Category: Policy

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Education Lessons Medicine Policy

Involuntary Commitment (III).

“What should we do?” the outreach worker asks. “He slapped a woman at the laundromat yesterday.”

The police know him well. For at least ten years, he, along with a cadre of other homeless individuals, has spent his days in the park and nights in empty lots in the neighborhood. He limps to the right when he walks; he reportedly fractured his leg many years ago while drunk and it never healed properly.

These days, the police frequently see him before 9am because the two 40-ounce cans of beer he finished earlier in the morning have led him to call 911.

“I just wanna die,” he bawls to the dispatcher. “I’m gonna kill myself, I’m gonna jump off that bridge, I’m gonna be dead, I just wanna die.”

The police are exasperated with the hospital: “We bring him there because he has tried to kill himself when he’s drunk. Less than three hours after we drop him off, he’s right back here again and drinking! They don’t do anything, so we don’t even bother taking him there anymore. If we arrest him, he’s in jail for a few days, but he doesn’t get any help. Then he’s out and back here again.”

You’ve looked at some recent hospital records for him; he’s had numerous visits to the emergency room. His blood alcohol level is usually around 0.3%[1. A blood alcohol level of 0.08% is considered the legal limit.] and he often says that he wants to kill himself. As the alcohol leaves his system, he retracts these statements: “Nah, I’m fine. I don’t wanna die.”

He was psychiatrically hospitalized over a year ago. At that time, he said that he heard voices and drinking alcohol made them go away for a while. He started taking medication. He said he felt better. The rest of his hospitalization was uneventful. He didn’t attend the appointment scheduled for him one week after he was discharged from the hospital. He returned to the park.

“The woman in the laundromat called the police and they knew exactly who she was talking about,” the outreach worker said. “He was napping in the doorway of the laundromat and the woman asked him to move so she could get her stuff inside. He got up, followed the woman in, slapped her across the face, then left. The police couldn’t find him when they showed up.”

After speaking with you, the outreach team goes to the park to find this man to talk with him about what happened. They also intend to discuss housing, something that he continues to decline.

“I don’t wanna follow somebody else’s rules,” he has said during moments of relative sobriety. “I wanna do what I wanna do.”

The outreach team is back in less than half an hour.

“He was really pissed off,” the outreach team says. “He chucked a can of soda at us.”

“He chucked a can of soda at you?”

“We were trying to talk with him and he wasn’t having any of that. He told us to ‘f@ck off’—the usual when he’s drunk—so we said we’d come back later to talk with him. We were probably about ten feet away when an open can of Dr. Pepper flew past our heads. We got a little soda on us, but we didn’t get hit. It would’ve hurt if his aim was better.”

Does this man have a mental illness? Does he need to be sent to the hospital for psychiatric evaluation? If he doesn’t want to go to the hospital, should he be forced to go to the hospital against his will?

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Education Lessons Medicine Policy

Involuntary Commitment (II).

His sister helped him move into the apartment about three months ago. She told you that he has a long history with the mental health system: His first hospitalization, which was over six months long, occurred when he was 19 years old. Since then, he’s been hospitalized close to a dozen times—often against his will—and each hospitalization has lasted weeks to months. Sighing, she said that because of his symptoms, he’s been evicted from nearly every apartment he’s ever lived in, fired from the few jobs he’s been able to get, and unable to complete his schooling to earn his college degree, something he’s wanted to do for many years now.

“When he starts to get better, he stops taking his medicines… then we start all over again.”

He had left the psychiatric hospital the day before you met him. His eyes looked flat and dull; he hardly blinked. Saliva was oozing from the right corner of his mouth. His head was tilted to the right. Though his arms trembled when he shook your hand, he spoke with a steady voice: “Nice to meet you.”

He understandably did not like the side effects from the medications he took.

“I feel so tired. I can’t think,” he said. “I can’t play my guitar.”

Because of his listlessness, you gradually reduced the doses of several of his medications. The drooling stopped. He showed more facial expressions. The tremor nearly resolved. He started playing his guitar regularly.

“I don’t think I need the medicine anymore,” he declared about four days ago. “They don’t help me. I’ll be fine. You’ll see.”

With the knowledge of his past history, you try to negotiate with him: How about taking this medication, but not that one? What about taking this medication right before bed to ensure sleep? Let’s try—

“No, I’m fine. You worry too much, doc! This time will be different. I can feel it. Everything is clear now. I won’t end up in the hospital.”

He begins to deliver monologues about his masturbation habits. He has taken an interest in a woman who lives down the hall… and the woman who lives upstairs and the visiting nurse for the man who lives in the corner unit. He spends his nights writing 1000-word poems of love and lust to each of these women. He plays his guitar for hours. The neighbors become annoyed, especially when he starts bawling and laughing at 3am.

It’s only been four days! He’s now dragging all of his furniture out of his apartment.

“NONE OF THIS IS MINE!” he roars. “GET THIS SH!T OUT OF MY APARTMENT!”

He’s thrown some of his belongings out of the window, as it is apparently easier and more efficient to clear out his apartment that way. His iron, toaster, and most of his silverware are scattered on the sidewalk below.

His brows are furrowed, his teeth are bared, and his hands are clenched into fists.

“SOMEONE is taking over MY room THEY plan to take over my body THIS is all MINE YOU can’t make it stop so I have to make THEM stop—”

He’s struggling to push a chest of drawers towards the door. Yelling, he yanks the top drawer completely out and throws it across the room.

“Please stop for moment—” you begin.

“YOU can’t make me stop no one can me stop YOU don’t understand THIS is an EMERGENCY SOMEONE is trying to make ME go away and NONE of THIS is MINE the furniture MUST be KILLED it tells to me to DIE—”

You see him reach for his guitar and you thank your instincts a few seconds later when you hear the guitar crash into the wall behind you.

Does this man have a mental illness? Does he need to be sent to the hospital for psychiatric evaluation? If he doesn’t want to go to the hospital, should he be forced to go to the hospital against his will?

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Education Homelessness Lessons Medicine NYC Policy

Involuntary Commitment (I).

It’s winter in New York City. The temperature is hovering around 32 degrees Fahrenheit. Large, slushy snowflakes are falling from the pewter sky.

You are already familiar with this woman; you had met her the previous Spring. No one is sure of her age, but she looks over 65 years old. She had said that she had immigrated to the US when she was in her 20s because she had a scholarship to a prestigious university. Something interrupted her schooling. She ultimately stopped attending classes and hitchhiked here. She’s been homeless on the streets of New York ever since.

She has never shared her date of birth for fear that the government would use that information against her. It’s not clear if her stated name is really her name. She’s a familiar figure in the neighborhood; people regularly give her styrofoam bowls steaming with hot soup, sandwiches wrapped in white butcher paper, shiny cans of soda, and cups of coffee. Some people have been giving her food for the past ten years. Upon receipt she murmurs, “Thank you,” and nods her head on her slender neck.

She never makes eye contact. The irises of her eyes have grey halos and her gaze is usually over your right shoulder. You’ve tried to learn more about her past, what led to her homelessness, and her interest in housing, but she usually ends the conversation and walks away. One time before bidding you good-bye she did comment, “The government secrets are safe with me.”

People in New York walk past her everyday while she sleeps and never realize it: She buries herself underneath black garbage bags stuffed with paper. What looks like a mountain of trash on the curb or underneath scaffolding is actually her private fort.

“The paper keeps me warm,” she has said. To prove her point while the autumn winds sent the dying leaves swirling through the air, she rolled up a sleeve of her parka to reveal wads of newspaper crumpled in her clothing. At times she donned a hat made out of a paper bag and stuffed it with newspaper to warm her head.

It is not yet 10am on this snowy morning and the weather forecasters predict that the storm will worsen as the day goes on. The snow is already sticking to the sidewalk. Over six inches are predicted to fall in the next few hours.

Today, the woman’s camp is underneath the short awning of the back door of a clothing boutique. Underneath her is a flattened cardboard box, the corners already beginning to darken and soften from the snow. On top of her are only four or five garbage bags, fewer than what usually covers her. Upon hearing you, she sits up and her face, as expected, does not show any expression.

Her parka is unbuttoned and underneath is a thin white shirt with a tattered collar. The skin of her neck is mottled and red.

“There’s a snowstorm coming through, it’s supposed to be pretty bad. Would you be willing to stay in a shelter until it’s done?” you ask.

“No, I’ll be fine.”

“It looks like you’re cold; you don’t have as many bags as you usually do and your skin is turning red. We don’t want you to be outside when it is this cold out,” you try again.

“I’m fine.”

“We worry that if you stay out here, you might get frostbite.”

“I’m fine.”

“Where have you gone in the past when there were big snowstorms?”

“I’m fine.”

Meanwhile, snow is beginning to collect on her coat, her bags, and in her hair. She makes no motion to move.

Does this woman have a mental illness? Does she need to be sent to the hospital for psychiatric evaluation? If she doesn’t want to go to the hospital, should she be forced to go to the hospital against her will?

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Fiction Policy

Automated Psychiatrist Machine.

Are you tired of waiting fifteen minutes only to spend ten minutes with your psychiatrist? Do you hate rearranging your busy schedule, fighting traffic, and trolling for a parking space just to spend a few minutes with your doctor? Wouldn’t it be easier if you could take care of your mental health according to your schedule, instead of someone else’s?

We are pleased to introduce the Automated Psychiatrist Machine (APM). The APM is an advance in medical technology that dramatically increases the efficiency of patient care and results in high patient satisfaction scores.

We know what a typical appointment with your psychiatrist is like: You check in and sit in an uncomfortable, crowded waiting room with strangers. You then see your psychiatrist, who may (or may not) ask you about your current symptoms. Maybe you just talk about your recent vacation or your plans for the holidays. He might ask you about side effects. Maybe the only question he asks you is how many refills you want. You wish that you didn’t have to see him every three (or six… or nine…) months, but he won’t write prescriptions for you if he doesn’t see you.

“But I’m fine. Do I really need to come in every six months?” you ask. The meds help. You don’t want to talk about stuff. You are a busy person with things to do and multiple lives to live. Who has time for anything else?

This is where the Automated Psychiatrist Machine comes in.

Located outside of various medical centers, APMs allow you to take control of your care. Do you work day shifts or care for children and it’s just not convenient to see your doctor during the day? Go see the APM after work. Did you get sick and now must reschedule your appointment? Go see the APM when you are feeling better. The APM is open and available 24 hours a day, seven days a week.

The APM has a touchscreen that will guide you through questions your current psychiatrist may (or may not) ask:

  • How many hours are you sleeping?
  • Have you noticed any changes in your appetite or weight?
  • Are you experiencing any side effects from medication?

The entire interaction takes less than five minutes. Once you answer the short set of questions, the APM will print out your prescriptions that you can take to a pharmacy at your leisure. Additions and adjustments are made to your medication regimen according to an algorithm.[1. The APM medication algorithm may not be evidence-based or take into consideration your specific symptoms or side effects.]

There is no reason for you to see a real psychiatrist anymore. Make no mistake: your psychiatrist will still be your psychiatrist, but you just don’t need to actually see him.

Psychiatrists, the APM can increase your productivity and efficiency, too! A small videocamera on the APM captures video of the patient so you can document a mental status exam. The more patients you refer to the APM, the more patients you can “see” in one day! According to research, the average interaction with an APM lasts about four minutes. That means you could potentially “see” 120 patients a day![2. Psychiatrists using APM could potentially see 15 patients an hour. An eight hour day thus equals 120 patients. Compare this to the 25 to 30 patients you see a day now.] And if insurance companies are willing to reimburse $120 a patient, you can see how the numbers add up.

And because of advances in technology, psychiatrists can now work from home. You don’t need to get up and go to your office. APM can securely channel video to your home computer so you can both review the questions patients answer at the APM and perform mental status exams. You’ll essentially go through the same interactions that you had with your patients before, except you don’t even need to be in the same room as them. You can still assert that you’re a psychiatrist, even though you never actually directly interact with patients!

The Automated Psychiatrist Machine will improve quality of life for both patients and psychiatrists alike. Ask your psychiatrist about the APM today.

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Consult-Liaison Education Informal-curriculum Lessons Medicine Observations Policy

Red Herring: Epilogue.

I encourage you to read the entire Red Herring series before reading this post. Consider this your “spoiler alert”.

The patient really is fine.

She returned to the gastroenterology clinic several times for treatments to widen her esophagus. (It’s a neat procedure: The GI doctors insert a small balloon into the esophagus. They gently inflate the balloon to stretch the stricture a few millimeters. With repeated stretching, the esophagus will remain open.) The patient ate more. She stopped vomiting. Her weight increased.

For the sake of flow, I did not include two complications that occurred during the course of events:

Medication problems. Although I had written a letter to hospital staff that included the patient’s history and list of medications, the psychiatrists in the first hospital omitted one medication from the patient’s regimen. As a result, the patient developed distressing symptoms consistent with schizophrenia. (In some ways, this was a blessing, as this omission confirmed her diagnosis. As the patient had demonstrated minimal symptoms of schizophrenia as an outpatient, I would have been tempted to taper off medications… which could have resulted in an “unnecessary” hospitalization.) I suspect this error prolonged her hospitalization.

Transfers of care from outpatient to inpatient settings (and vice versa) are fraught with problems that often adversely affect the patient. People have proposed universal health records, care managers, and other devices to help minimize this potential for harm. For now, most of us continue to do the best we can with the current system.

Decisional capacity issues. After the patient was hospitalized the second time, the gastroenterologists had concerns about the patient’s ability to consent to the procedure to evaluate her esophagus. While she could communicate a choice, they had doubts that she could appreciate her condition and understand the risks and benefits of intervention. Her worker ended up going to the hospital to discuss the procedure together with the patient and physicians. We were fortunate that he was available to do this.

I wanted to share the tale of the Red Herring for three reasons:

All physicians are subject to bias. Patients can suffer as a result. Patients with psychiatric diagnoses sometimes do not receive appropriate medical attention simply because of diagnostic labels. This can occur even if patients are not demonstrating psychiatric symptoms at the time of the encounter. Physicians, including psychiatrists, may assume that these patients exaggerate or misreport medical symptoms. Alternatively, physicians may assume that medical symptoms are due solely to psychiatric conditions.

According to Wikipedia (not the best source of medical information, but anyway…), the prevalence of esophageal strictures is 7 to 23% in the US. The prevalence of schizophrenia is less than 1%. The prevalence of bulimia in the US is about 5%. Though esophageal strictures are more common than either psychiatric condition, we all somehow believed that the latter was the culprit in the case of the Red Herring.

We all often forget that people are not simply mind or body. People with psychiatric conditions still have physical bodies that can bleed, break, and hurt.

Physicians need time to provide good care. 15 minute appointments maximizes profits for organizations and physicians in private practice. 15 minute appointments often do not maximize benefit and value for patients. (To be fair, organizations and individuals need money to maintain clinics. If clinics go bankrupt, everyone loses.)

If I saw this patient for only 15 minutes, once a month, it would have taken me much longer to build a relationship with her. Without that relationship, I could not have directed her to go to the hospital. She would have (accurately) experienced that as coercion. Furthermore, my understanding of her symptoms and condition would have been limited.

If I only had 15 minutes a month with this patient, I would not have been able to advocate for her as I did. If we want our physicians to provide this level of care, we all must recognize that physicians need time to do so. (My patient was enrolled in a program for individuals with severe psychiatric conditions. My “caseload” of patients was purposely kept low; this allowed me to spend a flexible amount of time with people and to see them on a more frequent basis.)

Physicians must advocate for their patients. For those patients who are able to advocate for themselves, we must encourage them to do just that. Helping patients obtain the services they need to lead healthy, independent lives with limited contact with medical establishments should be one of our primary goals. This is particularly true in psychiatry: we should do what we can to get people out of the mental health system so they can get on with living their lives.

For those patients who cannot advocate for themselves, we must advocate for them. They otherwise will not receive the care and interventions they need to maximize the chances that they can lead healthy, independent lives. We have all read articles citing the enormous financial costs associated with undertreated or untreated medical problems. Furthermore, we will have failed our moral obligation to promote beneficience.

Thank you for reading the Red Herring. I appreciate your attention.