An epic fail when it comes to mental health

Sometimes the health care system just does not work.

I had seen him one week earlier on a Friday afternoon, accompanied by his estranged wife. They were there because of concern about increased depression. He told me that he had stopped taking his lithium and paroxetine (Paxil) several months earlier because he felt they weren’t working. He also readily admitted to having returned to the habit of drinking one or two six-packs daily and more on weekends several months before the medications stopped working.

As the story evolved, I learned that he had stopped going to work and then was fired. He had no energy or ambition. He was not sleeping either well or regularly. This visit had been precipitated because he had gotten angry with a neighbor and tried choking him. When I asked him if he had had other times when he considered doing things that might harm others, he said that he had been driving around with his loaded gun, feeling very angry and wondering if he would feel better if he shot somebody, and whether it would be better to shoot somebody he knew or a stranger.

We talked briefly about the fact that his medicines might have stopped working because of the alcohol, but that he was now dangerously depressed, and that the options were to go directly to the crisis unit for admission or, if he refused, I would call the police. He readily agreed to admission. “That’s why I’m here doc. I need help before it’s too late.”

His wife drove him straight to Crisis in the hospital across town, where he was evaluated. They called and told me the decision had been made to admit him.

I was now seeing him in follow-up. The story he told me was unbelievable – but was confirmed by his paperwork and a phone call to the hospital emergency department.

He had indeed been seen and evaluated by the nurse practitioner on call, and was felt to be seriously depressed and “at major risk for harming himself or others.” Because it was late in the day, there was no open bed at that moment on the psych floor, and the psychiatrist had already left for home, he was kept overnight in the emergency room for admission in the morning. During that time, he underwent the standard and appropriate metabolic screening and a physical exam by the emergency room physician whose note confirmed the patient’s description of events.

Early Saturday morning he was visited in the ED by an intake worker. She reviewed the chart and spoke to someone on the psych floor, after which she explained to him that he did not need inpatient care. He was discharged home with (written) instructions to see his primary care physician so he could be restarted on his medications. He was also told to call for an outpatient counseling appointment after the weekend.

When he called, he was told that the counseling sessions were currently booking out to the fall but that he would be put on a waiting list, and that if he felt he needed services sooner, he should contact his primary care physician or return to the Crisis Unit in the ED.

We contacted a friend to make sure he no longer had a gun. We restarted him on his medication, which he agreed to take. Five days later he was brought back to the ED by the police who had been called by a friend. He was intoxicated and threatening to drive his car into the river. He was kept over night and then transferred to a psychiatry floor in a neighboring community for a two week stay followed by intensive outpatient therapy.

He’s doing much better.

Peter Elias is a family physician who blogs at his self-titled site, PeterEliasMD.

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  • drgg

    Unfortunately, this is now the standard of care. Psychiatric residency programs and psychiatric hospitals are closing down left and right.. The last one I heard about was Cedar-Sinai in Los Angeles. There is no money in psychiatric hospitals or for that matter psychiatric care at all. It is a money loser. This is actually not an atypical story.

    In this case,this patient was getting a lot of attention and I think was determined to get help by continually getting destructive and letting others know about it–until he got the help. Unfortunately, there are a lot less fortunate patients that never make it. Where does a psychiatric hospital exist that keeps patients 2 weeks? Give me the name of it. I’ll send my patients there.

  • Matthew B. Smith, M.D.

    All too familiar.

  • deetelecare

    Community hospitals, which were the first line of care, are also losing their psych floors quickly. My brother, who has been in psychiatric practice since the 1980s (and a DLFAP), admitted routinely to a Catholic community hospital in northern NJ well known for its psychiatric care for a working to middle class area. Now they took over a much larger hospital–and dropped the psych ward as unprofitable. While it’s made his life easier in a way–no more holidays doing rounds at the hospital, far fewer 7am consults–his patients and their families now have to go much farther for an ER. He’s working harder, longer at his private practice, barely breaking even, and makes most of his money from working at a local social service clinic in a different part of the county. And yes, he’s within a few years of retiring.

    Oh, and need I say that insurers DESPISE “behavioral health”? It’s hell on the old utilization metrics. And this will get worse, not better.

  • militarymedical

    Decades ago, babies were thrown out with the bathwater as psychiatric institutions closed their long-term wards and facilities, leaving unprepared and incapable patients to fend for themselves in finding on-going psychiatric care. Fewer and fewer national, state, local, public and private resources have been steered toward mental health in the decades since. We now reap the whirlwind in far too many untreated or undertreated and potentially dangerous mentally ill people left to flounder in “mainstream” society. Most mass-murders in recent years have been perpetrated by these unfortunates, who usually have free and ready access to means by which to carry out their destructive delusions or visions..
    It crosses the line into criminality that mental health continues to be the red-headed stepchild – or, more accurately, the unrecognized bastard child – of a national obsession with health care. The mentally ill deserve far better, and politicians, healthcare providers and the public need to wake the hell up.

  • bostonmeg

    As someone who has desperately tried in vain for years to find a therapist in the Boston area and the mother of a child with bi-polar who routinely goes off medication (grown child so I have no say) I can tell you horror stories about trying to find care. In the 1990′s we turned away from psychiatric help in general and we are all reaping the benefits of ignoring those who need us the most.

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