Sunday, April 12, 2015

Psychiatry Today: The Case of Derek Ward

Psychiatry has made great progress in past years. New medications and new forms of psychotherapy have provided help that previous generations had only dreamed of.

Yet, having treatments available is not the same as being able to give them to those who need them.

It has become more and more difficult for those who are severely mentally ill to get an appointment with a psychiatrist. In part, psychiatrists do not want to see such patients. But also, fewer psychiatrists even take health insurance. Fewer still accept the insurance that is offered by Obamacare exchanges.

Bloomberg reports:

Obamacare was supposed to help level the playing field by requiring individual and small-employer insurance plans to include mental health benefits. Yet because of the low reimbursement rate paid by many of those plans, few doctors will take them, and those who do have long waits.

Central Nassau Guidance & Counseling Services, a publicly funded mental-health clinic near where the Wards lived, doesn’t take any of the plans sold on the Obamacare exchange, which reimburse doctors 40 percent less than other insurance, says Jeffrey Friedman, the clinic’s chief executive officer. It already loses an average of $20 a visit for a privately insured patient, he says.

Politicians thrill to the notion that more people now have insurance. They ignore the fact that more people are having more problems getting access to treatment.

One is tempted to blame the psychiatrists, for not wanting to be inconvenience, but paranoid schizophrenics, for example, should probably be treated in a controlled, hospital setting.

Those who say that schizophrenics are no more dangerous or likely to commit a crime than are everyone else should explain it to the psychiatrists who do not feel equipped to deal with them in a private office.

The Bloomberg article does not take it into account, but more and more of today’s psychiatrists and mental health professionals are women. Having undergone residency and having worked with severe mental illness, they know the risks inherent on being a vulnerable female in a private office with a paranoid schizophrenic.

Before assuming that these women refuse such patients for less than noble motives, we should ask whether or not they may have a good reason to do so. Surely, you do not believe that they should be seeing patients who might put them in imminent physical danger.

The article also does not mention it, but the risk of lawsuits must weigh on the minds of psychiatrists. Dealing with high-risk and potentially dangerous patients, patients whose insurance does not pay enough, and risking a lawsuit if something bad happens, most psychiatrists choose not to accept them.

Bloomberg explains:

In the $100 billion mental health industry made up of doctors, clinics and hospitals, the hard cases — patients with government-funded insurance, psychosis or a history of drug addiction — are sometimes finding it nearly impossible to get help. Instead, a growing number of psychiatrists, hit with cuts from insurers, are focused on cash-paying patients with easier-to-treat conditions. The government-funded community clinics, meant to serve as the safety net, are at capacity after funding cuts during the recession.


An increasing number of doctors have been dropping insurance as demand grows from easier to treat, high-dollar cash clients — the anxious Wall Street bankers, worried soccer moms or depressed college graduates, who don’t usually phone them in the middle of the night or pose a safety threat.

Since 2005, the number of psychiatrists taking private insurance or Medicare has dropped almost 20 percent, to 55 percent, as of 2010, according to a study in the Journal of the American Medical Association. That compares with other specialties where 93 percent take private insurance and 86 percent take Medicare.

The case that grounds the Bloomberg article concerns one Derek Ward. Suffering from paranoid delusions and clearly schizophrenic, Ward could not obtain treatment. His mother had been trying desperately to find someone to see him, but she failed. It cost her her life and it cost Derek Ward’s his.

Examine the description:

Ward in the months before he brutally murdered his mother and then killed himself.

Voices had crowded the 35-year-old’s head. The once-successful personal trainer now spoke of drones spying on him and the CIA infiltrating his Long Island, New York, apartment.

For months, his mother Pat Ward, a well-respected English professor, had been frantically trying to get him an appointment with a psychiatrist. Yet dozens of doctors said they either didn’t take his insurance or wouldn’t see patients with Derek’s complex condition.

Many simply never returned her calls. At one Long Island hospital, four doctors to whom she was referred told Pat their next appointment was three months away — an all-too-typical wait time, according to Ward’s brother, Robert Lubrano, a Catholic priest who helped her in her quest.

Once when Derek Ward was hospitalized, physicians seemed not to know how to diagnose his condition.

Bloomberg reports on the hospital stay:

The stay provided no firm diagnosis, but doctors suspected Derek was suffering from post-traumatic stress disorder related to the loss of his grandfather and to memories of his brother’s death all those years before, Pat's friends say she told them. 

In retrospect it seems obvious that Ward was suffering from paranoid schizophrenia. But, while he had shown signs of mental illness when he was in his mid-twenties, he had not shown signs of paranoid schizophrenia until he was 34. This would be considered an extremely late onset for the disease.

Assuming that he did not have another kind of brain disease, Derek Ward seems clearly to have been suffering from a psychosis.

The worse he got the less the psychiatrists knew how to treat him.

If he was psychotic, he should have been undergone a long-term hospitalization, something that he might have refused, rather than a series of prescriptions and support group meetings.

Bloomberg reports:

Derek was becoming more disconnected, say Pat’s friends. He began compulsively smoking cigarettes, going through an entire pack in 30 minutes, Lubrano says. Other behavior was downright creepy. In the deep of the night, Derek would sneak into his mother’s room and blow cigarette smoke in her face. As her search continued, Pat twice more took him to the emergency room to get him more pills. Both times, doctors gave him five-day prescriptions and referrals to more psychiatrists — none of whom could see him, says Lubrano.

Wherever did we get the idea that severely psychotic patients should be treated on an outpatient basis?

Surely, we got the idea because it is cheaper, overall to provide outpatient than inpatient treatment. But, we also learned it from an anti-psychiatry movement that declared mental illness to be a symptom of social injustice and from victims’ rights advocates who believed that people suffering from a brain disease should be able to decide for themselves whether they wanted to be treated.

Before blaming psychiatrists for lacking compassion, we should look at the political and social conditions that determine the treatment of severe mental illness.

I suspect that most psychiatrists would have wanted Derek Ward to undergo long term inpatient psychiatric treatment. Most would have been willing to commit him involuntarily. 

And yet, given the configuration of our culture, psychiatrists are simply not allowed to do what they believe to be best for their patients.

1 comment:

Sam L. said...

Seems like a classic double-bind.