Willing, But Not Always Able, to Help the Mentally Ill
I could not agree more with the eloquent editorial on mental illness by Randy Danielsen (A medical catch-22. Clinician Reviews. 2010;20[9]:cover, 13-14). I have worked in corrections for about 10 years now and am oh so familiar with the fact that correctional facilities are the treatment of last resort for the seriously mentally ill. It is a tragic sign of our society’s shortcomings that the persons who need our help the most are being denied that help.
I know hospitalizing these unfortunate folks on a long-term or permanent basis would be expensive, but how could it possibly be more expensive than what we are doing now? Also, our outcomes would be so much better, and the person would be happier and safer. It would be a win-win situation.
Patty Workman, NP, CCHP, Charlottesville, VA
I have always been interested in and have intermittently worked with the severely mentally ill. What I would add to Dr. Danielsen’s editorial is that funding is not the reason the severely mentally ill and the families who love them are caught in this “government-induced” nightmare.
I am an “old” nurse who graduated in 1966—about the same time that states began, very happily, to close their state mental hospitals. This was in response to the federal government promising to provide more “humane” community services for those patients residing in state hospitals. Needless to say, these programs never adequately addressed the needs of the “severely” ill, who often don’t think they need help.
Also around this time, laws were changed to protect patients from being hospitalized or treated against their will, unless it was demonstrated that they were an “immediate threat to themselves or others.” As a result, even if resources are available to treat these severely ill people, many will refuse treatment, and there is little anyone can do.
I would add that some patients refuse to take medication, not because they think they don’t need it, but because of the side effects. In many cases, I would agree with them that the side effects are unacceptable. Sadly, the medical community continues to relegate the field of psychiatry to the periphery, and I believe this has hindered aggressive research into the etiology and treatment of the more devastating illnesses.
Over the course of my long career, I have witnessed numerous horror stories similar to the one described in your article. I wish I had a simple solution; but as a starting point, I think we should recognize that allowing severely mentally ill people to refuse all types of care was a mistake. If that can be changed, then we can look into what resources are most acceptable to patients.
Hopefully, the medical community will begin to accept that most severe psychiatric illnesses are biologically induced and should therefore be researched as vigorously as other illnesses.
Patricia M. Gamble, CRNP, Pittsburgh, PA
Thank you for yet another timely and insightful editorial in Clinician Reviews. I have a particular interest in this subject, as 87% of the patients in my practice have chronic and persistent mental illness in addition to their physical problems. I recently completed 40 clinical evaluations of NP students in a variety of clinical settings; 75% of the patients they examined had significant psych/mental health issues in addition to their physical health problems.
In 2005, the National Comorbidity Survey Replication noted that about half of Americans will meet the criteria for a DSM-IV disorder sometime in their lifetime. According to the Cross-National Collaborative Group, the number of people with depression has increased by 10% every decade since 1910. This increase is not due to better detection rates. This was an epidemiological study that utilized representative sampling and structured interviews that focused on the cardinal symptoms of depression rather than whether or not the subject had an actual depression diagnosis. The World Health Organization estimates that depression will be the single greatest cause of disability globally by 2020.
The 2001 data from IMS Health’s National Disease and Therapeutic Index showed that primary care providers were managing the psychopharmacology needs in 23% of schizophrenic persons, 18% of patients with depression, 16% of patients with dementia, 12% of bipolar patients, and 6% of patients with anxiety disorders. While psychiatrists treat most of the cases of schizophrenia, dementia is usually treated in primary care.
While a national legislative agenda regarding mental health is imperative if we are going to see large changes in the treatment of mental illness in this country, primary care providers, and those of us who educate them, have a role to play in ensuring that patients receive timely diagnosis and appropriate treatment. The research regarding bipolar disorder shows that, on average, it takes 10 years from the time a patient begins experiencing symptoms until a correct diagnosis is made. Most of these patients are misdiagnosed, usually by primary care providers, as having unipolar depression. The consequences of prescribing antidepressants to a person with bipolar disorder may include rapid cycling, induction of mania, and occasionally, suicide. I cannot think of a single physical health problem in which it is acceptable for it to take 10 years to obtain a diagnosis.