Posts under ‘behavioral health’

Visiting a patient today who has been out of touch and difficult to reach, I realized how isolation and loneliness will inevitably undermine any effort to improve an individual’s health over the long term. The details of his many comorbidities aside, one of the conditions from which my patient suffers most is loneliness, and the prescription for its treatment is not easy to elucidate or prescribe.

“I hate everyone and everything!” he yelled, staring at the high definition television he purchased last month. “I have no one to do anything with. I do everything alone. When I was drinking I had friends. And now? Twenty months sober and I have no one!”

When I arrived, his bottles of medication were strewn across the floor of his apartment.

“I ain’t takin’ this shit no more! F**k medication! F**k my health! I should just f**ckin’ die!” He continued to stare at the TV, changing the channels.

I gently took the remote control from him, turned off the TV, and placed the remote behind me on the couch.

“What the f**k are you doing?” he yelled.

“I’m getting you to listen,” I said.

The conversation continued in earnest, peppered with laughter, some return to swearing and yelling, and an eventual handshake and promise to talk tomorrow. I felt fairly certain that the suicidal talk was just that—talk, and nothing was going to happen to him tonight.

“Look,” I said. “I know you feel bad. I know you’re lonely. You’re sick of your meds. Let’s get together and talk about what to do and how to start over, OK?”

“OK.” He smiled. “Hey, tell your wife I said hi, eh?” He met Mary at my office once a few months ago and now gives me advice on what movies to take her to see.

“I will. No problem. Are you gonna be OK?” I hold the screen door open, making eye contact with him one more time.

“Yeah, I guess. F**k it! I’ll talk to you tomorrow.”

“Good night.”

“See ya, and thanks.”

Solitude. Loneliness. Isolation. There’s no pill, no test, no easy solution. And often, as clinicians, we’re flying by the seat of our pants and pulling rabbits from hats. My rabbit today was simply being present. And the hat? An old-fashioned nursing cap.

This afternoon, my boss sent out an email asking us all to review our caseloads and identify which patients we interact with almost exclusively vis-a-vis mental illness, behavioral health, or substance abuse. He then asked us to also identify those patients for whom mental illness is a major factor which often leads to self-neglect on the patient’s part, but who also carry multiple co-morbidities.

Well, as I reviewed my caseload and began to compose my email in response, the first list was rather short. There are perhaps half a dozen patients out of my 80 who have no other notable morbidities other than mental illness of some kind. The second list, which grew to considerable length quite quickly, numbered approximately fifty. Looking at the two, it once again became starkly clear how my work is, to a large extent, behavioral in the nature of its interventions. While I do indeed respond to many patients’ physiological symptoms and complaints—listening to noisy lungs, palpating edematous limbs, evaluating strained backs, assessing abdominal pain—the lion’s share of my work is often that of fielding calls of psychic distress, assuaging fears, and otherwise calming the minds and hearts of individuals in mental pain.

Yesterday, I recounted the tale of accompanying a patient to the gastroenterologist. I mentioned in that post that the patient’s depression with psychotic features will often preclude her ability to grasp the situation at hand during medical appointments. Examining this very kind woman, one could not necessarily tease out whether her psychological issues trump the physical when measuring their importance or need for intervention, but it is strikingly obvious that her ability to cope with her various diseases is considerably challenged by her mental state. One might further argue that her mental/emotional state directly affects her physiological state on a moment to moment basis as well as in the long term. A mind which is almost exclusively focused on the negative—dwelling in fear and anxious worry with a powerful undercurrent of powerlessness—can only serve to poison the well, figuratively speaking, exacerbating illnesses and their processes, strengthening symptoms, weakening the immune system, and delaying recovery.

The lack of parity in health care when it comes to behavioral health goes a long way towards diminishing the amount of time and resources devoted to mental health. Insurance plans are skimpy with behavioral health allowances, awarding paltry numbers of psychotherapy sessions during each treatment year. While an insured patient can go to the doctor an unlimited number of times for physical complaints with no questions asked, insurers will often question a patient’s need for weekly therapy, deny requests for extensions beyond short-term treatment, and make mental health clinicians leap through hoops of fire to win additional sessions for the suffering client. How can this be?

Here on the front lines, somewhat removed from the watchful eyes of bureaucrats who question our motives and actions, we struggle to treat the suffering sufficiently. But even our cutting-edge program is underfunded in terms of behavioral health, with only one full-time clinician to oversee and coordinate the care of over 800 patients. Relying on private and public mental health clinics in the city, we are often left holding the bag. Long waiting lists, incompetent clinicians, and flawed referral systems act as long-term deterrents to our patients‘ ability to receive the care they need. Frustration abounds. Sure, a CT-scan can be had under duress, but when a psychiatrist or psychotherapist is urgently needed, even moving a mountain will be in vain.

So, we limp along, the psychic band-aids applied, slowing the gushing river, but never stemming the tide. The imagery of life-boats and life-preservers comes to mind, but on the horizon—a tsunami.