Monday, June 18, 2012

A Patient's Insight into Psychiatric Woes

A psychiatric ward, for the uninitiated, is a means of narrowly controlled chaos. Few recognize that mental illness exists along a wide spectrum. It is only the worst cases that get the majority of the attention. My experiences were usually nothing like One Flew over the Cuckoo’s Nest. I experienced few instances of overt drama. My recollections mainly fall on days of utter, horrid drudgery and boredom. Most patients, in opposition to hospitalization as we usually view it, are not confined to bed. Instead, they nervously pace the corridors, frustrated by the necessary, but restrictive boundaries.

The truly awful details and problems stretch beyond the reach of interpersonal communication and personal reflection. Patients with bipolar disorder, schizophrenia, schizoaffective disorder, personality disorders, and major depressive disorder, to name only a few, are thrown together into close quarters. This is a recipe for disaster and it’s impressive how infrequently total disaster becomes a reality. With such a related, but wildly varied set of disorders, I'm amazed nurses and doctors can really do their job.

In the worst case scenario, hospitals combine psychiatric and substance abuse patients. Some insist upon keeping the two separate from each other and would never dare dream of having it any other way. Those who comingle the two may be seeking to reduce cost, but they compromise patient safety in the process. A person going through detox, nerves and patience already worn dangerously thin, can create problems. Combine a manic depressive still coming down from a manic episode with someone who is in withdrawal and be prepared to court disaster.

I spent most of my life in Alabama, where I was hospitalized several times and in multiple hospitals. A recent article talks about the nationwide need for beds in psychiatric units and hospitals.
Across the state and nation, hospital administrators say the demand for psychiatric hospital beds is escalating, although they're not sure why. The need spans all ages, from children to the aging.

In hospitals across Alabama, the lack of available beds has caused some psychiatric patients to spend hours in emergency rooms awaiting admission, often creating a bottleneck of care in the emergency rooms.
Psychiatric patients with some means swiftly learn how to work the system as it current exists. My psychiatrist could always find me an open bed where I would be under his care. I called him myself when I was strong enough to make the arrangements on my own. When I was very ill and weak, however, I was often so depressed I could barely bathe and eat. In those situations, had no choice to head for the ER and wait.

The law, as written, says that care must be provided and cannot be denied. That being said, open beds can be at a premium. One might turn up in the same city or, failing that, in an entirely different state. Quality is much less important than placement in these sorts of situations.

Mental illness remains poorly understood by modern medicine. In my periods of hospitalization, topics of conversation with other patients invariably drifted to our own unique combination of medications. No two peoples' cocktail was ever the same. The dosage differed, as did the precise prescription drugs used to treat our condition. The makeup of the ward also varied considerably. Often, the sickest of the sick and poorest of the poor inhabited the same close quarters as those much more economically fortunate.

Those of us who had the material resources to drive ourselves to the hospital were the lucky ones. The most challenging cases were usually the people who worn hospital gowns instead of street clothes. These people were the most severely ill. They’d arrived in style in the back of an ambulance, or in the back of a police car when committed against their will. Several were what was known as dual diagnosis—hospitalized for chemical addiction and mental illness at once. Their stories were often tragic and depressingly similar, living lives forever in and out of treatment facilities.

State mental hospitals, a holdover from a previous age of progressive reform, are continuing to shutter their doors. In Alabama, Bryce Hospital was the inevitable destination of many I observed over the years. Due to court order, Bryce could only hold patients for a maximum of 90 days. Their latest stint concluded, these severally mentally ill were turned back onto the streets. Before too much longer, they ended up back in Bryce once again. This continual process comprised a very pathetic existence for many with nowhere else to go but in and out and in and out again.

The need for more psychiatric beds is a national trend, said Mark Covall, president and chief executive officer of the National Association of Psychiatric Health Systems. There are many factors that could be driving it, he said.

The growth in demand for service could be a sign that the stigma of having a mental illness has lessened. Medical experts also say the economic climate, with people losing their jobs and homes and experiencing more stress, can boost the need for mental health care.

Covall said the recession and tight budgets also could be making less money available to provide community services that could help keep people from having a mental health crisis.
Paradoxically, we are becoming more tolerant and understanding of mental illness, while simultaneously unable to cope with the deluge of new patients. Class, privilege, and affluence make a huge difference. Psychiatric wards are very different from one another and this is especially the case as concerns quality of care.

I’ve been a patient in a hospital with severe budgetary restrictions, lack of sufficient staffing, and barely enough security to contain the potentially physically violent. And, I’ve been a patient in a gold standard facility, considered the best in the entire city. There, I would never have been able to even be admitted if I hadn’t had $200 in my bank account and excellent health insurance. I would have never been able to begin to pay my bill if I hadn’t had insurance in the first place. Those unable to pay out were quietly discharged.

Whether sour economic times increase mental illness is something of a chicken or egg conundrum. People have long turned to the bottle or to drugs under periods of great stress, this is true. Whether this proclivity is a result of a diagnosable psychiatric illness or addiction depends on the person. It is true, however, that people with greater financial stability and without a cultural bias are more likely to pursue treatment.

Essential to proper treatment and recovery is an active family, if not community involvement. The worst cases I observed as a patient were those who had no social network or means of support. Born into severely dysfunctional environments from the very outset, these people never stood a chance. I maintain strongly that a majority of societal ills are a result of detachment and distance from what is needed most. In this case, I mean basic compassion, as well as adequate emotional, familial, and financial resources.

My own hope is to see a cure for bipolar disorder within my lifetime. But, I also have to concede that this desire is a tall order. In many ways, psychiatry remains in a vastly primitive state. Doctors and researchers have made considerable strides in treating of many instances of cancer, for example, but mental illness is much more complicated. The science of addiction is a similarly misunderstood discipline. Both have been present from the beginning of recorded history. Until the next big breakthrough, we may have to treat the effects before we even scratch the surface of the causes.

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