Wednesday, January 31, 2007

The Behavioral, The Physiological, and Everything In Between

This afternoon, my boss sent out an email asking us all to review our caseloads and identify which patients we interact with almost exclusively vis-a-vis mental illness, behavioral health, or substance abuse. He then asked us to also identify those patients for whom mental illness is a major factor which often leads to self-neglect on the patient's part, but who also carry multiple co-morbidities.

Well, as I reviewed my caseload and began to compose my email in response, the first list was rather short. There are perhaps half a dozen patients out of my 80 who have no other notable morbidities other than mental illness of some kind. The second list, which grew to considerable length quite quickly, numbered approximately fifty. Looking at the two, it once again became starkly clear how my work is, to a large extent, behavioral in the nature of its interventions. While I do indeed respond to many patients' physiological symptoms and complaints---listening to noisy lungs, palpating edematous limbs, evaluating strained backs, assessing abdominal pain---the lion's share of my work is often that of fielding calls of psychic distress, assuaging fears, and otherwise calming the minds and hearts of individuals in mental pain.

Yesterday, I recounted the tale of accompanying a patient to the gastroenterologist. I mentioned in that post that the patient's depression with psychotic features will often preclude her ability to grasp the situation at hand during medical appointments. Examining this very kind woman, one could not necessarily tease out whether her psychological issues trump the physical when measuring their importance or need for intervention, but it is strikingly obvious that her ability to cope with her various diseases is considerably challenged by her mental state. One might further argue that her mental/emotional state directly affects her physiological state on a moment to moment basis as well as in the long term. A mind which is almost exclusively focused on the negative---dwelling in fear and anxious worry with a powerful undercurrent of powerlessness---can only serve to poison the well, figuratively speaking, exacerbating illnesses and their processes, strengthening symptoms, weakening the immune system, and delaying recovery.

The lack of parity in health care when it comes to behavioral health goes a long way towards diminishing the amount of time and resources devoted to mental health. Insurance plans are skimpy with behavioral health allowances, awarding paltry numbers of psychotherapy sessions during each treatment year. While an insured patient can go to the doctor an unlimited number of times for physical complaints with no questions asked, insurers will often question a patient's need for weekly therapy, deny requests for extensions beyond short-term treatment, and make mental health clinicians leap through hoops of fire to win additional sessions for the suffering client. How can this be?

Here on the front lines, somewhat removed from the watchful eyes of bureaucrats who question our motives and actions, we struggle to treat the suffering sufficiently. But even our cutting-edge program is underfunded in terms of behavioral health, with only one full-time clinician to oversee and coordinate the care of over 800 patients. Relying on private and public mental health clinics in the city, we are often left holding the bag. Long waiting lists, incompetent clinicians, and flawed referral systems act as long-term deterrents to our patients' ability to receive the care they need. Frustration abounds. Sure, a CT-scan can be had under duress, but when a psychiatrist or psychotherapist is urgently needed, even moving a mountain will be in vain.

So, we limp along, the psychic band-aids applied, slowing the gushing river, but never stemming the tide. The imagery of life-boats and life-preservers comes to mind, but on the horizon---a tsunami.
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