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Unresolved grief and perception of loss result in impaired relationships and increased psychopathology. Grief research and therapy support a beneficial response to emotional expression of grief in the context of search for meaning (Neimeyer's “mean-making”). Further, there are multiple forms of expression of grief be it verbal, artistic, or written. This paper addresses poetry therapy as an effective expression of grief.
Poetry therapy with analysis.
Too often we take life and friendship for granted. Frequently, it is only with death that our thoughts crystallize and the meanings of relationships become clear, powerful, and at times overwhelming. It is then that we truly understand our own mortality and our responsibilities to others. Poetry affords a therapeutic means for the expression of grief while serving as a monument to those now lost, but always remembered.
Too often it is difficult to express one's emotions and the meaning of loss during the grief process. All forms of expression should be afforded the bereaved. Poetry therapy is a unique means wherein special feelings and meanings can be effectively expressed and result in a therapeutic grief process.
Maximization of response with minimization of adverse effects is central to successful oncology chemotherapy. Since psychiatric comorbidity is significant in cancer patients, psychotropic co-administration with chemotherapy requires assessment of drug-drug interactions and cumulative adverse effects. Arsenic trioxide (ATO), indicated for treatment of relapsed acute promyelocytic leukemia (APL), prolongs QTc and has “black-box” warning regarding co-administration with medications with potential QTc prolongation. ATO administration is to be held if QTc > 500 milliseconds. This case describes ATO and olanzapine co-administration.
Case analysis with literature review.
43-year-old Caucasian male presented with relapsed APL characterized by non-traumatic bruising, anemia, and thrombocytopenia confirmed by bone marrow biopsy. Psychiatric comorbidity included Obsessive-Compulsive Disorder, Panic Disorder, and Bipolar NOS treated with fluvoxamine and benzodiazepines. Chemotherapy consisted of ATO, 0.15 mg/kg IV infusion over 2 hours. Fluvoxamine and fluconazole were discontinued early in treatment; olanzapine (2.5 mg bid) initiated thereafter effectively controlled obsessive-compulsive/affective features. Serial EKGs were performed; serum K and Mg were monitored daily and supplemented with intention of maintaining K>4.0 and Mg>1.8. EKG findings revealed: mean QTc on fluvoxamine and fluconazole, before ATO, 447 (431-464); mean QTc after ATO initiation, before discontinuation of fluvoxamine and fluconazole, 474 (445-500); mean QTc after discontinuation of fluvoxamine and fluconazole, while on ATO, 466 (441-496); mean QTc after olanzapine initiation, while on ATO, 479 (450-497). No adverse cardiovascular events occurred during treatment with ATO.
This case suggests olanzapine can be safely co-administered with ATO. Further studies are indicated.
Access to mental health treatment is often negatively impacted by cultural bias. This may relate to non-acceptance of psychiatric diagnoses as true illnesses, perceived shame by patient or family, or even fear of ostracism. As a result, treatable patients remain untreated with unnecessary morbidity, direct costs, indirect costs, and potential mortality. This case addresses depression and overdose in a Chinese patient.
Case analysis with literature review.
20-year-old Chinese single female was admitted for multidrug overdose (zolpidem/acetaminophen/clonazepam). When seen in psychiatric consultation, patient met DSM-IV criteria for Bipolar Disorder NOS, Anxiety Disorder NOS, and Polysubstance Dependence and was upset that overdose was unsuccessful. Patient described how parents were focused on performance success and would not accept her emotionality or depression stating “Depression, failure and suicide are not acceptable in China.” Patient summarized parental response to overdose: “they threw me in the basement with a basin where I kept vomiting for one day…then they thought that it was serious enough. They would come to the basement periodically and ask why I couldn't stop crying. They said it was my fault.” Mother instructed medical team patient needed to “sleep, eat, and exercise” and insisted patient be told she was responsible for hospital bill and her decision. After treatment with N-acetylcysteine, elevated transaminases stabilized and the patient was transferred to an inpatient psychiatric hospital.
Cultural themes focusing on success and lack of acceptance of psychiatric illness can lead to increased morbidity and potential mortality.
Cultural competence is often defined as the understanding and integration of patients' cultural themes including culturally-based syndromes, diagnostic process, and treatment. Cultural competence is essential to the advancement of global healthcare for it allows greater understanding of individual patients, focuses on combined interventions, and maximizes adherence. However, healthcare professional's culture and culture of medicine itself must also be considered. In westernized medicine, especially America, advances in technology and therapeutics play a large role in changing medical culture; but medical economics is as significant for one now witnesses a once noble profession changing into a “business.”
Commentary on clinical medicine practices and changes in medical culture.
Managed care and Medicare DRGs strongly affect American medical economics with resultant: decrease in physicians' incomes, increased number of patients seen daily, decreased time spent with each patient, and decreased subjective/objective quality of care. Physicians' roles have blurred with duties delegated to lesser qualified healthcare professionals in order to maximize patients seen and income generated by physicians. In psychiatry, performing multiple psychopharmacology visits hourly is economically more productive than an hour therapy session.
Doctors need to understand that in entering medicine they enter a life's career of nobility in which they serve others and do not expect to become wealthy, but at life's end are able to state “a job well done with caring for all.” Perhaps then less harm will be done to patients in the doctors' haste to earn more money by seeing too many patients too briefly.
Psychiatry in westernized cultures focuses on biologic bases of illnesses and associated psychopharmacologic interventions. Frequently, cultural themes are not addressed. Positive clinical outcome requires trust and compliance which may not be present if clinicians are unaware of specific cultural beliefs and practices. Maximal clinical outcome involves integration of biologic interventions with patient's culture such that patient and patient's family experience being understood and respected regarding cultural differences that may impact recommended treatment. In this case, unawareness of patient's culture led to medicine noncompliance in a high risk patient.
Case analysis with literature review.
17-year-old single African-American female of Nigerian/Yoruba heritage with prior psychiatric admissions for Asperger's disorder with Psychotic Disorder NOS and suicidal ideation was stabilized on aripiprazole. Maternal aunt recommended ritual cleansing to assist with treatment. The mother believed that the attending psychiatrist could not understand/support this cultural/religious intervention, and felt cleansing would be best supervised in Nigeria. Unaware of the actual reason for the trip to Nigeria, the psychiatrist emphasized need for medicine compliance without reference to integrative care. The 5-day ritual cleansing, known as spiritual deliverance, consisted of fasting, prayers, and discontinuation of aripiprazole. Upon cleansing completion, patient resumed psychotropics; later, believing improvement was solely secondary to cleansing, she totally discontinued aripiprazole. Shortly thereafter, decompensation with paranoid/suicidal/homicidal ideations resulted in emergency hospitalization.
Optimal clinical treatment requires integration of biologic interventions, psychotherapy, and patient's culture/religion. Unawareness of culture/religion can lead to medicine noncompliance and unnecessary decompensation.