What to say about psychiatry that isn't already completely covered by television and movies? It's unique among the specialties for its coverage in the media. Maybe because we're such social animals, or maybe because such shows about psychiatry or therapy appeal to a voyeuristic impulse in us to peer into people's most private thoughts and feelings.
Our exposure to psychiatry in medical school, however, is primarily with inpatient psychiatry - people who for whatever reason require hospitalization to deal with their mental illnesses. Reasons may range from soul-crushing anxiety attacks, to addiction, to suicidal ideation, to frank psychosis from schizophrenia, depression or bipolar disorder. I'll also say it's very upsetting at first to treat the subset of patients who are being held against their will due to court orders. One of the most basic tenets of medicine is that a physician must respect the autonomy of their patients, and psychiatric patients have often had a court take this autonomy away from them because of their actions or behavior. Not surprisingly, many patients are not happy about this. They may not be willing to accept they have a problem, or be very reasonably upset about the financial, social, or legal consequences of a hospital stay, or occasionally they don't necessarily feel that their delusions regarding their absolute dictatorial control of the US government and their need to evade agents of foreign nations by breaking into a pet store are actually a problem. However, others necessarily are disturbed by such things, often resulting in a temporary detention order, or TDO, to assess their need for psychiatric treatment. I'm not making light of mental illness, but psychotic states result in behaviors that are frankly bizarre, and the self-reinforcing nature of delusions often put patients into a state that makes them feel you are part of a plot designed to persecute them. Worse, there are times when a TDO can be devastating to a patient's life. An inpatient admission for psychiatric, alcohol or drug treatment is not a benign intervention and often has pretty major accompanying legal and social consequences. Patients are often facing criminal charges for DUIs, violence, or other behavior that has finally come to a head, and cost of treatments is often a huge burden.
The two major things I learned as a part of this process are that (1) the state of Virginia drastically underfunds the treatment of mental illness relative to other medical illnesses (and this is a very bad thing) and (2) anti-psychotic medications are amazing drugs. Let's start with a case - details, of necessity, are highly altered due to the sensitivity of psychiatric treatment but the fundamentals are real.
A 22 year-old-male is admitted to the inpatient psychiatric unit at a private hospital after his family brings him to the ER for bizarre and uncontrollable behavior...
He has a three-year history of psychiatric illness, having to leave college for inappropriate behavior in the midst of a manic episode. He does not work due to the poor control of his bipolar disorder, and has been hospitalized multiple times in the last three years. The pattern is of stabilization in psychiatric hospitals, followed by discharge and relapse once his medications run out due to an inability to afford them as well as compliance issues due to side effects. A lithium level is measured and it's subtherapeutic. The patient does not feel that there is a problem, his family is exaggerating his behavior, and with pressured and rapid speech relates to the treatment team that as soon as he gets out he is going to drive to New York City where he will take charge of a major banking house - once they recognize his intelligence - where he will then use his enormous wealth to cure world hunger. He is massaging his groin as he relates these future plans.
What kind of mental illness do you think our patient has? And what are the immediate steps that are appropriate in addressing them? Tell me what you would do and I'll write about the treatment and outcome in the comments
Nowhere does the pinch of inadequate funds for medical care appear more severe than in mental health treatment. There is too little money - especially in Virginia which ranks near last in the nation for per capita mental health spending - and too few psychiatrists working in rural areas to deal with the volume of mental health patients. There are too few beds in psychiatric facilities resulting in wait times in ERs that can be extensive, putting both patients and communities at risk. There is inadequate funding for drugs that patients need to prevent relapse into depressed, psychotic or manic states which result in hospitalizations that are far more costly than the expense of their routine medical treatment (hospital stay = cost of drugs + nursing care + doctor + boarding etc.) and the whole system is very disappointing. The mental health professionals that work within the system are frustrated by the absence of adequate resources, and a burden of patients that is too large for the number of physicians and facilities available. Inpatient psychiatry is usually run at a loss to hospitals who maintain them as a service to the community. Many state hospitals and facilities are being closed, and new ones are not being built because they are costly and not profitable.
What is the solution other than adequate funding for patients who need this care? There is no benefit to society to have people in the community with uncontrolled mental illness, unable to hold down jobs or function productively, and routinely hospitalized at great expense due to the poor control of their disease.
Mental illness can be devastating and it has not been treated with the same seriousness and concern as other medical conditions. There is not mental health "parity", possibly because of the continuing stigma for mental disorders and the absence of significant powerful lobbies for the mentally ill - unlike say the AARP for medicare patients.
At the same time psychiatry is an enormously rewarding field when you see what a difference you can make in people's lives with adequate mental health care. You can take someone who is completely psychotic and dysfunctional, and then using therapy and/or our relatively blunt pharmacologic instruments that broadly affect neurotransmitter receptors (or uptake of neurotransmitters) throughout the brain you can literally return people to sanity, to work, to their families, possibly even to happiness. That is not to say these drugs are without side-effects - they can be significant - but it is clear that not treating mental illness is far more damaging in almost every way.
The main drawback of the field is that with many serious mental illnesses the patients require chronic care - there is no "cure" for diseases like schizophrenia. Instead treatment consists of frequent tune-ups that keep the disease from manifesting and progressing, but this is not dissimilar from many other fields of medicine in which many of the patients are managed rather than cured.
The failure of our society to adequately address the problem of mental illness - primarily due to deinstitutionalization combined with a failure to keep the promise to build up adequate resources in communities to treat chronic mental illnesses - only causes more and more harm. The costs of not treating mental diseases are as high or higher than treating the disease. People with mental health problems that are adequately treated often can work, take care of themselves, take care of their families, and be productive. Those who are not treated often can not function at all. The unwillingness of government to address the unpopular need for higher spending on the mentally ill must be countered with the fact that not treating mental illness is far more costly - both financially and in terms of human costs on individuals, families and communities.
Now, I'm getting ready to start another psych rotation (working nights) as a 4th year medical student, and am excited about it as it's been one of the fields I've felt I've had a great positive impact on people's lives. Many fields of medicine in a brief 1 or 2 month rotation don't allow you to see the benefits you can have on people's lives. Many times a doctor gets to experience that from months or multiple years of developing a relationship with their patients and you dont get the same feel. But often in inpatient psychiatry you see big effects fast. If only that satisfaction weren't countered by the inadequate investment our society sees fit in treating mental health.
I only have a few more clerkships to discuss before I've covered the 3rd year basics (I delay them for multiple reasons) but I will have a piece on OB/GYN, Family medicine, and Neurology to complete the cycle before match.
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Great article. How to get the public to encourage their legislators to earmark more money for mental health services? I don't know.
Fascinating. This makes me want to go back to school.
Mental illness can be devastating and it has not been treated with the same seriousness and concern as other medical conditions.
This is easy to see in the public response whenever a person with known or probable mental illness does something that shocks or offends people. When Steven Kazmierczak shot and killed fellow students at NIU, there were idiots posting hateful things about his girl friend on line because she was clearly upset about his death. (Note to fellow humans: If someone you love does something terrible due to untreated mental illness, you do not immediately stop loving that person. The people who heaped abuse on Kazmierczak's girl friend were behaving in an inhumane manner. She wasn't.)
The same thing is going on with the Nadya Suleman case. People are sending death threats to the poor woman. She's clearly done something irresponsible, but she's just as clearly convinced of some things that make no sense to someone who is thinking straight. People are treating her as if she's scheming to get rich by having babies that need public assistance, but in reality, she's at best unwittingly scheming to remain poor (and incapable of understanding this.)
We don't seem to understand, as a society, that some people have poor reasoning capacity due to illness. Of course, we don't always address collective poor reasoning due to ignorance, which perpetuates the problem.
(Addendum: Sorry about the anonymous post above. That was me, posting in mid-quarrel with my browser.)
For the (imaginary) patient, from what you've said/described, I would imagine that he has bipolar disorder. His current manic state doesn't sound inherently dangerous, but given how fast people with unmedicated bipolar disorder can 'crash' I would be concerned about him being a danger to himself/others when he comes down from his current high. (Having seen this with a friend it was really frightening, although it did finally give us the impetus to convince him to try medicating.)
I was under the impression that there are newer drugs for bipolar disorder, other than lithium, that might be more palatable to this patient. Given that his family turned him in, it might be necessary to keep him as an inpatient for a few days, at least until he is willing to medicate.
IANAD, but I might also suggest ongoing intensive therapy in addition to medication, if only to help the patient stay on his meds.
Give him a Zyprexa a day for a couple of days. It can be a miracle drug sometimes.
A similar drug to lithium is valproate sodium (brand name in the US would be Depakote) which seam to have a similar course of action as lithium although I don't have a clue about the mechanism of action and the only paper I've found related to said mechanism of action is located at http://www.ncbi.nlm.nih.gov/pubmed/15379904
Laeng P, Pitts RL, Lemire AL, Drabik CE, Weiner A, Tang H, Thyagarajan R, Mallon BS, Altar CA.
The mood stabilizer valproic acid stimulates GABA neurogenesis from rat forebrain stem cells.
J Neurochem. 2004 Oct;91(1):238-51.
Bipolar mania is correct, the patient was stabilized with Seroquel, and after three days no longer had racing thoughts, and had a return of insight and judgment.
Something that is not complete garbage? Sure, psychiatry gets more coverage by volume than other sciences, but try comparing what's on tv and in movies - or for that matter, what's reported about it as 'news' with what is in the peer-reviewed literature. From 'recovered memories' to people who supposedly have dozens of 'personalities' to weird misconceptions about schizophrenia, to claims that B. F. Skinner 'imprisoned' his infant daughter, to conspiracy theories about the companies that market SSRIs, tv, movies, and news spread all sorts of nonsensical delusions about psychiatry. Ok, ok, I'll calm down now. I realize you just wanted a lead-in for your otherwise article.
Oops. I left a word out of my previous post. I intended: '... your otherwise excellent article.'
Clearly, this man deserves a New York bank. Get him one, stat, and use some of the TARP money for lithium.
For further reading, there is a book by J. Allan Hobson and Jonathan Leonard: Out of its Mind, Psychiatry in Crisis, from 2001. The closing of the state hospitals, the enormous costs of failing to treat, it's here, and lots more. With ideas for reform.
Part of the cure is having the well-trained and compassionate voices like Mark's be heard above the TV racket that treats mental illness merely as lurid entertainment.
I wanted to comment on something. Involuntary hospitalization of psychiatric patients has some very important benefits. Certain psychiatric illnesses cause a patient to not be conscious of their disease. A manic bipolar may spend all of his savings and sell his earthly possessions if not involuntarily hospitalized. Once the manic episode is over, they regret what they did and some wish they had been stopped.
There is also the big drawback that mental diseases come with a huge stigma.
That said, I loved my psych rotation. I think it can also be a great way to teach the doctor-patient relationship.
I would like to extend my gratitude towards all medical professionals working in the area of mental health.
I am one of those that, if not cured, have at least had life restored. For me, it was finding a medication that stabilised my persistent and debilitating depressive and manic episodes that had resulted in numerous hospitalisations, including compulsory treatment orders.
I have now been stable for 5 years, on one medication. This follows 15 years of predominantly psychotic depression, interspersed with a few medication-induced manic episodes.
I cannot begin to describe how I feel at being granted another chance at life - an opportunity to grow out of the needy, emotionally insecure and very, very sad person I was. I still understand who that person was, roaming the halls of psych units, self destructive and nihilistic - she is still inside me, but only as a much weakened form. Thanks to a couple of little tablets every morning, I am now contributing to the society that was good enough to look after me when I was ill.
I live in a country that provides free medical care and this is something else I am grateful for.
Throughout the years, I have been in contact with many, many mental health professionals (psychiatrists, psychologists, nurse practitioners)and they have nearly always exhibited compassion, humour and patience.
I remember sharing a joke with my psychiatrist, whilst in the midst of a manic episode, trying to persuade her that my husband was depressed, hence his obsessive concern about my elevated mood. She laughed with me, obviously enjoying my good mood as much as I was - but managed to convince me to attend the inpatient unit voluntarily.
I credit her for the genius of prescribing drug A over drug B, and not the years of talk therapy that accompanied my previous experiences of mental health care. I acknowledge that learning strategies to assist with the management of depression is useful, but nothing can compete with the fundamental improvement in mood that comes when the correct medication is discovered.
It has occurred to me that I might be assuming efficacy when in fact my improvement is due to a placebo effect. But I cannot afford to go down that path. The best evidence I have discovered is that this is an effective treatment in a high proportion of patients. After 20 years of medication, with every other pill eventually failing in one way or another, I am not prepared to play devil's advocate.
I never had a chance to thank the doctor that prescribed my current medication - she moved on before I could show her the one year on version of myself. So instead, I'd like to thank you on behalf of all the patients that never get the chance, or don't have the insight, to realise the enormous good that is done caring for the mentally ill.
As a person who has a family history of and suffers from anxiety issues, I think that a bit problem is the still widespread sentiment that depression and anxiety can be cured by "wanting to be happy" or "not being so selfish" or "thinking of others for once" or "pulling yourself up by your bootstraps", or "stop worrying so much". There's a large contingency that doesn't believe in mental illness or believes that it's the result of a character flaw rather than a disease.
This doubtlessly contributes to the lack of funding from the government.
I appreciate your post and agree with your points. I think, however, that your flippant tone sells the subject a bit short.
I'm glad you were able to help this young man but...
Is that where "treatment" ended? What about his family? Do they know what to do if it happens again? What happens when he believes he no longer needs meds and is cured? What happens when he inevitably falls into the pit of depression?
How will you help his parents if he is ever a successful suicide?
The people who are caretakers of the mentally ill also live lives of chaos, and they need help or they will be dragged under too. Please don't forget them.
Social workers are part of every inpatient admission. We of course think of these issues and one of the major responsibilities with each hospitalization is to try to get the patient "plugged in" to the system so that they won't run out of drugs again, and that the patient and family will have a case worker or social worker in the community who will check in on them, help them get work/schooling, and hopefully back on their feet again.
Scrabcake, I'm sorry if you felt my tone was flippant. It certainly wasn't my intention. Mental health is serious as a heart attack, and yes, here at denialism blog we take a dim view of people who minimize mental illness or deny that it exists.
I think a big contributor to mental health stigma is that people have difficulty empathizing with unfamiliar situations, as Scrabcake alludes to above. I can empathize with someone whose leg is in a cast because I know what physical pain feels like. But on the other hand, because I've never been clinically depressed or addicted to a substance, it's very hard for me to imagine a state of mind in which I couldn't just "cheer up" or "stop taking it". It's hard for people to think outside their own experience (and, in most cases, realize just how limited the scope of their experience is). This is why public mental health awareness programs are important.
Another issue is that far too many people hold on to this false distinction between "character flaws" and mental processes. People don't understand (or are unwilling to believe) that personality and behaviour are inextricably linked to chemical processes in the brain.
Man, I wish my issues were as interesting as this guy's! But instead of thinking I can run a bank and solve world hunger I get depression and ADD. *sigh*
On the other hand, my depression meds give me some great dreams, and for someone who used to rarely have dreams, it's a blast!
I've had experience with two different people trying to help them on to stay on their medication (paranoid schizophrenia and schizoaffective disorder.) One worked out, one didn't. But from what I understand, keeping people with delusional disorders of any sort on medication is a frustrating endeavor. Yet, holding people against their will after they are stabilized doesn't seem reasonable. Please excuse the obvious oversimplification. I haven't heard any good solution for this (except broad community support, which I don't think we'll ever see.) Was just wondering what you think.
Thanks for breaking the ice on a important issue that has massive implications for millions of people.
Here's one example of the level of mental illness in the US alone: once a week, millions of otherwise normal people turn zombie and head to a setting to participate with others in proclaiming by faith and worship that an unobservable "spirit" will lead them to an eternity of life in another dimension they call heaven. No spirit has ever been observed...no dimension called heaven, ever observed, experienced or recorded yet week after week the same ritual behavior with no observable result. Yet we "label" these people normal.
Inspite of the normal label this massive schizo delusion goes unnoticed, undiagnosed and untreated by the mental health community. However, if someone outside of the "groupfest" above says they see "spirits" or talk to imaginary friends we "label" that schizo-typo behavior and employ all kinds of interventions.
IMHO, until the mental health community begins to notice just how sick this entire "groupfest" population is they will have limited credibility in diagnosing and curing anything.
I worked in a private psych hospital as a tech for a short time in the late 1990's. I have also been taking antidepressants for more than 10 years. I have never been treated as an inpatient, but I sent a few weeks in "partial hospitalization" -- kind of like psych day camp. As a result of all that I am particularly interested in mental health issues. Some of my direct observations may be out-dated, but I still want to share some thoughts. : I have never experienced psychotic symptoms, and the schizophrenics I have talked to were not in a position to describe the experience (or anything else, really) coherently. I apologize for any errors or offence my ignorance may cause.
1) Antipsychotic medications suck. The side effects can be really nasty, to the point that non-compliance with a medication regimen can be a rational, or at least understandable, choice. There are other drugs to treat the side effects, but they can have their own issues. From what I've heard from patients, even when they are working they leave you in a weird state that isn't active psychosis, but isn't normal either. It's true that there isn't anything better, but that isn't much solace to the people taking the drugs.
2) The rapid improvement you see in a short rotation is partly illusory. We saw the same patients with the same symptoms over and over again. The patients without good community support (like the ones living on the street) were back more often, but even patients with active, supportive families (as evidenced by their visits) returned with a distressing regularity. The depressed patients on your ward may be ready to go home after a few days*
My outpatient psychiatrist says that the slow progress of most mental health treatment is disconcerting to other specialties, especially internists, pediatricians, etc. It usually take several weeks before antidepressants start to work, and it can take quite a bit of experimentation to find the right combination of medications. My particular cocktail took several years to develop. Aside from minor tweaks it's been stable for several years now. Luckily, I have had good medical coverage and parents able and willing to pay for therapy,** and I haven't been forced to change meds by my insurance company.
3) It is possible to evoke empathy for Steven Kazmierczak and similar people, at least face to face. I have no idea exactly what his illness was, but in a sense it doesn't matter. I might say something like this:
4) Following on to 3), mental illness is in general under-empathized (for want of a better word), but I have found that many people are more persuadable than you might think. It helps to have a personal story, but accurate information and a willingness to supply it forcefully can definitely help. I remember talking to someone who thought it was absurd that people could be classified as "disabled" because of panic attacks. I've never had a panic attack, or even talked about them with someone who has, but I still know what they are. I said something like
I'm not sure I convinced this person, but I think the idea that panic attacks may warrant disability status went from "completely ridiculous" to "plausible, though perhaps not likely" in her mind.
*Or may be forced to leave for financial reasons.
** I pay the bills now, but I couldn't work or attend school for quite a while. COBRA is lousy, but better than nothing.
***As with just about all illness, but especially mental illness, the subjective experience varies enormously. Nevertheless, this is a reasonably typical experience, I think.
I am in complete agreement, this was a great and informative article. Strides must be made to create a sense or urgency within in legislation with regards to this field.
Fred Smilek is the acting president of the Society to Save Endangered Species. It was founded two years ago by Fred Smilek along with his two best friends Charles and Jonathan. http://www.fredjsmilek.com
I have quite an extensive post on acute psychosis due to metabolic stress which causes low NO and low ATP in the brain. I am pretty sure that is the cause of essentially all acute psychosis, and I would include bipolar as being "acute".
http://daedalus2u.blogspot.com/2007/08/low-nitric-oxide-acute-psychosis…
(warning some of the stuff regarding postpartum psychosis is quite disturbing)
Lithium works (my hypothesis) by increasing ATP levels (it isn't really that simple, but it is pretty close). A ketogenic diet would help too (and would be additive to lithium), but it has to be quite strict ketosis. I think anything that reduces brain metabolic load will help, and especially anything that reduces the production of superoxide in the brain.
I see depression as the necessary aversive state between "normal" and the euphoria of the near death metabolic state, when you are "running from a bear" and your body needs to induce euphoria so you continue to run no matter what. I am pretty sure that is what the manic state is, the euphoric state in which you can run until you drop dead of exhaustion.
Headdesk with a double facepalm cluster!
Whiskey?
Tango?
Foxtrot?
Mania's awful. My husband had an acute manic episode resulting in involuntary hospitalization.
The law in Ontario, Canada makes it extremely difficult to treat those mentally ill people who, like my husband, have no awareness that they are ill until after the fact. He refused meds - what do you do in this instance?
We were lucky. His episodes are many years apart, and he didn't crash, just eased back over several months to his normal self. He doesn't seem to suffer from depression, so thankfully suicide is not a concern. But he's never had treatment for what is likely a bipolar disorder, despite several psychotic episodes.
Great posting. I saw your comment on how you treated this patient - but what do you do if the patient refuses treatment?