Paula’s sudden overnight altered mental status was missed by her doctors.

Everyone who had contact with Paula knew something was suudenly very wrong with her. But because she could not tell them what was wrong, no one thought to check and no one asked if she was able to function normally. [She couldn’t function as she had before]. When she told the psychiatrist she was confused, he disagreed. When she asked him to test her cognition, he refused. He would not have known what to do if he had given her a quick cognition test and she failed. She gave herself tests [badly- because it is hard to do when you are confused] and she failed or did not know if her answers were correct or not [which is a fail]. It is lucky that her doctor did not listen to her. if he had found her to be confused he would have wrongly assumed that she was demented and given up on her. Because he believed her to be depressed, he kept on trying to help her.

I don’t know why there isn’t a different protocol for how to workup a person who looks depressed and distressed. the protocol that psychiatrists use is useless, it only deals with behavioural changes and mood changes and life circumstances and ignores baseline vital signs or the repeated investigation of metabolic encephalopathy and acid base disturbance.

All doctors make the same cognitive mistake. They observe a behavioural pattern of depression and “forget” the medical syndromes that can cause these behavioural changes.

In part, it is because some of these syndromes are fairly recent and are often only seems in critical illness or injury.

Primary care doctors and psychiatrists should be trained to look for possible injuries that impair pulmonary ventilation, the motor part of breathing which has nothing to do with the lungs.

Imagine if Paula’s doctor had counted her respiratory rate. They would have freaked out. They would have forgotten what to do. They would vaguely remember that too slow breathing at rest can lead to hypercapnia and respiratory failure under some circumstances.

This is why there should be studies to rethink and reevaluate our approach to the syndrome of depression and of manic depressive insanity. If respiratory rate and tidal volume point to as potentially treatable respiratory acidosis or alkalosis then we must learn to do so in order to bring back normal mood, locomotor activity and mind.

The defective motor pulmonary ventilation, is probably a permanent injury, most likely due to peripheral neurological damage to parts of nerve, muscle, ribs, and/or spine.

But the underlying infection or exposure or poor bodily condition can be treated and the patient brought back to their previously functional normal state.

This is apparently not unknown in the field of neurology when neuromuscular illnesses causes respiratory failure. The patient is then treated for their respiratory failure.

The problem in some or many cases of depression is that the neurological injury is hidden or unlooked for and so the risk for hypercapnia respiratory failure [which will look like depression with altered mental status and mood initially and perhaps for a long time] is unknown.

Why not study this in order to see how many patients with serious depression and bipolar illness actually have a neurological motor defect interfering with acid base balance under certain circumstances.

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