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.

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.

My first thought was, “Whew! That’s all we bipolar folks need, to be associated in the public eye with that ridiculous tramp.” This won’t help at all.

My second thought was, “With all of the research going on into bipolar disorder, somehow stories about that tramp — who may or may not even have bipolar disorder — drift to the top of the list?” The mass media have nothing more constructive or meaningful to report, on the topic, than that? That by itself should be enough to depress anyone … !

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.

Since this shooting we’ve been treated to innumerable media stories on this troubled youth. And troubled, he was — clearly. His depression is evident in his suicide note(s).

The pertinent question here (here, being my mood-disorders blog!) is: Did his depression make him do what he did?

The answer is, no. In addition to being depressed, the shooter was also obviously sociopathic; he had a juvenile-criminal record. His sociopathy had far more to do with this than his depression.

If depression alone were sufficient to cause people to become murderously violent, such shooting sprees would be far more common than they are, because millions of people in the US, at any given time, experience depression. Plainly, then, there is no direct causal link between murderous violence and depression.

The danger in cases like this, is not in depression itself; it’s in the combination of depression and sociopathy. And sociopathy is likely the greater motivator here (and in most of the other similar cases). Without the sociopathy, the shooter would likely have been just another depressed, isolated loner. (Tragic, to be sure, since no one should be a depressed, isolated loner … but such people are no danger to others.)

That the shooter had been a ward of the state for years, and in and out of various treatment programs, underscores this point: While depression can be treated, sociopathy is more or less untreatable. Its presence makes any kind of treatment virtually impossible — sociopaths devalue other people, which includes mental-health professionals, so that no one could penetrate the shooter’s own “internal world.”

So what lesson is there, here? As far as depression and people who suffer from mood disorders, there is none … since mood disorders are not correlated to such violence. The lesson lies in separating depression from other factors in people’s lives, to find deeper, underlying causes for problems. In the case of the Omaha shooter, the deeper problem was his sociopathy. While he may also have suffered from depression, in addition to being a sociopath, that was just a minor complication by comparison.

In the past it’s often been said that depression is worse around the holidays, so much so that suicide is more common than at other times of the year. It turns out this is not actually the case! Read on for the clarification:

Most people have heard the bit of folk wisdom about how depression and suicide increase during the last two months of the year. The holidays can be stressful, no doubt about it: the crowds, the hassles, the cold weather, those annoying relatives you thankfully see only once a year.

And, of course, there’s seasonal affective disorder, perhaps better known by its apt acronym SAD. SAD is a mood disorder that strikes some people during the winter months, causing them to become depressed or lethargic. The disorder is not fully understood but thought to be caused by the decrease in sunlight during winter months.

While stress levels may increase, do suicide rates? After all, there are plenty of stressors throughout the rest of the year as well.

Actually there’s no evidence that suicide rates spike in December; in fact they drop slightly.

A 1987 study by researchers David P. Phillips and John S. Wills found that about 100 fewer suicides occur on holidays than other days of the year. Part of the reason may be that while holidays are stressful, they are also a time when friends and family come together, offering emotional and social support to troubled individuals.

Another story reveals an additional, interesting fact:

While depression does occur during the holidays, local authorities agree they see a spike in depression just after the holidays, primarily in January and February.

Dr. William Kennedy, a psychologist and special deputy with the Clinton County Sheriff’s Office and a member of the hostage negotiation team for the Wilmington Police Department, said people have high levels of anxiety during the holidays and just prior to the holidays, but most depression occurs when holiday celebrations are over.

“I think a couple of things happen just after the holidays,” Kennedy said. “One is, prior to the holidays and as the holidays are going on, people tend to have more connections. They tend to talk to more people, friends and family members. Just after the holidays, that tends to decrease.”

When people talk about depression, usually they’re talking about a depressed mood. People saying, I feel down or I’ve got the blues, he said. “When you see those types of symptoms last more than a couple of weeks and they’re there most of the time, and when you see other associated features — difficulty with sleep, decreases or increases in appetite, changes and lowering of motivation — then you start to think about clinical depression. That’s what you see an increase in just after the holidays,” Kennedy said.

Knowing this, perhaps people can plan in advance. Perhaps have a get-together or party or something in the middle of January … ?

Some findings are now coming out, as a result, and they are interesting. The most notable finding is the relatively (and unexpectedly) high number of Canadian workers who reported having been diagnosed with depression. But something buried in this report is actually more significant:

In the past year, one in five workers took days off due to depression, anxiety or stress. More than half were off work for more than a week, and 20 per cent for a month or more.

That is an awful lot of lost workplace time. That time takes a toll not only on the affected worker, but on co-workers (who must compensate for the person’s absence) and the business itself. As most of us know, depression doesn’t just hurt the patient; it affects everyone around him/her, and the workplace is not exempt from this. Unfortunately, too many workers either don’t get treatment, or settle for inadequate treatment, fearing discovery of their “secret.” Their livelihoods are at stake so they tend to be overcautious.

If society would simply accept the reality of depression, a lot of misery — for those who suffer from it, and those around them, as well as the businesses they work for — could be avoided.

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.

< Previous

Let’s get down to one of the most contentious aspects of mental health care in the U.S., today. Managed care was invented in the early 1970’s, as a way to hold down spiraling health-insurance costs. It has since become an institution all its own, a true driving force behind how mental illnesses are treated — in addition to driving all other areas of medicine. (Disclosure: I worked for 9 years for a managed-care company, so I know a good deal of this “from the inside” as it were.)

Before the advent of managed care, most people had “health insurance” through their employer. The employee got health care as needed, paid for it, then filed a claim and got reimbursed — between 50 and 80%, usually — for the cost. The need for the care was never questioned, the only question was what the insurance plan’s coverage allowed, usually up to a total amount per year.

As families grew, and lifestyles improved, people naturally became more demanding in their health care. They sought help for things which, previously, they might not have. Costs to employers, for health insurance, went up, as claim amounts rose. Stories such as people going to emergency rooms for hangnails, were swapped among executives concerned that their companies’ insurance premiums were being wasted.

At the very same time, another trend was developing. Medicaid and Medicare covered the indigent, disabled, and the retired, for their medical care. In some cases the reimbursements were quite generous. But budget deficits in the ’70s forced Congress to cut back on how much was paid out, and certain procedures were disallowed completely.

Hospitals, however, were required by law to care for all, without regard to their ability to pay. They lost money on Medicaid and Medicare patients. This deficit had to be made up elsewhere, and inevitably, that was from paying patients, especially patients who were paid by insurance.

Not only were insured patients going to the doctor more often, but their bills for each visit were going up, through no fault of their own. Insurance premiums escalated, sometimes as much as 25% or more a year.

Eventually, insurance companies and large employers developed what became the HMO (health management organization). These were originally closed groups of doctors and hospitals, who were either on payroll for the HMO, or who were paid for healthcare services according to specific, contracted payment amounts. Furthermore, some procedures were subject to review by the HMO for “medical necessity.” Thus was born what know as “managed care.”

The first HMOs were content to limit things such as emergency room visits (which were particularly expensive) and unneeded tests, reduce hospital stays, and deny payment for “experimental” procedures. Over time, however, this was not enough to stem the tide. Cost-passing from Medicaid/Medicare patients continued at an escalating pace, through the ’80s, so more and more, the HMO’s clamped down on what they paid for.

Regular, old-fashioned “health insurance” had by this time became brutally expensive, so more and more employers opted for managed care plans. This trend continues even today. Traditional health insurance takes up only about 2–3% of the total market, while HMOs account for well over 50%.

One arena of healthcare which was incredibly expensive, but which most managed care plans knew little about, was “behavioral health” or psychiatry. Psychiatry is rather unlike conventional medicine, in that diagnoses, condition evaluations, and treatment decisions are far more “iffy” and subject to judgement calls. Many managed care companies set up separate divisions, or even spun off separate companies, devoted solely to behavioral health. This allowed their caseworkers to specialize. Note, this was not done to help patient care, even though most HMOs claim this was the case; it was done so that more ways could be found to control costs.

The upshot, of course, is that managed-care patients often have to traverse a maze of bureaucracy in order to get what they need. Psychiatric hospitalizations and treatment plans are reviewed by a behavioral health company; but prescriptions are obtained through the HMO itself. In many instances the patient is given two or more phone numbers to call, if they have a question, but they don’t always know which one to call, and they still might get referred to someone else, who refers them to someone else, etc.

It’s really a very pathetic picture, especially given that folks with mood disorders often don’t have the wherewithal to handle such bureaucratic gymnastics. Also, it’s counter-productive for these companies to maintain separate bureaucracies, while trying to reduce operating costs.

Government programs don’t work the same way as commercial managed care does. Either patients are contracted out to commercial health insurers or HMOs, or their care is reimbursed according to delineated standards, such as their diagnosis, severity level, etc. In other words, government agencies pay for hospital stays only for certain diagnoses, and so long as the person is in poor enough condition to remain there; and it’s all decided by rote, not by careful analysis.

Either way, managed care companies and government agencies all too often save money in the short term, but lose money, long term. A patient who is discharged from the hospital too early, may wind up back in it all over again. An extra couple of days in the first stay, could have saved many, from the second, or eliminated that second stay entirely. Yet the companies and agencies are not learning this lesson. If anything, they’ve become increasingly parsimonious and even more short-sighted. In the end, they’re doing the patient no favors, and they aren’t really saving premium-payers or taxpayers anything.

One particular problem for those with mood disorders, is that insurance doesn’t always cover mental illness in the same way that other diseases are covered. Some plans have very low annual caps on total behavioral health payouts, which can be particular harmful if the patient needs, say, frequent therapy sessions.

Fortunately, though, over the last decade, an effort has been made to correct this situation. Many states, such as my own state of Connecticut, have passed “parity” laws, which require insurers to grant mental illnesses “parity” with others.

That it comes down to passing laws of this kind, though, is a travesty. What makes anyone think that mental illnesses are worth less than others? By what standard does one make such a determination? It’s all right for a depressive to go broke paying for Prozac, while a diabetic need not pay anything for insulin? Does this make any sense?

Of course it doesn’t! Nothing about mental illness makes any sense … not the illnesses themselves, not the way in which they’re treated, and not the way in which they’re paid for.

< Previous   Next >

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.

< Previous   Next >