What to say about psychiatry that isn’t already completely covered by television and movies? It’s unique among the specialties for its coverage in the media. Maybe because we’re such social animals, or maybe because such shows about psychiatry or therapy appeal to a voyeuristic impulse in us to peer into people’s most private thoughts and feelings.
Our exposure to psychiatry in medical school, however, is primarily with inpatient psychiatry – people who for whatever reason require hospitalization to deal with their mental illnesses. Reasons may range from soul-crushing anxiety attacks, to addiction, to suicidal ideation, to frank psychosis from schizophrenia, depression or bipolar disorder. I’ll also say it’s very upsetting at first to treat the subset of patients who are being held against their will due to court orders. One of the most basic tenets of medicine is that a physician must respect the autonomy of their patients, and psychiatric patients have often had a court take this autonomy away from them because of their actions or behavior. Not surprisingly, many patients are not happy about this. They may not be willing to accept they have a problem, or be very reasonably upset about the financial, social, or legal consequences of a hospital stay, or occasionally they don’t necessarily feel that their delusions regarding their absolute dictatorial control of the US government and their need to evade agents of foreign nations by breaking into a pet store are actually a problem. However, others necessarily are disturbed by such things, often resulting in a temporary detention order, or TDO, to assess their need for psychiatric treatment. I’m not making light of mental illness, but psychotic states result in behaviors that are frankly bizarre, and the self-reinforcing nature of delusions often put patients into a state that makes them feel you are part of a plot designed to persecute them. Worse, there are times when a TDO can be devastating to a patient’s life. An inpatient admission for psychiatric, alcohol or drug treatment is not a benign intervention and often has pretty major accompanying legal and social consequences. Patients are often facing criminal charges for DUIs, violence, or other behavior that has finally come to a head, and cost of treatments is often a huge burden.
The two major things I learned as a part of this process are that (1) the state of Virginia drastically underfunds the treatment of mental illness relative to other medical illnesses (and this is a very bad thing) and (2) anti-psychotic medications are amazing drugs. Let’s start with a case – details, of necessity, are highly altered due to the sensitivity of psychiatric treatment but the fundamentals are real.
A 22 year-old-male is admitted to the inpatient psychiatric unit at a private hospital after his family brings him to the ER for bizarre and uncontrollable behavior…
He has a three-year history of psychiatric illness, having to leave college for inappropriate behavior in the midst of a manic episode. He does not work due to the poor control of his bipolar disorder, and has been hospitalized multiple times in the last three years. The pattern is of stabilization in psychiatric hospitals, followed by discharge and relapse once his medications run out due to an inability to afford them as well as compliance issues due to side effects. A lithium level is measured and it’s subtherapeutic. The patient does not feel that there is a problem, his family is exaggerating his behavior, and with pressured and rapid speech relates to the treatment team that as soon as he gets out he is going to drive to New York City where he will take charge of a major banking house – once they recognize his intelligence – where he will then use his enormous wealth to cure world hunger. He is massaging his groin as he relates these future plans.
What kind of mental illness do you think our patient has? And what are the immediate steps that are appropriate in addressing them? Tell me what you would do and I’ll write about the treatment and outcome in the comments
Nowhere does the pinch of inadequate funds for medical care appear more severe than in mental health treatment. There is too little money – especially in Virginia which ranks near last in the nation for per capita mental health spending – and too few psychiatrists working in rural areas to deal with the volume of mental health patients. There are too few beds in psychiatric facilities resulting in wait times in ERs that can be extensive, putting both patients and communities at risk. There is inadequate funding for drugs that patients need to prevent relapse into depressed, psychotic or manic states which result in hospitalizations that are far more costly than the expense of their routine medical treatment (hospital stay = cost of drugs + nursing care + doctor + boarding etc.) and the whole system is very disappointing. The mental health professionals that work within the system are frustrated by the absence of adequate resources, and a burden of patients that is too large for the number of physicians and facilities available. Inpatient psychiatry is usually run at a loss to hospitals who maintain them as a service to the community. Many state hospitals and facilities are being closed, and new ones are not being built because they are costly and not profitable.
What is the solution other than adequate funding for patients who need this care? There is no benefit to society to have people in the community with uncontrolled mental illness, unable to hold down jobs or function productively, and routinely hospitalized at great expense due to the poor control of their disease.
Mental illness can be devastating and it has not been treated with the same seriousness and concern as other medical conditions. There is not mental health “parity”, possibly because of the continuing stigma for mental disorders and the absence of significant powerful lobbies for the mentally ill – unlike say the AARP for medicare patients.
At the same time psychiatry is an enormously rewarding field when you see what a difference you can make in people’s lives with adequate mental health care. You can take someone who is completely psychotic and dysfunctional, and then using therapy and/or our relatively blunt pharmacologic instruments that broadly affect neurotransmitter receptors (or uptake of neurotransmitters) throughout the brain you can literally return people to sanity, to work, to their families, possibly even to happiness. That is not to say these drugs are without side-effects – they can be significant – but it is clear that not treating mental illness is far more damaging in almost every way.
The main drawback of the field is that with many serious mental illnesses the patients require chronic care – there is no “cure” for diseases like schizophrenia. Instead treatment consists of frequent tune-ups that keep the disease from manifesting and progressing, but this is not dissimilar from many other fields of medicine in which many of the patients are managed rather than cured.
The failure of our society to adequately address the problem of mental illness – primarily due to deinstitutionalization combined with a failure to keep the promise to build up adequate resources in communities to treat chronic mental illnesses – only causes more and more harm. The costs of not treating mental diseases are as high or higher than treating the disease. People with mental health problems that are adequately treated often can work, take care of themselves, take care of their families, and be productive. Those who are not treated often can not function at all. The unwillingness of government to address the unpopular need for higher spending on the mentally ill must be countered with the fact that not treating mental illness is far more costly – both financially and in terms of human costs on individuals, families and communities.
Now, I’m getting ready to start another psych rotation (working nights) as a 4th year medical student, and am excited about it as it’s been one of the fields I’ve felt I’ve had a great positive impact on people’s lives. Many fields of medicine in a brief 1 or 2 month rotation don’t allow you to see the benefits you can have on people’s lives. Many times a doctor gets to experience that from months or multiple years of developing a relationship with their patients and you dont get the same feel. But often in inpatient psychiatry you see big effects fast. If only that satisfaction weren’t countered by the inadequate investment our society sees fit in treating mental health.
I only have a few more clerkships to discuss before I’ve covered the 3rd year basics (I delay them for multiple reasons) but I will have a piece on OB/GYN, Family medicine, and Neurology to complete the cycle before match.