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.

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“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.

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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.

The psych wards are full and why that matters

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“I can tell that things have been difficult.”

“That’s life, isn’t it? One thing after another.”

“Are you having thoughts of wanting to be dead?”

“All the time.”

“Are you having thoughts of attempting suicide?”

***

I recently met a patient in my family medicine clinic, a 28 year old gentleman who had immigrated to Canada as a young child. This man had experienced numerous struggles in his life, from escaping relative slavery in central Africa, to coming to Canada, achieving a professional education, and eventually got a job as an X-ray technician. That was, until recently.

For the last two years, the gentleman, “A”, had been struggling with depression and alcohol use, following the death of his mother. “A”‘s drinking quickly escalated over time, which worsened his depression, which caused him to drink more, and so on. “A” had disclosed these problems to his previous family doctor, who stressed the importance of alcohol cessation, and prescribed a medication.

As these things can sometimes go, “A” was not able to abstain from alcohol, and unsurprisingly (given the ongoing, heavy substance use), they found the medications ineffective for depression and stopped taking them.

“A” eventually ended up back in his previous physician’s office for a separate issue, and the physician decided to check on his mood. It quickly became apparent “A” had continued to drink, and was severely depressed. He was now off of work and almost entirely socially isolated. “A”‘s physician spoke to him about suicide, and it became apparent that “A” had recently attempted suicide via overdose. He was, “disappointed,” the attempt was not successful.

Because of this, “A”‘s doctor had recommended they go to an emergency department to be seen urgently by a physician. “A” had some friends that had previously been through the emergency psychiatry experience, and told his physician there was, “no way,” they would go through that.

The physician, in keeping with her professional and moral duties, issued a form 1; what is a form 1? In Ontario, a form 1 is a form issued by a physician when they have concerns regarding your safety, due to mental health. The form allows you to be apprehended and brought into a psychiatric hospital for assessment.

“A” was picked up by police and they drove him to the hospital. In hospital, they were admitted to the emergency department, and given a glorified, locked, jail cell to stay in. His clothes were taken and they were under constant observation by a security guard outside of the hospital room (cell) door.

After 48 hours, “A” was discharged, and had been lost to follow up for over the last year, until I had met them, again for a separate issue.

***

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“Are you having thoughts of attempting suicide?”

Silence.

“I need you to be honest with me here, I’m very concerned.”

“I’m fine.”

***

“A” was not fine. In fact, it soon came out that, yet again, “A” had covertly attempted suicide. He was actively planning another attempt, and had begun to set his affairs in order, as though he would soon be dead.

I issued a form 1.

Why does it matter that the psych wards are full?

“A” was very unwell, and to this day I don’t know how he is doing. After I submitted the form 1, they refused to return to my office. Let me begin by saying, this is the least favourite part about my job. On a personal philosophy level, I do not believe that physicians, or anyone, has the rite to tell people how to feel and what to believe. I also know when to recognize severe, serious depression, that may be treatable, which puts ones life at risk. This was the case with “A”, and I can sleep easy tonight knowing that I did not abuse my government-given powers to take away someone’s liberty.

But this didn’t need to happen.

Far in the past, or in some parts of the United States (if you have money), there is a mythical beast called the elective psychiatric admission. This is exactly what it sounds like – elective, meaning not mandatory. Examples of elective psychiatric admissions include people with a moderate depression, people with severe anxiety, or someone in the need of a mood stabilizer or antipsychotic titration. Useful stuff, no? The philosophy behind elective psychiatric admissions is that we tackle a problem before it gets to serious. You want to treat someone when they are climbing the stairs, not jumping off the balcony.

Unfortunately, I am sad to say that in my short psychiatric career, I could count the number of elective psychiatric admissions I’ve facilitated on one hand. Two fingers, to be exact. And that’s not to say I haven’t met people who may benefit from such an admission – I meet people like that at least once a week. But the reality is, because psychiatric hospitals are overcrowded, there is only room for emergency admissions. These are your form 1’s, the acutely suicidal, the emaciated psychosis.

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Of course those people (emergent patients) need hospital, and indeed they need hospital more than an elective patient, by it’s very nature. But that doesn’t mean elective patients don’t need admission, as well. Inevitably, people who may benefit from an elective psychiatric admission are discharged home. Many of those people appropriately improve on an outpatient regimen, but not everyone – some people get worse. Way worse. So much worse, in fact, that they shortly come in need of an emergent psychiatric admission.

You can see how the cycle continues. As long as we deny inpatient treatment to people who are at anything but absolute crisis mode, people will become sicker, and further overcrowd the hospitals. Think of the bipolar man in need of a lithium titration who instead stops his medication and has a severe manic episode. He thinks he can fly, jumps off a building, and breaks both legs.

What about the effect on emergency rooms?

If there is any area of medicine and mental health who sees first-hand the effects of overcrowded, full psychiatric hospitals, it is emergency departments. As emergent psychiatric patients are felt to need admission, a back log is created when the psych wards are full. This results in psychiatric patients being housed, long term in the emergency department, hopefully awaiting some attrition from the wards.

I don’t know that you have ever been in an emergency department, but they aren’t pleasant. The psych beds in the emergency, even less so. They usually float somewhere between jail cell and operating room sterility. Not only is this an abuse of vulnerable people in need of help, but this causes further problems. Physicians are able to dedicate less and less time to each patient, as the mental health population of the emergency grows, which is a recipe for disaster. There are reasons there are nursing ratios on psych wards, because vulnerable people with mental health problems need support. This isn’t the case in emergency departments, and people often go neglected and ignored. Most importantly, it often escalates them with respect to agitation, and suddenly you’re in the position of having to inject someone against their will to keep the overcrowded jail emergency from exploding.

Similar experiences to this are why “A” was so reluctant to go to a hospital and seek help. And because of that, he’s lost to the system. I hope he isn’t dead. I’ve done everything I could to reach out, and now, only time will tell how that story ends.

What I do know, is that psych wards are full, and it matters.

Editor’s note: This post is awfully critical of a lot. If there is one thing I am not critical of, it is the excellent work of my emergency medicine colleagues, who often find themselves overstretched as they save lives, due to poor government planning.

I am extremely critical of the dehumanizing psychiatric rooms so common in our emergency departments, and stand by my description of them as jail cells.

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