People with mental illness need more than medications
Emergency physicians take a fair amount of pride in the fact that we never refuse medical care to any patient who shows up at our door. It doesn’t matter when they show up, how they show up or who they are; we treat everyone the same. We see anybody that wants to be seen, regardless of their complaint or their ability to pay.
Since most parts of our healthcare delivery system do not function that way, we become the primary point of care for many in our community. The poor, the homeless and, often, the mentally ill turn to us because they have nowhere else to access care. Not surprisingly, the poor, the homeless and the mentally ill often represent the same individuals.
That segment of our community is seen in the emergency department on a regular basis both because they have nowhere else to go and because we are not very good at meeting their needs. For many of these patients, we get to know each other on a first name basis.
Delmont was one of those guys.
Delmont was in his early 40s and everyone in the emergency department knew his name. Many of us rather liked him as he was very polite and appreciative of anything we might give him. Often that was simply a safe, warm, and clean place to sleep for the night.
Whenever he arrived, his complaint was always the same. “I’m suicidal,” he would say matter-of-factly. He was never able to articulate a specific plan and no one could recall him actually having attempted to harm himself.
After many visits to the emergency department and the psychiatry ward for the same complaint, we came to believe Delmont was lonely and simply wanted to feel safe.
If the department was not too busy, we would often let him sleep on a stretcher and send him on his way when the sun came up.
At about 3 a.m. one winter morning several years ago, I was visiting with the staff at the nursing station, grateful for what was an uncharacteristically quiet night shift. We looked up to see Delmont standing in the hallway desperately waving his arms. As we hurried over to him, we could see that his face was blue and his eyes seemed to be bulging. He was frantically pointing to his neck where we saw a shoelace tightly knotted around his throat. Fortunately, his nurse always carried scissors with her and she was able to quickly cut cord.
Delmont looked up very sheepishly and began to cough and take several very deep breaths.
Once we were sure he was out if danger, she asked the question that was on all of our minds: “Delmont, what were you doing?”
“I don’t know,” he said. “It all just happened so fast.”
After that, we were able to get him admitted to a psychiatric hospital, but it wasn’t long before he was back out on the streets and back cycling through the emergency department.
A few years later, Delmont again made a serious effort to end his life. This time he was not as lucky. Our patient jumped off a bridge and hit the ground instead of the water, breaking his pelvis and a number of vertebrae. He was with us at the hospital for a long time with serious medical complications.
I am not sure what happened to Delmont after that, but I don’t have much reason for optimism. The cycle for the homeless with mental illness tends to have a strong downward bias.
In the previous column, I noted the way our society treats the mentally ill creates crisis rather than resolves it, but I don’t believe it has to be that way.
Before we began to depend on medication almost exclusively to treat mental illness, some psychiatric institutions worked hard to create a positive environment for people with mental illness.
They did not have the pharmaceutical tools we have today nor anything like the insight we have into how the brain works, but they gave patients three meals a day and a warm place to stay. Patients also had regular interaction with therapists and often chores or a job.
As imperfect as they were, those facilities worked hard to be humane and the best of them tried to give people with mental illness a safe place where life had a predictable rhythm and even a sense of purpose.
As he drifted in and out of short-term treatment facilities and homeless shelters, Delmont had neither safety, nor a sense of belonging, much less any sense of purpose.
We have medications now that are light years beyond those used a few decades ago and therapies that are much more effective than anything we had in the past, but we seem to be slipping backward in our treatment of mental illness.
My niece Kate, who lives in Minneapolis, has spent more than a decade working directly with people who are homeless and mentally ill. She is a fantastic person who does great work in a very difficult field.
The last time we visited, I asked her opinion of our current treatment for people with mental illness who are homeless. She told me there are essentially two different schools of thought: one in favor of first treating the mental illness and then addressing housing and the other in favor of first putting a roof over their heads and then attempting to treat their mental illness.
Kate’s organization helps people with mental illness get housing first. One of the lessons she has learned through hard experience is this: “Finding someone a home where they can drink alone all day is not the answer.”
In other words, when we provide the mentally ill medications, a place to live and enough money to barely get by, we are only going part way to a solution. What we aren’t giving them is the one thing that we all need, some sort of context that makes living worthwhile.
Here is an alternative. Instead of essentially paying to have the mentally ill get off the streets and stop being a problem, what if we found a way to pull them back into society. What if we developed treatment systems that included not just housing but jobs, hopefully in a structured community?
Through those jobs and in that community, they may be able to develop the relationships and sense of purpose that give life meaning.
(Mark Fourre, MD, is an emergency physician and chief medical officer of Lincoln County Healthcare, the parent company of LincolnHealth. He also serves on their board of trustees. Prior to joining Lincoln County Healthcare, Dr. Fourre was an attending faculty at Maine Medical Center where he developed the Emergency Medicine Residency Program and served as residency director.)