We have met the enemy and he is us

Over the course of evaluating hundreds of patients in the last 5 years, the most common chief complaint I have heard has been “I’m hearing voices telling me to kill myself.” This complaint nearly always indicates a very specific type of patient. They are almost always male, frequently arriving to the emergency room on foot or occasionally brought by ambulance. Their visit is precipitated by a long night of smoking significant quantities of crack cocaine, often accompanied by alcohol and other illicit drugs. Many of these patients are homeless and a significant amount have past or current criminal records. What becomes quickly apparent is that these patients are primarily interested in a warm, safe place to sleep off the inevitable cocaine crash that follows the hours of binging. Indeed, they are often very demanding, entitled and frequently abusive to staff despite the fact that they have presented voluntarily for “help.” In moderate to large quantities, cocaine will produce or exacerbate irritability that coupled with less than savory personality characteristics, form a rather difficult combination for hospital staff to address. In the end, the patients do not actually seek treatment but rather secondary gains (temporary housing, food, warmth, etc).

The main difficulty is that this population has learned that in order to obtain these secondary gains, they must endorse suicidal ideations or the aforementioned complaint of command auditory hallucinations. Otherwise, if such a patient presented simply stating that they had just used a large quantity of cocaine and needed to sleep in the hospital for the evening they would not be admitted, let alone treated in the emergency room. Since suicidality is primarily a subjective component, the hospital is then forced to at least observe the patient, if not admit them altogether. The primary motivation is liability avoidance. If this patient continues to insist that they are suicidal, despite evidence to the contrary, most clinicians will be reluctant to discharge them for fear that the individual may actually leave and hurt themselves. Unfortunately, this thinking completely contradicts any logical, rational clinical judgment, especially when there is strong evidence to indicate otherwise both in terms of past history and current objective evidence.

In my own experience, most of these patients are recidivists. Many of them present quite frequently (weekly, once a month, etc) with the exact same complaint and symptoms. The subsequent evaluation bears out little objective evidence of a true psychotic process, depression or suicidality. The former two components are easier to identify through the evaluation, either by direct observation or simple questions. The voices they claim to hear typically emanate from inside their head and say nothing else but “kill youself.” A person suffering from a non-substance induced psychosis, if they are having hallucinations, will often hear loud voices or sometimes noise coming from the external environment. One can also often see other notable symptoms of psychosis, such as internal preoccupation, thought blocking, responding to hallucinations (ie, talking back to the voices) and inappropriate affect (laughing for no apparent reason). With the cocaine abusing patient, these symptoms are rarely, if ever present.

The interview becomes somewhat difficult to conduct because of their irritability, little desire to answer questions at length, somnolence and general uncooperative behavior. The problem in the end lies in the question of suicidality. There really is no accurate way to objectively determine whether a person is genuinely suicidal or if they are simply lying for their own gain. There is no brain scan, blood test or magic question to assess for this. What we have however, is past history, research and related symptoms that can easily indicate otherwise. Examined as a whole, these factors can easily point the way to whether a patient is fabricating a condition for personal gain or truly suffering from an illness. Unfortunately, most clinicians simply do not want to discharge a suicidal person even if the constellation of symptoms points to the obvious. Certainly in our role in the ER, we are asked to evaluate many people like this. The medical team may be acutely aware that they are dealing with a malingering sociopathic criminal but rather than showing them the door, they ask for yet another psychiatric evaluation for a patient that has no true psychiatric illness. Essentially, they are passing the responsibility to another set of clinicians.

In the end, these patients absorb a lot of resources: time spent “evaluating” and observing them, catering to incessant demands for food, medications and other material comforts and in many cases hours spent needlessly securing them a bed in a psychiatric unit. In the psych unit, the course of events is as predictable as is their presentation in the ER. Most of their time is spent sleeping and eating, with little participation in treatment such as groups and psychotropic medication. After several days, the cocaine has been metabolized, they have rested and feel somewhat normal and demand discharge. Their self described symptoms of hallucinations and suicidality usually resolve spontaneously and they are released. This cycle repeats itself endlessly (I also feel it is important to add that admitting such patients to psych units can actually be quite dangerous to staff and patients because they often act out violently or display predatory behavior towards staff and more impaired patients).

Now this is not to say these individuals do not have problems or some form of psychiatric distress. And cocaine, in large quantities, can certainly induce psychosis. But the preeminent problem is substance abuse, not mental illness. They need rehabilitation from drug abuse rather than a short stay in a psychiatric unit, which in the end addresses nothing. Admitting such patients simply reinforces that abusing drugs and coming to the ER claiming suicidality will just get one admitted. We, as professionals, are enabling this behavior. We are reinforcing learned helplessness, maladaptive coping and drug use. I can imagine it is fairly horrible coming down off a $400 crack binge but at some point the onus of responsibility has to be placed on the patient responsible for the drug use. No medication or endless cycles of psych admissions will resolve this. But most clinicians ultimately choose the easier way out: admit the patient and not worry about him until they return in a few weeks. What this creates, aside from helplessness, poor coping, etc is a terrible strain on an already over-taxed system. The psych units are overflowing with such patients, especially the state system. Many of these patients have no insurance (or public funding like medicaid) so they are sent to facilities like Madden for treatment. Several patients I have dealt with (who did have more genuine mental health issues) describe the facility as a type of prison. That is, the majority of patients there would not be out of place in jail. It is simply another institution for them to reside in temporarily. Since we have so few resources to address the real problem, we simply engender a culture of transinstitutionalization. Many of these patients have spent much of their lives in jails, psych wards, group homes, nursing homes, being wards of the state, etc. They have few or no skills to help the navigate life without committing crimes or abusing the system for personal gain. It is still amazing to me that many of these patients think nothing of being admitted to a psych unit for the Nth time; most average people recoil in horror at the thought of having to be admitted to the psych unit.

So how do we deal with this? The answers, if any, are not obvious and likely difficult. The first and obvious matter to address is the very culture of admission. We are ruled by medical liability, so as clinicians we need to take on more responsibility and discharge the malingering population, plain and simple. It is clear that admitting them offers no benefit to anyone whatsoever. The clinician is simply protecting his or her professional license in the unlikely event that this patient would actually hurt themselves (I dare say they are more likely to die of an accident overdose than actually try and hurt themselves). The second matter is sociopathy. There is no “cure” for this. We cannot graft a conscience on an adult that has lived their life committing crimes, abusing drugs and generally having no regard for anything other than their own needs. The most we can likely accomplish is to stop enabling this behavior by reinforcing alternative consequences (eg, simply stating “hearing voices and I’m suicidal” will not get you an admission anymore). Given our restricted resources and prevalent drug culture, more therapeutic treatments (like drug rehab, therapy, etc) are often not an option. But to continue treating sociopathic, malingering, substance abusing clients like they are genuinely mentally ill is wrong and we, as professionals, are just as complicit in the problem as they are.

Additional reading.

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