But as outrageous as this case is … it turns out that it is not at all uncommon for psychiatric patients to be left for 24 hours — sometimes, for many days on end! — sitting in waiting-room chairs:

The unit [in which Green was left to die] is so routinely backed up with people waiting hours, or even days, for services that patients often spend the night nodding in chairs or sprawled in a corner. …

A survey of hundreds of U.S. hospitals released last month by the American College of Emergency Physicians found that 79 percent reported that they routinely “boarded” psychiatric patients in their waiting rooms for at least some period of time because of the unavailability of immediate services.

One-third reported that those stays averaged at least eight hours, and 6 percent said they had average waits of more than 24 hours for the next step in a patient’s care. …

Emergency physicians at other hospitals describe conditions far less grim, but they uniformly agreed that a hospital waiting room is rarely a comfortable place for someone in a psychological crisis.

“Optimally, you don’t want a patient sitting in the emergency room for any length of time,” said Dr. Bruce Schwartz, the director of clinical psychiatry at Montefiore Medical Center, in the Bronx.

Still, those types of waits can be routine.

In Austin, Texas, hospital officials have complained that a county decision to reduce the number of patients sent to a state psychiatric hospital has clogged their emergency rooms with mentally ill people with no place else to go.

In Massachusetts, some parents have complained about days-long waits in the emergency room for children who need placement in a pediatric psychiatric service.

California health officials have struggled for years with complaints about overcrowding in psychiatric emergency rooms.

I can attest to this phenomenon personally: I was once forced to spend 18 hours in an ER because I happened to arrive a few minutes after the crisis worker left (there are none available in my area, any more, except during “bankers’ hours” on weekdays), and had to get my “PC” (psychiatric consult) once she came in the next morning and only after higher-priority patients had been PC’d (as a depression patient, I didn’t rate very highly). This was in a small community hospital in the suburbs, not a massive, bustling, bursting-at-the-seams urban healthcare center like Kings County.

Note that this rule applies generally only to psychiatric patients. If someone were to arrive in an emergency room due to, say, a car accident or a heart attack, a regular hospital bed would be found relatively soon; no accident or heart-attack victim would be left sitting for days in an ER waiting-room. Yet, this is considered acceptable and even routine, for psychiatric patients. Why is this? We still have not gotten over the fact that mental illnesses are real, they deserve to be treated, and that the mentally ill are human beings entitled to the same dignity and compassion that anyone else with some other malady would be given. This simply cannot be tolerated any longer.

Note that this poor woman had been sitting in that waiting room — it wasn’t even a treatment room! — for some 24 hours by the time she fell on the floor. That’s right, they had been ignoring her for an entire day! (A video report from NBC’s Today is embedded below; the raw video is available from ABC News.)
New York Hospital patient ignored to death! – Videos are here

I have no doubt that everyone involved in this case chose to ignore her, because she was a “psych patient” who’d been reported as having been “agitated,” and whom they simply did not wish to deal with.

They got their wish — she will, in fact, never bother them again — but hopefully the authorities will not let go and will remind them of it as much as possible.

The treatment of the mentally ill in the US, especially in urban hospitals like Kings County Hospital but also in others around the country, is simply dreadful. Psych patients are considered burdens rather than people with ailments who need help, real help.

We simply must stop viewing psychiatric ailments as “eccentricity” or as “bothersome.” We have seen in this case (and likely in others that haven’t happened to be so well documented) that ignoring psych patients kills them. We can no longer afford the luxury of being casual about mental illness, or denying its existence (as the anti-psychiatry movement does).

Folks, do not forget poor Esmin Green, who died alone and ignored on the floor of a hospital in plain view of many people. Do not let it happen again, to anyone, ever. Stop treating the mentally ill as disposable. It must STOP, and it must stop NOW!

University Police Chief Donald Grady said Friday that Kazmierczak had become erratic in the past two weeks after he stopped taking his medication.

A former employee at a Chicago psychiatric treatment center said Kazmierczak’s parents placed him there after high school. She said he used to cut himself, and had resisted taking his medications. …
“He never wanted to identify with being mentally ill,” she said. “That was part of the problem.”

But the truth is, folks, that none of us lives in a vacuum! We’re all responsible for our part in the lives of others. No one benefits when a mentally-ill person terminates his/her treatment; everyone else in his/her life must pick up the slack and deal with the results of that decision. Denial of the reality of mental illness has repurcussions throughout one’s life. In this case, denial killed (not only the patient, but 5 others, and wounded more). Even in cases nowhere near this extreme, there is nevertheless a price to denying mental illness; interpersonal problems, inability to keep a job or take care of oneself, and so on. A mentally-ill person who refuses treatment for his/her disorder automatically places a burden on others.

The lesson here is a simple one: No one who’s on notice as having a mental illness, can afford the luxury of acting as if that illness doesn’t exist. You have to stick with your treatment, whatever that is, no matter what. If the treatment is not helping or not to your liking, then change it … but don’t decide not to pursue any treatment at all.

Perhaps this isn’t fair … after all, neither I nor anyone else with a mental illness asked for it, so why should any of us be saddled with this responsibility? But we all know that life is not fair. Lots of people have lots of illnesses and problems that they must deal with nevertheless. Looking for fairness in life, is a fool’s errand; you aren’t going to get it. So rather than obsess over fairness, obsess instead with making the best of one’s life. This means taking responsibility for one’s condition and treating it.

… uh, guess again, folks … the real story here isn’t entirely what you may think it is. Here’s a sample story on this revelation (this one from the New York Times):

The makers of antidepressants like Prozac and Paxil never published the results of about a third of the drug trials that they conducted to win government approval, misleading doctors and consumers about the drugs’ true effectiveness, a new analysis has found.

If this surprises you, why should it? Of course companies are going to publicize what’s in their best interest to publicize! FDA review of drug efficacy generally includes even those studies whose results aren’t favorable and may not have been published, so from a regulatory point of view, this is not a problem at all.

Now, I’m already on record as saying that the widely-touted 60% efficacy of antidepressants — which is supported by a majority of studies and therefore a sound conclusion — is not sufficient; that 60% efficacy of anything would not be acceptable in most other areas of life.

But come on, people, let’s not blow this out of proportion! We haven’t exactly discovered anything new here. In fact, I suspect this is really “invented” news, extracted as it is from information made public over the last couple of years. If this is the worst news they could find, after poring through this new information for that long a time, then let’s face it, it’s not that bad!

The cold hard fact is that antidepressants work for many people. The last thing we need is yet another mass-media blitz being plastered all over the country which tells people that they don’t work. Too many mood-disorder sufferers already get no treatment at all, convinced that nothing can help them … to add to their number, this way, is a travesty.

A new study discovers a majority of psychiatry outpatients have more than one disorder, and more than one-third have at least three disorders. Researchers found major depression as the most common diagnosis followed by social phobia….

Most patients had more than one diagnosis; on average, patients had 1.9 current diagnoses. Patients with principal diagnoses of posttraumatic stress disorder (PTSD) and bipolar disorder had the highest number of diagnoses.

Most treatment studies exclude patients with multiple disorders. The authors said, “We hope that by documenting the high frequency of comorbidity in clinical practice, this will provide the impetus for modifying how treatment studies are conducted to allow patients with multiple disorders to be included and to determine the outcome of comorbid disorders as well as the primary disorder that is being treated.”

Comorbidity is not really all that new; in fact, the current DSM-IV uses a multi-axial system, wherein personality disorders have been shunted into their own “slot” if you will (called Axis II). What this study shows is that there is a lot of comorbidity among what are Axis I disorders.

It’s nice to see my own intuition confirmed; it will be another thing entirely to see what psychiatry does with this information. Perhaps the current diagnosis system should be rethought, taking this tendency into account? They’re years away, yet, from releasing the DSM-V; perhaps it’s time to account for comorbidity in a more comprehensive way?

Now … I find this refreshing because — while I have never had ECT myself — I do know several people who have. Almost without exception, they found it helpful (if not the most pleasant experience), and most would do it again if they had to. This information almost totally contradicts everything else I’ve ever heard about ECT … i.e. that it’s a drastic treatment, has horrible side effects, it’s only used as a treatment of last resort, has injured people, etc.

Am I saying this book, and the Slate author who reviewed it, are right? No. I am, however, saying that perhaps the common fear of ECT is overblown, and maybe … just maybe … there are mood-disorder patients who could benefit from it, who will never get it, because 1) they are afraid of it and refuse to entertain it as a possibility; 2) people around them are afraid and tell them not to; and/or 3) their doctor is afraid to recommend it.

In other words … it’s something to consider. Something that — perhaps — we ought not be so quick to dismiss.

Unfortunately, I have few answers to offer to all of the many problems I’ve cited above (in my initial series of posts which you can read, in order, at The Heart of the Matter). They’re beyond my expertise, and in most cases, are beyond anyone’s skill, at this point.

My message is simple: Despite the problems, each of us is responsible for making the best of the situation.

Those of us with mood disorders, must stick with treatment, to the best of our ability.

Friends and family of mood-disorder patients, must help them along. And try not complain too much about it, especially in front of the patient. It’s not very nice.

For professionals in the field of mental health, my challenges to you are many: To become focused on cures as opposed to simply keeping a patient functional; listening to your patients rather than deciding, for them, what to do; working within the system as it is, to make that system work for your patients, rather than simply giving up when you reach the boundaries of what the system allows.

Especially for researchers, both physiological and psychological: Instead of identifying “risk factors” or biological markers, focus on causes, and the genesis of mood disorders. That is, precisely what is the process by which people go from being “normal” to having a mood disorder? What is behind this transition?

For people in managed care: Drop the fiction that mental and physical illnesses are somehow “worth” different amounts of money. They aren’t, and saying they are, is patently stupid.

For government: Halt the cost-passing game that’s making healthcare too expensive for too many of us.

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So far, you may think I’m in the “anti-psychiatry” camp, but I am not. By no means! For all of the problems with psychiatry I’ve pointed out so far, I think the anti-psychiatry folks are far more dangerous to those with mental illnesses, than even the worst psychiatrists.

When I talk, here, about the “anti-psychiatry movement,” I refer to a number of renegade doctors who’ve dedicated their careers to abolishing psychiatry. I do not presume that they are part of a conspiracy, in that I don’t think they collaborate directly with one another, but I do think that they espouse similar ideas, and behave in ways which make them appear to be an iconic movement. So I’ll speak of them collectively.

The anti-psychiatry movement has, at present, focused its efforts on wiping out the notions of ADD and ADHD (Attention Deficit Disorder and Attention Deficit-Hyperactive Disorder). They do not think these are “disorders” that children need to be treated for. Presumably because there are a lot of ADD/ADHD-diagnosed children, they hope to get more press for their ideas, this way.

But mood disorders are on their hit-lists nonetheless. They consider antidepressant medications to be ineffective and unsafe, and the same goes for mood stabilizers. Further, they consider ECT (electro-convulsive therapy) to be “barbaric” and want it abolished.

But in addition to treatments which they don’t like, the anti-psychiatry movement doesn’t like the way many illnesses are defined. Some, such as ADD and ADHD, they think ought to be eliminated, as they aren’t really disorders, but simply an alternate learning method that the child requires. Others, such as Post-Traumatic Stress Disorder (PTSD) need to be redefined, as too many people (they think) fall under it. Some in the anti-psychiatry movement explicitly claim that there is no such thing as mental illness at all; what we perceive as such, is merely individual eccentricity. There is nothing wrong with them, in this view, and nothing to treat.

If the anti-psychiatry movement has a valid point, it’s that psychiatry as a whole isn’t as responsive as it should be, to those it serves. I cannot argue this, not one iota.

What concerns me, though, is that the anti-psychiatry movement is based on all the worst stereotypes of mental illness, and in many cases, is founded on a desire to get rid of the notion of mental illness altogether. This is what makes this movement so dangerous. If they had their way, clinics all over the country would be emptied, and their residents dumped on the streets, without any treatment or medication, left to fend for themselves. That anyone would actually want to do this, is unconscionable, however, and indeed, is outrageously evil. No other word applies.

I would have more sympathy for the anti-psychiatry movement, if it offered alternative solutions to the problems that people face. But it does not. In some cases, the anti-psychiatry movement simply denies that there’s a problem at all; in others, they admit that something is there to be “fixed,” but they manage to find some fault with all of the known fixes, and have none of their own to offer. (Tom Cruise’s insistence on vitamins is not even worthy of discussion as an “alternative.”)

Perhaps the worst thing about the anti-psychiatry movement, is that it masquerades as an advocate for the truly mentally ill. Really, however, they don’t think that the mentally ill exist. Or if they do, they have no desire to see them get any meaningful help; what they want, rather, is to keep them ill so that they have a “cause” to fight for, and thus continued employment. Or worse yet — those who define all mental illness as non-existent — actually want to propagate misery (now you see why I call them “evil”). Their position is utterly ridiculous, however, and a quick walk through any psych ward will prove it … there truly are some people who are very sick and in pain; defining their illness away will set their suffering in concrete. I can think of few things more despicable than that.

When the anti-psychiatry movement has something compelling to offer those with mental illness, I’ll listen, as should we all. But so long as all they do is weep and wail over treatment methods, or posit that there is no mental illness, offering nothing constructive in their place, they don’t deserve anyone’s ear.

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1. A level of outpatient clinical care, similar to partial hospitals, but perhaps a couple of hours a day, one or more days a week;
2. Another level of outpatient clinical care, this one being only one or two hours a day, every day, early in the morning or in the evening so that patients can work;
3. Visiting-nurse or in-home counseling care, in which a qualified psychiatric nurse checks in on the patient in his or her home, either daily, or a few days a week;
4. And for those times when inpatient care is unavoidable, wards devoted to mood-disorder patients are in order. These are places where their particular needs are addressed, and which have a population of similar patients for them to relate to, along with outdoor activities (where practicable), since exercise is important to recovery.

There are other possibilities. Oddly enough, some of them are being tried, in various places, but they aren’t always accepted by the rest of the system. In fact, many renowned facilities are now doing some or all of these things. Why aren’t the rest? What are they waiting for?

That must change. But will it?

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While psychiatric-ward stays have saved many lives (including mine), overall, they aren’t always the best way to deal with a depressive. Since psychiatry has become crisis-oriented, however, they’re a necessary evil. They will continue to be, until psychiatry becomes less crisis-oriented.

One of the main problems with putting depressed patients into psychiatric wards, is that they’re often thrown in with a hodgepodge of other patients, who have other sorts of mental illnesses. Now, I don’t mean to put those other patients down, but people with mood disorders are quite different from people with, say, psychotic disorders. The comparison is not always a favorable one, and the message conveyed to a patient who already feels rather poorly about themselves, is that this is “their place.”

Most psych wards are restrictive, in that one cannot just walk around the hospital grounds. Again, this is for safety reasons, however, a patient can feel as if he or she is in jail — which again isn’t conducive to improving his or her state of mind.

As I said, the real problem is a crisis-orientation. Patients are allowed to get worse and worse, but remain on their own, and when they get bad enough — that is, when they’re suicidal — we stuff them into a “mental illness warehouse” to keep them safe. Then, for too many, cycle resumes all over again.

Again, I have to say that I am not impugning the caring or dedication of the people who work in psychiatric wards. I’m simply suggesting that psych-ward visits be eliminated in the first place, by not allowing depression patients to degrade to the point where they need to be “locked up” for their own safety.

In simpler terms, we need more intermediate treatment options than are usually available. We also need inpatient facilities which are devoted specifically to those with mood disorders, in which the environment isn’t so restrictive and, well, depressing.

A very good intermediate treatment option which currently exists, is known variously as “partial hospitalization” or “day treatment.” My best hospitalization experiences have been in such venues, and I cannot recommend them highly enough. Unfortunately, they are usually used (as in my case) as follow-up after an inpatient hospitalization, and not proactively to prevent an inpatient stay.

The reasons for this are varied, but they come down mainly to two: Staffing, and insurance. A hospital’s priorities are naturally going to be in its inpatient units, where “the worst of the worst” are. Outpatient treatment is secondary, and often suffers from budget cuts or consolidations. Insurance companies are generally unwilling to pay for outpatient programs unless they’re convinced it’s necessary in order to keep a patient out of an inpatient unit — but by the time that point has been reached, an inpatient stay is sometimes already required!

In any event, very few inpatient facilities cater specifically to mood-disorder patients, even though they comprise the majority of the mentally ill. This makes no sense, but it remains a fact. A facility for those with mood disorders could be constructed so as to offer some freedom of movement for patients, but with little compromise on their safety.

Most inpatient wards have a schedule of activities for each day; they don’t want patients sitting in bed feeling sorry for themselves. Obviously, keeping them active is a good idea, but unfortunately, more and more inpatient units are not maintaining sufficient staff to run all of these activities. Hence, while “on the books” they can claim to keep people busy, in practice, they don’t.

Most units offer one or more sessions of group psychotherapy a day. While these are probably useful to people who’ve been “through the system” and know what to expect, for most patients, who are in rough shape (otherwise, they wouldn’t be there!) and new to such environments, it’s utterly useless and sometimes frightening. Something much better would be a simple check-in followed by exercises or some other form of activity.

Another problem that many inpatient wards have, is that attending psychiatrists are usually treating several people at a time. Even the best of them can get mixed up, or drained, or inattentive to those who don’t make their presence felt. Unfortunately, most people suffering a severe depressive episode, are (by definition) unable to make their presence felt and demand the psychiatrist’s time. Hence, they get only minimal, assembly-line treatment.

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