Hallucinations, Haints and Hooey

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Once upon a time I saw a patient for followup, a woman I had seen for several visits in the past. She had voiced the usual oft-heard complaints about insomnia, changes in appetite, lack of energy, diminished interest in pleasurable activities, and other associated symptoms of chronic depression. Most of these had been addressed and had gotten at least partially better, to the point that her overall quality of life had improved, a clinical benchmark that I pay close attention to in all my patients. After all, if you’re not living better every day, what we’re doing is not working.

The sticking point here was that her chief complaint for this particular visit was continuing visual hallucinations. She would see people, most often a silent, ghostly woman, who would walk through the house, mostly staying in her bedroom. She never said anything (this patient never complained of any auditory hallucinations, just visual), but she would move things around on the dresser and sometimes even knock things off the dresser onto the floor when the patient came into the room. I pressed the patient for more details.

The objects were physically moving on the dresser, to different places than they started?

Yes.

They actually physically fell off the dresser onto the floor?

Yes

Hmm.

Now, there are a few things about hallucinations in psychiatric patients that usually hold true. The first is, most folks are very reticent to come right out and tell me about these symptoms, for fear that I will think they are “crazy”. Patients who are truly psychotic will often just not want to reveal it to others, and they may suffer silently for some time before the severity of their symptoms comes out. Secondly, hallucinations of various types are things that the patient experiences, but by definition others around them do not. If you are hearing music playing in the room where we are sitting and having coffee together and I do not hear it, and there is no discernible source for this music, you may be hallucinating it. Stands to reason. 

So, we discussed this for a few minutes more, and then I turned to her very quiet boyfriend, who was sitting in the opposite corner from the patient. He was sliding down into the chair, and it appeared that he was trying to become one with it. This was my second clue that something was not quite right here. I asked him some similar questions.

When she is seeing this woman who sweeps things off the dresser onto the floor, do you see her too?

No.

Ah. Do you see the objects on the dresser actually move?

Yes.

Ah.

Do you see them actually fall off onto the floor, as she describes?

Yes.

Hmm.

Now, before we go any further, some of my readers are most likely already aware that there is such a thing (or was, in the DSM) as folie a deux, a shared psychotic disorder:

(folie à deux |fôˌlē ä ˈdœ|noun ( pl. folies à deux |fôˌlēz| )delusion or mental illness shared by two people in close association.ORIGIN early 20th cent.: French, literally ‘shared madness.’ (OS X dictionary))

This was not that.

I was unsure at the get-go that the visual hallucinations that the patient described were legitimate. I was pretty much certain that the descriptions the boyfriend gave were bogus. The story just did not ring true from what we know and from my decades of experience interviewing and treating folks who are truly floridly psychotic. 

Why is all this important? Well, this lady was already taking medications for her depression, and they had seemed to help her. The level of her depressive symptoms was not nearly as bad as it had been on initial presentation. She was better, functioning better overall, as I alluded to in the very first paragraph. The problem that she and I had to come to grips with was that if she truly had psychotic symptoms that happened this often and were this obvious and that impaired her functioning, then I was going to at least consider and discuss with her the use of antipsychotics, big-gun drugs that treat these types of symptoms. As some of you know, they are useful and helpful drugs, but they are not without potential serious and significant side effects and risks. 

Use of antipsychotics can lead to weight gain, elevations in blood sugar and blood lipids, and even irreversible abnormal involuntary movements that can be quite debilitating, more-so than the symptoms they were prescribed to treat. They should  not be prescribed lightly, and with informed consent. 

The bottom line in this case? I decided, along with the patent, not to prescribe antipsychotics. I thought the risk to benefit ratio was too high to justify their use at this point. I was not convinced that these symptoms were severe enough to warrant that next step in medication treatment.

There are at least two major issues in play here, when all is said and done. 

One: it takes time and effort to sort out histories and stories and elicit details about symptoms, to better understand what we are treating. This is a necessary step to avoid shooting from the hip and simply writing a prescription for serious drugs that someone may not really need at all.

Two: with the ongoing changes in out healthcare system, it is going to be much easier to do exactly that-get minimal and superficial information about symptoms, reduce everything to the common denominator, and treat. Next patient. 

Complicating this, especially in the south where I practice, is the fascinating fact that people will report seeing their deceased relatives days, weeks or months after they die, hear them talk to them in actual conversations that they swear are real, and find that these phenomena are perfectly culturally acceptable. 

Are we dealing with hallucinations? Haints? Hooey?

Do people have hallucinations that are true psychiatric symptomatology? Do they actually communicate with those who have already passed on and is this a perfectly acceptable cultural norm in some places? Are stories like this made up for reasons of secondary gain or other reasons? 

What do you think?

 

 

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Tempus Fugit

Good morning, good afternoon, and good evening to all of you.

Some of you may remember my old Pet Peeve posts from a previous blogging life. I haven’t done one in some time, but here we go.

Fair warning. This is my peeve and my rant, not yours. You may disagree. That’s okay. I welcome your comments as always.

Patients are often very disrespectful of my time.

In the mental health center setting, I have taken to scheduling a thirty minute time slot for follow-up patient visits, and a full  hour for new patients, especially children. The reasons for this are probably obvious to you.

A new patient requires more time to do more extensive history, exploring more details about presenting symptoms, past history, substance abuse, family dynamics, medical problems and review of the overall goals and treatment plan as set forth for each patient. A follow-up may involve seeing someone back after starting a new medication, to review pertinent lab work that has been ordered since the last visit with me, or to deal with a new problem that has popped up. These follow-ups may also be routine six month visits with patients I have known and seen for twenty years or more.

Now, I try to make ready for each visit by looking back at the last note or two that I documented myself, looking at recorded histories that other clinicians have placed in the medical record, reviewing labs, looking at prescription data, and printing out the info that I would like to be holding in my hand as I talk to the person coming to see me. This takes me several minutes for each upcoming visit. I do this before the appointed time so that I may walk up to the lobby as close as possible to the top or bottom of the hour to call the patient’s name and start their appointment.

All this being said, remember that the mental health center I work in schedules patient visits for a specific time. There is no first come first serve thing, no OB office scheduling in massive waves that results in three hour waits, no “morning clinic” or “afternoon clinic”. If your appointment is for ten AM, I expect to see you at ten AM. Usually not before, and definitely not after if I can avoid it at all.

Now, of course, if the transportation company gets you there an hour early and I have nothing to do at that time, I will see you early. If an emergency preempts you, which happens rarely in my clinic setting, I will certainly do my best to see you as soon as the crisis is over and dealt with. If that is not possible, I will reschedule your appointment for as soon as possible on an upcoming day.

What’s the problem with all this?

People show up late.

If they have a thirty minute appointment, they show up fifteen or sometimes twenty minutes into it and expect to be seen for a full appointment time. I may have thirteen appointments scheduled that day, and the next person may already be there, so I am not going to penalize them by pushing them back to accommodate someone who is late. If there is a legitimate reason, then we deal with that. Sometimes, though, folks just show up when they want to show up. That’s not my problem, and that’s not cool. Rudeness and disrespect are no reason for accommodation.

People don’t plan.

Now, please understand that I know if you have schizophrenia, it is difficult for you to plan your normal day and execute normal tasks. That is part of the illness. I’m not talking about that. I’m talking about not planning to leave home on time, arrange the proper transportation for an appointment that you’ve know about for six months, and allowing for things that might make you late.

People don’t respect themselves.

Yes, sometimes they feel that they are not good enough to warrant setting aside time just for them. Again, this may come from several things that I won’t go into  here, but the fact is that time set aside for you is your time. No one else’s. It is time for you to see the doctor, talk, ask questions, and get the help you need.  I am an experienced clinician, but I will not compromise your care by cramming a one hour initial assessment into fifteen minutes because you couldn’t find a ride. Sorry. Reschedule, please, so that we can take our time and do it right.

My fear is that as healthcare is changing and patients are not as responsible for owning their own care and paying for it, that it is cheapened and means less to them sometimes. If you are paying two dollars out of pocket for a thirty minute appointment in a state mental health center as opposed to two hundred dollars in a private outpatient setting, is the time worth the same to you? Is the treatment you receive worth the same to you, in your own mind?

I wonder.

Rant over.

Thanks for listening. I welcome your comments, as always.

Something I Didn’t Write That You Should Read

Sometimes, someone else says the things that we feel passionately about better than we do. It really is a waste of time to reinvent the wheel, so I’m going to post this link to an article that I’d like all of you to read, if you would be so kind. 

My friend Martha Anne Tudor, who once wrote for the New York Times herself, sent this to me yesterday. 

Juliann Garey writes eloquently in When Doctors Discriminate about how having a mental illness, just having it, sometimes leads to suboptimal medical care. 

“Last year the World Health Organization called the stigma and discrimination endured by people with mental health conditions a hidden human rights emergency.”

Please read this article, think about it, comment on it, and share it with others. 

Have a great Tuesday.

Aliens, Computer Chips and WiFi

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“I have been WiFi’d,” she told me with a straight face. 

I waited a minute, not sure what kind of followup question this revelation required. Sometimes it’s best just to sit there and say nothing and let the situation play out as it will.

“I think the FBI is behind it, of course, but it could be somebody else. I don’t know. All I know is that they have WiFi’d these animals into my brain.”

She pronounced it “Wee-Fied”, which for some reason sounded so extremely silly to my geeky brain that I almost laughed out loud. Of course, I maintained decorum. I am a trained professional, people. 

“I see them. Sometimes they touch me. I don’t think you can see them, because, you know, the Creator doesn’t want just anybody to be able to do this!”

I knew where I stood at that point. No doubt at all. 

Delusions are funny things.

I think that they have changed some over the years I’ve been in practice, influenced by external events, the economy or the general social fabric I guess. 

Used to be, people had the old run of the mill thoughts that they were loved by famous people, that the government was watching them (we certainly have to take that one off the books now, don’t we?!) or that they had been abducted by aliens. In 1947, that made perfect sense, since every weird and wonderful wacko on the streets of Roswell, New Mexico, was wearing a tin foil hat and preparing us for the imminent invasion that never came. 

More recently, the delusions seem to have morphed with the times, involving implanted computer chips, WiFi, cell phone towers and control by flying government drones. 

There are still the timeless delusions that one is the lover of a famous movie star, that one is rich beyond all imagining, or that one is Jesus Christ. I always worried about that last one. What if Jesus decided to come back as a mental health patient and he revealed Himself to me and I didn’t believe Him? Meredith Gould, if you are reading this post, can you weigh in on this one for me? I’m not entirely kidding here…

Now, I’ve said it before and I’ll say it again, lest those of you who are often angered by my writing get even more so after this post. 

Mental illness is not funny. It’s real. It injures and harms people. It impairs their ability to live, to work and to love. Freud was right about that, among other things

However, I would not be able to do this hard work, this very draining, very emotionally gut-wrenching work, if were not for my love of my patients and the little things they say to me each day, the things they teach me, the things they do (consciously or not) that make me laugh. 

Sometimes, psychiatric symptoms are terribly serious and very severe.

Sometimes they are, in spite of the gravity of the situation and the illness being examined, simply amusing. 

I take my vocational calling very seriously.

I am learning to take myself less so.

 

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. 

 

Breaking a Few Eggs

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“Most EDs do not have separate secure areas in which psychiatric patients can be held. They typically don’t have a psychiatrist immediately available to evaluate the patient and provide guidance on management, and they do not have extra nursing staff to monitor often unpredictable patients.”

azmd, in a comment on one of my blog posts  on KevinMD.com.

Well, we have been talking for a few weeks now about the way psychiatric patients get to the ED and what happens or does not happen when they do. Many of you have lamented the lack of personnel, the dearth of services and the waits that these patients experience because of dwindling inpatient resources. What can be done about this deplorable set of circumstances?

First and foremost, I believe that hospitals are going to have to provide separate service areas for these patients.

The stark white room with only a gurney and a chair, with no television or magazines or anything stimulating to do, must go. Replace it with a hallway or a suite of rooms with a centrally located nurses station and a common area that give patients a little more room to walk, space to interact and even a special area for visitations from family. The lone guard outside the door, symbolizing both threat and security, must be replaced with trained mental health staff in this special area, staff who know about the signs of escalating agitation and potential for violence in these patients. A small emergency room within the main ED, this area could be secure and therapeutic at the same time, much as an inpatient psychiatric unit might be. This should become a standard for emergency departments who wish to receive mental health patients.

Psychiatric coverage is going to be needed for these service areas.

As many commenters have pointed out, both patients and providers alike, it seems that there are never enough psychiatrists around to see mental health patients when they do come to the ED for help. One criticism, spot on in some cases, is that psychiatrists do not respond in a timely manner to requests from the ED physician for consultation and help in the management of difficult psychiatric presentations. They do not come out in the middle of the night to see patients and they do not give timely input that would be helpful to the ED staff. In many rural areas, even if there  is a small community hospital, there are no psychiatrists anywhere. There are no mental health centers to send a screening clinician.

Services such as telepsychiatry may be the answer to psychiatrist shortages in the future.

Being able to see multiple patients in multiple hospital EDs over a regular or extended shift, without the hassle of driving from place to place, is one of the virtues of telepsychiatry. A patient who might have sat for days waiting for an inpatient admission because no mental health input was available to begin treatment in the ED, may be the beneficiary of a mental health consultation and initiation of services from the first day they are evaluated. A fair number of these patients, their treatment begun in the ED, may actually be improved enough to go home directly from the hospital after a few days.

Now, I know what is going to  happen as soon as these kinds of changes are proposed.

There will not be enough space. There will not be enough money (when is there ever enough money?). We can’t dedicate an entire area of precious emergency department real estate for a babysitting service for mental health patients. Psych patients will be running amok all over the department, threatening and yelling and getting into other patients’ business. We can’t spare staff for this in the ED. Psychiatrists will never come down to see these patients even if we do set them up in their own place. Telepsychiatry equipment is expensive and we’ll never be able to afford it.

The fact is, as my old mentor Everett Kuglar MD used to tell me, these patients are not going to go away. Someone is going to have to treat them.

No matter how much hospital administration tries to ignore their existence, no matter how little funding state legislatures provide for their care, people with schizophrenia and depression and substance abuse problems and other mental health problems are going to be with us.

We can choose to ignore them, but the problem will only get worse. We can choose to maintain the present day status quo, which in my opinion will only lead to more frustration for patient and provider alike.

We can choose to spend a little money, time and physical and human resources to turn this around.

Sometimes if you want to make an omelet, you have to break some eggs.

Cutting the Gordian Knot

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Good morning, emergency department junkies. The rest of you too.

So, we’ve been talking for a month about the ED and mental health. Who shows up at the door, why they come, what they suffer from, how they are treated, and how they interact with the environment there. It’s true that you can’t know where you’re going until you know where you are.

In case you missed some of my previous loquacious musings, let me sum it up for you.

Mental health treatment in the emergency department is a mess.

How do we address this Gordian knot of court system, families, law enforcement, patients, social work, medicine, mental health, nurses, doctors, and health care facilities? Where to start?

Julie Andrews has the answer.

Let’s start at the very beginning.

A very good place to start.

1) Getting into the system is confusing, cumbersome, and downright terrifying for patients.

We’ve aready talk about families abusing the court system to get loved ones committed based on inaccurate information or even on malicious grounds. We’ve seen how hard it is, No Wrong Door notwithstanding, to figure out how to acccess the appropriate services when you’re depressed, hopeless, or psychotic.

2) Because of this, some patients never get started with the treatment they so desperately need.

They suffer in silence. Other patients’ first encounter with this complex system is so traumatic to them, so painful and degrading and humiating, that it becomes their last contact. They give up on getting help via traditional pathways. I have heard you comment on my blog, over at the Shrink Rap site, on Twitter and Facebook about this. I hear you. You’re right.

3) The trauma of gaining admission to the existing mental health treatment system is real.

You’ve also weighed in on this loud and clear. Just after one of my readers commented on the physical trauma of being manhandled into an ED, I saw a patient who had been tasered by law enforcement to subdue him before transport to the emergency department for a mental health evaluation. Do you think that patient will remember the caring and compassion he got in the ED, or the painful shock of being tasered to get him there? What will stick out in his mind? What will encourage, or hinder, him from coming back to seek help the next time he is ill?

Tomorrow, I will begin to share some of my thoughts about how we can do it better.

I will lay out some simple, some not so simple, changes that we could start making right away to streamline the entry into the mental health care system. I will welcome your reading, digestion and rumination on these changes. Then, I will also invite you to share these with family members, colleagues, and institutions you have been in contact with.

It is only through meeting these problems head on, seeing them for what they really are, that we will ever effect any meaningful change.

In my lifetime, I want to be a catalyst for change in my field. I want to shake some things up. I want to see us treat patients fairly, efficiently, effectively, and with compassion.

I am not satisfied with coasting along for the rest of my career thinking that the status quo is the best we can hope for.

I know that we can do better.