On mental illness and stigma in medicine

Today I saw a patient for a pre-operative evaluation. This is a consultation for a patient that needs surgery, but who has other medical problems that make the surgeon nervous, and the surgeon basically wants someone like me to sign that I evaluated the person so that I can be blamed if something goes wrong. At least that’s my semi-cynical version of it. My fully-cynical version of it is that surgeons make relatively little money seeing a patient in clinic (though a lot more than a family doc or internist does), and they don’t want to waste time evaluating a patient when they could be operating and billing for the real benjamins.

Of course, I’m messing with the details of the story, but it went something like this: this woman was elderly, but under 80, and had the usual medical problems that go with that age, but not more – mild diabetes, mild high blood pressure, a few other things like that, but no history of smoking, no lung disease and no significant heart disease.
I think that over time I’ve collected a few doctor readers, so I’ll add this list of meds, more or less: some vitamins, a beta blocker, metformin, maybe there was an ACE inhibitor in there, can’t remember, a statin, a laxative, a bisphosphonate and some ranitidine, and a few other drugs, which I will get to in a minute.

She also had a recently discovered cancer, which was the occasion for the operation. The operation is a large one, but not “heroic” or the kind of thing they call people to come sit in the balcony to observe. It’s not a Whipple or anything close, but it’s not a lumpectomy either. It probably will not lead to a cure, but will almost certainly lengthen her life considerably, and will definitely prevent at least some of the uglier complications in the future. It is the standard of care.

Now, the rub: one of her diagnoses was “Depression.” No further explanation. In addition to the above, she also receives lithium at a healthy dose as well as paroxetine. This was the first time I saw her and she is an immigrant who does not speak any language I speak, so we had to speak through her son translating. But she was perfectly pleasant, totally coherent (able to give full medical and surgical history since childhood) as far as I could tell without speaking her language. To my shame, I didn’t ask what her profession had been. (I just didn’t think to while trying to sort out a complicated medical history.) I had never seen her before, and she came with almost no written medical information other than the recent imaging and investigations that were directly related to this cancer. I have no idea how her depression presented, why lithium was added, how long she had been stable or ill, or anything about that particular illness other than what I saw. To be fair, I also had no information about the history and control of her diabetes or blood pressure, though all three issues were controlled during my examination – blood pressure was good, sugars fine as well as HBA1C.

And then this: among all of her documents, I come across a paper that is a statement by a consultant psychiatrist that she is competent and able to both consent to and undergo the operation.

The surgeon and anesthesiologist had both refused to treat her without this evaluation. The surgeon’s referral put the demand for a full psychiatric evaluation (at the family’s expense) above cardiac, geriatric, oncologic, or functional evaluation, and refused to proceed or even make a tentative statement on her suitability for operation without this.

The surgeon, for that matter, does not speak her language either. But I assume he saw a similar patient to the one I did, as he had seen her less than 3 weeks before.

Just the fact that she came in taking certain medications, with a psychiatric diagnosis, one that, for that matter, has no bearing on her ability to decide how to live her life or to comprehend information, could have caused life-prolonging, standard-of-care treatment for cancer to have been withheld, to have been considered “inappropriate” or “unnecessary” or “unsuitable.”

In her case, fortunately, the psychiatrist did not write a full three page summary of her personal flaws (as I have seen sometimes in these types of evaluations), but rather summed it up with a line something like, “Patient understands implications of illness and treatment options and is competent to make any and all judgments blah blah blah.” But how many of these cases never make it that far? How many times, when surgery is an option, do surgeons see a diagnosis like that, or a drug like lithium and decide that the patient simply isn’t a candidate for surgery, or decide not to present all of the options?

I also wonder, if it had been an older man with “depression,” whether he would have been put through this humiliating evaluation, or whether only hysterical women need to be qualified as competent. Or if it had only been the paroxetine and not the lithium? What was it that pushed her into questionable incompetence? Does the referring doctor understand the implications of demanding an evaluation like that – that they are essentially calling into question a person’s sovereignty over their own body? I am hard-pressed to think of any kind of mental disability, including those conditions that include intellectual disability, in which a person cannot be presented with options in a manner fitting their understanding.

I don’t know whether to be angry, or to want to cry, or what. But I think mostly I’m afraid that someday I will be that little old lady with an ugly diagnosis on my chart, whose life is seen as only questionably worth saving.

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20 Comments

  1. The only odd thing I find about this is, why was she on lithium if she had unipolar depression?

  2. I went through a similar ordeal when a pain management specialist wanted to inject my back with corticosteroids. I had to receive clearance from a psychiatrist saying that I could undergo such treatment, despite the fact that I was bipolar. I never got the “go-ahead.” The psychiatrist who did this ended up causing a lot of problems in my life, including blocking me from getting opiates for a while.

  3. I suspect it was both the lithium and the language barrier. At this point, enough people are on SSRIs that no one around here blinks. But if the surgeon couldn’t talk directly to the patient and there’s a reason to think she has bipolar disorder, that would set off alarm bells.

    I’m not defending this, mind you, I’m just offering my assessment of their motivation. Don’t even ask me to get into the belief that only psychiatrists can assess a patient’s capacity to make decisions.

  4. Fifty One Fifty:

    Lithium is often used to augment antidepressants in cases of clinical depression.

    This whole entry scares me.

  5. Hi Sara,
    One more reason the world needs more open-minded, knowledgeable, non judgemental doctors like you. I am very concerned about how others percieve me (like my dentist and optometriast , or when I had to see a gastroenorologist (sp?) when I write all the meds I am on on the intake forms…I always think they must think I am one completely crazed. When I try to explain the mood stabilizer and the anti-depressant and the benzo, and the stimulat are all for plain old depression…everyone looks at me sideways. “Sure, sure it is dear” uh-huh.

    Great topic and glad you brought it up and the woman was lucky you were her doctor.
    …aqua

  6. Yeah, I assume it was augmentation. I wrote that I didn’t know why they added it because I do not know if there had been an episode of psychosis (though usually our computers have the code that is popular, “Affective psychosis”). But even if so, why would someone bipolar or someone who had been psychotic need a psychiatrist to approve *cancer* treatment? I don’t agree with the whole concept, as I said above, I don’t even agree with the idea for someone with intellectual impairment.

    I also found this terrifying on a personal level (and of course a societal one, but that hits less in the gut). Nothing I do in my life (especially when I get to that age) and nothing about who I am will have mattered in evaluating my life as much as one label or diagnosis.

    5150 – someone nixed STEROID INJECTIONS? Was it because of the steroid itself (I’m terrified of ever needing steroids) or did they accuse you of being “psychosomatic” and therefore not likely to benefit?

    I’ve had a similar thing happen already – and this was back when I was floating just a unipolar diagnosis officially – at a gynecologist. Since then, I never disclose anything. I was at this gynecologist (young woman) for a routine Pap and checkup (no odd complaints of intercourse pain etc), and said I’m basically healthy. Well, she opened the computer from the HMO and the electronic record popped up huge on the screen DEPRESSIVE DISORDER NOS (thanks to my FP) and all the sudden, AFTER our contraception conversation (“Condoms, every time, it’s an acceptable method to me,”) she made some comment about my mood disorder which I remember as being insulting, and then, out of the blue, started talking to me about PERMANENT birth control and IUDs. This was years ago – I was maybe 22 at the time, during the time when IUDs were considered absolutely contraindicated for nulliparous women. I didn’t tell her that I was in med school.

    I just fought back my humiliation and got out of there. I still wish I had some way to get back at her or at least point out how horribly inappropriate this was. She also wrote on the pathology form that goes with the Pap in huge letters, “22 year old female with history of psychiatric disorder.” I was terrified because all kinds of people from med school worked in labs processing papers like that.

    And all of this makes me hate the world of medicine even more. I hate doctors and their bourgeois mentality. I’ve started looking into other options for the end of this year – public health, biotech, something altogether different. Because really, what else remains for me? To live in this shit forever or to be pigeonholed into going into psychiatry training?

    However, since stopping the lithium (which has temporarily been done by the shrink due to the incessant vomiting and weight loss that freaked him out), some things have been nicer. I’ve liked bantering and joking with patients again. The woman in the story actually evoked some warm feelings in me. Even my partner, well, I’ve felt the affection and enjoyment of his company that had been gone for so long. My mood will crash sooner or later, but I realize how much of my humanity was being stolen by that drug. I always said this, but now that I can compare and those warm feelings toward people came back, I realize how horrible it was, not in that it made me feel horrible like the Cymbalta or anything, but that it robbed me of something very essential and good.

  7. Sara, i once got genetic counseling from my case manager about not making schizophrenic babies… It broke my heart… and yet if i had a physical disability it would have been a totally different story. I think i would have made a good mum. love, Milo

  8. Jeez times two.
    Hopefully one day psychiatric stuff won’t be so damn stigmatized.

    Until then, I’m glad you’re aware, alert, and articulate. You have much to teach this world!

  9. Sar – your ability to be objective, and yes, you were totally objective, is rare these days.

    Seriously. you should seriously consider doing a double specialty in family medicine and psychiatry. You’d make a killing (especially if you got into the private system and out of the mainstream).
    ~R

  10. 5150 – Steriods can induce severe psychosis and mania in people with bipolar disorder – could that be why your psychiatrist had to approve the treatment for your back?
    I had that issue back in October – i had steroids prescribed @ a walk in clinic on a friday, and on Sunday I was floridly psychotic. On Monday I was throwing things and running up walls, and on Tuesday the shrink wanted to hospitalize me, until he told me to get the steroids… within 48 hours I was perfectly fine.

    They mess with your system. Badly.

  11. That is so sad that that happened to that lady (and to so many people). And the stigma continues. Since when is a psychiatrist needed to see if someone is competent (EVEN someone with a “shock horror” psych problem). In some ways the medical culture is getting better, and in some ways things never change.

  12. sara, that post was an excruciatingly difficult one to read. i feel for that woman, and in some ways, I’m glad she was not fluent in english; perhaps some of the absurd humiliation will not make it through the language barrier. i hope so.

    i routinely, when i fill out forms for healthcare providers, list the medications (antidepressant and mood stabilizer) along with the explanation “maintenance medication for (bipolar) depression” – regardless of whether it’s “maintenance” or not. i understand that any doctor prescribing medication needs to know whatever i’m taking. but my dermatologist/gynecologist/dentist/etc do not need to know any other details unless I choose to share them. I may have a mental illness….but that doesn’t remove my autonomy or individual right to decide who knows what about my private life and experiences. Which, I realize, is exactly the point of the post.

  13. Wow. This get’s me upset too… and I like how you brought it back to your own fear at the end… So much of my anger about various injustices or shortcomings within the mental health industry is simply a veneer for my fear, my absolute completely terrified panic, that one day, I will be the one to suffer, helplessly, at the hands of the current mental health construct or what have you. And at certain points I guess I have suffered as such, but I could have had it a lot worse – and it’s a constant fear that I live with everyday, this extreme pressure to remain stable because I don’t trust the safety net that would be there (?) if I were to every “fall” again in any significant sort of way.

  14. Sarah – I think that the evaluation must have been done by a psychiatrist speaking her native language (no shortage of those). She must have been informed of the reason for the visit. Or just the nature of the questions (do you know the year? the month? who’s president?”) would have been obvious.

    About the other thing, you might want to try not even putting the explanation. Enough doctors are awkward about mental illness that they probably won’t even ask.

  15. Oh yeah. I also wanted to say that I am fortunate enough to have the medical education to know when and who really does need to know and to take it upon myself to safely omit information. But again, that leads to things like that gynecologist seeking revenge.

  16. Aaaaaaaarrrrrrrrrrrrrggggggggggghhhhhhhhhh. This is why I hate dealing with new medical “professionals”. I recently had a TIA (aka mini-stroke), had to be flown by helicopter whole works, and this doofus comes in my room the next morning, my room in the stroke unit – which THEY put me in, I did not request it, he looks at me for 2 seconds and says, “The ER docs wouldn’t say this, but they were thinking it, and I agree – this is just a conversion disorder. You’re bipolar and obviously not dealing with it well and you’ve made up these symptoms to compensate.” I thought my husband was going to kill him. He said, “You OBVIOUSLY do not know my wife. She Mentors other bipolar patients and she doesn’t make crap up.”

    I came to them with:
    *BP 193/110
    *Left side weakness/left-hand numbness
    *RAGING headache left-side
    *family history 3 generations worth of death by TIA/stroke by mid-50’s
    *50% blockage of right carotid artery

    Yeah, definitely all in my head. My shrink was so SO angry. She’s filing a report against the Risk Management team at his hospital. She’s had several patients with this problem and they were 1. female, 2. being treated for a mental illness, and 3. had VERY clear physical symptoms ranging from a ruptured eardrum to a mini-stroke. But the “professionals” just see lithium and the human patient no longer exists. It’s gotten to a point where I ask new docs point blank if they are prejudiced against my bipolar disorder.

    See. hot button issue there. Sorry for the rant.

    OH, and to the steroid injection person. I’ve had a couple for my L5-S1 problems, 1 sent me into a moderate mania, and the other sent me into a 6 week agitated depression. make sure you tell your shrink if you’re going to have the injection so you’re prepared. And these psychiatric reactions are not just limited to those with pre-existing mental illness. Steroids are weird things.

  17. […] lady, Sara at My Sad Alter Ego appropriately rails against a fellow clinician pointing out that depression does not equal lack of competence. The patient lies in his bed, breathing heavily, his heartbeat marked by syncopated triplet rhythms […]

  18. How many times,….decide not to present all of the options?

    All the time. Common consults: ‘Old psych meds’, ‘patient known to psych, ‘patient with issues’. Worse, patients who have No psychiatric diagnosis or meds whatsoever, but have simply committed the crime of living to a ripe old age have to get a psych consult just because the surgeon doesn’t have the time to talk to them. As a psychiatry resident it pisses me off, and I have no hesitation in indicating the uselessness of the consult in my report.

  19. We have come so far in understanding psychiatric conditions, come so far in treatment with new and more effective medications and yet this asinine stigma still exists.

    The only way to combat it is to talk about it. The more we try to keep it under wraps (it’s depression for me), the less chance we have to confront ignorance and change perceptions.

    My personal opinion is that people fear mental illnesses because they don’t understand them or they don’t know anyone in their personal lives who deals with it on a daily basis.

    I must triage 20 people a shift. I would venture that at least 75% of them are taking an SSRI or a benzodiazepine for anxiety. We see ads for SSRIs on television in prime time. With so much information out there, it is depressing (no pun intended) to think an educated surgeon would be so ignorant.

    Part of what the health care team needs to realize is that underneath the medications, behind the patient presenting with psychosis to the ER, attached to the psych diagnosis is a human being. Someone who deserves to be respected and cared for and treated with dignity. Why is that so hard to get across to people?

  20. […] Previously published here. […]


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