Thursday, February 16, 2012

The End of the Stories: Patient A

Thank you to everybody who commented on my hypothetical jail patient scenarios in my post Send Them Away. I thought it was interesting that people with different professional backgrounds and levels of experience pretty much agreed on what to do, who to keep and who to send out.

Since people seemed to enjoy speculating on the back stories, I thought I'd supply the endings.

Patient A was kept in the jail and admitted to the infirmary. After a few days of medication he quickly got better and was able to tell you what happened since his last release. His mother tried to get him an appointment at the local mental health clinic shortly after he got home, but she was told there was a three month wait until the first available appointment and that she should call the police or take him to an emergency room if it was an emergency. After he ran out of his thirty day supply of release medication he went to the emergency room to get it renewed, but when he ran out of meds a second time he was told he could no longer get his meds renewed through the emergency room. It didn't really matter though since his benefits were cut off while he was in jail and he couldn't afford them anymore anyway.

His mental state went downhill quickly after that. His mother, the much-beloved Cookie Lady (as she was known in the neighborhood), didn't stand much of a chance. I'll spare you the details. As a well-trained forensic psychiatrist you know that ethical standards for correctional work forbid you from collecting forensic evidence in jail as a treating clinician, so you are circumspect about your documentation as it regards the current offense. Eventually, an outside forensic evaluation is done and Patient A becomes an insanity acquittee. He is transferred to a forensic hospital.

Immediately after the verdict, there is public uproar. The local newspaper publishes an opinion piece calling for reform of the public mental health system and looser standards for civil commitment and involuntary treatment. A state delegate proposes legislation for outpatient civil commitment. The governor organizes a task force to study the issue and the entire police force is required to undergo crisis intervention and mental health training. Mental health advocates decry Patient A's incarceration, loudly insist that jail couldn't help anybody, and accuse the jail (not you in particular, but the jail) of giving lousy, horrible, inadequate or nonexistent care. (Meanwhile, the somatic jail doc has diagnosed Patient A's new-onset diabetes and Patient A is getting a diagnostic workup for the lump that was discovered on his admission physical---it turned out to be benign. Because of patient confidentiality, none of this can be revealed to the public but you know it.) Meanwhile, on the newspaper internet discussion board some people express outrage that "that dangerous nut case" should have been sent to prison forever, given the electric chair, or made to undergo the same horrible acts he did to his mother. Patient A reads all about this in the newspaper delivered to his ward, and hears about it on the ward television news reports.

Years later, many years later, Patient A is quietly granted conditional release by a sympathetic judge, with the support of the local state's attorney. He goes to live back in his old neighborhood---now gentrified beyond recognition, where he spends a few minutes every morning sipping coffee at the corner Starbucks. His neighbors---a young attorney fresh out of law school, a music student at the local conservatory, and a young couple who work for the local newspaper, see him there and exchange casual greetings. They think he is a shy but likable guy, a quiet but kind person. They enjoy having him as a neighbor.


Liz said...

i tried to post earlier, but my computer froze midway through posting.

when i got out of the state psych hospital, i was given a few weeks to a month of meds and sent home. i was glad to be home. not so glad that it would take four months to make an appointment with the psychiatrist.

i was lucky to be able to withdraw without killing myself or someone else. and in fact, i'm thankful to have had that reason to stop taking any medications; i'm doing much better without them.

it is totally unfair to get someone's body and brain acclimated to these strong drugs, without any support to slowly go off the drugs or to continue them if the person finds them helpful.

it infuriates and saddens me. i'm also angry that people are so supportive of locking people up and throwing away the key once something horrible happens. but before that, they aren't willing to do anything to help and don't seem to support community mental health services, which, at least in my area, are hard to get in to, hard to pay for, and don't help a whole lot anyway.

i'm sad for patient a and his terrible ordeal. i'm sad for patient a's mother, especially; apparently she loved her son and wanted him to have the help he needed. and she must have been terrified for him and for herself. i hope that he is able to live well now in testimony to her love.

Anon Anon said...

The problem with conservative, crime and punishment thinking, is that it is unable to trace a problem far back enough to the original source, in this case, the man's inability to get his medication. No wonder two recent studies have found that left-wing thinkers are both more intelligent and more educated than right- wingers.
What happened with B and C?

jesse said...

Oh Wow. I think I saw that story in a newspaper sometime in the past. No one where he lived knew what he had done.

What I got out of these vignettes is the extent to which so much of the information you get is erroneous. The most basic details of record keeping may be missing or inaccurate, so you have to be extremely careful about extrapolating.

ClinkShrink said...

Oh my guys, I'm flattered that Patient A's vignette was so realistic! Actually, it's entirely made up. The process and minor details are true to life, though, as far as the clinical decision making and the public reaction and the patient seeing him or herself in the news.

jesse said...

It may be totally made up but something just like it appeared in the NY Times some years ago. The patient was living in Brooklyn.

ClinkShrink said...

Jesse: The general pattern of the vignette is pretty common I think---repeated incarcerations for minor offenses before something major happens, along with community failure to treat or noncompliance.

Anon Anon: Endings to B and C coming up, as soon as I write them, probably over the weekend.

Mary Katherine Parker said...

I'm so sorry that he couldn't get his meds when there are other options. Many pharmaceutical companies offer prescription assistance programs and medications for reduced fees. PPARX comes immediately to mind. I've often thought that having individuals who need community service hours help input data for these patients could really help make a difference.

Liz said...

sometimes, "other options" are mythological comforts. when i was released from the state hospital, yes, i had trouble affording to get my script filled. more than that, though, i had trouble obtaining a NEW prescription for the medication the state psych hospital had started me on after the initial two week prescription ran out. while i was there, i resigned from my job and lost my insurance. my long-term psychiatrist retired. and the area mental health center had a four month wait to see someone. i even tried to see a private psychiatrist with my last 150 bucks and the lady took my money, talked to me, and told me she couldn't prescribe anything, because, with two recent suicide attempts, i was a "fascinating liability." the drug company which even at its best takes a time commitment, can't help without a prescription.

Anonymous said...

After a few more years of stability, Patient A's medication stops working. He tries to resume contact with the local community mental health centre, but they have closed due to budget cuts. Patient A could go to the ER, but having been abused during prior forced hospitalizations he is terrified of hospitals, doctors and nurses. (He reported the abuse, but the authorities refused to believe him on the grounds of his mental illness).

Patient A's health rapidly spirals and his neighbors come home one evening to find him in a state of severe agitation and shouting abuse at what can only be hallucinations. They call the police.

Upon seeing the police, Patient A's fear and agitation intensifies and he resists arrest, terrified that they will take him to the hospital. Having decided before even seeing him that Patient A is violent and dangerous due to his mental illness and criminal record, instead of trying to de-escalate the situation or call for paramedic back-up the police taser him. To death.

Anonymous said...

So, so familiar.

In my county, it's almost easier to get a psychiatrist if you're in the public system. There are several on staff at community mental health, and some agencies have psychiatrists on staff as well. Some are good, some are bad. The care isn't always great, but it beats the alternative at times.

The problem lies when people get well enough to not need case management services. Most of the clinics require that you be seen for therapy with one of their therapists if you want to see one of their psychiatrists. Therapy is an extra expense, and it can be a waste of everyone's time if you don't have goals for therapy - not everyone needs therapy for the rest of their lives. There are private psychiatrists, but they do not accept insurance and rarely have openings.

What often happens is people who were in the public system are referred to a primary care provider, generally the only clinic in town that accepts Medicaid. They have a reputation for frequent medication errors, failure to order necessary lab work, and it's difficult to get an appointment in an emergency.

I drive out of county to see my psychiatrist. It works better that way. Unfortunately, not everyone has the means to do that.