Stanley T. Lewis, MD, MPH, AAHIVS
Fannie Lou Hamer famously said, “I’m sick and tired of being sick and tired.” She was specifically referring to the discrimination suffered by blacks in the 1960’s in the struggle to secure voting rights. However, that statement reflects a sentiment that is universal and timeless. No one wants to feel sick and tired. And certainly no one wants to feel sick and tired all the time! There comes a time when things must change. There comes a time when you’re worn out and you just can’t take it anymore.
But when is that time? Specifically, when is it time to treat affective disorders like depression or bipolar disorder? When is it time to treat schizophrenia and other psychoses?
Danger To Self Or Others
The most emergent time to intervene in the life of a person suffering from a mental health disorder is when that person becomes a danger to him/herself or when that person threatens another person. This situation is so serious, that it is one of the few non-criminal situations that can result in the loss of one’s freedom. While being mentally ill or even psychotic is not illegal, it is unacceptable/illegal to threaten to take your own life or threaten to take the life of another person. Danger to self or others is a psychiatric emergency and calls for immediate intervention. While some state laws vary, any person threatening or attempting to take their own life or the life of another can be detained and held for a period of time as to assess their mental health and capacity by a trained medical professional.
Perhaps we have become immune to the reports of famous people having ‘nervous breakdowns’ or exhibiting bizarre behaviors. The reporting often fails to convey the serious nature and potential consequence when a person’s emotional state reality spirals out of control or they lose grip on reality. Insight and access to the proper support are vital to any attempt to abort the mental health crisis. And news reports will tell the story of the famous because the sensational sells and gets ratings. However, the magnitude of the problem is far greater than tabloid stories. When a person becomes a danger to themselves or others, it is an incredibly vulnerable time for the patient, their loved ones, and perhaps other members of the community. We tend to find ways to contextualize things that we don’t understand in ways that allow us to diffuse the intense emotional burden that thinking about it seriously would require. We find a way to make it ‘other’ or ‘oh well’. We even sometimes say that we are sick and tired of these stories! But I would suggest that these stories are real and far too common and too important to ignore. We can and must do a better job of highlighting the seriousness of mental health disorders and improve the sensitivity and empathy we have for the victims of these disorders.
Likely To Deteriorate Or Progress
Mental health disorders are a tremendous burden for patients and on our society. When a person suffers from a mental health disorder, they run the risk of losing their life as mentioned above, but they are also at extremely high risk of losing other aspects of their lives that can be devastating as well. Depressed people are very hard to live with. Spouses can get exhausted and leave. Those suffering from bipolar disorder can have an extremely difficult time holding a job and employers don’t always recognize the illness before they terminate employment. Schizophrenic people have a terrible time keeping most all aspects of their lives straight. In periods of psychosis, they can lose everything and often end up homeless and in extreme poverty.
Intervention in times when there isn’t an obvious danger to self or others can be tricky. Keeping in mind that being depressed, bipolar, or even psychotic are not illegal, people suffering from these and other mental health conditions retain their rights to ‘life, liberty, and the pursuit of happiness’. If a patient has no insight, but their mental health status is deteriorating in ways that are likely to result in the patient becoming a danger to self or others or deteriorating in a way that catastrophic loss is likely or imminent, a healthcare professional can be obliged to intervene. Patients may or may not welcome such intervention and they may outright refuse offers of help. Enlisting the assistance of a patient’s friends, family, and support system may be helpful, but ultimately, providers must respect the patients’ autonomy and right of self-determination.
Insight is a beautiful thing and perhaps the most positive predictor of a successful outcome to any mental health diagnosis. No words are more empathy-evoking than ‘I need your help’ when spoken by a person with a mental health disorder. The ability to acknowledge that there is a problem AND the desire and sincere effort to face down a mental health problem is incredibly courageous. To do so, a patient must reject the pervasive notion that they are indeed ‘normal’. Then, they must go a step further and seek the advice and counsel of others. Finally, they must trust that their healthcare providers are caring, knowledgeable, and able/willing to diagnose and prescribe a course of treatment to restore good mental health.
It is important to keep in mind that insight is often, if not always, a journey. It is a goal whenever a provider attempts to intervene. Mental health disorders can be incredibly frustrating to treat because insight is not a stagnant or linear characteristic. Insight can wax and wane. It’s easy to get sick and tired as a provider, but it is just as easy to get sick and tired of actually having the mental illness. Only the patient has far greater consequences if their frustration results in giving up on treatment. The morbidity and mortality of mental health disorders are sobering and cannot be taken lightly. On the other hand, successfully treating mental health disorders is incredibly rewarding. In some instances, it’s like saving a life. In some instances, it is actually saving a life.
About Stanley T. Lewis, MD, MPH, AAHIVS
Dr. Lewis is an Internal Medicine physician with more than 20 years of clinical and research expertise. Dr. Lewis is the chief medical officer at St. Hope Foundation and has served for several years as the Assistant Professor of Medicine in the Department of Internal Medicine at the University of Texas Medical School in Houston. Dr. Lewis is a researcher and HIV specialist recognized by the American Academy of HIV Medicine. Dr. Lewis’ motto is “I am here to care for the patient.”