September 2014 – Maria Yang, MD

Recent things I have read that I have found interesting, curious, or vexing:

The Social Security Administration maintains a “compassionate allowances” list, which is a list of “medical conditions [that] are so serious that their conditions obviously meet disability standards”.[1. You can learn more about how diseases make it on to the “compassionate allowances” list here.] Cancers, genetic conditions, and diseases still known by eponyms make the list. (Medical types: This is your list of zebras, not horses.)

“Can you receive SSI (Supplemental Security Income)[2. The Social Security Administration mails a check of about $721 once a month to individuals who receive SSI. To receive SSI, you must have “limited income and resources” AND you must be disabled, blind, or age 65 and older. I got lost while digging through all the subsections, so I don’t know what the “limited” income is. “The limit for countable resources is $2,000 for an individual and $3,000 for a couple.”] while living in a public shelter for the homeless?” the Social Security Administration asks.

Answer: “Yes. You can receive up to the maximum SSI benefit payable in your State while living in a public shelter for up to 6 months out of any 9 month period.” (Emphasis mine.)

While it is true that most people are in the shelter system for less than three months, is it possible that some people who receive SSI will need more help over a longer period of time to get out of the system?

If someone must stay in a shelter, that usually means that he can’t pay rent. Most employers prefer to hire employees who have actual home addresses. No job means no income. No income means difficulties finding affordable housing. And it is mighty difficult to pay for housing and food with only $721 a month.

Psychiatry has little to offer in the realm of prevention.[3. Some would also argue that psychiatry has little to offer in the realm of treatment. In moments of frustration, I agree.] We have no medications to prevent schizophrenia, though omega-3 fatty acids might reduce the likelihood that a youth already showing some signs of psychosis will develop “full blown” psychosis. (Researchers are putting efforts into preventing psychosis, which is exciting.) Most people don’t go to therapy prior to experiencing uncomfortable and distressing emotions.

The WHO has a paper about social determinants of mental health that cover the entire lifespan. Frequent themes in the paper include providing education for women; attending to the mental health of mothers before, during, and after pregnancy; reducing poverty; and providing support to people in school and in work. The prevention of and reductions in psychiatric symptoms were not due to medical interventions.

Incorporating mental health into daily living helps people stay well and develop the resiliency to deal with crap. It’s not a separate thing. We know that people who have had adverse childhood experiences are more likely to have psychiatric and medical problems as adults. Exercise, spending time with friends and family, maintaining stable relationships, eating nutritious foods, learning about stuff, finding value in work and hobbies, avoiding conflict and trauma—all of these activities are useful in preventing major psychiatric conditions.

How many of us in psychiatry focus on these social determinants in our daily work? How have we let ourselves become “prescribers”? Can we change that so that we “prescribe” education and activity more often, and only prescribe medications in the most severe circumstances?[4. This is easier said than done, given that we cannot control the behavior of other people or systems. I also detest the word “prescriber”. That’ll be another post.]

Someone pointed me to this article with the polarizing title: Bad Managers Talk, Good Managers Write. The author argues:

When managers write, you create work product — white papers, product requirement documents, FAQs, presentations — that lasts and is accessible to everyone in the organization. From marketing to sales to QA to engineering, everyone has a document off which they can work and consult.

The upshot is that the manager also takes public responsibility for what happens when the rest of the team executes on the point of view taken by the documents. That ratchets up accountability through the organization.

This is also the benefit of keeping a blog. You create a body of work that people can read, refer to, and learn from. More importantly, regardless of your work (whether it is your formal profession or what you do “on the side”), it gives you the opportunity to reflect on things that matter to you, clarify your thinking, express your ideas, and connect with interesting people, including yourself.

This post is overdue by one year! It may help to review the third scenario and a primer on involuntary commitment before reading on.

Why the delay? Because I still wrestle with the question at the end of this post.

Recall in the third scenario the man, described as a chronic inebriate, who frequently tried to kill himself while intoxicated. He recently had slapped a woman in a laundromat and had thrown a can of soda at outreach workers. How would you apply involuntary commitment criteria here?

1. Does this person want to harm himself or someone else?

While intoxicated, he has said that he wants to kill himself and we know that he has, in fact, harmed other people: He slapped a woman in the laundromat and he threw a can of soda at some outreach workers. While these may be minor insults in the grand scheme of things, they still suggest that he is disinhibited enough potentially harm someone.

2. How imminent is this risk of harm to self or others?

Probably imminent. Since he is frequently intoxicated, he is frequently disinhibited.

3. Are these behaviors due to a psychiatric condition?

Maybe.

Is an alcohol use disorder a psychiatric condition?

Think about your answer again.

Though “alcohol use disorder” is listed as a condition in DSM-5, some would argue that it is not a psychiatric condition. They would say that it is a choice. They would also argue that the mental disturbance that comes from alcohol use is temporary while “true” psychiatric conditions do not have the same cause-and-effect phenomena that we often see with alcohol.

However, we also know that this man has reported auditory hallucinations in the past and, regardless if his alcohol use is a psychiatric condition or not, his intoxication is clearly affecting his ability to function.

At least that is how I formulated it.

Related: Will hospitalization help treat the underlying psychiatric condition?

Possibly. The likelihood that he can become intoxicated with alcohol in the hospital is very low (but not impossible).

What actually happened?

The man was going around in circles from emergency room to street to jail. The police wanted him admitted to the hospital because the only time the police weren’t picking him up was when he was sober, which was when he was in the hospital. The outreach team had housing for him (he could have moved in tomorrow!), but he was too intoxicated to accept the invitations.

There was a big meeting and we concocted a big plan: The outreach team would find and talk with the man in the park in five days at 11am. He would likely be intoxicated and belligerent by then. The police would meet us there. The police would help transport the man to the hospital on an involuntary order. The emergency department staff would admit him to the hospital, whether he agreed to or not. Once he received treatment in the hospital, he would be discharged into his own apartment, with hopes that he would stay off the streets and away from alcohol.

What could go wrong?

On the appointed day, we found him in the park.

“Hey hey hey,” he said, putting his arm around the outreach worker, a goofy grin on his face. He offered the 40-ounce can of beer to us. “It’s the first one. Half full. I’m an optimist.” He laughed.

My heart was starting to sink: Even though he slapped a woman and threw a can of soda at someone less than a week ago, he wasn’t doing anything right now that would warrant an involuntary hospitalization.

But the show must go on, right? Multiple people and systems were involved. We had a big plan. And going through with the plan would be in his best interests, right?

Right?

“So,” the outreach worker started, “what do you think about going to the hospital with us?”

He laughed. “I don’t need to go to the hospital. I’m fine.”

“The doctors can check your health, make sure everything is okay….”

“Naw, don’t need it. I feel fine.”

Indeed. He was buzzed, but that wasn’t a reason to go to the hospital.

He looked over our shoulders, smiled, and shouted, “HEY!”

Behind us were four men with broad shoulders and thick legs. We all recognized them as police officers, though they were wearing casual clothes. They nodded at us.

“Wanna go to that bar with me?” the man asked, pointing to the brick building down the street.

“Sure!” the police said, chuckling. “It’s 11am.”

The outreach worker and I stood by our car and watched them disappear into the bar. We said nothing. Still nothing had happened that would warrant hospitalization, voluntary or not.

Several minutes later, the police officers and the man emerged from the bar. The man was singing:

Hello!
Is it me you’re looking for?
’cause I wonder where you are
And I wonder what you do
Are you somewhere feeling lonely?
Or is someone loving you?

The officers started laughing. Everyone was having a good time.

The police led the man to a squad car and opened the back door.

“We’re going to the hospital.”

“F@ck no,” the man said, smiling, having no idea what was happening. My heart sank further.

“Get into the car.”

“No!”

“Look, get into the car—”

—and that’s when he spit at a police officer.

WHAM! It happened so fast that I couldn’t believe what happened. They threw him against the hood of the police car. Two officers pinned his arms down. The other two looked ready to strike him.

I wasn’t the only one who noticed. Pedestrians began to rubberneck. Some young men began to call, “What did he do? Why you doing that?”

“It’s none of your business. Keep walking. There’s nothing to see here,” a police officer barked.

“No, that ain’t right. Why did you do that?”

A woman with flowers in her grey hair and a flowing peasant dress around her thin frame approached.

“That’s police brutality, that’s what. We need to get rid of the cops.”

In the meantime, the police officers had handcuffed the man—for what? for what?—and placed a mesh bag over his head so that if he tried to spit again, the netting would catch it.[1. This mesh bag is called a “spit sack”.] They pushed him into the back of the car and closed the door.

The crowd on the sidewalk grew. Close to three dozen people started to shout and chant at the police officers.

The outreach worker and I got into our car. What was happening?

The ambulance the police had called arrived. A paramedic got out and, hands on his hips, talked with one of the police officers. His brow was furrowed and he was frowning. The officer shrugged, then pointed to our car.

The paramedic walked over and knocked on my window. I rolled it down.

“What did this man do? Why are we taking him to the hospital? Did he actually do anything that warrants an involuntary transport?”

My cheeks burned.

“No.”

The paramedic[2. God bless this paramedic. We need people like him to ask these questions.] glared at me. He then turned around and walked away.

The police and paramedics moved him from the back of the police car into the ambulance while the crowd continued to bristle. The ambulance honked as it tried to weave through the crowd.

After the police drove away, the crowd dispersed.

The outreach worker and I sat in our car in silence. My cheeks were still burning.

He was in the hospital for about two weeks. The first three days were against his will. He agreed to stay in the hospital for the remaining 11 days.

The outreach worker met the man when he was discharged from the hospital to escort him to his apartment. He attended AA meetings four days a week. He took his two medications every night. He saw his counselor every week.

He avoided the park. The police started calling our office: “We never see him anymore. Do you know what happened?”

I never saw the man again, though heard occasional updates from his psychiatrist. The man didn’t drink any alcohol for nearly a year. When he did slip, he asked to go to the hospital. The police never got involved.

Even now, I still ask myself, “Did we do the right thing?”