Letters to the Editor
New Insights into Mental Illness
TO THE EDITOR: Let's face it. Despite unprecedented pharmacologic advances, treating patients with mental illnesses in the 21st century remains challenging and time-consuming. Unlike the euphoric pill-swallowers featured in pharmaceutical company advertisements, our patients' responses are more often modest at best. Definitive diagnosis of clear-cut psychopathology with dramatic response to pharmacologic treatment occurs but remains the exception rather than the rule.
Most of the patients who fill our waiting rooms resist tidy classification into the research-based diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). The multifactorial etiology of patient complaints often eludes the magic pharmacologic bullet, and the risk-benefit ratio of expensive medication blurs.1 Counseling, while clearly of additional benefit in numerous studies, remains time-consuming and is often ongoing. Without doubt, these are the cases that try our patience and strain our office schedules.
It was therefore with no small interest that I read The Awakening: One Man's Battle with Darkness,2 an account of a 19th century German pastor named Blumhardt, who unintentionally attracted similar patients in an era when psychopharmacologic medications were practically nonexistent. On some days he saw up to 35 people, with complaints running the gamut of physical to mental disorders. Many had exhausted the medical options of their day.
In an unsensational, down-to-earth manner, this book documents remarkable improvement in many of these people. The unassuming style and authenticity of the accounts make quick dismissal difficult. Blumhardt wrote to a government official, "It was never my intent to treat mental illness."2 In fact, Blumhardt had the greatest respect for the medical profession, noting that "especially in the case of mental illness, most pastors cut a pathetic figure alongside physicians."2
What then, was Blumhardt's secret, and why did people flock to his rectory in such numbers that the civilian authorities had to restrict his "practice"? Primarily, Blumhardt recognized the tremendous need people have to be forgiven. In an amoralistic age, when values have become relative, the concept of forgiveness may sound dated; however, regardless of their religious or secular background, people still have a sense of right and wrong and suffer when they violate their internal code of ethics. Most modern counselors see the associated guilt, rather than the wrong-doing itself, as the problem. Blumhardt encouraged his parishioners to confess the actions that troubled them most and to make restitution wherever possible. The results were remarkable!
Since reading this book, I have become more aware of the spiritual aspects of mental illness. I have noted concrete improvement in patients with mental illness who had found a sense of forgiveness by simply sharing their past wrong-doings with a trusted confidant. While many physicians may be more comfortable relegating spiritual matters to the clergy, we can't afford to trivialize or ignore the importance of spiritual issues to our patients. This book is a must-read for persons who wish to broaden their understanding of the complex interplay between medical, psychiatric and spiritual components of the human experience. After all, the patient before us contains all three.
CHRISTOPHER M. MAENDEL, M.D.
10 Hellbrook Lane
Ulster Park, NY 12487REFERENCES
- Venning, G. Antidepressant drugs have previously been shown to be ineffective in mild depression. BMJ 2000;320:311.
- Zèundel, F. The awakening: one man's battle with darkness. Farmington, PA: Plough Pub. House, 1999.
Family Physicians and End-of-Life Care
TO THE EDITOR: The article, "End-of-Life Care Content in 50 Textbooks from Multiple Specialties" in a recent issue of JAMA1 concluded "that top selling medical textbooks offered little helpful information on caring for patients at the end of life." The authors reported that family medicine, geriatrics and psychiatry textbooks have the greatest volume of helpful content on end-of-life (EOL) care. One third of the chapters in family medicine textbooks were found to have helpful content on EOL care, and 20 percent were considered to have minimal content, while 45 percent had no content. Geriatrics and psychiatry textbooks had a similar pattern.
This same study1 found that family medicine textbooks had better content in chapters on Alzheimer's disease, death and dying, and chronic obstructive pulmonary disease, compared with chapters on lung cancer, coronary artery disease and cerebrovascular accident. Chapters in family medicine textbooks on trauma, leukemia and adult respiratory distress syndrome were worse than chapters found on these subjects overall. The authors considered 13 domains from all elements of EOL care.
These findings should please family physicians but should also inspire continuous efforts in EOL care. EOL care competence can be addressed in various ways for the family physician. American Family Physician and other family medicine journals should continue to publish articles on EOL care. The AFP articles on advance directives is an excellent example.2 A series covering the above mentioned 13 domains might be considered. Lectures, workshops and seminars at scientific meetings provide an excellent forum to provide training on EOL care.
The American Academy of Family Physicians' continuing medical education program could consider an EOL care conference. The residency core educational guidelines include a section on EOL care. The American Board of Family Practice ensures coverage in the certification examination with 12 percent devoted to geriatrics and may consider EOL care as a possible office record review topic. And, we appeal to textbook editors to bolster their EOL care content. We are covering EOL care in these forums, and I entreat those involved to ensure our competence in EOL care.
I'm sure that family physicians--academicians, writers, speakers, researchers and clinicians--are aware of the progress to-date, and the current status of EOL care education and training, and will continually lead the way in EOL care. I recommend that all family physicians read this article for better awareness of this important, but sometimes neglected topic.2 (Editor's note: A more recent article on EOL care is available for review [Ackermann RJ. Withholding and withdrawing life-sustaining treatment. Am Fam Physician 2000;62: 1555-60,62,64].) Family physicians who are competent in EOL care, improved through comprehensive education and training, will continue to provide quality medical care to their patients.
RICHARD W. SUMRALL, MAJ, USAF, MC, FS
347 ADS/SGGF (Flight Medicine)
Moody AFB, GA 31699REFERENCES
- 1. Rabow MW, Hardie GE, Fair JM, McPhee SJ. End-of-life-care content in 50 textbooks from multiple specialties. JAMA 1999;283:771-8.
- 2. Aitkin PV. Incorporating advance care planning into family practice. Am Fam Physician 1999;59: 605-12.
Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax:913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.
Copyright © 2001 by the American Academy of Family Physicians.
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