Too Ill to Treat

rAn article posted in the Augusta Chronicle newspaper on January 13, 2017 by Bianca Cain Johnson, Staff Writer, has left me no option but to write this blog post today. I would like to quote some parts of the article, then address some of the comments in turn, as they are provocative or distressing to me.

I should say right away that this is my personal mental health musings blog, and that my opinions are my own, in no way reflecting the policies or procedures or opinions of my employer. I should also state that there was very little factual or historical information in this article about this particular case, but for me it just brought up several broad issues of the treatment of mentally ill persons, our approach to violent behavior and other broader issues that I wanted to address.

From the article:

“According to a sheriff’s office incident report, the 31-year-old had been at the hospital for several days, but because of his mental illnesses and history of being violent, the hospital was having trouble finding a mental institution to take him.” (italics mine)

“A doctor re-evaluated him on Tuesday morning and determined he could be released.”

“…the patient stated, “the only way to get attention is to show out”.”

After he had allegedly injured a guard and nursing staff, “the patient was restrained and given medication to calm down, (and) employees heard him comment “this is what I wanted”.

Remember “too big to fail“, as it pertained to banks or motor vehicle manufacturers? Well, in mental health nowadays we run up against admission and placement issues for those patients who are “too ill to treat”. It may be because they have some element of intellectual disability. It may be that they are floridly and actively psychotic. They may be actively suicidal with access to a lethal method and a serious, specific plan. It may be, like the patient in this article, that they have a previous history of violence. For these and other related reasons, what you find is that some facilities among our dwindling number of mental health hospitals now cherry pick the patients that they want to take. If patients are too sick, too acute or too potentially violent towards themselves or others, they are denied admission and treatment, and are often stuck in emergency departments for days or weeks.

Can you imagine the outcry if a patient with chest pain that was too severe was denied admission to a cardiac care unit, or if a patient with a stroke that left him prone to emotional outbursts was denied neurological treatment?

A doctor re-evaluated the patient and made the determination that he was ready to be released. We do not have nearly enough information about that determination to be able to comment on it all, but we can say that we as physicians are notoriously bad at using our (non-existent) crystal balls to predict violent behavior. Of course, there are known risk factors, characteristics, static points of history, and previous episodes of violence that might sway one towards thinking that there was a better than average chance that some violent behavior or acting out was coming, but to be able to predict that with any significant degree of certainty is fraught with problems.

Please see this article on mental illness and violence for more detail about these related issues.

The issue of the patient knowing or learning or figuring out that in a busy emergency department the best way to be heard or to get drugs or to be assessed is to act out is another huge issue. This involves separating out acutely ill patients who act out unwittingly or because of lack of control, versus those persons who know exactly what they are doing and plan to be violent or agitated with a specific goal in mind (to be separated from the general population or to be given injectable medications, for example).

The comments about this article, which I will leave you to read on your own if you wish, were predictable. This issue is politicized, psychiatric patients are called nuts and commenters express nostalgia for the days when they could just be locked up “for a long time”. One commenter stated that the evaluating doctor should have his license pulled immediately. In my opinion, none of these kinds of comments is helpful.

What do I see going on here as a medical director for a mental health center, and even more so as a telepsychiatrist who sees patients in over two dozen South Carolina emergency departments? What did this particular case make me think about?

First of all, we know that deinstitutionalization was a real thing. Hospitals were closed, patients were discharged to their families, to supervised living situations, or to the streets, and the local mental health centers were supposed to pick up the slack and treat them as outpatients, all in the name of streamlining care and saving money. When I started medical school thirty eight years ago and did my very first psychiatric rotations as a junior and senior student, state hospitals, VA hospitals and mental health nursing homes were still very full of patients who were too ill to function well in society. Many were there for long term stays of weeks, months or even years.

Gradually over my career I have seen many inpatient facilities cut back and close beds and finally close their doors entirely. The ones that survive are much smaller, treat patients for much short length of stays, and are run via much more stringent business models than ever before.

Many patients now get their medical care and most of the psychiatric care in an emergency department, not from their own personal doctor. Once admitted there for evaluation, it can sometimes be a very difficult and complicated ballet to assess the patient for his primary illnesses or presenting problems, available resources, need for inpatient versus outpatient treatment, payor sources and requirements, and family involvement. Add to that the hospital administration’s take on treatment, as well as pressure from ED doctors to get patients in and out as rapidly as possible, and it becomes somewhat overwhelming.

In those past years, patients who were truly psychotic or actively suicidal or a danger to others could simply be committed to the state hospital and held there as long as necessary to achieve remission, or as close to it as possible. This is not nearly as easy or smooth a process now as it once was.

As I mentioned above, we do not have crystal balls, but we do have fairly detailed screening procedures for harm to self or others, for example. We can assess, apply evidence based guidelines, offer the best recommendations we can based on these parameters, and decide if a patient must held or can be released. Recommending and treating based on numbers alone, administration goals, or by algorithm rarely work well.

If a patient is acting out of his own volition, is cognitively processing things appropriately, is not overtly psychotic  or in withdrawal from substances, and he still destroys property or intentionally  hurts others on the staff or other patients, then he should be charged for these actions accordingly and would perhaps be better served in the county jail than the emergency department.

I would welcome stories of  your own experiences in this area, your opinions and ideas for how to make these tense situations more rewarding and beneficial for both staff and patients.

 

 

 

 

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Now I Know My ABCs

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So what is the one thing that I see over and over and over again in the management of emergency room psychiatric patients that makes me fear for our survival as a country and even as a species?

Is it the severity of psychotic illness? The rampant drug and alcohol use that starts now when kids are pre-adolescent? Is it the broken families that are producing another generation of children who have one parent or no parents and are raised by distant relatives? Is it financial poverty? Is it reliance on government assistance?

Well, I could write about any of these and make a case for all of them, but that’s not what keeps hitting me right between the eyes most days that I sit in my chair and talk to people via the Polycom screen.

The problem?

Lack of education.

One of my standard questions when taking a medical history is “How far did you go in school?” I ask everyone this question because it is so very important in understanding someone’s frame of reference and their ability to assess a problem and deal with it realistically, be it a kidney stone or an episode of depression. I get answers to this question that are all over the map. I have seen teens who have graduated college already. I see old women who never graduated high school but raised entire families on their own. I see proud aging men who ply their trades, hard workers with calloused hands who had formal schooling up to the third grade and no further. I have seen professionals with decades of formal training and multiple degrees who are as psychotic as they can be, completely out of touch with reality due to drug use or mental illness.

Two things come to mind here of course. One is that mental illness is no respecter of educational level. I have written about this before and I will write more about it I’m sure. The other is that many people do not see the need, or are not given the opportunity, to further their education beyond the very minimal level that gets them by in the world.

This is not a prescription for growing a strong, healthy society.

Often, the answer to my question about education, “How far did you go in school?”, is answered exactly like this:

“All the way.”

That person almost always means that they finished high school.

In many parts of our society, and among many sociocultural levels, finishing high school is the ultimate achievement. The peak. The Holy Grail. You are expected to make that level of education and then to get out, find a job, make your own living and support yourself in the world. Many of the families I see are more than happy to kick their kids out of the front door and onto the street the minute, the second they turn eighteen, never thinking twice about it. The problem is that economic considerations, lack of parenting, lack of role models, early drug and alcohol use, the necessity of working to help support the family and other issues get in the way and take precedence over getting a good education. Kids are passed to get them out of one classroom and into another to avoid further negative behavior. They are still socially promoted, something that might eventually get them a degree but that might be worse than useless to someone who cannot read, problem solve or think critically.

When one thinks nowadays that getting a high school degree is going “all the way”, educationally speaking,  then we have a real problem. There are many other countries (Japan, China, and India immediately leaping to mind) who are producing generations of kids who are hungry to gobble up degrees from our colleges and universities and take high-level and high-paying jobs that Americans are not aspiring to at all any more. It is a sad state of affairs indeed.

It breaks my heart to see a hardworking middle aged man, my own age, in the emergency room, who has a third grade education and is embarrassed to tell me that he cannot read or write.

We have become a nation of people who value smart phones more than we value smart people.

I know that mental illness is a strange beast, hard to ferret out and even harder to diagnose and treat some times. I know that its causes and precipitants are multiple, some genetic, some economic, some cultural. I know all this. I also know, as surely as I know my own name, that if we do not pay attention to the education of our society in America, and our society globally, that we are going to slowly slide down the slippery slope of ignorance, class warfare and division that will be the end of us.

We must turn this around.

We must make it a priority, starting now, to educate our children.  We must teach them to see things as they are, think critically about problems, think creatively about solutions, invent new wonders, and leave the world a better place than they found it.

This is not a luxury for us in the twenty-first century. It is a necessity.

Aftermath

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Good morning, everybody.

I have another question from our studio audience today. (Please keep those cards and letters coming)

“What happens after a telepsychiatry consult? Do you get any kind of feedback about what happens to your patient?”

Excellent query.

As I have mentioned in previous posts, doing telepsychiatry is a lot like any other emergency room work. It can be tediously slow and boring. It can be horrendously busy. It can get stale when one sees the same thing over and over again. It can be tremendously exciting when a fresh new problem associated with a rare diagnosis presents itself. Another caveat of doing this work is that we often see a patient, are very invested in the story they tell, make recommendations for their care, and then never see or hear from them again.

So, what usually happens after I do a telepsychiatry consult? What is my ongoing connection to the patient? This can break out several ways.

First, if a recommendation is made to release the patient to outpatient followup, and the ED staff agree with this, then they may be sent home minutes to hours after the consult report is sent it. In that case, of course, no more contact is made. The patient is off to follow up in a local mental health clinic or with a private psychiatrist, and that is that.

If the feedback from the telepsychiatrist is to admit for safety, to restart medications, or to further observe to make a more definitive diagnosis, then it can go two ways. An inpatient bed may be found fairly quickly (something that is getting more and more rare in the state of South Carolina, where I practice) and the patient will be transferred to the other facility as soon as that is practical. There is  no real “active mental health treatment” in the ED per se, so this scenario is optimal if inpatient intervention is needed.

More common is the recommendation for inpatient admission followed by days (or sometimes weeks, unfortunately) of waiting for an appropriate bed to open up. In this case, treatment may be started, at the very least the medication portion of treatment, while the patient waits. If that happens, then within seventy two hours, when the commitment papers need to be recertified in order to hold the patient in the ED, a follow up consult may be sent, and the same telepsychiatrist (or one of his or her colleagues) will re-evaluate the patient. If sufficient progress in relief of symptoms has been made at that time, suggestions for release and follow up may be made. If not, then continued hold may be suggested to the attending in the ED.

The latter is one scenario that allows for me as a telepsychiatrist to actually see, paradoxically, progress in my patient. If an antipsychotic is started for a patient who is floridly delusional and agitated to the point of needing physical restraints and intramuscular medications to prevent harm to himself and others, forty-eight to seventy-two hours of treatment and observation can sometimes work miracles. Someone who was afraid of the camera and tried to hit me through it (yes, that has actually happened) may be able to much more calmly explain how they felt on admission after three days of treatment. That is the closest we telepsychiatrists usually get to seeing a positive outcome or even a “cure”, as much as one with true mental illness can ever be “cured”.

A spinoff of this is the patient who is seen, for whom a treatment plan is crafted, who is then discharged, but then “bounces back” with the same or similar problem that got them there in the first place. This happens quite often with folks who have substance abuse problems.

Alcoholism, for example, is a “cunning and powerful” disease, and the patient who reappears in the ED with a blood alcohol level of 450 a week after being seen for intoxication is far too common. Other patients who have chronic mood disorders, psychotic disorders, or even personality disorders may revisit the ED many times with superficial lacerations to forearms or wrists, repeated overdoses with sub-lethal amounts of pills or other problems that recur. This is good in the sense that the telepsychiatrist gets a much more accurate picture of the pathology involved over time. It is bad in the sense that the patient may be traumatized over and over by the admission and evaluation experience, and emergency resources are used where outpatient mental health services should be employed instead.

Finally, if the patient has presented with a one time, first episode, self-limited process, then a consult may be done, a disposition reached and the patient discharged, never to be seen or heard from again. I like to think when that happens that we have helped them move through and past a bad patch in the road and that they go forth and live their life well and happy. I am not so naive that I think this really happens in every case, but it’s a nice thought. This may also happen with those who are itinerant or transient patients. They may or may not be back the next time the direction of the wind shifts and the leaves begin to fall with the temperatures.

I hope this gives you a sense of what happens after telepsych consultation is completed.

In the style of Steve Jobs, I have one more thing for you before I move on with my day and let you do the same.

I received an email yesterday from the powers that be that told me our merry little band has received tentative approval to work from home. Up until now, to do my telepsychiatry duties I have had to physically go into an office in the local mental health center. Now granted, this has not been an extreme hardship, in that the office is exactly six  minutes from my apartment. However, working from home would mean that I have control over the thermostat, that I get to make my own coffee, that lunch is ten steps away, and that when a sixteen hour shift is over I can walk two rooms over and fall into bed if I wish.

It’s the little things people.

I’ll be sure to let you know how that scenario plays out. Could make for some interesting writing about autonomy versus isolation and other associated issues.

As always, thanks so much for taking a little time out of your own day to read my musings. I welcome your comments, feedback, and suggestions for things you’d like to read about here.

Have an excellent day (or evening, for those of you who insist on staying fourteen hours ahead of me. You know who you are.)

 

Tele-Psyched

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A couple of nights ago, our little Telepsych Program that Could reached a major milestone. 

We saw our 16,000th consult patient in the state of South Carolina. 

The Telepsychiatry Program in the SC Department of Mental Health has been going strong for almost six years now, and things just get busier and busier. Some days I come to work and there are ten consults queued up to be seen in various emergency departments around the state. Other days there have been as many as thirty. As I have mentioned previously, each consult, much like a “real” consult on the floor of a hospital, might take anywhere from one hour to two hours or more to complete, from record review to on-camera interview to typing the actual report to be sent to the requesting hospital. 

This milestone gives me pause and makes me think, again, about several very real issues. 

1) Mental illness is very common in the state of South Carolina, and in the rest of the country.

2) Many people have access to mental health services only through their local emergency rooms.

3) Telepsychiatry is filling a need in my state, and is expanding around the country

I have worked in the mental health field for twenty seven years, and I hope to be actively involved in the provision of mental health services to those who need them most for many years to come.

The illness is real.

The sheer volume of work is sometimes overwhelming. 

The rewards for a job well done are many.

Congratulations to my colleagues in telepsychiatry for reaching this major milestone in our program. I am honored to work with you as we try to provide the best mental health care possible for the citizens of South Carolina. 

 

Through a Glass Darkly

For now we see through a glass, darkly, but then face to face…

1 Corinthians 13:12

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I have been asked one question about my work in telepsychiatry more that any other, hands down.

“Can you really help a mental health patient like that, through a television screen?”

The quick and dirty answer? Yes, absolutely.

The extended answer? Read on.

Psychiatry is an intensely personal specialty. It requires knowing yourself as a doctor, as a therapist, as a consultant, and as a person more than any other kind of medical practice I have ever been exposed to.

It requires four years of residency after four years of medical school to train to become a psychiatrist for a reason. You must not only master the big picture and the fine points of the specialty. You must understand what makes you tick. You must know how you respond to stress, challenge and adversity. Without this knowledge and training, one makes a very marginally competent psychiatrist at best.

As a psychiatric consultant, I ask questions that in normal social discourse would be considered forward, intrusive, even bordering on abusive. I ask about the intimate details of your medical history. I ask about your work history and why you were fired from your last job. I ask about your sexual history and yes, I usually want to know if you’re straight or gay. Not to pry, but because it gives me a tremendous window on your life, how you perceive yourself, and how others perceive you.

I want to know about your legal history. I ask how many DUIs you’ve had and what lead to the Criminal Domestic Violence charge. I want to know the details of your last suicide attempt. Why did you cut yourself instead of overdosing this time? Was your intent to die, or just to reach out and make a statement to someone who had wronged you?

Think about the last really deep conversation you had with a very close friend, a sibling, a parent, a spouse, a lover. What made it special? What made it real? What made it possible for you to let that person have access to a very deep part of you that no one else knows about?

It is the connection, the intimate connection between two people that allows these kinds of conversations to happen. Pure and simple. You know it. I know it. In our friendship, if you are not willing to let me in, to share your hopes, your fears, your dreams with me on the very deepest levels, we might as well be two strangers who met in an airport bar and had a chat during a layover.

Now, several of you have argued with me over the last few years that relationships on social media cannot be real in that sense. You cannot have that kind of deep, emotional and spiritual connection with another human being over Facebook, Twitter or any other social media platform. Many of you have said the same about telepsychiatry. You can’t possibly talk to someone and learn enough about them over a television screen to help them.

All I can tell you is that over the last four years my colleagues and I have done almost fifteen thousand consults via high speed lines and high definition video monitors. Personally, out of the thousands of consults I have completed myself, only two patients that I can recall now refused to talk to me over this medium. Both were very ill and their level of paranoia precluded them connecting on a meaningful level with anyone, in person or via video.

The flip side of that coin? I remember very well, with great pride and a very deep sense of fulfillment, the father of the emotionally sick child I had just interviewed. He was at the end of his rope. His child was suffering, dying in a very real way before his eyes. He did not know what else to do.

After our interview I went over the treatment plan with him. I told him that there were things that could be done to help his child, and that we were going to do them, starting at that very moment. His face changed. He smiled a very weak smile. I could see the hope in his eyes.

Spontaneously, he jumped up out his seat, two hundred miles away from me, and reached out to shake my hand.

I knew at that moment that the medium was powerful, the connection real and the intervention worthwhile.

We had seen each other through a glass darkly, and then face to face.