One thing I've learned the hard way is when I tell patients on NED (Notice of Emergency Detention) - the guys brought in in cuffs - that I'm not discharging them for 48 hours, I need to have an aide in the room with me. I don't quite get this, but people think that they can do dangerous things, get picked up by the cops and judged as a danger to self/others and delivered to us - and I should just hold the door open while they walk out. Oh, you were choking your mother while drunk and she called 911? But you didn't really mean it? Especially when the cops arrived and you said that really you wanted to kill yourself, not her? Ah, well then, if you didn't mean it, you can go! Oh, there's a gun at home? But you promise not to shoot it at her? Well, then, let me get the door! I really don't like it when they say, oh but let me talk to the person in charge. Look buddy, I'm it. I legally get to make this decision, and you're staying. That's when some of the young bulls decide they need to turn over the table and kick things and yell. Anyway. I'm not telling people that anymore without someone in the room with me, someone whose job is to get in between us.
We were notified recently that one patient didn't make it. A significant number of our clients are there after making an unsuccessful suicide attempt - they were either found and brought to the emergency department, or they told someone right before doing it, or someone found the note, etc. This young man had made several attempts and had severe PTSD. I won't be more specific than that to protect confidentiality, but we all cared so much and spent so much time to line him up with resources upon discharge. I'm the one that discharged him, and I did it several days after the insurance company stopped paying us because I thought he wasn't sufficiently recovered. The news that he then committed suicide about 2 weeks later was heart-breaking. His therapist and I talked a long time about what we could've done differently but at the end of it, you can't save them all. We try.
I've learned a tremendous amount about psychosis. This is something you rarely see in the outpatient world. In fact, in my year of private practice I didn't see it a single time. But I encounter it every day now. There's three main disorders that involve psychosis - schizophrenia, a severe manic episode of bipolar disorder, and then severe depression. Psychosis by definition is hallucinations (usually auditory) and delusions. The hallucinations are often commands or a voice that says terrible things ("you're bad", "you're a loser") and the delusions can be clustered into the common areas of being spied upon (usually by the government), sexually inappropriate, or religiosity. There's also somatic, which seems like we've had a lot of lately. People will fixate on an organ system or body part, convinced there's a problem there and talk incessantly about it. Usually they've been to many doctors, had many workups, all with negative results. "You're fine", they are told, "just go see a psychiatric provider." I ask every single patient, every single initial evaluation that I do, "are you having any strange thoughts? hearing any voices? seeing anything out of the corner of your eye? are people after you?" - again, I've learned the hard way, you never know what that answer will be. This sweet little college girl may be hearing voices because she's so depressed, saying over and over again how terrible she is, she'll never amount to anything, she should kill herself. Of course, that could just be depressive rumination. So it's up to me to distinguish. How does the voice sound? Often it's low, masculine, guttural, horrible, demon-like. When does it happen? If they say, oh only when I'm in bed, trying to sleep, then it could be rumination. But if it's anytime, and it happened Tuesday when I was at the store, that gets my attention.
Another part of my job is convincing schizophrenics to take the new long-acting injectable medications. Schizophrenics are notorious for stopping their meds and decompensating after discharge. We are a revolving door for them. Pharmaceutical companies now offer a single monthly shot of anti-psychotic that can change all that, and in fact Invega has just introduced a quarterly shot. It's the best thing for these patients by far, but one of the features of schizophrenia is what we call "lack of insight" - meaning, they just don't get that they're sick. I convinced 2 guys on Friday to take their first shot, and I felt pretty good about that. I think one only did it to avoid going to court on Monday - we were going to argue for "COM" - court-ordered medication.
I'll finish with a picture of me and Dani at our favorite hang-out: Vino Vino in Hyde Park. We were there a for wine-tasting dinner and had such a lovely evening.
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