Are you manic right now?

I recently had a patient who was diagnosed with pneumonia. We had been treating with antibiotics, as well as some temporary puffers, for symptom relief. Unfortunately the puffers did not suffice, and the antibiotics had not acted quickly enough. One evening, after he finished dinner, this gentleman began experiencing shortness of breath. He was concerned, and called an ambulance, who took him to the hospital.

On arrival to the emergency room he was offloaded from the ambulance and given some oxygen, which helped him immensely. His breathing actually settled relatively quickly and he was able to breath without the oxygen mask. The emergency room physician (ERP) took this opportunity to get a more wholesome history from him.

“Do you smoke?”

“Not for the last few years.”

“Do you take any medications?”

“Just the puffers and antibiotic my doctor had prescribed.”

“Very good. Do you have any medical illnesses?”

The patient paused for a moment to think. He had been through this rodeo before, for other medical problems. He was wondering whether or not to mention to the doctor a previous diagnosis of bipolar disorder.

In the past, he had told physicians and paramedics about this diagnosis to underwhelming results. Instantly, the affect of the providers would change. Suddenly, his credibility was drawn into question. Where before he was allowed to speak and describe his story without interruptions, he was now met with requests to, “slow down.” The questions like, “are you feeling like yourself right now?” seemed to bother him the most.

This ERP on this particular day however seemed professional enough, and the patient wanted to be as transparent and honest as possible, so that his medical care could be the most informed it could be.

“I’ve been diagnosed with bipolar disorder, though I’m not on any medications, and I don’t know that I agree with the diagnosis.”

The silence was deafening, although it only lasted a second. The physician quickly regained her composure and started down another line of questioning.

“Have you used any drugs recently?”

“No.”

“Do you smoke?”

“I already told you I didn’t.”

“Are you manic right now?”

He tried his best not to role his eyes.

“I feel perfectly fine, I’m sleeping eight hours a night.”

“Are you having thoughts of violence or suicide?”

He looked at her sternly and decided not to answer this question – he was here, after all, for pneumonia. No razor blades had been held at any wrist.

The conversation continued and eventually the physician left to order some investigations. Various nurses were in and out of his hospital room, all of whom seemed to suddenly have a lot less to say.

The patients condition improved, and he was eventually discharged on a low dose steroid for a few days to aid in his recovery.

“I don’t think I’ll take this tonight but I’ll take it in the morning.”

It was the ERP’s turn to role her eyes. The patient felt obligated to explain himself.

“If I do have bipolar disorder, the absolute last thing I want to do is take a steroid tonight, be awake the whole night, and have an episode.”

“Alright, see ya,” the doctor said as she left the room.

Now I had heard this story from the patient second hand of course, and I’m sure the dialogue wasn’t exactly as I have described above. But there are some things that are certainly true. This man was extremely aware of the prejudice he received, by virtue of the (unconfirmed) diagnosis he carries, and suffered because of it. He felt insulted, degraded, and less than human.

Great way to make people want to seek treatment for mental illness, eh?

There were a few things that bothered me about the story, the least of which was this physician’s skill in assessing mental illness. For the record, you could ask a naked man screaming about Jesus on top of a Walmart, who hasn’t slept in eight days, “are you manic right now?” and I would be shocked if they said yes. To those of us in the field, we recognize the mental status exam and the whole picture as key instruments leading to diagnosis. Personally, I don’t see the utility in asking seemingly well and euthymic (normal emotion) people what they think of their mental status, irrespective of their diagnoses, when they are seeking help for an unrelated medical problem.

Bipolar people get pneumonia too, y’know.

The physician’s apparent novice skill in this field isn’t why I chose to write this post – it’s the prejudice that came attached. Because this man had a diagnosis of mental illness in the past, and one of the “scarier” ones, his credibility was immediately drawn into question. Are you sure you didn’t accidentally take a bunch of cocaine before you arrived here? Are you positive you don’t want to blow your brains out after you leave here?

That’s not to say that this information doesn’t matter, because it does. On a professional level, whenever I assess someone with mental illness that may put them at risk, I’m always on the look out for any red flags or warning signs.

I’m also sure to treat the patients like humans.

Medicolegally, I understand the need. “Oh Doctor, you didn’t ask about suicide when you assessed Mr. so and so five months ago? And why is that? He did have bipolar disorder, after all.” And Im not saying theese questions shouldn’t be asked. How you go about it however, is another story.

Do any of you have real life examples or prejudice inflicted upon you, or a friend as a result of mental illness? Without going into too much personal detail, share below!

Dr. Travis Barron is a resident physician in Toronto, Canada.