Mental Illness IS Real After All… So What Was I Treating Before?

July 26, 2011

I recently started working part-time on an inpatient psychiatric unit at a large county medical center.  The last time I worked in inpatient psychiatry was six years ago, and in the meantime I’ve worked in various office settings—community mental health, private practice, residential drug/alcohol treatment, and research.  I’m glad I’m back, but it’s really making me rethink my ideas about mental illness.

An inpatient psychiatry unit is not just a locked version of an outpatient clinic.  The key difference—which would be apparent to any observer—is the intensity of patients’ suffering.  Of course, this should have been obvious to me, having treated patients like these before.  But I’ll admit, I wasn’t prepared for the abrupt transition.  Indeed, the experience has reminded me how severe mental illness can be, and has proven to be a “wake-up” call at this point in my career, before I get the conceited (yet naïve) belief that “I’ve seen it all.”

Patients are hospitalized when they simply cannot take care of themselves—or may be a danger to themselves or others—as a result of their psychiatric symptoms.  These individuals are in severe emotional or psychological distress, have immense difficulty grasping reality, or are at imminent risk of self-harm, or worse.  In contrast to the clinic, the illnesses I see on the inpatient unit are more incapacitating, more palpable, and—for lack of a better word—more “medical.”

Perhaps this is because they also seem to respond better to our interventions.  Medications are never 100% effective, but they can have a profound impact on quelling the most distressing and debilitating symptoms of the psychiatric inpatient.  In the outpatient setting, medications—and even psychotherapy—are confounded by so many other factors in the typical patient’s life.  When I’m seeing a patient every month, for instance—or even every week—I often wonder whether my effort is doing any good.  When a patient assures me it is, I think it’s because I try to be a nice, friendly guy.  Not because I feel like I’m practicing any medicine.  (By the way, that’s not humility, I see it as healthy skepticism.)

Does this mean that the patient who sees her psychiatrist every four weeks and who has never been hospitalized is not suffering?  Or that we should just do away with psychiatric outpatient care because these patients don’t have “diseases”?  Of course not.  Discharged patients need outpatient follow-up, and sometimes outpatient care is vital to prevent hospitalization in the first place.  Moreover, people do suffer and do benefit from coming to see doctors like me in the outpatient setting.

But I think it’s important to look at the differences between who gets hospitalized and who does not, as this may inform our thinking about the nature of mental illness and help us to deliver treatment accordingly.  At the risk of oversimplifying things (and of offending many in my profession—and maybe even some patients), perhaps the more severe cases are the true psychiatric “diseases” with clear neurochemical or anatomic foundations, and which will respond robustly to the right pharmacological or neurosurgical cure (once we find it), while the outpatient cases are not “diseases” at all, but simply maladaptive strategies to cope with what is (unfortunately) a chaotic, unfair, and challenging world.

Some will argue that these two things are one and the same.  Some will argue that one may lead to the other.  In part, the distinction hinges upon what we call a “disease.”  At any rate, it’s an interesting nosological dilemma.  But in the meantime, we should be careful not to rush to the conclusion that the conditions we see in acutely incapacitated and severely disturbed hospital patients are the same as those we see in our office practices, just “more extreme versions.”  In fact, they may be entirely different entities altogether, and may respond to entirely different interventions (i.e., not just higher doses of the same drug).

The trick is where to draw the distinction between the “true” disease and its “outpatient-only” counterpart.  Perhaps this is where biomarkers like genotypes or blood tests might prove useful.  In my opinion, this would be a fruitful area of research, as it would help us better understand the biology of disease, design more suitable treatments (pharmacological or otherwise), and dedicate treatment resources more fairly.  It would also lead us to provide more humane and thoughtful care to people on both sides of the double-locked doors—something we seem to do less and less of these days.


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