23 May 2011

mental health mondays :: are the inmates running the asylum?

one of the greatest obstacles to dealing with mental health issues, as i keep mentioning, is getting people to actually recognise when they or someone they love have mental health issues. people aren't socialised to think that their brain isn't working properly. they're socialised to think that other people's brains, brains of those they've never met and never will are the only ones that are working improperly. it's remarkably difficult to admit that you need help, not just for any reasons of pride or negative stigma [although they play a role], but because it can be really difficult to tell if you need help.

once you do make that first step, however, you've taken your destiny in your hands and you can feel better about the fact that you and others are going to work at retraining your brain to work with you instead of against you. the problem is that all too often, the process of getting help is slower, more frustrating and more absurd than anything your disordered brain has come up with on its own. because things weren't challenging enough for you before.

DOWN THE HOLE WE GO...



wait for your card to come up
for starters, there is the process of getting an initial appointment for an evaluation. the most common way in which people seek help is through their family doctor, which puts a lot of pressure on a resource in short supply in canada [shorter in some places than in others] and means that the judgment call as to who gets psychiatric help is left in the hands of someone who hasn't been trained to recognise the signs of someone in need.

let's take a look at a real case a person we'll call "e". e went to her family doctor because she was having such crippling problems with anxiety that she sometimes found it impossible to go to work or even leave the house. the doctor prescribed a standard anti-anxiolytic and recommended that she see a psychologist, since her employer-funded insurance plan covered the costs. e asked to see a psychiatrist instead, but was told by her doctor that it wasn't necessary. she went to three psychologist appointments, which is about the number that even a good insurance program will cover per year and continued to take her prescription. she ended up entering the world of psychiatric treatment by accident a couple of years later, when a doctor at a clinic suggested that going to see a psychiatrist would be a good idea, at least to validate the prescription she was taking.

what's strange about this story is not that e ended up going to see a psychiatrist so late, but that she ended up seeing one at all. after all, but for the fact that she ended seeing someone other than her family doctor who happened to have a different opinion, she might have stayed on her same prescription, or on similar ones, for a long time. as long as she wasn't curled up in a ball on her floor or threatening to throw herself out a window, things were fine. and the barometer of how fine things were was the patient herself, which is all well and good, as long as she's reliable. the problem with people suffering from mental disorders is that they're not reliable. in this case, the fact that she was high-functioning [holding down a good job being an indication of that] most likely led her doctor to decide that she was unlikely to need further evaluation.

now, as you can probably tell, this is leading to the revelation that the doctor made the wrong decision, but before we completely dismiss that decision, let's look at some of the factors that might have gone into it: the patient was clearly able to function in the real world, she reported an improvement from the drugs and her privately-funded health plan did allow her to receive some counseling without taking resources from the publicly-funded system. [in canada, psychiatry costs are covered under the national health care system, whereas psychology costs are borne by the individual or their private insurer. since the largest number of people are going to be those with no private insurance option, there is a logic to trying to steer those who do have a private option towards it. the problem is that there are differences between psychiatry and psychology besides who funds them.]

now, receiving a referral to see a psychiatrist [you can't see one without being referred] is just one step. if you can't fork over the money to go see the private psychiatrist of your choice [which is more expensive than seeing a psychologist and a lot of private health plans cover one and not the other], it means that you have to follow the proscribed method for getting an appointment. in quebec [other provinces have similar processes], in order to stop people from rushing to one facility that bears a good reputation, patients are required to have their first evaluation done at the facility closest to them. basically, you call the hospital closest to you and give them your postal code. they tell you whether or not you should be coming to them or going somewhere else. sometimes, you get lucky and the person on the phone will enter your postal code and tell you where exactly you should be going. often times, they'll just tell you whether or not you're their problem.

returning to our sample case, it took e over a week to determine where she had to call to book an appointment, because her postal code happened to fall in an area where there was some debate over who held jurisdiction. a couple of months afterward, the law was changed so that, even with a family doctor, a patient has to make an appointment to come in and be evaluated by the closest public clinic so that they can determine the seriousness of their condition and decide whether or not they should be allowed to start calling around to see where they're supposed to make appointments, making things that much more complicated. [another prospective patient reported that, when he pointed out to the public clinic that he had a referral from a family doctor, was told that  it didn't matter because "family doctors will give referrals for anything".] no one seems willing to comment on the fact that the more likely someone is to need psychiatric help, the more likely they are to be intimidated by the increasingly onerous process and give up there.

once one does succeed in making an appointment, the wait time is generally three to four months. much is made of the supposedly extraordinary waiting times for medical services in canada, but it's worth noting that a study conducted for the new england journal of medicine revealed that the delay in getting an appointment tended to be less discouraging among canadian patients than among americans. perhaps, having negotiated the minefield to actually figure out who to call, we're more than happy to take a bit of a break from thinking about it.

when patient e finally went to her psychiatric evaluation, she was greatly encouraged. she was interviewed extensively by two doctors who determined that she was not, in fact, suffering from anxiety and depression, but from bipolar disorder. and to complicate things, the medication she had been given initially to combat her anxiety may have aggravated this condition. whoops. she left with new prescriptions and assurances that she would be seen regularly by the lead psychiatrist in order to get the treatment that she needed.

how do you like your options?
unfortunately, this turned out to be a little bit optimistic. being seen regularly involved being seen for ten to fifteen minutes once every three to four months in order to have her prescriptions tweaked and renewed. when she raised the subject of getting psychiatric counseling, she was told flat out that she was not an appropriate candidate for therapy. why? much like her former family doctor, her psychiatrist felt that she was functioning fine by taking her medication.

a study conducted by the libertarian fraser institute points to some interesting details on delays in psychiatric treatment that aren't generally explored. according to their study, how much treatment is delayed depends heavily on what the treatment is. they estimate that the wait to receive pharmacotherapy [drugs] is about 4 weeks in canada, but the wait to receive forms of therapy that require significant interaction [cognitive behavioural therapy, community therapy, etc.] took triple or quadruple that amount of time. and that's assuming you can get recommended for those to begin with.

in patient e's case, since her psychiatrist had determined that she was a poor candidate for therapy, her options were extremely limited. she could continue to take her medication as she had been, or she could request a second opinion. how is that done? this is where things get tricky. although there are, of course, other psychiatrists working in the department, it's not simply a question of asking to be reassigned. it turns out that transferring a patient to another doctor is needs to be initiated by the first doctor. that's right. if you feel that the treatment you're receiving is substandard and does not meet your needs, your recourse is to ask your psychiatrist to admit their inability to treat you properly and recommend you to someone else.

you would not be alone in finding this whole system deranged. there is, in fact a structural paranoia at work, whereby anyone who actually seeks help [as opposed to having it forced on them] is met with suspicion and every effort is made to contain them, so as to prevent them from accessing/ draining resources. if there are solid studies available that would indicate that people who seek psychiatric help are receiving services to a greater extent than they require [hence limiting resources available to those who are deemed to require treatment], i'd love to see them. until i can see those numbers, i remain convinced that there is a fundamental irrationality at the heart of medicine's arbiter of rational thought.

fyi, followers of mhm might want to check out personality disorders, a new blog that touches on similar topics from the point of view of someone who knows more about it than i do. 

2 comments:

Jerod Poore said...

This is the entry that shows up as number one on the Google hit parade for negative urine Rx.

I'm really, really sorry about accidentally deleting your comment instead of publishing it. I suck.

flora_mundi said...

No worries... Such is the wonder of the internet. I'm still confused as to how I got associated with urine but hey, if it helps someone, all the better...

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