The famous polymath, Darwin fan, physiologist and psychiatrist, Dr Emile Kraepelin discovered, over 100 years ago, that manic depressive insanity was a respiratory metabolic syndrome.

Kraepelin said so, in as many words. Kraepelin discovered the abnormal [depressed, or irregular] breathing rate in depressive and manic patients respectively, the sympathetic activation response that followed. Other psychiatrists did not understand what he was trying to tell them. Maybe the other psychiatrists were not as learned in biology and physiology. As a result, 100 years have passed and no one has tried to replicate Kraepelin’s studies on the pattern of vital signs that accompany the disturbing altered mental states in bipolar depression and mania. Psychiatry has never updated its language or practice and has completely shut itself off from the study of encephalopathy and metabolic dysfunction capable of distorting brain function, mood and locomotor activity. By not paying attention to Kraepelin’s reporting of abnormal vital signs in depressive attacks especially, especially the ventilatory disturbances, psychiatrists have done a real disservice to the field of psychiatry and to all their depressed and bipolar patients. Depressed breathing means some type of respiratory failure to most doctors. I do not think that Kraepelin’s colleagues appreciated the seriousness of this physical signs. Kraepelin understood why some of these patients died suddenly, but he did not understand why most did not. Even more puzzling, most recovered their baseline mental status spontaneously, although it might take decades without treatments, and there were none then. Treatments today are hit or miss, because psychiatrists do not know what they are treating; sometimes treatments help, sometimes they cause more suffering and terrible side effects, and sometimes they sedate the patient but only bring back some of the mental status, leaving the patient knowing that they have not regained their baseline function, preventing them from a full recovery.

Paula recovered even though her doctors did not know what they were doing and did not understand hypercapnic respiratory pump failure. I helped her. I learnt that her memory for personal thing was so disrupted that she did not remember how to do her job of 15 years and asking her what her own address was, became a clue to the possible return of these abilities and memories.

I asked her what her address was every day as the doctor fed her different pills over the year she was ill. Every day she did not know if she did or did not know her address; that is pretty severe memory loss. We had her try different medications until one of those medications helped her to remember her address and know it to be correct; at least a couple of times, if not every day. This was the best we could do with the tools the doctor gave us. Her memory for her address was spotty at first and improved over months and years with Paxil, an SSRI . Paxil is a serotonin helper [agonist] and is involved in many different bodily systems, including bone, liver regeneration, platelets and breathing, it has complex actions that go beyond the brain. It took 10 years on Paxil for Paula to regain her baseline mental ability. Early side effects [mania, hypomania] faded after 5 years or so, as her body adapted to the Paxil .

Had we been given a choice, we would have preferred that Paula have a proper physical workup and arterial blood gas tests, but this was not an option.

It is still not an option; not until psychiatrists shift to medical and metabolic causes of the altered mental [and mood] status that accompanies different patterns of depression, mania with abnormal vital signs.

The old ideas of psychiatry should be put out to pasture and research into hidden organic causes of altered mental status and metabolic encephalopathy should begin.

Only then will these patients recover, and most likely, recover back to their old selves- completely normal- like Paula, thanks to that lucky first aid class where she discovered her ventilatory defect, thanks to Dr Emile Kraepelin and his studies and thanks to me.

Paula and I think that many others can be helped, once psychiatry rejoins the practice of internal and emergency and critical care medicine.

Altered mental status IS encephalopathy and altered mental status is ALWAYS a medical emergency or it will lead, if not to death, then it will lead-as it does now- to long tern disability.

This is not the “worried ” well, this is serious; Lives are at Stake.

There is no more time to waste!

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