Tuesday, November 18, 2008

Gallows Humor

I recommend this New York Times article about humor (or the lack thereof) in psychiatry. I think psychiatrists tend to be serious not only out of respect toward patients and their experience, but also because the profession does not yet enjoy the (self-)respect that would allow it to laugh at itself. Sometimes drawing too much attention to the absurd, however tempting it might be, is not a wise (career) move.

That reminds me, I need to reread Thomas Pynchon's The Crying of Lot 49, one of the great ones, if only for the character of Dr. Hilarius, who among other absurdities, calls his patients in the middle of the night just to see how they're doing (and also to try to enroll them in an LSD study). In fact, I wish I could rename this blog "Dr. Hilarius"--would Pynchon emerge from seclusion to sue me I wonder?

Not long ago I read a comment on another blog that speculated on whether a mental disorder can be considered "terminal." I think the answer is an emphatic no, but the reasons why are curious (they do not include: "Because our treatments are so great."). Like other doctors, we see a number of people with chronic and severe problems that are unlikely to get a great deal better. In fact, a significant percentage of what we see is at least somewhat resistant to treatment (if something gets better quickly and completely in this business, it probably would have gotten better on its own).

We do not enjoy anywhere near the same prognostic science that, say, oncologists do though. And it isn't only a matter of science; it is a matter of semantics and ethics. When we say that someone is terminally ill, we presumably mean that, no matter what he does, biology will take its course within an arbitrarily limited period of time, six or twelve months or whatever. Mental disorders are not like that, of course. We speak of supportive treatment in psychiatry, but not of palliative care.

Like, say, dentists and pain specialists, psychiatrists tend to concern themselves more with quality of life than with mortality. Suicide is a tragedy whenever it happens, but in terms of sheer volume it is dwarfed by mortality from other causes and by the overall scope of mental suffering that goes on. Mental disorders more commonly kill in less spectacular fashion; people die younger than they otherwise would have because they don't take care of themselves, or drink or smoke, or whatever.

Reduced life expectancy is not exactly the same as having a terminal illness, but it is also not the same, say, as dying with "incidental" prostate cancer, in which an eighty-year-old man's histological quirk had nothing really to do with the timing of his demise. So I obviously never tell anyone they have a terminal psychiatric diagnosis. "Chronic" is the much more appropriate term, and diabetes is the medical parallel I most often use. Like diabetes, many mental disorders will not go away, and may reduce life expectancy and even quality of life, but can be usefully managed over time.

There is, of course, another reason why no legitimate psychiatrist would come out and pronounce a mentally ill person's condition as "terminal." One could only do so out of knowledge that life would end suddenly and unexpectedly in the near future as a result of the mental illness. We know what that means. This would not only presume knowledge we don't have, but could also amount to a self-fulfilling prophecy. So I worry that when people speak of "terminal" psychiatric cases, they're seeking permission. And that would be no laughing matter.


Anonymous said...

Every occasion is amenable to humour - even a funeral. It's the style and timing that's important.

Life can be so absurdly serious and plastic-y like processed cheese - humour adds texture, nuance and unpredictability.

Yes, you should even joke with psychiatric patients - in appropriately measured and tactful doses.

The more familiar a patient becomes with their disease/disorder/condition, the more liable they are to be contemptuous towards it; so less discretion is needed.

Does humour work with depressed patients? Maybe it's a question of wavelengths. I don't think a failed joke is terminal, so it doesn't hurt to try.

Novalis said...

Actually, for funerals, suicide, and humor, see "Harold and Maude" (preferably again and again), one of the most charming movies ever made. Requisite hilarious psychiatrist scene included.

Anonymous said...

'Harold and Maude' makes me warm and fuzzy just thinking about it - now I will have to watch it again!

Part of that hilarious psychiatrist scene you mentioned has actually been immortalised in a song (Funerals) by a band called 'The Operacycle'; along with a sample of the mother's hysterical screams and near breakdown at finding her son at it again - ie suiciding.

Life imitates death; death imitates life; and art just laughs at the circus.

Oh death can be so much fun...

Maybe the film can be useful as a therapy aid

Joseph j7uy5 said...

Psychopharmacology has changed greatly in the past twenty years. Twenty years ago, few primary care docs treated depression with antidepressants; and when they did, they typically used subtherapeutic doses of tricyclic antidepressants. Therefore, it was common for psychiatrists to see people who responded quickly and well to treatment.

Now, I rarely see someone who hasn't had two or three decent -- but not necessarily adequate -- trials of antidepressants.

This establishes a point similar to what you said, "if something gets better quickly and completely in this business, it probably would have gotten better on its own." If a condition is going to respond to a simple intervention, then the patient is treated by the PCP, and never even sees a psychiatrist.