Robert W. Daly

Recognition and management of complex sleep-disordered breathing.

Purpose of review The recent rapid evolution of our understanding of the mechanisms involved in control of respiration during sleep has yielded new insights to guide our care of difficult-to-treat sleep apnea patients with complex sleep-disordered breathing. This review will describe these recent advances in the literature and suggest a model for their incorporation into clinical practice. Recent findings Control of respiration during sleep shows amplified instability relative to that seen during wake in these difficult patients. Baseline (eupneic) carbon dioxide levels as well as the responsiveness of the ventilatory system to changes in carbon dioxide are all-important in this relative instability. Furthermore, the instability seen during sleep varies widely across sleep states. A further refinement of our definition of stable and unstable sleep has been developed that directly informs our understanding of the control of respiration across a night of sleep. Summary Complex sleep-disordered breathing is a distinct form of sleep apnea. It has recognizable characteristics that are present without, and often worsened during, positive airway pressure treatment. Both sleep state stability and the behavior of the respiratory control system contribute to this complexity. It is only with a clear understanding of the factors contributing to complex sleep-disordered breathing that implementation of truly effective clinical therapy can be achieved for this disorder, which to date is poorly controlled.

When others must choose: Deciding for patients without capacity

I N 1985 T H E N E W YORK STATE TASK Force on Life and the Law convened with the goal of enhancing public understanding on a host of social, legal, and ethical issues raised by medical advances, and, when appropriate, recommending regulations and legislation. In March 1992 the task force released its eighth report, When Others Must Choose: Deciding for Patients without Capacity, which examines decision making for patients who lack decision-making capacity and who have not signed advanced directives for healthcare decisions. The task forces discussion builds on two of its prior reports: Do Not Resuscitate Orders (1986) and Life-sustaining Treatment: Making Decisions and Appointing a Health Care Agent (1987).

Before Depression: The Medieval Vice of Acedia

Abstract Given renewed interest in the role of human action in the development of depression, I re–examine a tradition in the West which interpreted phenomena akin to the symptoms and signs of modern depression as “a spiritual disease.” In medieval Europe, acedia was a vice, an undesirable trait of character acquired in the course of living a life. Persons suffering from the vice of acedia were implicated as agents in its development and to some extent responsible for overcoming it. In Part I of this paper, I note the contemporary interest of psychiatrists and others in this vice, consider the warrants for asserting that it is akin to some forms of depression, and recount, in brief, the history of this vice from the fourth to the fifteenth centuries. In Part II, I discuss how medieval scholars, confessors, and spiritual guides understood the question of responsibility for acedia and how they distinguished between this vice and melancholia. I argue that acedia was a vice that could be distinguished from melancholia and that, while akin to clinical depression, this vice should not be identified with depression. This investigation of and commentary on acedia is intended as a contribution to the contemporary discussion of the role of human agency in the development of depression and in its treatment.

A theory of madness

Is there a difference between a person who is sane and that person when he is, in some way, mad? By extension, do the states of affairs we speak of as psychoses, neuroses, personality disorders, and adjustment reactions display any common features? We need adequate and coherent answers to these foundational questions if the persons about whom these judgments are made are to be properly perceived and if psychiatry as a historically emergent institution is to be rendered moderately intelligible.

Values: A view from the clinic.

ConclusionThe purpose of this paper was to suggest the basic terms of a schema for the description of the values and the processes of valuing of the individual person and to explore three difficulties that stand in the path of satisfactory description.To return to the spirit of James, I recognize that this essay is short on facts and evidences, but I have supposed that the reader already has an adequate “acquaintance with particulars” with which to judge the utility of these several “abstract formulas”.