Mental Illness in the Adult

I separate my observations about mental health in adults versus children. The causes, expressions, volatility, and prognosis separate them into discrete categories that only occasionally speak to one another. My next blog will speak for children.


Mental health issues color much of what we see in family medicine. One will not be successful in practice without this understanding. Once the physical part of medicine was revealed, I became interested in the invisible part. The emotional life of man, the strangest, most unknowable, and most fascinating parts. Psychiatry is pure mystery in an infinite regression of permutations no matter how many diagnostic labels are put on it.


Wisdom is that it is often better to describe the dysfunction than apply the hard die cast of diagnosis. Is the predominant manifestation a mood, thought or behavioral disorder? In the adult, life choices, trauma and time have often modified expression to include all three, obscuring what lies on the bottom shelf.


Much of day-to-day mental health distress presents with somatic symptoms. A deeper evaluation reveal depression and anxiety – the most common expression of psychic distress. This is less a specific diagnosis than a description. A mood disorder. It is an almost universal manifestation of dis-ease – thus the huge market in antidepressants.


Next most common are the cluster of personality disorders marked by long-term patterns of thoughts and behaviors that are unhealthy and inflexible. The National Institute of Mental Health reports the prevalence of any personality disorder at 9% of the population. There are at least 10 different sub types, some more intolerable than others to those who endure relationships with those afflicted.


Although there is subjectivity in application of a particular label, it is not difficult for providers to identify these patients. A behavior disorder. You won’t like these people. And it is difficult to effectively treat a patient one does not like. A professional relationship requires a level of detachment for the provider to avoid being manipulated or responding emotionally to behavior directed at them. Because it is that behavior we need to modify. We’re not likely to change the way this person thinks, and it is the behavior that is toxic to their relationships.


These levels of mental health disorder are distinguished from major psychosis where the diagnosis is much easier than maintaining patient compliance. Thought disorders. And the smarter you are, the harder to accept treatment. This expression of mental illness is like diabetes. It is for life. There is a relapse rate of over 80% a year for patients who stop their medication. Yet, accepting the illness and adhering to the drug regimens are the major challenges.


One of the core aspects of schizophrenia is the lack of insight the patients have about their illness and their lack of volition or forward movement to do anything about it or take charge of their life. Some experts have even defined the illness as a volitional absence. Perhaps, it is just a different perspective for which you must be in their world to understand.


If you listened carefully to these patients, you would hear this: “a relapse for you is not a relapse for me. What you find problematic is not a problem for me.” They like the way they feel under the influence of their aberrant chemistries more than how they feel on the medications that make them appear more normal to us. The pills made them feel disconnected. Like fog in their head, full of smoke. Meds give them the creeps, like they are jumping out of their skin.


So, they remain incognito, until their delusional system escapes into the open air. Hidden behind their façade is a ramifying delusional system that makes up their private world. The branches of it protruded like an extra eye or arm when they are on medications and fully flow unedited and unadulterated when they go off them. Then, for a season, medication can be mandated. But only for a season, until outward expression of the disease fades again. Because the ethical consideration of autonomy trumps beneficence in contemporary society.


With development of anti-psychotic medications, there was a nationwide movement to deinstitutionalize severely mentally ill patients and move them into community settings. However, lack of adequate resources and appropriate oversight resulted in shifting the newly denationalized patients onto the street, into the prisons, or into poorly regulated facilities. Misguided kindness creating unintended consequences.


Unable to get a handle on their meds, these mentally ill patients become recidivists, frequent fliers, high utilizers of health care collars, cycling in and out of the medical system. Meanwhile the patient’s brain lives in a psychotic short circuit, burning through neurons. Being psychotic is not a free lunch for the hippocampus and the billions of neurons and their packets of neurotransmitters. Untreated or partially treated psychosis can lead to profound and permanent cognitive decline and loss of intellect.


So, we find ourselves in a sea change of managing undertreated and undermedicated patients with a cornucopia of mental illness, drug addictions, criminal records, and a textbook of medical issues. All the patients have histories filled with shame and humiliation, the substrate for a volcanic rage that can seep to the surface with seismic results.


The risk of suicide is high – given the number of relapses, lack of adequate services, stressed out and humiliated families, where mental illness meant shame and social death. Relentless financial pressure is ever present.


What do my patients with severe and persistent mental illness die from? Diabetes, heart disease, strokes, kidney disease – all the common things that go untreated, under recognized, and often neglected conditions.


More than any other illness, mental health has been kidnapped by the system. It has become a solipsistic system with complex eddies and histories that reflect the times as much as scientific discovery.


Psychiatry as a profession is seen as something less than a hard science. It is not built on biopsies, CAT scans and blood tests. Its bible, the DSM, is a phenomenology of signs and symptoms bundled into disease states. It is used by insurance companies for billing purposes and as a justification for disability claims, insanity defenses, access to Social Security, longer time for SAT exams, early retirement, and special benefits.


If you don’t fit a category, then you don’t exist as an entity. Thus, the fight to be legitimized as an illness continues in the back rooms of lobbying groups and in the psychiatrists’’ committees themselves. Legitimization is followed by funding and powerful players in the field control funding. It is work very much embedded in politics and the payment system.


Parents advocate for labels: ADD, autism, learning disabilities so their child can access an IEP. Then those same parents demand such labels be removed when they are detrimental such as their child desiring to enter military service


In a society based on instant gratification, instant treatment with a pill, instant redemption, there needs to be another way to measure an inch forward. Our ethical hierarchy merits reconsideration. Perhaps the relief of suffering is the only pertinent principle in this broth of human misery and fractured lives. Our frame of reference needs recalibration.


Tim Powell MD

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