Sunday, March 20, 2016

The Screeners - Annotated: Psychiatric Lessons From A Short Science Fiction Story

I recommend reading the original version (preceding post) first before reading the annotated version.

What follows actually happened in the year 2066......

I could tell my brother needed help. We had been underground for too long. Whenever that happened he stopped sleeping regularly, he started to act crazy. This time he was looking for footprints - evidence that somebody was trying to get in through the hatch. I explained to him that the hatch was hydraulically locked from the inside. It was designed to take a direct hit from a grenade-launcher. But who could even hit it at that angle, flat against the two foot thick concrete roof of our bunker. This time he was sprinkling flour rations on the floor under the hatch. Anyone who came in had to step on that area and he would have their footprint in the flour.

This is an almost universal experience of family members directly observing their relatives with bipolar disorder.  They notice they become unpredictable sometimes to the point that they are frightening.  This is often manifested in their capacity for rational thought and personality changes.  In this case they observe paranoid behavior - defined as an unrealistic fear of harm or manipulation.  Family members are often at a loss in this situation because the person with the problem denies that there is anything wrong.  In many cases, the personality changes go on for months and lead to problems with employers and spouses.   

But the powder around the entrance was the least of our worries. His apartment was within a hundred feet of the hatch. He sat in his apartment looking out the window. He kept a plasma cutter nearby. It was for self defense, but he also told my son that if anyone did breach the hatch and they came for him - he knew exactly what to do. He would turn the plasma cutter on himself. He did not want to give the invaders a chance to torture and kill him. He would kill himself first. It would be over quickly.

This is a little known form of suicidal thinking that occurs in paranoid people.  They are so fearful of the unknown assailants that they are prepared to kill themselves - rather than be tortured or slowly killed.  In fact, they are not in danger at all.  This problem requires an intense effort to diagnose and treat - independent of any medications.

He had been getting worse for the past ten years. Long periods of laying in bed for days and weeks, barely eating and drinking. Not saying a word. That usually happened after weeks or months of being hyper, talkative and staying up all night. If you caught him at exactly the right time, he was interesting, funny, and you felt good talking with him. At the wrong time - it could be a nightmare. He could accuse you of trying to steal his American Gold Eagles. Everybody knew he had a tube of them somewhere in the bunker. Everybody knew because whenever he got hyper and started talking a lot, he would hold some of the coins in his hands and show everybody that he had them. During one of these episodes, he gave a couple of them away. Gold Eagles worth tens of thousands of dollars - just handed out to strangers at a watering hole.

Very typical behavior of untreated bipolar patients.  During periods of hyperactivity and euphoria they may give away large sums of money to casual acquaintances without being able to assess the consequences.  This can lead to financial duress or in the extreme, financial ruin. 

He had bipolar disorder, just like our mother. He has never seen a doctor, I just know from my experience with my mother. I remember going to see the doctor with her. She would see her every couple of months, unless she was having problems and then it would be more frequently. She liked that doctor and trusted her. She would always tell me that if she got too sick to make it to the doctor, my job was to call the doctor's office and let her know that she was not doing well. The doctor came over to our house one day to see my mother. Mom didn't say much, but the doctor knew what she needed and a short time later she was better. That went on like that for about ten years until I was ready to go to college. That was when the Supervolcano blew and we all had to go underground for three years. Mom was 60 by then. She couldn't adapt to living underground. She could not sleep underground in the phosphorescent lighting. She would stay up for weeks and get harder and harder to understand. She would start swearing and eventually made no sense at all. Then she would crash and not be able to eat. My wife and I would encourage her, but she would say: "Let me die....pick up that knife over there and kill me." We knew that she was not joking. Until the air finally cleared, there were no doctors and no medicines. She only had a month of medication when we went underground. Nobody could get more than a month at a time - even though everybody knew it was going to be a long time before we could come up for air.

Bipolar disorder definitely runs in families with what appears to be sporadic inheritance because of the polygenic nature of the disorder.  Bipolar disorder is sensitive to sleep and circadian rhythm disruptions and patients need to be counseled and constantly reminded about this.  Severe cognitive problems and catatonia can result and lead to severe disability. 

At about the one year mark - Mom died. She just got more and more confused. She stayed in bed and did not eat or drink anything for five days. The paramedic in our bunker said that she probably died from dehydration.

I don't think it is common knowledge that bipolar disorder can be a fatal condition.  At the turn of the 19th century, well before there were any useful medications - some forms of bipolar disorder were highly fatal.  Estimates from Boston Hospitals at around that time suggested that malignant catatonia resulted in about an 80% fatality rate.  Untreated mania in those days also resulted in a significant number of deaths from congestive heart failure due to constant agitation.  These facts are often ignored during an era where even episodic care during exacerbations of illness can prevent death.  Inpatient psychiatrists and consultation-liaison psychiatrists still find themselves in many life and death situations per year with hospitalized patients on the verge of dehydration and starvation due to severe psychiatric disorders.  In many situations, one of the best treatments available for this problem - electroconvulsive therapy is unavailable due to legal and political constraints.   

"Kevin is getting bad again" - my wife walked in. She was wearing standard desert camouflage hardened to withstand all of the fly ash. "I just saw him. He had melted a jar of peanut butter in the microwave and and he was throwing it all over the place. He has it splattered all over the walls. It looks like a Jackson Pollock painting." My wife was going to study art before the Supervolcano or "SV" as some call it now. Most people just talk about surviving it by using the phrase "when the air cleared." "We have to do something before he ends up like your mom or somebody takes advantage of him and gets his gold."

Highlights the familiy predicament of dealing with a family member who has had a transformation of their conscious state.  They are no longer predictable or rational.  Most emergency medical personnel confronted with this situation would ask the person a few questions and leave.  If the person became verbally aggressive, the outcome of the situation is highly dependent on the skill of the emergency personnel or involved law enforcement officers and there can be very adverse outcomes.

"More like hitting him over the head and taking it you mean. You would think that a guy who can be that paranoid would not put himself in those situations." I knew the words were meaningless as soon as they rolled off my lips. I had been watching bipolar people in my family for decades and they are unpredictable. Expect to see them in a certain situation and they disappear for weeks or months. "We have to try to get him to Minneapolis and see if they have scavenged any medication or if any new medical supplies have been flown in."

We had been to Minneapolis a couple of times since the air cleared. The trip is not too bad - 300 miles by a skimmer across the fly ash. So far nothing was growing up through the fly ash. We make good time with a skimmer and the metal composite tires make that trip many times before they need to be replaced. It just takes 20 minutes to recharge the batteries and we are back home the same day. The medical infrastructure was slowly being rebuilt. Practically all of the health care administration in the state was in Minneapolis and many of these bureaucrats survived the near extinction event. Surgical services and Cardiology had been restored. Last year they began doing heart, lung, liver and pancreas transplants at what used to be University Hospital.

There is a long history of discrimination against psychiatric and addiction services, despite the fact that they are routinely assessed as being in the top 10 disabling conditions world wide.  The discrimination is well documented on this blog and it occurs at all levels.  The so-called critics of psychiatry do not mention this phenomenon because it is inconsistent with their view that psychiatry is the source of all problems and not the selective rationing.

Treatment for mental disorders was always a problem. As people started coming out of their bunkers and heading back into the city general medical care was available in many places. The only treatment for mental disorders occurred in the same clinics where people went to get treated for infections and lung problems from the fly ash. People still got cancer and heart disease. People still got involved in accidents and injured themselves. Doctors with various skills were still around even though training programs were just restarting. Doctors tended to be old or really young.

In this piece, collaborative care and its ultimate goal of eliminating psychiatry rules the day.  An interesting proposition is who all of the critics will blame when psychiatrists are gone.  The obvious choice would be the next batch of prescribers, but in my story they became history as well.  There is clear history of mismanagement in medicine - rationalized by "cost effectiveness".  The most cost effective approach is to marginalize all professionals and pretend to replace them with checklists or artificial intelligence

My wife and I did some fast talking, convinced Kevin it would be an exciting trip, loaded him in the skimmer and took off. Within 4 hours we were standing in line in a large warehouse that had been converted to a medical clinic. Half an hour later we were face to face with a triage person:

"Nature of the problem?" he said matter of factly.
"My brother has bipolar disorder and he needs treatment." I replied.
"We don't see a lot of that here, are you sure about the diagnosis?" The triage person seemed a little impatient.
"My mother had it and she told me that her grandfather had it. He does a lot of what she used to do. His whole personality changes at times and he has problems taking care of himself. She used to see a doctor who treated bipolar disorder. Do you have a doctor like that?"
"Not anymore...but we do have screeners."

You don't have to live in the year 2066 to experience the above dialogue.  It is occurring right now in hundreds of clinics across America.  No access to psychiatrists or mental health professionals who could be very useful in treating the problems that they were trained to treat. 

We walked to the west side of the warehouse and entered a small room. There were a few people there. We got in to see the screener in a about 20 minutes. He looked like a clone of the triage person right down to the American Health Care pin on his lapel. He listened to me describe the problem for about two or three minutes, reached in a drawer and pulled out a piece of paper. It had three questions on it. After every question there was a line that varied from "None" to "Most of the time." Kevin made three checkmarks - one on each line at about the 75% mark.

This is a standard approach being used right now.  A checklist will be made right out of the DSM criteria.  Then it will be pared down to 3 or even 1 question rating scales.  Without the presence of a diagnostician, the checklist score and cutoff becomes the default diagnosis.  The interesting aspect of a screening instrument for bipolar disorder is that in many cases the affected person will not endorse any problems on the scale even when they are quite symptomatic.  

"Well he qualifies for treatment." the screener remarked. "The Army just brought in a shipment of medication for mood problems."
"My mother used to take Phosphotide 23, before the volcano blew. It worked pretty well."
"No ... all I have is this stuff.   It is taking a while to get drug manufacturing up and running again. Only the west coast facilities were untouched and they have shifted all of their production to what people really know antibiotics, heart meds, asthma medication. But I have plenty of this medication. Give it a try. Take two of these tablets every night".

There are widespread complaints about Big Pharma and medication prices.  I have written several pieces on this blog myself.  Medication expenditures have created a large number of medications and a significant surplus, but they are ironically rationed by Pharmacy Benefit Managers and managed care companies, even to the point that generics drugs require a negotiation.  In this case the patient is being given a medication that is probably not indicated for his condition and may make him worse.  Similar problems can occur with treatment based on screening tests.   

He handed me a large bottle of medication. The darkened label on the bottle read: "amitriptyline 25 mg tabs". The expiration date was July 20, 2025. I looked back at the screener and asked: "Is there anybody he can talk to about some of his problems? He goes off on a tangent and my wife and I don't know what to say to him."

This is a current problem in the business oriented behavioral health system.  Psychotherapy is rationed and in many case therapists have productivity expectations that they cannot sustain and that leads them to quit.  Contrary to popular myths people with severe mental illnesses benefit greatly from talking with their psychiatrists and are often reluctant to see other therapists or physicians.  In many systems of care today patients with severe mental illness see a "prescriber" for 15-20 minutes - 2 - 4 times a year. 

"No I'm afraid not. At American Health Care we do screening. My understanding is that the new government and the remaining businesses got together and decided that was the most cost-effective approach."

"Cost-effective" is a buzzword that is unevenly applied.  That should be evident from comparing psychiatric services (or behavioral health services) to every other medical specialty in any health care system.  There is a sharp contrast between what this concerned family member knows about bipolar disorder (disabling and killing his mother and disabling his brother and making him unpredictable) and how the health care system responds to his concerns.  It is as if  he is talking about a trivial condition.

Within thirty minutes we were back in the skimmer, moving at good speed across the fly ash. I glanced over at my wife. Her large blue mirrored-out glacier glasses did not conceal her worry. I looked at the plume we were kicking up in my rearview screen and thought:

"I hope this works."

Our concerned family member here is hopeful, but it is highly unlikely that the medication he picked up will be effective and it may make the situation worse.  The patient and family would have benefited by a detailed risk-benefit and monitoring discussion, as well as a follow-up plan.  In a typical screening procedure that occurs today, a person may leave the office with one or more month-long prescriptions and no clear plan for monitoring or contingencies if the medication does not work or it is not tolerated.  Follow up periods are frequently too long to make much of a difference and many people either discard the medication immediately, don't get it refilled, or get side effects - don't report them and discard the medication.  More frequent meetings for psychotherapy or closer monitoring are the exception rather than the rule.  

The more I thought about this near apocalyptic science fiction story, the more I realized that this is the type of care that many (if not most) people get right now and it is the type of care that is being promoted over seeing psychiatrists.

George Dawson, MD, DLFAPA


I tried to write this science fiction piece in the spirit of the one page sci-fi stories that are always on the last page of the journal Nature under their heading Futures Science Fiction

From the perspective of a psychiatrist (and a family member) of course.

This is a pure fiction and it contains no references to any real people or corporations. Any resemblance is purely coincidental.


The picture at the top of this file was uploaded from Wikimedia Commons.  This attribution is from their side and when the file was accessed on March 19, 2016, the link in this reference did not work:  Work of the Bureau of Land Management, a U.S. Government Agency. Taken from the BLM website:  No photo credit is given.

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