Recently, a young adult child of a friend of mine was admitted to a hospital for a first manic episode. She presented in the most typical of ways with sudden changes in energy, sleep, mood, thinking, behavior, and judgment. She did not see that there was anything wrong, but was eventually hospitalized, against her will, due to dangerous behaviors.
Of course she continued to struggle with insight (realizing she was ill) in the hospital, begging everyone to let her go home. But her symptoms persisted and even worsened. Trying to help, I called to speak to the doc to get a little information about how the young woman was doing and her care. The psychiatrist gave me a list of four medications that she had started, all within about 72 hours, and told me that my friend’s daughter would be leaving the hospital within a couple of days. My friend had spoken to her child that day, and the young woman was clearly still symptomatic. I asked about discharge planning and was told abruptly, “Well there is an appointment at the clinic, but I am sure she won’t go. And she won’t take her meds, but there is nothing I can do about it.”
Sure enough she was discharged a day or two later — still very manic and delusional — and was completely confused about her medications and was taking them sporadically, if at all. Within another few days she was back in the hospital, where she is now.
I was flabbergasted at the doctor’s approach and, in particular, her cavalier approach to her patient’s challenges with insight and lack of ability to participate in her care. While the inpatient psychiatrist cannot make this young woman physically take her meds or get to her appointment, as treaters we need to make our initial treatment plan with full awareness that the illness will make it hard for patient to think clearly and engage with treatment. Her lack of insight is part of her illness, not just a second thought. We don’t just shrug our shoulders and say, “Well it’s not my fault if she doesn’t get there.” It’s not easy to work on this, and we will often fail many times before we succeed, but let’s at least make it part of our responsibility, not just blame it on our patient who is having the struggle of her life.
We can try a lot of strategies in this situation, such as being choosier about meds — one or two instead of three or four, for example. We can work hard to connect her with social services and/or have more family involvement, which this patient was allowing but may not be an option in some cases. Can there be a phone call with the outpatient treater before they leave the hospital? Can we walk them over to the clinic or make sure they know how they will get there, including bus lines or buying gas or asking for rides? Why not push a little harder to keep her in hospital when she is still clearly very symptomatic? I know it’s hard and I know it’s a lot of work, but I think that just about any effort is better than giving up before we even get our patients out the door.
Hospital worker photo available from Shutterstock