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.

I evaluated her several hours after she was medicated. She was sitting in a chair outside of the trauma bay, completely doubled over and sleeping. Laverne, I said. She bobbed up. Laverne was a black woman in her mid-60′s. She had a round, small head that made her look somewhat childlike save for the fact she did not have one tooth in her mouth. Her lips curved into her mouth involuntarily. Her hair was very short, showing some patches of gray and loosely concealing some dirt. She smelled strongly of urine. Her movements were jerky, spasmodic, like a poorly controlled marionette. She was on the edge of teetering out of her chair but somehow recomposed herself enough each time to prevent falling.

Laverne asked for some more crackers and soda; she clutched at an empty can and some graham cracker wrappers. She was loud and seemed unable to modulate the volume of her voice. Given that she had no teeth, she was at first profoundly difficult to understand. Spittle flew out of her mouth at every sibilant. I offered her a wheelchair and she told me she would do just fine with her cane if we didn’t have to walk too far. I put all of her belongings in the wheelchair instead and she followed me to my room. She walked painfully slow, with a pronounced stoop and shuffle. But she was determined. She looked up every once in a while, squinting into the flourescent lights and grimacing. We arrived in the room and she sat down on the bed heavily. She was holding a bible.

I brought her some more food and drink. A banana, some jello, a small sandwich and juice. She laughed. I better not eat right now unless you got a bathroom close. I sat down next to her to talk. Her constant jerks and loud halting speech made her seem more animated than she was. When do I get to go home, it’s probably late. What time is it? Five-thirty PM I told her. I asked her about what happened at the drugstore. Well, see, I have nine dollars on me. But I think I tried to buy too much gum. Wintergreen, you heard of that? Thats my favorite. She didn’t know why the police got involved. I didn’t try to steal nothin. I got money, see? She showed me a small hazmat bag that hospital security had placed some coins and crumpled up bills in.

I told Laverne that she was here for a psychiatric evaluation and she was agitated earlier so the doctors had to give her meds. I asked her if she lived anywhere. Wanda. I live with my daughter Wanda. She got a house on the South side and I live in the basement. It’s nice, warm, I got a lot of food and I just bought a big TV for $50 at Salvation Army. She spread her hands to show me how big the TV was. Wanda’s car is broke so she can’t come get me. I can take the bus home. I take the number three then transfer over to number 55. I have money for a transfer. But maybe you can get one of those cars for me. What hospital is this? Oh. Maybe you can do that.

Laverne was born in a small town in Mississippi. Her father was a captain in the military, stationed in New Mexico. When she was 2 weeks old, she fell seriously ill. Lumps on my neck and such, but I got good care cause of my daddy. My grandmother took care of me pretty good. She said I was born with a white veil. Do you know what that is? I’m clairvoyant. I see things other people can’t see. Sometimes I know when certain people are gonna die just by lookin at them. My momma used to beat me for sayin this stuff. Locked me up in closets or the attic without food sometimes. One day, I looked at her, and I saw she had rotting flesh. I knew she was going to die soon and I told her. She nearly beat me to death. But a week later, she got cancer. Knew the neighbor was gonna die too, heart attack. Sure enough. I told my momma that when I was eight. But I learned to be quiet, people didn’t like hearing that stuff. I could also see demons, dead people. Ever seen Sixth Sense? She laughed. I know when people are using drugs too. I can see inside them. I got to preachin around Hyde Park one time. Took my bible out with me, foretellin the end of the world. People didn’t like that neither.

Laverne was married for a while. She said her husband beat her. He died 27 years ago. Can I have a pain pill? My legs hurt. See this scar? It’s from an accident when I was 19. She showed me some old scars on her swollen left knee. She rubbed on her lower back. Had spinal surgery too. Three thousand stitches. The car she was in at that time was hit by another car and spun them around pretty good. Probably before seat belts. It don’t stop me from walkin though. I need to get air every day.

I asked her if she had ever taken psychotropics before. Well, I don’t remember their names. Thorazine, that was one. But I don’t need medications. I didn’t bother asking her about hospitalizations. I imagined there was a long pattern of involuntary admissions when she did talk about demons and prognosticating people’s deaths, let alone preaching in the street.

She finished eating and I helped her to the bathroom. I ordered a medicar for her that would take her from the ER to her doorstep. I gave her all of her belongings back. Her winter boots were soaked in urine. She had a big purple faux fur coat and she wore 3 pairs of pants. It’s cold out there for an old lady! The medicar wasn’t going to arrive for about 90 minutes. I gave her some Tylenol for her pain. She sat back down in a chair quietly and slumped over to sleep, waiting to go home.

But back to the NYT piece. It goes on to state that pharmacological treatment is often completely ineffective and even the old stalwart of psychotherapy often fails. First, medication. Depression, while certainly a real illness, can often be treated by non-emergent means. Personally I usually advocate for a therapy first method before trying psychotropics. Here, I agree with the NYT piece that most depression will not be treated effectively by anti-depressants unless it is fairly severe. One has to look at consumer expectations again here. In my experience, I have found that many people today are simply unable to tolerate “feeling bad,” even if these feelings are caused by relatively routine stressors. The stressors can certainly seem catastrophic to the person experiencing them (and to casual observers). For example, having a spouse die who was your main support. It is reasonable to expect that this would produce profound feelings of sadness along with ancillary symptoms of sleep and apetite disturbances, impaired concentration, decreased energy and so on. There are reasonable things to expect from a traumatic event. But again, for many people the first reaction is to eradicate this feeling entirely and it usually starts with medication. Now medication can certainly help with some of the aforementioned ancillary symptoms if they are severe enough (inability to sleep for example) but it will not adequately treat the depression. Most consumers are misguided in believing that the anti-depressants will restore their mood to a level prior to some stressor(s) or traumatic event. Not so. Short of some science fiction like invention of completely erasing your memory of the trauma, no drug will be able to treat that. Nor should it.

By that logic, most of us should be taking anti-depressants as we go through life, which is routinely compounded by traumas large and small, stressful events, unforeseen changes, many of which are unpleasant and painful. Is that realistic? Of course not. There needs to be some acceptance, and expectation, that occasionally we will feel depressed and downright terrible as a result of these events. That is the human condition. To expect otherwise is wrong. I’ve seen plenty of people in the ER that have come in almost immediately after some trauma (I use this term loosely; it could mean witnessing a murder, breaking up with your partner, having your beloved dog die) asking for relief. Aside from the fact that anti-depressants take a considerable amount of time to work properly (several weeks is typical), it encourages a way of thinking that completely bypasses one’s natural mechanisms of coping through pain. The answer becomes: “I don’t have to feel this if I take this pill.” Perhaps. But I still argue that it is wrong. Unfortunately, most physicians and psychiatrists are trained to do just that. You have a constellation of symptoms that resemble depression, never mind the etiology, here is a medication that will relieve your pain. Except that it usually does not do that and once again, it completely bypasses a person’s mechanisms for coping with pain on their own.

What we need to focus on instead is providing a means for people to communicate their pain and grief, helping them engage their coping mechanisms and if they lack these mechanisms or have maladaptive ones, equip them with something adaptive. There are very concrete ways to do this (cognitive behavioral therapy for instance).

Now lest one think that I am completely opposed to medication, far from it. There are many instances when depression, in more severe forms, demands anti-depressants. In these cases people will often respond well to such medications. Usually this kind of depression is removed from experiencing any particular traumatic event, stressor or external event.  More often than not however, changes in mood are precipitated by such events. Some of these events are not in our control, but many others are. And that is an important factor to understand. Aside from coping, tolerance and awareness, there must also be acceptance of responsibility. Here is an example. I assessed an adult male who presented for depression and some vague suicidality. As we talked, it became fairly clear that his depression was directly precipitated by his failures in a romantic relationship. He had a girlfriend of several years, broke up with her as he met another woman who ultimately did not reciprocate his feelings and he was left with neither woman. When I saw him he felt guilty, remorseful, sad, and somewhat angry at himself (and to a certain extent the women). Was it reasonable to expect that one would be depressed over this? Yes. Is an anti-depressant needed? No. What is needed is what I mentioned earlier. One needs to learn to navigate through these unpleasant and unwanted feelings and accept that they have been cause by external forces, most of which were caused by the individual in question. If the only course of treatment is to prescribe an anti-depressant, then there is a complete failure. The depression will not remit and the individual will gain nothing from this experience. He will likely continue making the same choices leading to more failures, which will lead to more, or worsening depression.

I will explore some more of these points later on as there are some important points raised by the NYT article. One that comes to mind immediately is our lament about the difficulty of accessing mental health treatment. If most of these treatments are largely ineffective or misguided then we need to look at not just treatment being more accessible but by improving the treatment. Clearly, there is still a very long way to go for either of those two things to happen.