Mental Illness and Social Realities

Does the definition of “mental illness” differ from place to place?  Is there a difference between “depression” in a poor individual and in one of means?  Are the symptoms identical?  What about the neurobiology?  The very concept of a psychiatric “disease” implies that certain core features of one’s illness transcend the specifics of a person’s social or cultural background.  Nevertheless, we know that disorders look quite different, depending on the setting in which they arise.  This is why people practice psychiatry, not computers or checklists.  (Not yet, at least.)

However, sometimes a person’s environment can elicit reactions and behaviors that might appear—even to a trained observer—as mental illness.  If unchecked, this may create an epidemic of “disease” where true disease does not exist.  And the consequences could be serious.

—–

For the last three years, I have had the pleasure of working part-time in a community mental health setting.  Our clinic primarily serves patients on Medicaid and Medicare, in a gritty, crime-ridden expanse of a major city.  Our patients are, for the most part, impoverished, poorly educated, have little or no access to primary care services, and live in communities ravaged by substance abuse, crime, unemployment, familial strife, and a deep, pervasive sense of hopelessness.

Even though our resources are extremely limited, I can honestly say that I have made a difference in the lives of hundreds, if not thousands, of individuals.  But the experience has led me to question whether we are too quick to make psychiatric diagnoses for the sake of convenience and expediency, rather than on the basis of a fair, objective, and thorough evaluation.

Almost predictably, patients routinely present with certain common complaints:  anxiety, “stress,” insomnia, hopelessness, fear, worry, poor concentration, cognitive deficits, etc.  Each of these could be considered a feature of a deeper underlying disorder, such as an anxiety disorder, major depression, psychosis, thought disorder, or ADHD.  Alternatively, they might also simply reflect the nature of the environment in which the patients live, or the direct effects of other stressors that are unfortunately too familiar in this population.

Given the limitations of time, personnel, and money, we don’t usually have the opportunity for a thorough evaluation, collaborative care with other professionals, and frequent follow-up.  But psychiatric diagnostic criteria are vague, and virtually everyone who walks into my office endorses symptoms for which it would be easy to justify a diagnosis.  The “path of least” resistance” is often to do precisely that, and move to the next person in the long waiting-room queue.

This tendency to “knee-jerk” diagnosis is even greater when patients have already had some interaction—however brief—with the mental health system:  for example, a patient who visited a local crisis clinic and was given a diagnosis of “bipolar disorder” (on the basis of a 5-minute evaluation) and a 14-day supply of Zyprexa, and told to “go see a psychiatrist”; or the patient who mentioned “anxiety” to the ER doc in our county hospital (note: he has no primary care MD), was diagnosed with panic disorder, and prescribed PRN Ativan.

We all learned in our training (if not from a careful reading of the DSM-IV) that a psychiatric diagnosis should be made only when other explanations for symptoms can be ruled out.  Psychiatric treatment, moreover, should be implemented in the safest possible manner, and include close follow-up to monitor patients’ response to these interventions.

But in my experience, once a patient has received a diagnosis, it tends to stick.  I frequently feel an urge to un-diagnose patients, or, at the very least, to have a discussion with them about their complaints and develop a course of treatment—which might involve withholding medications and implementing lifestyle changes or other measures.  Alas, this takes time (and money—at least in the short run).  Furthermore, if a person already believes she has a disorder (even if it’s just “my mother says I must be bipolar because I have mood swings all the time!!!”), or has experienced the sedative, “calming,” “relaxing” effect of Seroquel or Klonopin, it’s difficult to say “no.”

There are consequences of a psychiatric diagnosis.  It can send a powerful message.  It might absolve a person of his responsibility to make changes in his life—changes which he might indeed have the power to make.  Moreover, while some see a diagnosis as stigmatizing, others may see it as a free ticket to powerful (and potentially addictive) medications, as well as a variety of social services, from a discounted annual bus pass, to in-home support services, to a lifetime of Social Security disability benefits.  Very few people consciously abuse the system for their own personal gain, but the system is set up to keep this cycle going.  For many, “successful” treatment means staying in that cycle for the rest of their lives.

—–

The patients who seek help in a community mental health setting are, almost without exception, suffering in many ways.  That’s why they come to see us.  Some clinics do provide a wide assortment of services, including psychotherapy, case management, day programs, and the like.  For the truly mentally ill, these can be a godsend.

For many who seek our services, however, the solutions that would more directly address their suffering—like safer streets, better schools, affordable housing, stable families, less access to illicit drugs, etc.—are difficult or costly to implement, and entirely out of our hands.  In cases such as these, it’s unfortunately easier to diagnose a disease, prescribe a drug which (in the words of one of my colleagues) “allows them to get through just one more night,” and make poor, unfortunate souls even more dependent on a system which sees them as hopeless and unable to emerge from the chaos of their environment.

In my opinion, that’s not psychiatry.  But it’s being practiced every day.

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13 Responses to Mental Illness and Social Realities

  1. leejcaroll says:

    This is an interesting abstract: A comparison of psychiatric symptoms between Anglo-Americans and Mexican-Americans with schizophrenia.http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2000-16232-005 The author concludes “Results suggest that the presentation of even a very biologically determined disorder such as schizophrenia can be shaped by sociocultural factors. Specific aspects of Anglo-American and Latino cultures that may influence symptom patterns in patients suffering from schizophrenia are discussed.”
    Another issue: In the US we do not always take care of our ill and elderly, leaving them at the mercy of the medical and menatl health system. Anxiety, stress, etc are natural outcoms of lonliness, fear, of having to take no one to take care of you. Without a support system to lean on the medical and psych system may be taking the place of this important societal structure.

    • stevebMD says:

      leejcaroll,

      The comments in that abstract remind me of what my supervisors and other peers tell me when I point out that it is possible a patient isn’t “mentally ill,” he’s just experiencing the devastating burden of his surroundings. They routinely say something like “Oh, you don’t know what it’s like to live the way he lives. There’s no way he’s not mentally ill… you’d be, too!! You just don’t understand him.”

      I fear that some people assume mental illness is the only possible explanation for some patients’ suffering. Once someone makes that assumption, it’s way too easy for them to latch onto research like this, proving their point and effectively squelching any alternative opinion.

  2. Great post – I really enjoyed this one. This is something that is seen worldwide, not just in places where there is low socio-economic status or living conditions. Anywhere with time constraints, particularly government funded medical centres with limited budgets for wages and maintenance tend to opt for the easy diagnosis and get the next patient through asap. While this works for “getting the patient through just one more night” you are entirely correct in saying that it is not psychiatry. I doubt in many of the government funded medical centres that the fast diagnosis is for the benefit of seeing many more patients to help, but for the benefit of seeing more patients to get more money. I have experienced it in a high socio economic region as well. It is worrying when medical professionals prescribe on the basis of a statement that someone could look up on google. At this rate anyone will be able to walk into a doctors office and place their order for whatever prescription they want, whenever they want. Scary.

  3. leejcaroll says:

    Definitely a definitional issue. What is mental illness? What is appropriate response to devastating circumstances?
    (Anecdote: I was advised that ‘rational suicide’ was acceptable in my case by a psychiatrist, neuroophthalmologist and other mental health professionals, because nothing more could be done for my trigeminal neuralgia pain that, at the time, was so bad I was getting my face washed under general anaesthesia. I was virtually housebound and disabled because of the pain. It was interetsing that the psychiatrist, owner of a pain clinic I was attending, called the head psychiatrist for the Maryland Court system. He was told I could not be involuntarily committed as a suicide risk because my suicidality was a legitiate response to a legitimate situation. I think that doc was unusual (as were the others) in accepting that sometimes life causes you to behave in ways that are situationally appropriate but against societal norms.

    • stevebMD says:

      leejcaroll: “What is mental illness? What is appropriate response to devastating circumstances?”

      I would argue that the former question needs to be answered first, before answering the latter question with a prescription for a psychotropic. Unfortunately, sometimes that’s not the way it’s done.

    • leejcaroll says:

      An afterthought: Friends of mine believe in ghosts and tell stories of seeing ‘spirits who walk through walls and talk to them’. In psychiatric terms they would be disagnosable. In their real life, they are fine- absent this belief in the spiritual and psychic world. If seen by a psychiatrist who did not know them and asked “Do you hear voices or see people who aren’t there?” the answer is “Yes.” Without context, without time to talk with them, they could well be handed a psych script and label for their ‘disorder’.

  4. stevebMD says:

    Great op-ed piece from SF Chronicle, August 2010 (just was forwarded to me today). “We must address the avoidable causes of disease,” the author writes. I agree, social injustices are no excuse to pump someone full of antidepressants or antipsychotics.

    http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/08/22/ED0M1F0U4O.DTL

  5. leejcaroll says:

    “If I had known more about the resources available to Jeremy’s family, I might have recognized sooner that his real problem was hunger.”
    I think the problem is not that simple. You can know about all the resources – that does not necessarily translate into thinking of that when a patient comes into the office. My feeling is, when a patient presents with body complaints, the thght is not what might their life be like but what diff dx causes abdominal pain. Esp if you are not practicing in a low income area.
    Hunger is not necessarily a cause of disease but of discomfort and pain, yes. Psychiatrically, I think it is more complex relating to your reply to the ? what is mental illness?
    Carol
    (http://apainedlife.blogspot.com/ )

  6. JFMD says:

    Having been in the field more than 30 years, the picture you draw of rapid fire diagnoses pressed out by a system that churns people has become all too familiar except in a few enlightened settings. As you may know, there was a good deal more funding several decades ago.

    Yet, as much as the financial and ‘efficiency’ factors have become dominant with the corporatization of health care, the driver is the values that underly the broader culture, with the trickle up everywhere in evidence. Across the board — not simply in psychiatry, but in the practice of medicine, both the pill and technology have been replacing human touch and that deeper exchange that can do more to mend what is frayed than many other interventions, particularly when in the hands of a skilled practitioner. (Have you read Verghese’s Op-Ed Piece NYTimes Feb 27 and my letter to the editor of March 2 in response; it it the first at the top of the Letters page.)

    However, I do believe that in spite of the depth and skill of many fine psychiatric colleagues, the isolation of practice itself reinforces and sustains this state of affairs. Patients — often from unbelievably traumatizing and traumatized environments — are seen individually, one after another — a scenario that reinforces the isolation and stigma so many of them bring and that we experience and that leaves practitioners themselves in a state of continual ‘overwhelm.’

    New paradigms of care are urgently needed to integrate newer, more effective therapies with economic realities — using groups in innovative ways as well as people drawn from the communities themselves to provide bridging and outreach once trained. Finally, reconnecting psychiatry with other providers (not confined to behavioral health staff either) can become catalytic for shifting the patient and caregiver experience.

  7. […] at least part of my time working in community mental health (and have written about it here and here).  Before that, though—and for the majority of my training—I worked in a private, academic […]

  8. […] stressors that detrimentally affect their physical and mental well-being.  In these patients, we give psychiatric diagnoses far too liberally (often simply to give patients the opportunity to keep coming to see us, not because we truly […]

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