Great Case Records of the Massachusetts General Hospital in the New England Journal of Medicine this week. A psychiatrist is presenting a case of complicated disorder and coordinating care with oncologists after a cancer diagnosis is made. It must have taken an editorial change in the Journal to get psychiatry more front and center in this prominent medical journal. This article has a lot of meaning for me, because the bulk of my career was spent on these issues. When you are the inpatient doc or the psychiatrist staffing the case management teams - either Assertive Community Treatment (ACT) or some other case management model a lot of this important work falls to you because there is nobody else out there. Contrary to the popular hype about collaborative care - people with severe mental illnesses generally avoid medical clinics and non-psychiatric physicians. There are always some exceptions, but as I have said many times there are reasons that people do not go into psychiatry. Talking to people with communication problems, irrational thought processes, and atypical social behavior are high on the list. Some of the best primary care physicians recognize this and like the oncology clinic described in this paper give people with severe mental illnesses wide latitude in terms of appointments and treatment schedules, but they can only do so much.
What is needed on the front end is a psychiatrist with strong medical skills to figure out the problem and get other medical staff involved. I don't mean looking at PHQ-9 scores and suggesting medication adjustments. I mean actually talking with the patients. Very frequently a person with impaired judgment due to a psychiatric disorder will be fully cooperative in one setting but not another. Consider a patient who is acutely admitted with very high blood pressure (260/140). He has a history of schizophrenia and hypertension requiring moderate to high doses of two different antihypertensives. In this case the patient has gone off of both medications and maintenance antipsychotic medication. He is agitated and paranoid. It is impossible to determine if he is also delirious due to the presence of cognitive disorganization from acute psychosis. He will not allow testing or physical examination beyond the blood pressure determinations and eventually stop cooperating with that. The inpatient psychiatrist makes an assessment and swings into action. He tries to establish rapport with the patient to convince him that this is a medical emergency. At the same time he has contacted the hospitalist service and there is agreement that he needs to go to an acute care bed as soon as possible. The hospitalist reminds the psychiatrist that they cannot touch the patient unless he consents "or it is assault". His advice is to call when he is ready to cooperate or call when he gets obtunded by encephalopathy or a stroke and they will treat him acutely. In this case the psychiatrist eventually convinces the patient to check out the ICU and walks him over there. Once he is in the bed - he is fully cooperative with all recommended measures including a complete physical exam.
In addition to the lack of a logical progression to the care of severe medical problems there can also be obstacles at the level of presenting the diagnosis to the patient. I have presented diagnoses of cancer and diabetes mellitus to patients with psychiatric disorders only to be told that the diagnosis is impossible. "I could not possibly have diabetes doctor, because I don't have a pancreas." comes to mind. In terms of evidence, holding up an image of a lung or brain tumor may get the response: "I don't think that is my x-ray doctor. That is somebody else's x-ray." Those responses and the lack of ability to cooperate can be very frustrating for primary care physicians and specialists. These patients are always very easy to get rid of. All it takes is a comment like: "If you want me to treat you - you are going to have to stop smoking. If you can't stop smoking - I can't treat you." At the other end of the spectrum I have had Internists coach me over the phone on what to do for a patient, because they knew the patient would never come into their office or pick up a prescription.
The most frustrating cases are the ones that I saw too late. The mistakes of informed consent as in: "Mr. Smith you have colon cancer and need to have surgery to have the tumor removed. At this stage you have an excellent chance for recovery but we have to operate in the next few months." Mr Smith has schizophrenia. He smiles and seems to understand everything. He just wants to get out of the clinic and away from doctors back to his home where he will be much less anxious. He never returns until two years later when concerned relatives call the police because of their concern about him. The police find him alone at home. The house is in disarray. There is blood everywhere. Mr. Smith is emaciated and has lost 35 lbs. He is brought to the hospital and admitted to inpatient psychiatry. He is seen by the oncologist who originally consulted on his case. He now has widely metastatic colon cancer and no chance for survival. That whole sequence of events can be prevented by a psychiatrist willing to discuss these potential outcomes long before the clinical picture worsens.
An infrastructure that allows for continued outreach and rapport building is also useful. I had many patients with terminal cancer diagnoses admitted to my inpatient unit, not only because they were mentally ill and medical services would not admit them, but because there was no place else for a mentally ill person with terminal cancer to go. Pulling all of the necessary resources and teams together with an initial acute admission potentially saves lives. This paper is a good example of that, but acute care psychiatrists may still be held to the "acute dangerousness" standard for care and these admissions are actively discouraged.
In the case of the NEJM article, the patient is a 63 year old woman with a history of lung cancer, chronic obstructive pulmonary disease (COPD), hypertension, hypercholesterolemia, asthma, insomnia, and restless leg syndrome. She has also had two previous cancer diagnoses. A previous diagnosis of lung cancer had been treated surgically with lobectomy and adjuvant chemotherapy six years earlier. She had a past history of stage IIa estrogen-receptor positive and progesterone-receptor positive, HER2/neu negative invasive ductal carcinoma of the left breast. The breast cancer was treated with lumpectomy, whole breast irradiation, and chemotherapy. The patient had a previous psychiatric diagnosis of Attention Deficit-Hyperactivity Disorder treated at times with various stimulants and modafinil. She was a admitted to the inpatient psychiatry unit for treatment of depression with electroconvulsive therapy.
In the process her psychiatrist comes up with a list of 13 factors that affect cancer care in patients with severe mental illness and cancer and strategies to approach them. The factors follow initially what is known about cognitive and social behavioral deficits in the population with severe mental illness. That would include an inability to understand the diagnosis or treatment. In many cases, the patient is unable to provide informed consent due to cognitive deficits. System wide deficits are identified at the level of the provider, the health care system, and society and culture. Any physician who tries to provide medical or psychiatric care to these populations has seen most of these deficits.
In addition to the factors affecting cancer care there is a separate table of Differential Diagnosis of Depression in a Cancer Patient that every psychiatrist working in these settings needs to be aware of.
The psychiatrist in this case provides psychotherapy focused on the patient's understanding of the illness and their decisions to cooperate with care. That included but was not limited to biological interventions for depression. ECT and lurasidone were the main identified treatment modalities. An enhancing mass was noted in the right breast on chest CT scan to follow up on previous cancer treatment. That was subsequently diagnosed as ductal carcinoma of the right breast. In this case, the radiation oncologist modified the radiation treatment to maximize the flexibility of treatment for the patient. She was able to complete all 5 treatments without difficulty.
From a psychiatric standpoint she was discharged as improved after 19 days taking lamotrigine, gabapentin, quetiapine, and modafinil. She had received 6 ECT treatments. But as importantly, she had follow up oncology care, identification of a new cancer diagnosis, and coordination of that care also occurred in that setting. This is a very compelling study at that level and a clear departure from the rationed inpatient care that people have come to expect when psychiatric units are run by business people.
George Dawson, MD, DFAPA
References:
1: Irwin KE, Freudenreich O, Peppercorn J, Taghian AG, Freer PE, Gudewicz TM. Case 30-2016. N Engl J Med. 2016 Sep 29;375(13):1270-81. doi: 10.1056/NEJMcpc1609309. PubMed PMID: 27682037.
2: Shtasel DL, Freudenreich O, Baggett TP. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 40-2015. A 40-Year-Old Homeless Woman with Headache, Hypertension, and Psychosis. N Engl J Med. 2015 Dec 24;373(26):2563-70. doi: 10.1056/NEJMcpc1405204. PubMed PMID: 26699172.
Supplementary:
From the New England Journal of Medicine earlier this year:
New England Journal of Medicine Discovers Assertive Community Treatment. link
