Stuck in My Craw

One of the things I was taught in medical school: common things are common. 

These things have been more common lately. I know I’m starting the grumpy old man phase of my blogging life, but good grief, people. Really?!?


No direct eye contact. No acknowledgement, verbal or otherwise, when greeted with a cheery good morning. Annoying behaviors designed, quite consciously, to actively annoy and derail the time in the office. Texting, typing, talking and playing games on phones in the office when active input would be appreciated! Ignoring questions outright or refusing to answer. 

Sullen mood: 

No, I’m not talking about serious depression or active psychosis. I’m talking about deliberately hostile, staring, scowling, defiant presentations designed to minimize communication. Really?

Lack of responsibility: 

“I don’t know why I had to come here.”

“I’m not sure how that gun/knife/weapon got in my gym bag, but it’s the kid’s fault that found it and turned me in that I got in trouble.”

“My teachers suck. They don’t know how to teach. They’re stupid.”

“Because I don’t like to do chores, that’s why.”

“I just don’t do the work. I don’t feel like it. No, I never turn my homework in.” 

“They can’t do this! They can’t take away my iPhone/iPad/Gameboy/PlayStation/XBox/flat screen TV just because I have four Fs and a D!”


It’s the teacher’s/principal’s/parents’/other kids’/government’s/doctor’s fault.

Anger for anger’s sake.

Refusal to problem solve or to see anything positive at all in a situation. 

Adversarial stance (kids and parents both!)

“Fix me!”

“We’ve tried everything and nothing works for him.”

“Nothing you can do will help.”
This was a week, friends. 

This is not entirely a mental health crisis. 

This is a crisis of investment in parenting, house rules, expectations, empowerment, upbringing, respect for elders, and establishment of normalcy in childhood. 

Enjoy your weekend. 

Next week, we all have more work to do. 

Why Do We All Want to Die?

I use an ongoing spreadsheet to keep track of and to report my demographics and stats for each telepsychiatry consult shift I do.  I’ve done thousands of consults in over two dozen South Carolina emergency departments over the last half-dozen years. We have now gone over thirty thousand consults as a group.

It never ceases to amaze me, as I fire up my computer, log on to my systems and bring up that spreadsheet for the shift ahead, that one column is remarkably uniform and consistent, sometimes for days at a time. It is the column that asks for an abbreviated reason for the consultation request. It usually looks like this:







SI stands for suicidal ideation, and that is one of the most common chief psychiatric complaints that we see in the emergency department.

Sometime I am simply so busy trying to see all of these people (there was a multi-day stretch recently that we had up to thirty different consults queued up waiting for one of us to see them) that I cannot afford the luxury of slowing down, looking for trends, trying to analyze why we might be so busy during that particular weekend, and the like. There is just not time. However, it is hard not to see the obvious pattern created by the number of people who come into the EDs and state to a staff member that they want to kill themselves.

Why do we all want to die?

Sure, the world has its ups and downs and stresses, but there seem to be so many people who are bent on their own destruction lately that it is mind-boggling.

Allow me to posit some reasons for this disturbing trend.

We do not feel that we belong.

I heard something on the way to something else the  other day that stated that folks who are forced to check that box called “Other” on standard forms do not feel special when doing so. They actually can be made to feel apart, cast out, cut off from the mainstream, in that they do not fit any of the standard groups listed on such forms. To be “other” is to be different, odd, not a part of the group. It is socially and emotionally ostracizing. It means that we do not belong. That hurts.

We do not feel loved.

Okay, okay, I know that is shrink talk and too touchy feely for some of you, but hear me out. I hears over and over from folks in the ED that they do not feel loved by their parents, their spouse, their children, or anyone else. Once again, whether it is feeling like the “other” or not loved by anyone at all, it is a massive cause of self loathing, isolation and hopelessness that will drive someone towards not wanting to exist at all.

Everything seems too hard these days. Nothing is guaranteed.

It used to be if you went to school, graduated, kept your nose clean and played by the rules, you would almost certainly succeed in life. You would be able to find a job, you would have a place to live, you might find love and even raise a family. Today, it seems that none of this is guaranteed, and that for some it all seems just out of reach. Sometimes, people who appear at first blush to be lazy are just depressed, unmotivated, not well-trained, not educated, and simply down on their luck. They see little hope for success no matter how hard they try, so they don’t try. It is sometimes easier to just give up, find someone or something to blame, and give up, rather than really working to make things better.

We feel hopeless.

Hope keeps us getting up in the morning. Hope keeps us going to school, working our way up the ladder, doing the jobs that no one else wants to do, taking on challenges that we are afraid of. If we lose hope, we have lost our will to challenge ourselves. We have lost our dreams for the future. We have lost our ability to see ourselves in the distance, happy and healthy and successful.

What exacerbates these core states and feelings? What makes it hard to fight back and move past them? What do I see most often in the emergency department when someone has come in after cutting, swallowing a bottle of Tylenol, or drinking themselves into oblivion?

Relationship problems are always in the mix. A teenager breaks up with the love of her life and now thinks that life is over. (She cuts herself on the arms and legs where no one can easily see her attempts to deal with her pain). A middle-aged man is a raging alcoholic but has no insight into how this is devastating his family. His wife leaves him, taking their three small children with her. He comes in with a blood alcohol level five times the legal limit. An elderly man has just lost his wife of sixty years to cancer. He is quite literally lost without her, and he does not want to go on. He is a retired police officer, owns several handguns, and knows how to use them.

Financial problems and reversals can produce high levels of anxiety that seem insurmountable. Some folks are almost paralyzed by just not being able to buy gas for the car or groceries for the kids this week. Others may be more well to do, but the shock of losing value in their retirement portfolios or not being able to make the mortgage payment on a huge house that they really cannot afford leads to guilt and shame and feelings of failure. Both can feel like the easiest way out is to simply not be here any more.

Some patients are dealing with chronic mental or physical conditions that they are simply tired of. The ups and downs of bipolar disorder, the pain of congenital spinal malformations, the physical and emotional trauma of cancer and its treatment can all lead to feelings that it would just be better to end things on your own terms rather than waiting on the  diseases to decide when it is time for you to die.

Perceived failures and disappointments (both disappointing yourself or others) often leads to the mistaken notion that if you kill yourself, the problem goes away for not just you, but everyone involved with you. The thing that most of these folks have not thought about to any degree is the pure devastation that is left in the wake of a suicide. The family members, spouses and friends who must live on after you are gone must ask all the hard questions, the “what ifs”, the whys. The guilt and emotional suffering they feel is tremendous and it never really, truly goes away.

Fear and anxiety drive many suicide attempts. Odd, in that most people think that only those who are severely depressed kill themselves. Anxiety, severe and unrelenting, actually leads more folks to actually successfully complete an attempt than depression. The underlying shame, guilt, or other emotions that drive the anxiety are often not discovered in time, or are so well hidden by the patient that it is only after the successful suicide that these are uncovered and better understood, often from the note or other communication left by the deceased.

What is the common feeling that weaves its way through it all? Hopelessness. If you think that there is no way out, that there are no viable solutions left, that you have exhausted all reasonable possibilities for making your situation better, then that gun or bottle of pills or telephone pole look like rational and logical answers for your unanswerable questions. You give up. You quit looking for answers. You feel lighter, happier, more confident because you have made that decision to just let it all go. If there is no intervention, swift and appropriate, you will die.

What are all these stresses and problems complicated by, as if it could get any worse?

One of the most common accelerants for suicidal ideation and attempts is intoxication with alcohol and other drugs. Decreased inhibitions, poor judgment, impulsivity and poor decision-making all lead to potential problems when one is already contemplating self harm. If you are already stressed, at the end of your rope, and contemplating ending it to escape the anxiety and pain you feel, reach out and get help. Drinking, smoking and popping pills rarely makes things look better.

Poor social support is another major deficit that exacerbates suicidality. I see countless patients who truly do not have family, friends, church or anyone else they can call on in time of need. They are really, truly alone. Isolation and disconnection from other people kills.

Lack of access to care also makes things worse just when the help is needed the most. The shrinking of available mental health resources in this county has lead to a dearth of programs that address acute illness and this does not bode well for someone who needs help now, not three weeks from now or at the next available appointment time.

Concomitant mental and physical illnesses can spell disaster. Those dealing with longstanding cardiac disease, severe diabetes, metastatic cancer, and other devastating illnesses may be overwhelmed with the emotional counterpart of the illness and if not noticed or addressed, it may steadily worsen and become malignant itself.

What to do if you find that you are one of those people who is thinking that death looks like your only option?

Call 1-800-273-TALK.

Talk to your family, your girlfriend, your husband, your minister or priest.

See a psychiatrist or other qualified mental health professional right away. If you are turned away when you call, call somewhere else. Don’t accept anything less than an option for immediate assessment. This is your life in the balance, and it is important.

Suicide kills over forty-four thousand people in the United States every year. For each completed suicide there are twenty-five attempts. On average, there are over one hundred twenty suicides per day in the US.

There are many reasons that many of us really want to die.

The job for the rest of us is to convince those folks on the edge that there is help.

There is treatment.

There is hope.



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.





“And, by the way…”

He came in for his routine yearly visit with me, stable for the most part in that he was living with his chronic psychotic illness and moving through the world in a fairly normal, logical way most days. He was in his mid-twenties, neat, clean. He was attending to his personal hygiene and wearing rumpled but passable casual clothes. His hair was combed, but it had not been cut or even trimmed in quite a while.

“I don’t think my antidepressant is working,” he announced matter-of-factly.

Like many of my patients, he was and has been subject to that best of all psychiatric interventions, polypharmacy (Yes, I AM being sarcastic), whereby if a patient tells you they are having an exacerbation of symptoms on their current regimen of drugs you simply add another one and hope that augmentation is a real phenomenon. (The drug companies assure me that it is.)


I waited.

He waited.

“Tell me more.”

He did.

His change in symptoms was both vague and intriguing, troublesome and irksome. We’d been down this road before, he and I, several times.

He thought it was the medicine.

I did not.

Ninety-nine per cent of the time it was not.

Medicine is just an easy target. There it sits, on the nightstand, on the window sill above the kitchen sink, in a purse, under the bed. In a brown bottle, with a white childproof cap, neatly labeled,  it is the best absorber of causation ever devised by modern medicine. If something is not right, if something is difficult to figure out, if something is not working or responding the way we all think it should be at week one, week four, or week eight, then it must be the medicine. What else could it possibly be?

“I’m more depressed. I don’t want to do anything. I don’t leave the house. I have no interests. I don’t sleep. I don’t eat.”

We chatted. He weaved and bobbed. I confronted and clarified.

“Maybe it’s the medicine,” I offered, not wholeheartedly but with some degree of inevitable resignation.

“I told you it was the medicine,” he said, triumphant.

We talked about a dosage change. A small increase. A homeopathic sacrifice to the gods of common sense and exasperation.

“There,” I said. “Anything else you think  I should know before we stop?”

He was silent.

I typed in the new dose of the medicine and sent it on its way to the pharmacy in electronic form.

I got up, proffering my hand.

“And by the way,” he said, a calculated afterthought. “I’m very lonely, you know. I’m very lonely. Do you think I’ll ever have a girlfriend?”

I sat back down.

My next patient had already canceled.

I had not been able to do psychotherapy, even rudimentary, time-limited, short-term psychotherapy, in such a long, long time.

I laced my fingers in my best Freudian way, stroked my white goatee, and crossed one leg over the other.

“I’m listening,” I said.


Would You Like Sides With That?

SIde effects are weird things. 

Now, when I prescribe medications for patients, one of the things I always do, after talking about the reason for the med, the dosing, the cost and the the like, is to discuss the most common side effects that I expect they might experience. Why? Because they are likely to have one or more of these obnoxious effects, and if I predict them in advance it makes me look like a smart guy. 

I was taught in medical school that “if you hear hoof beats, look for horses, not zebras”. Or, stated another way, “common things are common”. 

I always tell patients NOT to go home and Google the drug I have prescribed for them. They will be hit with every side effect in the book, legalese out the wazoo, and they will come away afraid to take not just that medication, but any medication that anyone might prescribe for them in the future, ever! I ask that they trust me to give them the lowdown on how the medication should work, how long it will take, and what very common side effects they are likely to see. 

Dry mouth, dizziness, weight gain or weight loss, hair loss, dry skin, sedation and confusion are all side effects that I might mention to a patient. 

Note that these are side effects of the medication itself

But what about side effects of another kind? Side effects of the treatment as a whole? 

By this I mean, what if the patient, after adequate treatment, starts to evidence behavior that he or his spouse or family is not expecting, and even dislikes? What do I mean by this?

Well, if a very depressed woman starts to get better, feels like going out and demands that her couch potato husband take her to dinner and a movie once a week, when he’d rather stay at home, that might be a problem. Her treatment has been very successful, she is more energetic, her interest in doing things has picked up and she is more assertive in asking that her spouse accompany her to do these things that she wants to do. He got used to the “old” her, the person who was lethargic and passive and never made demands on him. He does not like this “new” less depressed wife he now has. This is a side effect of the treatment that is unwanted, in the husband’s opinion.

What if a young woman who has schizophrenia is put on medications and in therapy groups that begin to slowly help her get out of her social isolation and enjoy being around others, even members of the opposite sex? Once again, her parents have gotten used to her being at home,  watching TV on the couch all day, for the last decade. Now, she wants to get out and go places, see people and even date. They are worried that she might even want to have (gasp!) sex! To them, she seems manic, out of control, hyperactive, when in fact she is now able to act like a normal young woman her age and experience things that she never expected to again. 

Side effects can come from medications, from the treatment as a whole, and sometimes can be seen as negative, even when to the patient thinks things are going much better. 

As in many aspects of mental health care and treatment, communication about these kinds of effects and behavioral changes should be attended to early on so that doctor, patient, and family are all on the same page. 

All (Patient) Lives Matter

She is tall, thin, and wears torn jeans like a mannequin. The silky top flows around her, masking the thin torso, the exposed ribs. Her hair is long, fine, and the ends are perfect. Her face is smooth, drawn, a bit careworn, but that is why she is here. She carries herself with an aristocratic bearing that is not learned, but genetically endowed over generations. She is rich, entitled, and she expects to be treated well. She is not sleeping. She does not eat. She is struggling. All the money in the world does not offset true twenty-first century angst. She asks for sleeping pills, as her nightly regimen of cannabis and cocktails is no longer working. Batting her natural lashes, and giving a gentle but directed toss of her corn silk smooth hair, she expects to get them. When asked to settle up at the end of the visit, she pays with cash. 

She is lying on the hard floor of the seclusion room, stark naked, legs akimbo, her belly flopped over onto the floor like a sack of flour. She has been given intramuscular injections of an anxiolytic and an antipsychotic, so she is drooling, sedated and uncoordinated. She cannot stand. Her speech, such as the vitriolic outpouring of expletives and sexual references is, is slurred and marked with staccato streams of spittle. She is actively hallucinating, screaming back at the demons who mock her and tell her to kill herself. She has a college education. She is a beautiful woman, engaging, smart and witty when she is not being torn apart by the illness that has run rampant in her family. When she comes to see me in a few weeks, after she has weathered yet another psychotic storm, she will be mortified that I saw her this way. We will talk it through, and we will do our best to make sure it never happens again. 

She sits quietly in the chair in my office, listening to her mother. Detail after detail of how bad she is, how she constantly acts out at home and at school. How she is not like her mother’s four other kids, how she is a disgrace to her family. How her mother is almost ready to give her up because she can no longer tolerate or handle her. A single tear rolls down her smooth brown face. She asks if she can play with the the toys. She looks at mother. She looks at me. I nod. She gently holds a small doll, stroking her hair. She has been abused since the age of two. She is now six. She never smiles. 

She is short, wiry, with skin tanned like leather. Her clothes are dirty, torn, and mismatched. Her hair is matted, a black-brown tangle of exposure to the sun and nights spent huddled in a cardboard box. Her face shows the telltale pockmarks and acne that help confirm the diagnosis that was already surfacing in my mind five minutes after our visit started. She bravely tries to connect with me via humor, a bad street joke, and when she smiles her teeth are rotting in her head. She tics and jerks and can’t sit still. She looks at the door, then back at me. She has places to go, dealers to meet. How much longer will this take? Would Valium help, maybe? Xanax, then? She knows that she will not get what she came for, and it makes her angry. I am a safe target. She explodes. 

He is older than me by eleven years. He is handsome man, robust and tanned with a perfectly coiffed head of thick, smooth, snow white hair. His face is clean shaven. He wears a lime green Polo, khakis by the same designer, and Italian leather loafers with no socks. He has a simple gold wedding band on his left hand, a college ring on his right. He fidgets, clasping and unclasping his fingers. He sits slumped in the plastic emergency room chair, and I know that this is not his usual posture without even asking. He struggles to lift his head. Eye contact seems painful to him. His voice is a raspy, tired whisper. They were married for forty-nine years. She was sick for the last five. Yes, he has several guns at home. Yes, he has thought about it. Yes, he drinks, every night, four bourbons instead of two. Could he just go home, please? Could he just go home? He is so, so tired. Could he just go home? 
All lives matter. 

Paging Dr. Carnac

“If you could read my mind, love, what a tale my thoughts could tell…”

Gordon Lightfoot

She sat across from me, as many teenagers do in my office, sullen and staring and closed off, body language reflecting self-protection and not openness to inquiry. I had just asked her about her family history, wanting to know if anyone in her family had ever been treated for mental illness. 

“I thought you were just for the medicine,” she spat.

“Excuse me?” I asked.

“The pills, the medications. I thought you were just here to give me the medicine. Isn’t that all you’re here for?”

Now I’ll grant you, on busy days when my pen is writing a lot of prescriptions or I’m send dozens of them through cyberspace to the local pharmacies, I wonder myself if that is not true. Of course, what this teen did not know, and what you may not know either, is that a lot of history, information and assessment play into my thinking before I hand you that prescription for Prozac or lithium. 

How do psychiatrists get their information? What do we need to know about you to treat you? My routine varies a little bit depending on the situation and the background for the visit. That is, the information that I review and seek may vary somewhat depending on whether I am seeing you for a probate court examination, a routine medication check, the initial visit to establish a diagnosis, or for an emergency evaluation in an emergency room via telepsychiatry. 

I always try to look at previous records. You may have brought some laboratory reports or X-rays with you. I’ll look those over. You may have had your primary doctor send me her records so that I can see how she is treating your hypothyroidism, hypertension or diabetes mellitus. You may have seen us in the SC Department of Mental Health system in the past, and so I would have electronic access to your outpatient records via my computer. Because of the opioid epidemic in the country, our governor has mandated that we check records of controlled drug prescriptions, who they were prescribed by, which pharmacy filled them, and which doctors are writing for the drugs. There is now a specific database that I can access to get that information, and I must document in your record when I see you that I have looked at the database and reviewed the information there. There are other databases that detail your previous appointments, diagnoses, and doctor visits. There are hospital records that tell me about your previous admissions, what they were for, and how long you stayed. There are court records from previous evaluations, information from the department of social services or adult protective services, the department of juvenile justice and law enforcement. 

Now, this is a lot of sensitive and private information. You might wonder about the ethical or legal nature of a doctor looking up all this detail about your life, and whether or not he might really need it at all. The answer to that is of course yes, if in getting and reviewing that information I can better establish a diagnosis and treatment plan and help you with the problems you presented to me with, or provide the best report to the doctor, judge, or agency who asked for me to report to them on your condition. All of this must be done with your express consent, unless an emergency situation exists or a court order compels the use of such information. I cannot go to the controlled substances database, for instance, and snoop on a friend or neighbor to see how much Xanax they have been using over the last two years just because I am curious. This information is available ONLY for professional purposes.Violation of that rule and unethical access to or use of personal protected information is a punishable offense. Especially in psychiatry, we take privacy and confidentiality extremely seriously. Otherwise, we know and you know that you would never in a million years come see us and divulge the things you do in confidence to your provider. No meaningful treatment could happen.

Collaborative information from families, spouses, friends or others may be extremely helpful as well. This is especially true in emergency room consults, when the patients I see may be intoxicated (I have seen folks come in with blood alcohol levels six times the legal limit and they are still trying to sit up and talk to me!)  or psychotic and incapable of providing their own historical background for the admission. In those cases, speaking with the treating physician or nursing staff in the ED, or trying to contact the referral source may also be helpful. Families are often right there with the patient in the ED and this is very helpful, but you might be surprised how many families simply drop their loved on off at the door and keep going, not answering their home or cell phones afterwards because they do not want to be a part of the treatment process at all. 

Laboratory records, including routine blood work, drug levels, X-rays, CT scans or MRIs and reports of other studies may be extremely helpful in establishing a diagnosis and coming up with the appropriate treatment. I have seen “psychotic”patients who I was consulted on for treatment of their “schizophrenia” who did not have a mental illness at all. Sometimes, thyroid problems mimic severe depression. A pulmonary embolism, a potentially fatal event, can look like severe anxiety and panic. I have seen children in the ED who were “too quiet” that turned out to have what is called status epilepticus, meaning that they are having continuous sub-clinical seizure activity that might not be diagnosed at first. Cocaine and other stimulant medications can make someone look as psychotic as can be, with or without a previous diagnosis of a primary psychotic disorder like schizophrenia. Urine drug screens are very helpful, as someone might tell me that they “have a drink or two every night but that’s all” and end up positive for sedative, narcotics or cannabis, or multiple drugs at one time. 

There are many screening tools in mental health that are also very helpful in figuring out what is wrong and what to do about it. These are beginning to be more and more important as we move into the age of managed care in the state of South Carolina (behind about forty-five other states who already have to worry with this), with providers wanting to see proof that interventions are indeed working and making someone better. Managed care companies do not pay for interventions that are not best practice and that do not show concrete evidence of getting patients better. Screening tools such as depression or anxiety inventories, checklists to assess attention deficit disorder, and questionnaires that look at activities of daily living are all helpful in diagnosing and treating mental illnesses of all kinds. Some of these are self reported and might be filled out in the waiting room as you wait to see your doctor or your counselor, others are given to parents or teachers, and others might be sent to your previous providers. 

Once again, I cannot stress enough that this information is confidential and used only by your provider in treating you UNLESS the interview or encounter is part of a court ordered evaluation, forensic evaluation, or is something that must be divulged as part of a mandatory reporting scenario. That is, if I see someone and suspect that there is child or elder abuse involved, for instance, it is mandatory that this abuse be reported to local authorities so that an investigation may be started by law. 

Is your spouse, simply by virtue of the fact that you are married, automatically entitled to your private information? No.

Is your mother, who loves you dearly and wants what is best for you, able to get the scoop from your psychiatrist about all of your sessions if you are in your forties? No.

Is your information automatically public record after your death, so that anyone might look at it because you are gone? No. 

Although Carnac the Magnificent could hold up a sealed envelope and come up with questions and answers that no one else could see, modern day clinicians including psychiatrists are not prescient or clairvoyant. We must gather background information, ask the right questions, keep our eyes and ears open, listen to what you are telling us, and use our best clinical judgment based on the evidence base, our training, and our experience to make an accurate diagnosis, come up with a reasonable treatment plan, and communicate that to you, enlisting you as a partner in your own treatment. 

Anything less than that would be, as Gordon Lightfoot would say, mind reading. 

As far as I know, mind reading is not evidenced based and is just not good medicine. 


It’s a common scenario in emergency room telepsychiatry. 

Sixteen year old female comes in after an argument with her boyfriend or her parents (usually fathers, sorry guys). She decides that she is going to get back at the person she fought with, and show them a thing or two. She rifles through the medicine cabinet. The thing that immediately jumps out at her is a big bottle of acetaminophen, the 500 count. It’s cheaper that way you know. She thinks what the hey, it’s Tylenol. How bad could it be if I take a handful or two of it? It’s headache medicine. She proceeds to do just that. Someone finds her, calls 911, gets her to the local ER. Her acetaminophen levels are through the roof, and rising rapidly. Houston, we have a problem. A big problem. Acetaminophen taken in even larger therapeutic doses over a long time can cause liver damage. Overdoses of it can cause liver failure. These ODs kill livers. And sixteen year olds who didn’t really mean to die. 

He’s a stud, a late twenty something with nice tattoos and even nicer pecs who thinks the world is his oyster and the girls will always fall for him. He works hard in construction during the week, but the weekends he considers his to blow out and party like it’s 1999. (RIP, Prince) He starts with marijuana at nine, alcohol at fifteen, cocaine at seventeen, and now and again a little crystal if he can score it. This time, on this Saturday, he goes a little too far. The cocaine, most likely cut and adulterated with God only knows what, treats his heart like crap. He has an arrhythmia that won’t go away. Hearts need to beat regularly. If they don’t, dirt nap. 

He is one of the most genteel and dignified men I’ve ever seen. His silver hair is still thick and full, his skin is ruddy and healthy looking, and he is dressed in nice khakis and a polo shirt. He smells of alcohol, his other vice (expensive cigars). He saw his family doctor the morning before he was admitted to the ER. He is on a small dose of antidepressant and something for sleep. His alcohol use is escalating, he has isolated himself, and he rarely sees his friends any more. He has stopped reading, and he doesn’t care at all this year about another love of his, presidential politics. Oh, and as for love? His partner, his true love, his wife of sixty five years, finally said goodbye to him when she passed away peacefully in her sleep six months ago. He has felt lost, alone, and abandoned ever since. He can’t shake it, and now he’s not even sure he wants to. “Let me die, Doc. Please just let me die.” 

The sixteen year old wakes up, feels a bit better, eats a little. 

“It was just Tylenol, for God’s sake. I was pissed at my dad. I didn’t mean to kill myself. Can I just go home, please?” (Insert grand eye roll and turn away from Doctor, arms crossed)

Her insight is nil. She damn near died. There are real problems at home, not to mention the fact that she has zero coping skills when normal day to day problems arise. She see none of this-yet. 

“It’s a fluttering, Doc. My heart is all a flutter, I guess, you know. The way I affect the ladies. They see me, and boom! They fall for me. It’s a curse.” 

He winks at me, unshaven, hair mussed, but still brash and arrogant and full of the misdirected passion of youth. He has little insight into the fact that he is a heartbeat away from nonresidency. 

“Oh, c’mon, Doc, give a guy a break. I still got some weekend left before seven AM work time on Monday. There’s beer in the fridge at home, buddies are blowing up my phone. I’m good. I’m really good. Let me out of this prison. Please!”

A single tear runs down his handsome tanned face. He looks up at me, telegraphing quite clearly that if he does not get some help, if he is sent home, that he will die. Oh, did I mention that he is an avid hunter and has a safe full of guns at home?

“May I please be discharged now? I’d like to get home to feed my dogs, and take a nap…” He trails off, head hanging down to his chest, hands clasped limply in his lap. He begins to sob, quietly. 

The common threads here are obvious. 

Some patients are at extremely high risk of self harm, even death. Some are young and naive, some are full of the vigor of young adulthood, and some are old and tired and sad. 

The other common thing about all these types of consults is that each patient, without fail, asks to go home. They have almost succeeded in poisoning themselves to death, they are playing Russian roulette with needles instead of guns, and they have given up on any further happiness in life. Somehow, they get to the ER and seek help. Yet, they can’t see the gravity of the situation, the extreme risks, the pain they would cause the ones left behind. They only want what they want, which is not to be in the emergency room. 

What to do?


You push me…

I pull you…

…with any luck, back into your own life. 

Don’t remember what a pushmi-pullyu was? Watch the video below and it’ll come back to you.

Olfactory Oligarchy

She was a very nice lady, always deferential as true southern ladies are. She would come into my office, holding it together and trying not to cry about her life situation. She was on the downside of middle age, morbidly obese, unhappy, and feeling quite stuck. On the outside, she was always bright and shiny, dressed neatly and cleanly, makeup on, hair done perfectly, nails a bright fire engine red. Underneath it all, she felt used, abused, dirty, depressed, fat, and hopeless. It took her many months, years even, before she would even begin to let me in on those very well defended feelings.

And yet, the one thing that stands out very vividly in my mind about her, about each and every visit with her, was her smell. She used the old fashioned Ivory soap, the white bar, the classic stuff. How did I know? The smell was unmistakable, and for someone like me with a very sensitive system that is allergic to anything that looks at me sideways, it was a true irritant every time she came to see me. I would see her for thirty, forty, sometimes even sixty minutes, and in that time my breathing would change, my eyes would water, and I finally learned that before I went out to the waiting area to get her, I would open my office window just a crack, just enough to let clean outside air circulate and keep me from a coughing fit as she told me about her latest woes.

As we have talked about in previous posts, olfactory memories are extremely vivid ones.

I was reminded of that lady, a patient of mine from many, many years ago, today.

Now, a psychiatrist uses several senses many times each day as he goes about the business of treating patients. Sight is important, in that watching how a patient walks, looking for tremors or other abnormal involuntary movements, assessing dress, makeup, general level of grooming, affect and a myriad other variables is important from the very first moment of a visit. Listening is our stock-in-trade, so naturally a good sense of hearing and being able to truly listen to patients is of utmost importance. And of course we may use our sense of smell. You might not think about that as the most important arrow in a shrink’s quiver, but it is one of them.

There were many varied smells in my office today.

There was the clean, just-showered-for-the-doctor’s-appointment smell, the person who had prepped themselves, put on clean clothes and come to talk with me about the latest situations in their life.

There was the ubiquitous (at least in the mental health field) coffee and cigarette smoke smell. If you’ve ever smoked or spent much time around those who do, you know that the smell gets into everything and stays there, including in clothes and on the breath.

There was the acrid, pungent, unwashed-for-days-if-not-weeks smell that connotes a state of beyond dirty. One wonders sometimes if the folks who come to the doctor’s office dressed in clothes that could prop themselves in the corner at night, with a smell so offensive as to be almost unhealthy, are themselves immune to it. Some of them, of course, are simply so depressed or psychotic that all efforts at self-care simply stop. Others, I have come to believe, take on this aromatic mantle and wear it without a second thought.

Finally, there was today the over-perfumed, overpoweringly sweet smell of someone who is in the habit of drenching herself with Yves or Ralph or Gucci, the more the better. Unlike the nauseatingly acrid smell of the unwashed above, this person overwhelms with sweetness and fruitiness or whatever the smell of the season is. Not altogether unpleasant, this can still lead to stinging eyes and coughing fits if there is no circulating air in the small consulting room.

So, my clinic day today was, as it often is, a microcosm of life.

If I could not hear and could see but through a glass darkly, I could still get a wealth of information from my patients by simply paying attention to the smells they bring to my office.

The reasons behind each smell and the extent of it are myriad and fascinating. One must not only use his sense of smell, but must tie that data together with oral history, visual cues and other things that make each person unique as they present for mental health care.

One more reason that I love what I do.

We would do well to remember the words of the Bard penned in Romeo and Juliet.

“A rose by any other name would smell as sweet”.

Still Waters Run Deep

There was an article in today’s Aiken Standard, my local paper, via the Associated Press wire. The title was “Robin Williams’ autopsy found no illegal drugs”. Aside from my annoyance at the misuse of the possessive, I did think about some things after reading this article.

The autopsy showed that Williams did indeed have evidence of therapeutic levels of his prescribed medications in his bloodstream. It is not a secret to anyone now that he had struggled for years with both mental health and addiction issues, and was in treatment at one time or another for both. He was being prescribed medications to help him with these conditions, and it appears that he was taking them.

He did not have any alcohol or illegal drugs in his system at the time of his death.

His wife, according to this story, was most likely home when he decided to kill himself and completed the act. He killed himself by hanging with a belt.

Even those with money to burn, success, achievements, loving family support, and ongoing treatment and medications can feel terribly isolated, alone, and hopeless. Depression can be devastating. Help can seem light years away.

I see so many hundreds, even thousands of people who struggle with addictions. Life on drugs and alcohol is sometimes overwhelming, fraught with relationship problems, legal problems and financial ruin.

On the other hand, sometimes life without drugs is just as hard to bear, maybe even more so if you have been addicted for years. The raw emotion of it, the demands and stresses and trivial annoyances of daily life seem just too big, too complicated, and too much trouble to deal with. They seem unsolvable.

For Robin Williams, even with treatment, fame, fortune, and family, it was all just too much. He decided that he could not go on.

I cannot and would never judge him or anyone who committed suicide. I have not been inside their heads, and I do not know what final thought they have right before they decide that they must die.

I do know that if someone needs help, if life is just too hard and whatever they are doing is not enough to sustain them, then action is imperative.

Sometimes still waters run deep.