Why solutions to mental health continue to evade us

Another tragedy, another tragic series of errors, another avalanche of debriefings and politicization, and in Washington, DC, there are 12 more dead.  What can we say about this?  It seems that the standard commentary fails.  Aaron Alexis was not an angry white man, nor a conservative.  He carried no assault rifle and he had a secret security clearance. He doesn’t seem to have been motivated by race.  He was a educated consultant.  He certainly wasn’t a radical Islamist.  In fact, he was allegedly a Buddhist.  (A demographic not known for violent outbursts these days.)

We can talk about effective security and we can write about background checks and all the rest. All of these are relevant points.  But the other relevant issue is that the shooter was a man who seemed to have mental illness.  We now know that he had a history of violent outbursts.  It is also alleged that he “heard voices.”  In the coming weeks experts on mental illness will hold forth in every conceivable venue.  Thanks to the inconvenient absence of the shooter, who was killed by police, the analysis will be largely speculative.  That won’t stop anyone.  We will hear impassioned please for better mental health coverage and we will hear bold declarations that “something has to be done” to improve access to mental health.  And when the grass begins to grow over the graves of the deceased, not much will have happened.

I know this because I see the mentally ill all the time.  Why do I see them? If you read me with any regularity you’ll know that I’m not a psychiatrist.  I practice emergency medicine. And I see the mentally ill because emergency departments are where many of society’s mentally ill find themselves, if they interact with “the system” at all.

Indeed, we have a system of mental health hospitals and clinics, in this state and in others.  And bless their hearts (as we say here), those state mental health workers, nurses, counselors, psychologists and psychiatrists alike, are a dedicated lot.  They spend their days and nights trying to sort through the thoughts and behaviors of untold men, women, boys and girls who are confused, broken, hallucinating, homicidal, suicidal, anxious, depressed, addicted and everything in between.

They take the story they are told, by family, friends, police or other physicians, and find the best treatment, then make the best predictions about what might (or might not) happen when the patient is released.  Furthermore, they are woefully underfunded and understaffed.  And they are crushed (overwhelmed is too soft a word) by rules, regulations and forms built to protect individual’s rights, but which sometimes make intervention a thing of legal peril.

Furthermore, and I tread lightly here, the mental health system is also stretched a bit thin by patients who are not, in fact, mentally ill.  A small but significant subset use “mental illness” to achieve the requisite incapacity necessary for disability claims or to avoid accountability for their actions.  They create a lot of hay through which the mental health system must sift to find the needles, as it were.

But I doubt if anyone will mention what makes mental health care the most difficult.  We all know that the workers are understaffed and underpaid and the patients typically uninsured.  But there’s something else.  You see, if a patient has chest pain, a fever or a broken arm, they aren’t generally afraid to acknowledge it and their loved ones know exactly what to do … and feel no shame about it.

This is not the case with mental illness.  Many self-aware patients acknowledge their problem.  But a significant number of those with the most dangerous and difficult conditions don’t.  Or can’t.  They aren’t hallucinating, they’re just seeing things more clearly than everyone else.  And they aren’t delusional; it’s just that the CIA and the aliens actually are after them … if only we could understand!

When the mind is impaired, the very tool we use to make decisions about our health and welfare, then it becomes remarkably difficult for even the best system to make a difference. And when patients (and many of their loved ones) see mental illness as a moral failure, not a disease, then all the money and staff in the world won’t solve the problems posed by men like Aaron Alexis.

I have more questions than answers. But the pundit’s cry, “we have to address mental health in America” is just so much window-dressing.  In the real world, the solutions continue to evade us all.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

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  • azmd

    The fact is that a lot more patients with psychosis and homicidal impulses could be identified, without too much difficulty, by someone with the right skill set and enough time to draw the patient out after gaining his or her trust. However, as with many things in medicine, such an evaluation often requires more time than is made available to most clinicians these days. If all the interviewer has time to do is race through a hasty checklist, “Are you hearing voices? Thinking of suicide? Thinking of hurting others?” our yield on detecting the dangerously mentally ill will continue to be low.

    Also, in states with more liberal civil commitment statutes, patients like the Navy Yard shooter can be brought in for evaluation and treatment, even if they refuse voluntary hospitalization. Scientific evidence suggests that there is an association between less stringent criteria for civil commitment and lower homicide rates.

    There are many things we could do to improve the detection and treatment of mental illness, but the question is whether or not we as a country have the will to devote resources towards accomplishing those goals.

  • FugaziedUp

    After practicing for 14 years, if there was one thing I could pass on to those considering a career in medicine, it would be to advise them how much of their time will be consumed with the psychosocial dysfunction of our patients and its consequences, and how little will be spent treating actual medical disease. Additionally, mental illness has been around since man has graced this beautiful Earth, but only now have the mentally ill had the means to end the lives of innocent people in a matter of seconds with the pull of a trigger. I agree with Dr Leap that our mental health system could be improved, but we could also do more to limit the access of firearms without infringing on the rights of our law-abiding citizens. Still, with improvements in both, it is unlikely that mass shootings will end any time soon unfortunately.

    • querywoman

      Caligula was nuts, and Nero may have been nuts also. There have always been ways to kill lots of people.

    • querywoman

      A lot of doctors are mentally ill by my definition. Many have delusions of grandeur and Napoleon complexes.

  • querywoman

    What do you do with patients who present with chronic skin disease in the ER? Do you misdiagnose them as “mental” and blame the skin disease on picking at it?
    My dermatologist is an activist for psoriasis. I have atopic eczema, and it’s similar. Give us each 40 more years, and we’ll both do more for skin disease activism.
    Don’t misdiagnosis people as mental cases when they are not.
    I went through a bunch of quack doctors, including derms, before I found him.

    • T H

      That is a good question. Another good question would be – why didn’t the PCM recognize a very common skin ailment at the outset? Another good question would be – why go to the ER for a chronic condition. A simple skin biopsy would’ve shown your diagnosis.

      • querywoman

        Years and years passed before I ever got a skin biopsy! I’ve only been to ER’s out of exasperation. Once I went to an urgent care center because I clawed my legs so badly I broke the skin. I got a tetanus shot that time.

        Why are so many doctors so ignorant of skin disease? The skin is the largest and most visible organ.
        My dermatologist is a skin activist, and he’s an old man now. I was born with a skin problem, and I’ve fought the stigma all my life.

        I took two doxepin in the past 24 hours, maybe 8 hours apart, and I slept so heavily in the afternoon that I may not have heard 3 cell phones ringing by my bed.
        There isn’t much alternative for me than to take the doxepin as needed for itching. The last time I went to the derm, the young resident thought I should take doxepin every day. I told her I’d not be awake very much if I did. It won’t make my eczema lesions go away.
        I do special bandaging treatments of the lesions with halobetasol treatment.

  • querywoman

    I’ve already posted one critical post about skin disease always being dismissed as a mental problem.
    But, the real truth about mental health care is that most people voluntarily go for treatment. It’s a myth that psychiatrists are pushing drugs on people.
    The average American psychiatrist has a busy practice with people voluntarily asking for care, often with anxiety or depression. Many people who hear voices also seek psychiatric treatment voluntarily.
    The old Soviet Union was criticized for sending political dissidents to mental institutions. I read that many people in the old Soviet Union voluntarily sought care at the mental institutions for their better living conditions and were truly grateful for their care.
    How to reach people like the Unabomber and others who are mass killers before they do something drastic is the real question. Look at Dr. Amy Bishop Anderson, who supposedly never sought mental care, but was regarded as very strange.

    • Anoop Kumar

      Yes, many people voluntarily go for treatment, often with the idea that a pill will solve their problems. Just because it’s voluntary doesn’t mean than the treatment is the right one and complete. Medication helps, but doesn’t solve, as all the overdoses and withdrawals we see daily attest to.

      • querywoman

        There is no specific blood or physical test for mental illness. Basically, mental diagnoses are just names for collections of symptoms.
        American doctors will regularly push mental pills off patients. Many people want those meds, so they must work.
        It’s still a mystery how to treat “mental” illness.
        Meds won’t cure poor social conditions!

  • Rob Burnside

    Non-conformists in our society–any society, really–are usually marginalized, sometimes deliberately so. In her reply to your fine post, Querywoman mentions the former Soviet Union, where deliberate, aggressive marginalization was routinely practiced by the state.

    We should all read, or re-read, at least the first chapter of Aleksander Solzhenitsyn’s “Gulag Archipelago” wherein he explains how a dissident’s (anyone perceived to be a threat to state order) reputation was first destroyed by deliberate, behind-the-scenes prevarication and rumor initiated by agents of the state or the Communist Party, which were one and the same. Once reputation suffered, so did the means to make a living. Crumbling social support followed. Social anomie led to psychosis. There was little the targeted individual could do as his life fell apart, and (I’m paraphrasing) “by the time they came for you, you were ready to go.” Next stop– a sham trial and the Siberian “work” camps. Many were sent directly, with no trial.

    Perhaps–and I’m only guessing– the Navy Yard shooter had (or believed that he had) a similar experience. “What?” you ask. “Here in America, in the 21st century?” Yes, it happens all the time, especially at the local level where one political party totally dominates government over an extended period of time and opposition/criticism of any sort is systematically eliminated. Stigma, as you suggest, plays a huge part. Once you’ve sought psychiatric care for anything, in the eyes of many you are forever a mental patient. It can, and will, be held against you, and actually used against you—often by the very people who caused your distress in the first place.

    I’m not in any way defending homicide, or “suicide by cop,” or suggesting that we live in a modern-day Soviet Union. I’m writing to thank you for your post, and to echo what fellow poster Querywoman alludes to in her reply–minus organic brain disease, severe psychiatric problems often begin with simple marginalization. Put another way–as a society, we engender our own problems, and mass shootings–whatever the motive may finally be attributed to– might also be symptomatic of an underlying societal illness. Dare we call it HNS (Human Nature Syndrome)?

    • Anoop Kumar

      Yes, marginalization is a hallmark of genius and insanity, and both can attract crowds to their margins. What I have noticed is that a lack of meaningful relationships seems to be a recurrent theme that leads to destructive behavior. At that level, the problem and solution is cultural. We’re generally not a culture that starts conversations randomly on the street with people – we’re often interacting with our iphones instead of noticing people (myself included). Yet that interaction is something that seems fundamental to health, which explains the explosion of social media. It’s like social media is a way to connect without the fear of having to really converse.

      • Rob Burnside

        Point (s) well-taken, Anoop, and apologies for the length of my post — perhaps “a way to connect without fear of” being interrupted! Ooops, gotta go, my phone’s ringing…

    • querywoman

      And if you take psychiatric meds, it’s hard to get another medical problem treated because every symptom is dismissed as “depression.”
      For me, that stopped when I finally went into diabetes.

      • Rob Burnside

        And isn’t this an insidious form of marginalization? In my opinion, QW, it is. If you haven’t been marginalized for seeking psychiatric assistance in the first place, you’re sure to be marginalized for it somewhere down the road. I’m glad it’s no longer a problem for you!

  • Tammy

    A much more sane blog post than the previous post on KevinMD which put the blame for the Navy Yard shootings squarely on “unregulated gun access”.

  • Tammy

    previous KevinMD post blaming “unregulated gun access” for Navy Yard shootings:
    http://www.kevinmd.com/blog/2013/09/unregulated-gun-access-drain-medical-resources.html

  • Dave Mittman, PA, DFAAPA

    Amen. Hard to even make a dent.
    We have to figure out to the best of our ability what common signs a sub-set of patients who will be a danger to society exhibit and get them help or hospitalization. We are too afraid to get sued, or make a mistake and I realize how hard that is but people die because of others being socially correct.
    In reading about the shooter in CT, a number of people knew he was significantly diseased. The shooter at the Navy base was hearing voices telling him to kill and carving phrases in his guns. Would a serious evaluation by police and psychiatrists have helped? We won’t know until we try something new.
    Dave

  • querywoman

    I’m not going to list non-gun ways to massacre people cause I don’t want to give any ideas.

  • Suzi Q 38

    Until someone is dangerous, it is difficult to determine who gets unwanted psychological help or not. Some people are just very different and antisocially crazy. They have not been dangerous, so they remain untreated. Medical or insurance does not have loads of money to pile on their condition when they are not asking for help. Even if they were to be contained in a mental unit, they would be out in a day or two.

  • Rob Burnside

    There’s an old saying Valerie: “Discretion is often the better part of valor.” And it’s either spot-on or terribly wrong. Problem is, we sometimes need a crystal ball to tell the difference.

  • Thomas

    You do know you and other psychiatrists have no way of predicting violence better than anyone else. By your same logic, past violence is not indicative of future violence, though that it used all the time to make violence predictions (however poor). You also know that many medications prescribed are associated with increasing violent behavior, so being prescribed treatments you mentioned actually can help predict increased violence, not necessarily the alternative.

    If treatments helped people in ways they are interested in being helped, I don’t think you would see much problem with treatment adherence. The truth is that treatments offered are minimally helpful, and often lead to hosts of other problems that distressed people didn’t have to deal with before (metabolic side effects leading to health problems like diabetes, dyskinesia, cognitive impairments, and new symptoms associated with other mental health disorders like anxiety, malaise, oversleeping, etc.). People make their own risk assessment, and decide they are better off without the burdens, costs, and stigma treatment often entails. I mean, the way you describe family and friends having to be covert police over their mentally ill loved one just adds to treatment resistance. Why would someone maintain contact or express their feelings if expression of anger or disappointment leads to a commitment? Why would someone share their real experience with their doctor if it means risking being locked up.

    The way you describe how people/society should relate to people who are mentally ill only keeps people who are struggling from engaging in treatment. Coercive treatment is short-sighted and an oxymoron.