Wednesday, February 20, 2013
A lesson on mental illness care: connecting two tragedies
For the past month I've been trying to formulate a blog that could capture my thoughts about mental illness and the prevention of violence. At this point my ideas are still not crystallized, but perhaps writing this will help.
A few days before Christmas I received a phone call from a former patient's mother. She called while I was at the mall with my family doing some last minute shopping. I had taken the day off work. My patient, who I will call "Mark," and his family had left the state of Georgia and my care approximately 6 months prior. Fighting to contain her grief Mark's mother told me that her son, who was just 25 years old, had taken his own life.
It came as a shock, though admittedly during the brief time that I doctored Mark I had been very concerned about his well-being. His mother said that she wanted me to know because I had worked so hard to help her son. As I listened to the story of the months leading up to his suicide I was flooded with questions: Could I have prevented this? How did he kill himself? Had he found another physician after he moved? Had he been seeing a psychiatrist, as I had recommended?
I had only cared for Mark for three or four months. When we first met, early in 2012, his mother and he were desperate. She called me one evening after clinic hours. I was at my son's saxophone lesson and stepped outside to take the call. She found my medical practice and phone number on Google. She thought I might be able to help. He'd had a tough childhood. His sister was severely disabled. Then, he suffered a traumatic life event in college. Mark, though obviously very intelligent, had dropped out, unable to function. While he was my patient Mark confided that he was desperate to be independent and get back to normal functioning, but felt crippled by his health. He was a very likable young man who I connected with.
He described multiple symptoms: head pressure, mental fogginess, intense pain and burning all over his body coursing from his center outward and down his extremities, nausea, heartburn, post-nasal drip, an intensely dry mouth, insatiable thirst, difficulty swallowing, loss of appetite, change in his bowel habits, weight loss and muscle wasting. Mark felt that he was dying from a medical condition that remained undiagnosed. As he explained it, his trouble had started while was under the care of a psychiatrist. He attributed some of his symptoms to a medication, a serotonin re-uptake inhibitor, Effexor, which he felt had permanently changed him.
He asked if I could test him for permanent damage caused by traces of the drug that might remain in his blood stream months after his last dose. He had left his psychiatrist's care wanting another opinion and a thorough evaluation of these physical symptoms that were relentless and incapacitating.
I embarked on a very thorough medical evaluation, including a plethora of blood tests, an MRI of his brain, a neurology and an allergy and immunology consultation. I knew all the while that the root problem was very likely his underlying psychiatric condition. Mark acknowledged ongoing depressed mood and severe long-standing anxiety, but was primarily concerned about his physical health. I asked to speak with his psychiatrist, but his preference was that I evaluate his condition independently, and he refused. When questioned about thoughts of self-harm or harming others Mark stated, "I could never do that to my mother."
After frequent lengthy office visits and phone calls over a period of several months I was not able to arrive at a unifying medical diagnosis that explained my patient's condition. I was, however, increasingly concerned about his psychological health and referred him to another psychiatrist. I had become aware of underlying paranoid overtones in his affect, which I felt were delusional. He had been concerned about a pharmacy contaminating his prescriptions with a substance that made him ill. He asked me if I knew what the substance was (I had never heard of it), and asked me to investigate it. He expressed suspicion about various commercial labs and preferred that I send his lab specimens to a smaller lab that he had researched and chosen. He felt this lab would do a more accurate job with his lab testing. He asked me my opinion on his future career. He said he was very interested in the military, and asked if I thought that might be a good direction for him. Inwardly I cringed at the thought, and tried to steer him toward a more flexible career choice, and one that would not involve use of firearms.
After several months of working closely with Mark his mother informed me that the family would be moving out of state. Although the timing was not ideal, his father could not turn down the job opportunity and Mark could not stay on his own. Despite my referrals he had never established with a new psychiatrist. In a last ditch attempt to get him some help, I made a phone call to a psychiatrist who I knew and trusted. The psychiatrist agreed to see Mark several times prior to his move. It was the best we could think of.
I felt that I needed to clearly articulate my clinical impression to Mark's mother prior to their departure, which was that my patient was suffering from a psychiatric condition that caused a disorder of thinking in the form of paranoia and delusions. I mentioned schizophrenia. Mark's mother acknowledged that this diagnosis had been previously suggested, but that she and Mark wanted another opinion.
At the time of his last visit Mark brought in a fairly organized list of the symptoms he was suffering from and how they impacted his ability to function. He wanted me to write a letter attesting to the fact that he was unable to work or go to school because of his condition. I agreed to write a letter describing his condition, which was difficult given the fact that there was no psychiatrist involved and his diagnosis appeared to be primarily psychiatric. I explained this to Mark and had a direct conversation with him about my clinical impression.
The visits to my psychiatrist referral never occurred. My patient moved later that summer and I had no further contact until the phone call in December. The news about my patient's tragic suicide came one week after the shooting at Newtown, where, as we all know, another young man with significant psychiatric illness inexplicably sacrificed not only his life, but the lives of 26 children and teachers. I immediately wondered if my patient had shot himself, but somehow during our brief phone conversation, I could not bring myself to ask his mom how he died; it seemed irrelevant to her grief at the time. These two events cast a shadow over my holiday season.
I continue to try to make reason of these two tragedies, hoping to arrive at a pithy lesson by connecting the two that I can bring to clinical practice to avoid future heartbreak. What makes it so difficult to get patients with psychiatric illness the help that they need? In this case it was not problems of access, but the underlying disease process itself made my patient resistant to care.
I am still searching for broader answers, but perhaps I will start with a call back to my patient's mother to find out more details. In the meantime, I remain highly skeptical that improved mental health care alone, without restricting access to firearms will be enough to curb gun violence in our country.
Juliet K. Mavromatis, MD, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals. This post originally appeared there.
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