?

Finding the Middle Ground:

There's no one-size-fits-all answer to this intricate dilemma. Each case demands individual consideration, taking into account the patient's mental capacity, level of understanding, and potential for recovery. Open communication, involving the patient, their family, and a multidisciplinary team of healthcare professionals, is crucial in navigating this sensitive terrain.

Potential Approaches:

• Enhanced Supportive Care: Focusing on improving the patient's quality of life through pain management, emotional support, and addressing underlying psychological issues.
• Conditional Palliative Care: Providing palliative care while continuing to offer and encourage life-sustaining treatment, with the possibility of transitioning back to active recovery if the patient shows signs of willingness.
• Advance Directives: Encouraging patients to discuss their wishes and preferences beforehand, allowing for informed decision-making when faced with difficult choices.

Psychoneuroimmunology: An Introduction to Immune-to-Brain Communication and Its Implications for Clinical Psychology

Julienne E. Bower and Kate R. Kuhlman

Annual Review of Clinical Psychology 2023 19:1, 331-359

Abstract

Research conducted over the past several decades has revolutionized our understanding of the role of the immune system in neural and psychological development and function across the life span. Our goal in this review is to introduce this dynamic area of research to a psychological audience and highlight its relevance for clinical psychology. We begin by introducing the basic physiology of immune-to-brain signaling and the neuroimmune network, focusing on inflammation. Drawing from preclinical and clinical research, we then examine effects of immune activation on key psychological domains, including positive and negative valence systems, social processes, cognition, and arousal (fatigue, sleep), as well as links with psychological disorders (depression, posttraumatic stress disorder, anxiety, schizophrenia). We also consider psychosocial stress as a critical modulator of neuroimmune activity and focus on early life adversity. Finally, we highlight psychosocial and mind–body interventions that influence the immune system and may promote neuroimmune resilience.

The full article is here.

Here is a summary:

This research delves into the fascinating field of psychoneuroimmunology (PNI), exploring the intricate communication pathways between the brain, behavior, and immune system. It sheds light on how our mental and emotional states can influence our immune response, and vice versa, with profound implications for clinical psychology.

Key Insights:

• Immune-to-brain communication: Inflammation, a crucial immune response, plays a central role in this dialogue. Immune cells release signaling molecules that reach the brain, impacting mood, cognition, and behavior.
• Psychosocial stress and immunity: Stress acts as a potent modulator, amplifying inflammation and potentially leading to various physical and mental health issues like depression, anxiety, and even some neurodegenerative disorders.
• Early life adversity and resilience: Early life experiences can leave lasting impressions on the neuroimmune system, influencing vulnerability or resilience to stress and disease later in life.
• Implications for clinical psychology: Understanding PNI opens new avenues for intervention. Therapies targeting stress management, mindfulness, and social support could bolster neuroimmune resilience and improve mental health outcomes.

Future Directions:

• Deciphering the complex mechanisms of immune-to-brain communication, particularly the role of specific molecules and brain regions.
• Developing PNI-informed interventions for diverse clinical conditions, tailored to individual needs and vulnerabilities.
• Integrating PNI knowledge into clinical training and practice to offer a more holistic understanding of mental health.

How to Navigate the Pitfalls of AI Hype in Health Care

Suran M, Hswen Y.

JAMA.

Published online January 03, 2024.

doi:10.1001/jama.2023.23330

What is AI snake oil, and how might it hinder progress within the medical field? What are the inherent risks in AI-driven automation for patient care, and how can we ensure the protection of sensitive patient information while maximizing its benefits?

When it comes to using AI in medicine, progress is important—but so is proceeding with caution, says Arvind Narayanan, PhD, a professor of computer science at Princeton University, where he directs the Center for Information Technology Policy.

The interview and the video is here.

Here is my summary:

• AI has the potential to revolutionize healthcare, but it is important to be aware of the hype and potential pitfalls.
• One of the biggest concerns is bias. AI algorithms can be biased based on the data they are trained on, which can lead to unfair or inaccurate results. For example, an AI algorithm that is trained on data from mostly white patients may be less accurate at diagnosing diseases in black patients.
• Another concern is privacy. AI algorithms require large amounts of data to work, and this data can be very sensitive. It is important to make sure that patient data is protected and that patients have control over how their data is used.
• It is also important to remember that AI is not a magic bullet. AI can be a valuable tool, but it is not a replacement for human judgment. Doctors and other healthcare professionals need to be able to critically evaluate the output of AI algorithms and make sure that it is being used in a safe and ethical way.

Overall, the interview is a cautionary tale about the potential dangers of AI in healthcare. It is important to be aware of the risks and to take steps to mitigate them. But it is also important to remember that AI has the potential to do a lot of good in healthcare. If we develop and use AI responsibly, it can help us to improve the quality of care for everyone.

Here are some additional points that were made in the interview:

• AI can be used to help with a variety of tasks in healthcare, such as diagnosing diseases, developing new treatments, and managing chronic conditions.
• There are a number of different types of AI, each with its own strengths and weaknesses.
• It is important to choose the right type of AI for the task at hand.
• AI should always be used in conjunction with human judgment.

Young people turning to AI therapist bots

Joe Tidy

BBC.com

Originally posted 4 Jan 24

Here is an excerpt:

Sam has been so surprised by the success of the bot that he is working on a post-graduate research project about the emerging trend of AI therapy and why it appeals to young people. Character.ai is dominated by users aged 16 to 30.

"So many people who've messaged me say they access it when their thoughts get hard, like at 2am when they can't really talk to any friends or a real therapist,"

Sam also guesses that the text format is one with which young people are most comfortable.

"Talking by text is potentially less daunting than picking up the phone or having a face-to-face conversation," he theorises.

Theresa Plewman is a professional psychotherapist and has tried out Psychologist. She says she is not surprised this type of therapy is popular with younger generations, but questions its effectiveness.

"The bot has a lot to say and quickly makes assumptions, like giving me advice about depression when I said I was feeling sad. That's not how a human would respond," she said.

Theresa says the bot fails to gather all the information a human would and is not a competent therapist. But she says its immediate and spontaneous nature might be useful to people who need help.

She says the number of people using the bot is worrying and could point to high levels of mental ill health and a lack of public resources.

The info is here.

Here are some important points-

Reasons for appeal:

• Cost: Traditional therapy's expense and limited availability drive some towards bots, seen as cheaper and readily accessible.
• Stigma: Stigma associated with mental health might make bots a less intimidating first step compared to human therapists.
• Technology familiarity: Young people, comfortable with technology, find text-based interaction with bots familiar and less daunting than face-to-face sessions.

Concerns and considerations:

• Bias: Bots trained on potentially biased data might offer inaccurate or harmful advice, reinforcing existing prejudices.
• Qualifications: Lack of professional mental health credentials and oversight raises concerns about the quality of support provided.
• Limitations: Bots aren't replacements for human therapists. Complex issues or severe cases require professional intervention.

The death of the self in posttraumatic experience

Dorothy, J., & Hughes, E. (2023).

Philosophical Psychology, 1–21.

https://doi.org/10.1080/09515089.2023.2294776

Abstract

Survivors of trauma commonly report feeling as though a part of themselves has died. This article provides a theoretical interpretation of this phenomenon, drawing on Waldenfels' notion of the split self. We argue that trauma gives rise to an explicit tension between the lived and corporeal body which is so profoundly distressing that it can be experienced by survivors as the death of part of oneself. We explore the ways in which this is manifest in the posttraumatic phenomena of dissociation; indescribability; and the fragmentation and repetition of time. Acknowledging that the traumatic loss of part of oneself involves significant grief, we then consider whether the bereavement literature might be helpfully applied. We focus specifically upon the continuing bonds model, which emphasizes an ongoing and meaningful relationship with the deceased through an active process of memorializing. In considering how this might be appropriated to the death of the self in trauma, we suggest that the development of an intrapersonal relationship between parts lost and living might, over time, offer a unique way in which to adapt to loss and approach the future.

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Here is my summary:

The article argues that the feeling of a "death of the self" commonly reported by trauma survivors isn't just a metaphor, but a profound rupture in their sense of being. Drawing on philosopher Bernhard Waldenfels' concept of the "split self," the authors explain how trauma can create a stark disconnect between the lived experience of the body and the pre-trauma sense of self. This can manifest in dissociative symptoms, feelings of unreality, and disruptions in one's understanding of time. They argue that this "death of the self" lies at the core of several posttraumatic stress disorder (PTSD) symptoms, particularly the tension between hyperarousal and detachment. The article ultimately suggests that recognizing this experience of self-death could be crucial for developing more effective trauma interventions.

Here are some additional key points:

• The article emphasizes the subjective and embodied nature of trauma, rather than viewing it solely as a psychological event.
• It highlights the importance of understanding the complexities of dissociation in trauma survivors.
• The article challenges traditional notions of PTSD by suggesting that self-death might be a more accurate description of the central trauma experience.
• It offers therapeutic implications for treating trauma by focusing on integrating the fragmented pieces of the self.

Our moral self, the set of deeply held values and beliefs that guide our actions and judgments, lays the foundation for our lived experience. It shapes how we make sense of the world, navigate relationships, and interact with others. This moral compass provides a sense of coherence and belonging, anchoring us in a broader community of shared values.

However, when we experience trauma, this foundation can be severely shaken. Traumatic events, especially those that violate our core values or sense of justice, can shatter the very beliefs that once structured our lives. This can lead to a fracturing of the moral self.

Despite the profound rupture trauma can cause, the human capacity for healing and growth is remarkable. Even from the ashes of fractured morality, post-traumatic growth can emerge. This process involves integrating the fragmented pieces of the moral self with an expanded understanding of oneself and the world. 

Negative Wealth Shock and Cognitive Decline and Dementia in Middle-Aged and Older US Adults

Pan, L., Gao, B., Zhu, J., & Guo, J. (2023).

JAMA network open, 6(12), e2349258.

https://doi.org/10.1001/jamanetworkopen.2023.49258

Key Points

Question

Is an experience of negative wealth shock—a loss of 75% or more in total wealth over a 2-year period—associated with cognitive decline and dementia risks among middle-aged and older US adults?

Findings

In this cohort study of 8082 participants, those with negative wealth shock had faster decline in cognition and elevated risks of dementia when compared with those who had positive wealth without shock.

Meaning

These findings suggest that negative wealth shock is a risk factor for cognitive decline and dementia in middle-aged and older adults.

The research is linked above.

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Key findings:

• Negative wealth shock, defined as losing 75% or more of total wealth within two years, was associated with accelerated cognitive decline and higher risks of dementia.
• This association was stronger for younger participants (under 65) and white participants compared to older and non-white participants.

While the study offers valuable insights, it also has limitations:

• The study is observational, not causal, so it cannot prove cause and effect.
• Wealth changes after negative wealth shock were not considered, potentially impacting results.

Overall, the study suggests that negative wealth shock may be a risk factor for cognitive decline and dementia, highlighting the potential impacts of financial hardship on brain health. Further research is needed to confirm these findings and explore underlying mechanisms.

Additional points:

• The study used data from the Health and Retirement Study, which tracked over 8,000 participants for 14 years.
• Participants with negative wealth shock had a 27% higher risk of developing dementia compared to those without wealth shock.

The study suggests potential social and psychological mechanisms linking financial hardship to cognitive decline, such as stress, depression, and reduced access to healthcare.

Lawsuit Challenges New Jersey’s Out-of-State Telehealth Licensing Law

A. Vaidya

mhealthintelligence.com

Originally posted 18 DEC 23

Here is an excerpt:

The lawsuit states that J.A. was diagnosed with pineoblastoma, an aggressive brain tumor, at 18 months old. His physicians referred him to MacDonald in Boston. The treatment enabled J.A. to beat his cancer. However, he must continue to undergo scans once a year for the rest of his life to monitor the cancer’s return.

New Jersey’s current telehealth licensing law requires patients seeking specialty care out of state to decide whether to incur the cost of traveling to meet with the specialist for initial or follow-up consultations.

“Without telemedicine, patients suffering from rare cancers and diseases like J.A. must either forego lifesaving treatment or suffer by traveling out of state every time an appointment with a national specialist like Dr. MacDonald is needed,” the suit states. “Many cannot bear the burdens of frequent travel.”

Without the option of telehealth, J.A. and his family would not have been able to consult with all the specialists they needed due to “financial and time constraints,” the lawsuit further states. Even more recently, telehealth enabled J.A. to consult with MacDonald when an anomaly appeared on one of his scans.

Maintaining multiple licenses in different states places an administrative and financial burden on physicians, especially for specialists like MacDonald and Gardner, “who have national practices and only occasionally consult with or treat patients from New Jersey,” the suit notes.

Thus, the lawsuit argues that the licensing law violates the Dormant Commerce Clause and Privileges and Immunities Clause, which prohibits states from enacting laws that excessively burden interstate commerce in relation to local benefits. It also violates the First Amendment, which prevents the government from restricting conversations between patients and their providers, and the 14th Amendment’s Due Process Clause, which bans the government from limiting the ability of parents to direct their children’s medical care.

“Plaintiffs, who are New Jersey citizens and out-of-state specialists with patients in New Jersey, seek to vindicate their constitutional rights — and ensure they can continue to provide and receive — lifesaving care,” the lawsuit states.

The article is here.

Two in three UK doctors suffer ‘moral distress’ due to overstretched NHS, study finds

Denis Campbell

The Guardian

Originally posted 28 Dec 23

Two in three UK doctors are suffering “moral distress” caused by the enfeebled state of the NHS and the damage the cost of living crisis is inflicting on patients’ health, research has found.

Large numbers are ending up psychologically damaged by feeling they cannot give patients the best possible care because of problems they cannot overcome, such as long waits for treatment or lack of drugs or the fact that poverty or bad housing is making them ill.

A new survey found that 65% of doctors overall, including nearly four in five (78%) GPs and more than half (56%) of hospital doctors, have experienced “moral distress” as a direct result of situations they have encountered working in the NHS.

Seeing patients with malnutrition or hypothermia, or stuck on trolleys in A&E corridors asking for help or forced to choose between heating their home or getting a prescription dispensed are among the events triggering their distress, medics said.

“There’s barely a doctor at work in the NHS today who doesn’t see or experience this distress on a daily basis,” said Prof Philip Banfield, the leader of the British Medical Association.

The NHS is “impossibly overstretched”, has thousands of vacancies for doctors and has a quarter fewer doctors a head of population than Germany, he added.

“In practice that means we can almost never give the standard of care we would want, only ever the care we can manage. That takes its toll, as we see here,” Banfield said.

The info is here.

Key points:

The study also found that:

• Nearly half (47%) of doctors believe the cost of living crisis is contributing to their moral distress.
• 72% of doctors say being unhappy at work has affected their mental health.
• 85% of doctors have experienced fatigue as a result of their work.

Causes of moral distress:

• Doctors are often in situations where they have to make difficult decisions about who to treat first, or whether they can afford to give a patient the treatment they need.
• They may also feel that they are not able to provide the level of care that they would like to because of the lack of resources in the NHS.

Impact of moral distress:

• Moral distress can lead to burnout, depression, and anxiety.
• It can also make it difficult for doctors to continue working in the NHS.

Americans are lonely and it’s killing them. How the US can combat this new epidemic.

Adrianna Rodriguez

USA Today

Originally posted 24 Dec 23

America has a new epidemic. It can’t be treated using traditional therapies even though it has debilitating and even deadly consequences.

The problem seeping in at the corners of our communities is loneliness and U.S. Surgeon General Dr. Vivek Murthy is hoping to generate awareness and offer remedies before it claims more lives.

“Most of us probably think of loneliness as just a bad feeling,” he told USA TODAY. “It turns out that loneliness has far greater implications for our health when we struggle with a sense of social disconnection, being lonely or isolated.”

Loneliness is detrimental to mental and physical health, experts say, leading to an increased risk of heart disease, dementia, stroke and premature death. As researchers track record levels of self-reported loneliness, public health leaders are banding together to develop a public health framework to address the epidemic.

“The world is becoming lonelier and there’s some very, very worrisome consequences,” said Dr. Jeremy Nobel, founder of The Foundation for Art and Healing, a nonprofit that addresses public health concerns through creative expression, which launched an initiative called Project Unlonely.

“It won’t just make you miserable, but loneliness will kill you," he said. "And that’s why it’s a crisis."

The info is here.

Key points:

• Loneliness Crisis: America faces a growing epidemic of loneliness impacting mental and physical health, leading to increased risks of heart disease, dementia, stroke, and premature death.
• Diverse and Widespread: Loneliness affects various demographics, from young adults to older populations, and isn't limited by social media interaction.
• Health Risks: The Surgeon General reports loneliness raises risk of premature death by 26%, equivalent to smoking 15 cigarettes daily. Heart disease and stroke risks also increase significantly.
• Causes: Numerous factors contribute, including societal changes, technology overuse, remote work, and lack of genuine social connection.
• Solutions: Individual actions like reaching out and mindful interactions help. Additionally, public health strategies like "social prescribing" and community initiatives are crucial.
• Collective Effort Needed: Overcoming the epidemic requires collaboration across sectors, fostering stronger social connections within communities and digital spaces.