Sunday, December 03, 2006

Just a Little Misery



Dr. John Crippen (not his real name) over at NHSBlog talked yesterday about the proposal for mandatory psychiatric evaluations on all patients admitted for hospice care. Regarding a cancer patient, he writes:

Of course he is bloody well down. He is about to depart from life. He is about to leave his wife and children. Forever. He knows this. He is not just down. He is seriously pissed off. Dying is an unpleasant business. Best avoided. But, if you have to do it, do not expect it to be fun or a clap-happy "learning experience."

He goes on to ask:

Do patients with cancer suffer from severe depression? Of course they do. Occasionally. And when they do, they need help, and support and possibly medication. But this is a rare occurrence. Patients ingrownowing toe nails get depression too, but you are not going to attach a psychiatrist to every chiropody clinic. Are you?If this trend continues, we will end up imposing a psychiatrist on every patient with cancer. Unnecessary, patronising and offensive.


I was thrilled to think of myself, in my professional capacity, as being "attached" to chiropody clinics, "imposed" on patients, and a referral for my services is "unnecessary, patronising and offensive." Great. What more could my image want?

One of his commenters talks about his cat's death and asks facetiously, "We were all a bit miserable....Do we need psychiatric help?"

I posted about this topic a while back. See
Help Me If You Can, where I wrote about my childrens' comments that their classmates go to therapy for a year when their parents get divorced. It's all part of the same line of questioning: Does one NEED therapy (or medications or any other psychiatric intervention) when bad things happen, be it cancer, grief, divorce? Treatment may help those who do become depressed following a stressor: half of all patients suffering from an episode of depression will identify a clear precipitant. Treatment may help those who are reacting in a dysfunctional, unusual, or highly symptomatic way. Treatment may offer a degree of comfort to distressed people even in the absence of mental illness. But does everyone who is exposed to awful circumstances NEED treatment? Nope. Some times life is just hard and there's no escape from suffering. It's hard to know what to say to this: Grief runs its course, people generally adapt to difficult circumstances, but it's hard to say Don't Get Help, when really, some folks find it helps.

Shiny Happy Person returned this weekend, and she writes one of the most eloquent descriptions of depression, as opposed to simple misery, that I have ever seen:

Utterly miserable is what a lot of people mistake for depression, but they are not the same thing. God, I should know.

Depression is both the most godawful, visceral agony, and a numbness so overwhelming you can't imagine ever feeling real again. It is an inability to feel or be affected by anything other than your own intense pain. It is frostbite of the mind. It is that dream where you want to scream but no sound
comes out. Depression is the feeling of walking through glue, both physically and mentally, which reflects in the effort it takes to open your mouth to speak. Depression paints the world monochrome and muffles all sounds. Depression strips away your personality and leaves you two-dimensional. Normal human functioning diminishes; sleep dwindles to nothing, food becomes an alien notion, weight falls from your bones in a physical representation of your character and the person you have forgotten you used to be. Depression is crawling on hands and knees to get to the bathroom; it is lying in bed and wondering if you would be able to move if the house was on fire. It is trying to carry out a familiar activity and not having the first clue what to do.

12 comments:

Dinah said...

to my co-bloggers, Help! why are my block quotes printing like bad poetry>?

Midwife with a Knife said...

Ah... I think it's the unfortunate nature of psychiatry. I think people find psychiatrists a bit intimidating (like.... you know more about what's going on in my head than I do. ACK!), which leads to some sort of distrust or something. (For what it's worth, being a vaginal doctor has it's pitfalls, also ;))

If it makes you feel any better, our residency program used to "impose" mental health on us. There was a therapist who worked with the ob-gyn department where I was a resident who we were required to see a few times throughout our residency. At first it seemed like a huge imposition (just imagine cranky residents being forced to do one more non-patient care related activity).

It did really benefit a close friend of mine. When the shit hit the proverbial fan (bad case... baby died, mom died, the resident in question wished he had died), a friend of mine (that particular resident) felt more comfortable seeking some mental health care that he very much needed (and might not have sought if he had no prior exposure except as a medical student on a psych rotation, which is minimal exposure, and not the same as being a patient), and very much benefitted from, and without which his life might be drastically different to this day.

He didn't end up being treated by this particular ob-gyn dept. therapist, but he at least felt comfortable enough to go meet with him to get some referrals for psychiatrists who were outside of our particular hospital (you know, people he didn't work with).

(This bit of a story was posted with the permission of the involved resident).

Anyway, good mental health care changes and saves and preserves lives. You shrinks get a bad rap sometimes, but let me assure you that people appreciate what you do, both as health care providers and as patients. If I didn't have a psychiatrist to help me figure out what to do with some of my patients, I wouldn't be able to be a good obstetrician.

Alison Cummins said...

I was bemused by the hospital's reaction when my father-in-law, admitted for end-stage emphysema, said "I want to die." First they sent a psychiatrist who prescribed an antidepressant. The same evening they started a morphine drip and called the priest for last rites. He was dead by morning.

If "I want to die" is a reasonable request by a competent adult to be followed up with immediate action to hasten that end, then it seems odd to treat it with antidepressants.

If "I want to die" is the suicidal ideation of the clinically depressed and warrants immediate medical intervention, then why the rush to start that final morphine drip?

I'm not one of those who thinks that the only people who can benefit from the insight of someone trained in psychiatry/psychology are those with an organic brain disorder. But that was peculiar.

Mandatory psychiatric evaluation for the dying seems completely appropriate to me. I presume it would include a review of medications the patient is taking to ensure that they aren't contributing unnecessarily to paranoia or simulating dementia or anything, for instance. Someone dying of cancer with brain metastases might conceivably have personality changes that others have trouble adjusting to. And just because suffering is to be expected doesn't mean it has to go unalleved in any way.

Of course, the policy may simply be a CYA move to rubber-stamp the sedation of difficult patients. I don't know, I'm not there.

Nutty said...

I'm in the UK. We have a national shortage of psychiatrists. The last figures I saw for it were that 14% of consultant psychiatrist posts were vacant. In that climate, most mental health problems, including clinical depression, are dealt with in primary care by the general practitioner, with support from counsellors where appropriate. Referrals to psychiatrists are generally for severe or enduring mental illness.

I have bipolar disorder and spend quite a bit of time with others with bipolar disorder. From that, I know that not everyone diagnosed by their GP with bipolar disorder is referred to a psychiatrist. Ditto many other mental health conditions, and more so with tight budgets in many parts of the country.

Further, in the UK, people do not get initially assessed by a psychiatrist. Their GP assesses them first, and then passes them on to the mental health team if appropriate. Why should this be different for cancer patients?

And why should people with severe mental illness who already have difficulty seeing a psychiatrist have their access further curtailed so that the psychiatrist can spend time assessing people who should have been assessed by their GP?

DrivingMissMolly said...

At work my medical insurance has a $2000 deductible for my out of network psychiatrist. Each visit with him is $190.

My $100,000 life insurance policy will pay if I kill myself. Go figure! It's like..I want to tell them, please help me because if I kill myself it's going to cost you the hundred thou, but nobody listens.

I wish I didn't have to see a psychiatrist. It is too expensive and good ones are hard to find. Then there is the stigma.

I wish I had cancer instead of depression and a personality disorder.

I also have a problem with the dynamic of older male psychiatrist and younger female patient. Something just isn't right with that but I can't put my finger on it.

I guess that I am feeling hopeless right now. I want to move up my December 20th appointment to see my psychiatrist but not only do I NOT have the money, my boss wants a two week notice whenever I take vacation leave and it takes me a long time to get to the doc's office and back since I am afraid to drive to Dallas so I take the train.

Poor pitiful me. (sigh)

I think when a person is ready to die, from, for example, a terminal illness, it is insulting to make them see a shrink. Sometimes it is just time to die. Doctor's need to know when to back off, especialy if the patient is terminal, accepts it, and isn't manifesting signs of mental illness.

healthpsych said...

In the hospital environment I worked in previously, a mandatory screening by a psychologist was part of the multidisciplinary treatment program for amputees post-surgery. The purpose was two-fold - to screen for delirium and other cognitive changes possibly related to surgery/pain medication and to assist with adjustment. Quite sensible, although some patients were less than impressed. However, because it was incorporated into the overall care package, resistance/offence taken was generally lower.

Otherwise, standard screening for all patients? No. Often called in for patients who medical staff feel are not coping with their medical condition or other illness-related issues but sometimes that's just part of the normal adjustment process and it's perfectly valid to feed that back.

Dinah said...

It feels like a sticky issue to me: I'm not much for "imposing" psychiatric treatment on people, but sometimes people who are forced into treatment (or who are recruited from some type of programatic screenings) benefit.

So I agree with John and everyone else who is not in favor of mandatory evaluations upon entry to hospice, sadness is natural in the face of awful circumstances.

I also object to telling someone who wants care because they are distressed in this setting (care being either someone to talk to or a full psych eval to consider the addition of medications) that their reaction is natural and they don't Need treatment.

As awful as everyone feels about psychiatric evaluations: offensive, intrusive, imposed, attached, insulting are words that have been used here. Essentially, a psychiatrist shows up at the bedside and asks a lot of questions-- it's not that horrible a process, and often, if the shrink and the patient click-- it's helpful. The patient is free to say "Go Away" (believe me, I've heard it many times. I go.) If the patient is more amenable, it's not the end of the world if the result of the evaluation is that the doc writes a note saying the patient is having an appropriate response to horrible circumstances and either does not want or does not need further psychiatric treatment. It's not the end of the world if the psychiatric suggests further treatment and the patient refuses, or if the patient doesn't want to take the recommended medication. You wouldn't flip if a neurologist showed up at your bedside and said "I hear you're having headaches."

To Alison: an awful story about your father-in-law, but I do understand why his doc might want someone to check out his comment about wanting to die; in this case it's possible the main doc just didn't want to sit with him long enough to figure out if this was cause for concern.

To Nutty: I agree.
To MWWK: Strange to have psychiatric care imposed in a work place, glad it was helpful to your buddy and thanks for the kind words. Generally, I've found the world of psychiatric patients (I see voluntary ones who come looking for me) to be rather appreciative and it makes for nice days.

HP: interesting.

These talks remind me of the fact that it was (when I was a young resident, oh the good old days) required that couples have psych evals before entering into in vitro fertilization. Talk about an unhappy crew of evaluees: these were married couples who'd already spent years trying to conceive, all with health insurance. It's the oddest thing: 16 year old single unemployed crack addicts are allowed to get pregnant without prior psych evals, and here the issue isn't one of "treatment" it was one of being allowed to get pregnant.

Psych evals are still required (I think) before bariatric surgery. I once suggest to the surgeon that my patient was not a good candidate--major mental illness, difficult to stabilize, on many meds, and now they want to mess up the entire absorption process? You'll be happy to know that the surgeon preformed the surgery anyway. Years later, he's fine (and a bit thinner).

Gerbil said...

I sometimes wonder whether this kind of pre-mortem consult is actually for the benefit of the physician. I'd imagine that it's awfully stressful, anxiety-provoking, and downright depressing to know that you really can't provide much more than palliative care for your patients with terminal illnesses. So the obvious thing to do is to project your stress, anxiety, and sadness onto your patient and call for a psych consult, right? Then you can feel like you've actually done something.

Uh, yeah.

Perhaps patients should be given a choice: they can see a chaplain (or their own clergyperson), a psychologist/psychiatrist/soical worker, or just have some last private time with their families. Because really, death is sad and scary enough as it is. If a person does not expect (or want!) to live out the week, why try to treat his/her "depression" with a medication that will take 2-3 weeks to work? IMHO, better to allow him/her to decide how, and if, to make some peace--and whether a complete stranger ought to be privy to it.

Midwife with a Knife said...

Apparently tonight is my night to blog and surf the net when I should be working.

Anyway, I think it is rediculous to require IVF pts to have psych evals (although infertility can be a stressful experience for many people). I do, however, think that the required (in most IVF programs, anyway) psych eval for egg donors is reasonable. I think that that's a sufficiently weird situation that having someone with an untreated mental illness or who simply can't anticipate how knowing that a baby that came from their egg will make them feel is asking for trouble.

I suppose that one could make the same argument about sperm donors.

healthpsych said...

Often called in for patients who medical staff feel are not coping with their medical condition or other illness-related issues but sometimes that's just part of the normal adjustment process and it's perfectly valid to feed that back.

***

Sorry...read that again and I just wanted to clarify that I meant feed that back to the medical staff - not the patient - when the patient doesn't feel they need psychological assistance.

*note to self - must engage brain before posting*

ClinkShrink said...

I fixed your block quotes.

NeoNurseChic said...

I wrote a long comment on his post over there. But the one thing I'll go back to now is that at the headache center, every new patient has to have an eval by a psychologist/psychiatrist at the first appointment. This is done before you ever even see a nurse or doctor. Many patients in the waiting room freak about this being the centers way to weed out the "true" headache patients versus the ones where it's all in their head, for whatever reason. And I'm sure you can imagine why. Anybody who goes to a specialty center (especially one like this one where the wait for a 1st appt is very very long) has been to, at the very least, their primary doc and a general neuro. Lots of people (myself included) have heard that the headache is made up or due to stress or whatever...any way people can find to rationalize something they don't understand. So you can imagine the feelings people have when they have to have a psych eval at the 1st appt. I have personally spoken with many people while sitting in the waiting room about that very thing - just to put them at ease and tell them the real reason is just to look for any psychiatric comorbidities that may be contributing to headaches. Depression and migraine theoretically use the same neurotransmitters and theoretically, when one is worse, it exacerbates the other. That is the real reason for the psych eval. Apparently, they do not put cluster sufferers through that, but I think that's dumb. Cluster sufferers almost uniformly suffer from depression due to their disease. Sure, maybe it's not a contributing factor in the case of cluster headache. Neurotransmitters do not have anything to do with clusters. But I still think it would be important to have that psych eval.

So I've mentioned that - and I guess that's sort of along these same lines. They don't do it because CH sufferers aren't worsened by depression, etc.

I personally have found it very helpful that the center has a psychiatrist and psychologist. I don't see the psychiatrist anymore there, but it used to be when I was in the hospital, he always came around on Tuesdays. I have my own psychiatrist now, so he doesn't come if I'm in the hospital. And the psychologist still comes every day. This would be if I had depression or not. He always starts off the conversation the first time with, "Heard you were back in here. How ya doin?" in a very slow, southern drawl...imagine Eeyore saying those same words, and you've got his mannerisms down! Now if I had some serious psychiatric illness, I'm not sure he would be the most helpful, but he's well-liked by most in this population. Does a lot with mindfulness meditation and biofeedback.

Should every person be given a psychiatric eval in hospice? No. And yes, I agree with Dinah that while it should not be forced, nobody should be denied just because they are "supposed" to feel sad when they are dying. But I want to take it one step further. When in the hospital and the pscyhologist comes around, I like it. I like that somebody stops by to ask how I'm doing - and doesn't mean, "how's your headache on a scale of 1-10?" All too often in medicine, we treat symptoms and diseases, not people. So maybe if not a full-out psychiatric eval, they could have a psychologist or counselor on staff at the hospice just to stop by each patient's room (especially new patients) and ask them how they're doing. I don't see anything wrong with that. I bet they'd end up finding people really did like to talk to them.

My 0.02.

Good topic, as always! Take care!
Carrie :)