It’s morning. I’m meeting with a young woman who has a lengthy drug history augmented by involvement in gangs. She has been afraid to leave her house for the past four weeks, and does so only to attend our therapy appointments. Since she has no friends and no ties to family, I appear to be her only connection to an external world. Her paranoia stems from a realistic fear of retribution from prior criminal associates and from exaggerated fears likely associated with extensive methamphetamine usage. She relates stories of being shot at, of being robbed, and of robbing others. It’s difficult for me to parse out whether the symptoms of paranoia, in addition to auditory and visual hallucinations (shadowy figures and voices that tell her what to do) that come and go, originated before her heavy drug use or as a direct result of it. We’ll probably never know.
Community mental health is as much about the impact of drugs and alcohol on people’s lives as it is about addressing diseases of the brain. It’s uncommon to encounter a patient with a severe mental disorder who hasn’t dealt with substance abuse, regardless of socioeconomic status or ethnicity. It’s more pervasive, pernicious, and destructive than one could imagine, and it’s everywhere. While we try to help those who now struggle with demons of the past, a public health approach to mental health requires fighting these predecessors and aggravators of mental illness.
Afternoon. I receive a call from a patient’s brother. He tells me that the patient has decompensated after a three-week trip with his girlfriend. He suspects that the patient is off medications for bipolar disorder and has been drinking alcohol heavily. He has been verbally aggressive with family members—quite out of character for this regularly buttoned-up, mild-mannered man, but predictive of spiral into agitated mania. A few hours later, the patient arrives for his appointment, 15 minutes early.
He is visibly upset, and demands to see me. Immediately, I sense that he is in a different psychic space than usual—on edge, with bloodshot eyes that stare at me with a too-strong gaze. I will see him in a few minutes. He paces. I consider alerting Security, but decide against it given the lack of any previous violence and the risk of diminishing what is now a tenuous alliance.
We start the weekly psychotherapy session as we have for the past year, but this time he abruptly opens with a raised, pressured voice. He outlines various wrongs committed by his family members. I reveal his brother’s concerned phone call and explain that his privacy was maintained. This seems to increase the patient’s vitriol toward the family. On a dime, his irritation switches, latching onto my carpet: “Why is it blue?! Why don’t you answer me?!” he yells.
I honestly reply that I’m not sure what to say. And at that, he marches out of my office and down the street. I walk after him, hoping to help, but knowing that much is out of my control in what appears to be the early stages of mania with an overlay of recreational drug use. I call out, but I am ignored. I have no legal grounds to place the patient on a psychiatric hold—he has made no threats to himself or to others and is able to provide for his basic needs, at least as far as I can assess. And so I place a rather meager phone call, which goes to his voicemail. I express my concern, and I offer to see him next week or sooner, should he so choose. I wonder when I’ll see him again.
Controlling variables is a primary tool of academic research, and the lack thereof a foregone conclusion in the clinical world. Community mental health practice requires constantly letting go without giving up. Many with mental illness cannot see their own deterioration of health, while family and friends are privy to the ups, downs, and in-betweens. Who is to say ultimately what is in the best interest of each person? Mental health advance directives may allow individuals to direct treatment in anticipation of times when they are ill, such as in the case above. Simple, low-cost interventions from text message medication reminders to weekly phone check-ins may help stave off the otherwise inevitable consequences of untreated mental illness. While there is no cookie-cutter answer, it’s clear that all of life’s variables overlap and we need approaches that meet people where they are.
Later that day. A patient arrives at the clinic unannounced, and says he was hospitalized last week with an acute asthma exacerbation. As is often the case, he has been prescribed prednisone, a steroid to decrease inflammation in the lungs, by the internal medicine doctors. But the prednisone is causing severe mood lability and disorientation in this already tenuous man. He explains that he is confusing his prednisone with his mood stabilizing medications and thinks he may have taken too many of the latter. Without anyone to assist him or tend to him while he recuperates, he is at risk for an accidental overdose. I instruct him to wait out the rest of the afternoon in our clinic, in order to be observed and be around people. He remains alert and relatively calm throughout the day and eventually goes home. He calls a few days later. He couldn’t bear to take the prednisone, for fear of what it would do to his mood, and is now back in the hospital, unable to breathe from his asthma.
These are but a few anecdotes from a day in a community mental health clinic. In reality, each of us has a story to tell about mental illness and experiences that reveal the heavy burdens often unrecognized until too late. Even in the public health community, stigma drowns out the voices calling us to rise to the biggest health challenge of today. The future of community health will be determined by the way we respond to mental health needs, and will depend greatly on the inclusion of those who suffer as well as their loved ones. In the meantime, we’ll just have to see what tomorrow brings and respond the best way we can.
Neil Sachs, MD, MPH ’07, graduated from the School’s Interdisciplinary MPH Program and works as a resident psychiatrist at the San Mateo County Psychiatry Program.
Anthony Battista, MD, MPH ’10, is also a graduate of the Interdisciplinary Program. He is a first-year resident psychiatrist at the San Mateo County Psychiatry Program.