A Medical Catch-22

Many of us remember the 1961 satirical novel (which later became a movie) by Joseph Heller, Catch-22. The term catch-22 has become a (forgive the pun) catchphrase describing an ineffective bureaucratic process and reasoning that results in a “no-win” state of affairs. Increasingly in the past few years, I have heard patient stories that demonstrate a medical catch-22. Let me relay one such story. The patient’s name has been changed to protect the innocent and to adhere to HIPAA standards. The guilty are obvious. 

Stacey, now 30, is the middle child of five children. She manifested bipolar symptoms when she was 12, with dramatic and unpredictable mood swings.¹ At that time, despite counseling and treatment, she experienced significant symptoms of mania: irritability, restlessness, increased energy, little need for sleep, racing thoughts, hypersexuality, and a tendency to make grand and unattainable plans. She became a two-pack-a-day smoker. 

During this time, she would run away from home, on a number of occasions actually taking the family car. She spent a great deal of time in juvenile detention. Her depression symptoms included sadness, anxiety, irritability, loss of energy, uncontrollable crying, weight gain, increased need for sleep, difficulty making decisions, and thoughts of death. These symptoms worsened over time, and Stacey refused to use prescribed medication or to attend individual and family counseling. 

Often, she would run away for weeks at a time, then show up in the middle of the night. It was during this period that she became pregnant with her first child. Shortly after the birth of her son, and due to safety concerns, Stacey’s parents were granted temporary custody of the child. It took two years for her parents to obtain legal guardianship of the child, because of Stacey’s recurrent inability to attend court proceedings and give permission for the necessary court action.

During her young adulthood, Stacey’s condition became even more difficult to manage—due in part to her legal right to make her own decisions and to the fact that she would “escape” for weeks at a time. During these years, her parents would find that she had been incarcerated or had lived on the street or with total strangers. 

She was diagnosed with schizophrenia² and was able to receive Social Security money each month for her disability. Her symptoms now included recurring episodes of elevated or depressed mood, with significant distortions in perception. Her symptoms affected cognition and emotion. She demonstrated auditory hallucinations, paranoia, bizarre delusions, disorganized speech, and social and occupational dysfunction. 

Stacey gave birth to a second son. Again, due to her disability, she was unable to care for this child, and Stacey’s parents gained legal guardianship. Over the next few years, Stacey would give birth to two other children, who were subsequently adopted, and an additional pregnancy was terminated by abortion.  

Once, Stacey showed up at her parents’ house and in front of two of her children attempted to cut her wrists. She was taken to the urgent psychiatric care center and hospitalized. She checked herself out 72 hours later. This became a recurring pattern. She would have outbursts, be hospitalized, then check herself out—back to the streets. 

Unable to manage her Social Security checks, Stacey frequently went to casinos to spend her money rapidly; she would then have no money for food, clothing, or transportation. She has been banned from most casinos because of outbursts and inappropriate behavior. 

Her parents believe Stacey has become a danger not only to herself, but also to the lives of her children and siblings. Her behaviors have escalated to include threats to harm others. 

Recently, Stacey was found wandering around town and talking to herself. She was again admitted to the local psychiatric facility. Her intake examination revealed she was undernourished, with poor hygiene. Her drug screen was positive for cocaine, and a pregnancy test was positive. A hearing took place, and she was committed for 30 days for evaluation and treatment. An assigned caseworker explained to her parents that, due to financial constraints, they would not be able to hold Stacey past the 30 days, despite her pregnancy.  

There is no doubt that Stacey is suffering from a serious mental illness that has severely impaired her functioning. Caseworkers, counselors, and physicians all agree that Stacey’s health and well-being, particularly now that she is pregnant, can only be maintained by the most restrictive psychiatric setting. Unfortunately, the long-term psychiatric hospital has denied a request for admission. Stacey will be returned to outpatient treatment where she will, undoubtedly, be lost to follow-up and treatment. The risks to the fetus and to Stacey are extreme.

It has become commonplace to see and hear media reports about police interactions with mentally ill people. Yet it is not uncommon for correctional officers and officials to voice concerns that our jails have become de facto mental health hospitals, with more people than ever before incarcerated with—and sometimes because of—mental health problems. Correctional personnel continuously remind us they are neither trained nor funded for these types of responsibilities.

Mental health funding has faced the budgeting sword in many states over the past couple of years. While the social implications are tragic, there is also a significant cost. Law enforcement and emergency services are not designed to provide mental health services to patients on a prolonged basis. The needs of the chronically mentally ill quickly overwhelm those systems and become very expensive to address.     

Releasing patients from the psychiatric wing of a jail, a crisis center, or a psychiatric hospital without ensuring that treatment is continuously maintained is a profound medical error, with risk to patient and community—not to mention a waste of taxpayer’s money. There is an astonishing recidivism rate among repeat offenders with serious mental illness, even though parole or probation conditions usually mandate follow-up treatment. Even when effective medications are dispensed, many patients suffer from anosognosia (impaired awareness of illness) and subsequently do not continue their medications or follow-up care.  

According to the Treatment Advocacy Center, anosognosia is the single largest reason that individuals with schizophrenia and bipolar disorder do not take their medications. It is caused by damage to specific parts of the brain, especially the right hemisphere, and affects approximately 50% of individuals with schizophrenia and 40% of individuals with bipolar disorder.³ 

Another major factor in noncompliance is alcohol and substance abuse; this further complicates treatment of the seriously ill. Commonly, such patients revert back to abusing drugs or alcohol. It is clear that abuse of these substances mars one’s ability to appreciate symptoms, to make proper judgments, and to have the insight necessary to recognize one’s dysfunctional behavior.

The National Alliance on Mental Illness estimates the cost of untreated mental illness to be more than $100 million annually. Ignoring the needs of the mentally ill contributes to and fosters:

• An inability to maintain employment

• An increased burden on law enforcement

• Overcrowding of cases in an already strained legal system

• Stressed jail facilities

 • Overburdening of local crisis centers 

• An increase of the homeless population in our communities.⁴

The plight of mentally ill patients in this country is heartbreaking. Of course, no single answer or approach will fix this problem. It will take multiple funded agencies working together with clinicians and caseworkers to provide the necessary continuation of care for the chronically mentally ill to correct this catch-22. 

I’d love to hear from you if you have comments about this editorial. E-mail me at PAeditor@qhc.com.            CR

Many of us remember the 1961 satirical novel (which later became a movie) by Joseph Heller, Catch-22. The term catch-22 has become a (forgive the pun) catchphrase describing an ineffective bureaucratic process and reasoning that results in a “no-win” state of affairs. Increasingly in the past few years, I have heard patient stories that demonstrate a medical catch-22. Let me relay one such story. The patient’s name has been changed to protect the innocent and to adhere to HIPAA standards. The guilty are obvious. 

Stacey, now 30, is the middle child of five children. She manifested bipolar symptoms when she was 12, with dramatic and unpredictable mood swings.¹ At that time, despite counseling and treatment, she experienced significant symptoms of mania: irritability, restlessness, increased energy, little need for sleep, racing thoughts, hypersexuality, and a tendency to make grand and unattainable plans. She became a two-pack-a-day smoker. 

During this time, she would run away from home, on a number of occasions actually taking the family car. She spent a great deal of time in juvenile detention. Her depression symptoms included sadness, anxiety, irritability, loss of energy, uncontrollable crying, weight gain, increased need for sleep, difficulty making decisions, and thoughts of death. These symptoms worsened over time, and Stacey refused to use prescribed medication or to attend individual and family counseling. 

Often, she would run away for weeks at a time, then show up in the middle of the night. It was during this period that she became pregnant with her first child. Shortly after the birth of her son, and due to safety concerns, Stacey’s parents were granted temporary custody of the child. It took two years for her parents to obtain legal guardianship of the child, because of Stacey’s recurrent inability to attend court proceedings and give permission for the necessary court action.

During her young adulthood, Stacey’s condition became even more difficult to manage—due in part to her legal right to make her own decisions and to the fact that she would “escape” for weeks at a time. During these years, her parents would find that she had been incarcerated or had lived on the street or with total strangers. 

She was diagnosed with schizophrenia² and was able to receive Social Security money each month for her disability. Her symptoms now included recurring episodes of elevated or depressed mood, with significant distortions in perception. Her symptoms affected cognition and emotion. She demonstrated auditory hallucinations, paranoia, bizarre delusions, disorganized speech, and social and occupational dysfunction. 

Stacey gave birth to a second son. Again, due to her disability, she was unable to care for this child, and Stacey’s parents gained legal guardianship. Over the next few years, Stacey would give birth to two other children, who were subsequently adopted, and an additional pregnancy was terminated by abortion.  

Once, Stacey showed up at her parents’ house and in front of two of her children attempted to cut her wrists. She was taken to the urgent psychiatric care center and hospitalized. She checked herself out 72 hours later. This became a recurring pattern. She would have outbursts, be hospitalized, then check herself out—back to the streets. 

Unable to manage her Social Security checks, Stacey frequently went to casinos to spend her money rapidly; she would then have no money for food, clothing, or transportation. She has been banned from most casinos because of outbursts and inappropriate behavior. 

Her parents believe Stacey has become a danger not only to herself, but also to the lives of her children and siblings. Her behaviors have escalated to include threats to harm others. 

Recently, Stacey was found wandering around town and talking to herself. She was again admitted to the local psychiatric facility. Her intake examination revealed she was undernourished, with poor hygiene. Her drug screen was positive for cocaine, and a pregnancy test was positive. A hearing took place, and she was committed for 30 days for evaluation and treatment. An assigned caseworker explained to her parents that, due to financial constraints, they would not be able to hold Stacey past the 30 days, despite her pregnancy.  

There is no doubt that Stacey is suffering from a serious mental illness that has severely impaired her functioning. Caseworkers, counselors, and physicians all agree that Stacey’s health and well-being, particularly now that she is pregnant, can only be maintained by the most restrictive psychiatric setting. Unfortunately, the long-term psychiatric hospital has denied a request for admission. Stacey will be returned to outpatient treatment where she will, undoubtedly, be lost to follow-up and treatment. The risks to the fetus and to Stacey are extreme.

It has become commonplace to see and hear media reports about police interactions with mentally ill people. Yet it is not uncommon for correctional officers and officials to voice concerns that our jails have become de facto mental health hospitals, with more people than ever before incarcerated with—and sometimes because of—mental health problems. Correctional personnel continuously remind us they are neither trained nor funded for these types of responsibilities.

Mental health funding has faced the budgeting sword in many states over the past couple of years. While the social implications are tragic, there is also a significant cost. Law enforcement and emergency services are not designed to provide mental health services to patients on a prolonged basis. The needs of the chronically mentally ill quickly overwhelm those systems and become very expensive to address.     

Releasing patients from the psychiatric wing of a jail, a crisis center, or a psychiatric hospital without ensuring that treatment is continuously maintained is a profound medical error, with risk to patient and community—not to mention a waste of taxpayer’s money. There is an astonishing recidivism rate among repeat offenders with serious mental illness, even though parole or probation conditions usually mandate follow-up treatment. Even when effective medications are dispensed, many patients suffer from anosognosia (impaired awareness of illness) and subsequently do not continue their medications or follow-up care.  

According to the Treatment Advocacy Center, anosognosia is the single largest reason that individuals with schizophrenia and bipolar disorder do not take their medications. It is caused by damage to specific parts of the brain, especially the right hemisphere, and affects approximately 50% of individuals with schizophrenia and 40% of individuals with bipolar disorder.³ 

Another major factor in noncompliance is alcohol and substance abuse; this further complicates treatment of the seriously ill. Commonly, such patients revert back to abusing drugs or alcohol. It is clear that abuse of these substances mars one’s ability to appreciate symptoms, to make proper judgments, and to have the insight necessary to recognize one’s dysfunctional behavior.

The National Alliance on Mental Illness estimates the cost of untreated mental illness to be more than $100 million annually. Ignoring the needs of the mentally ill contributes to and fosters:

• An inability to maintain employment

• An increased burden on law enforcement

• Overcrowding of cases in an already strained legal system

• Stressed jail facilities

 • Overburdening of local crisis centers 

• An increase of the homeless population in our communities.⁴

The plight of mentally ill patients in this country is heartbreaking. Of course, no single answer or approach will fix this problem. It will take multiple funded agencies working together with clinicians and caseworkers to provide the necessary continuation of care for the chronically mentally ill to correct this catch-22. 

I’d love to hear from you if you have comments about this editorial. E-mail me at PAeditor@qhc.com.            CR

Many of us remember the 1961 satirical novel (which later became a movie) by Joseph Heller, Catch-22. The term catch-22 has become a (forgive the pun) catchphrase describing an ineffective bureaucratic process and reasoning that results in a “no-win” state of affairs. Increasingly in the past few years, I have heard patient stories that demonstrate a medical catch-22. Let me relay one such story. The patient’s name has been changed to protect the innocent and to adhere to HIPAA standards. The guilty are obvious. 

Stacey, now 30, is the middle child of five children. She manifested bipolar symptoms when she was 12, with dramatic and unpredictable mood swings.¹ At that time, despite counseling and treatment, she experienced significant symptoms of mania: irritability, restlessness, increased energy, little need for sleep, racing thoughts, hypersexuality, and a tendency to make grand and unattainable plans. She became a two-pack-a-day smoker. 

During this time, she would run away from home, on a number of occasions actually taking the family car. She spent a great deal of time in juvenile detention. Her depression symptoms included sadness, anxiety, irritability, loss of energy, uncontrollable crying, weight gain, increased need for sleep, difficulty making decisions, and thoughts of death. These symptoms worsened over time, and Stacey refused to use prescribed medication or to attend individual and family counseling. 

Often, she would run away for weeks at a time, then show up in the middle of the night. It was during this period that she became pregnant with her first child. Shortly after the birth of her son, and due to safety concerns, Stacey’s parents were granted temporary custody of the child. It took two years for her parents to obtain legal guardianship of the child, because of Stacey’s recurrent inability to attend court proceedings and give permission for the necessary court action.

During her young adulthood, Stacey’s condition became even more difficult to manage—due in part to her legal right to make her own decisions and to the fact that she would “escape” for weeks at a time. During these years, her parents would find that she had been incarcerated or had lived on the street or with total strangers. 

She was diagnosed with schizophrenia² and was able to receive Social Security money each month for her disability. Her symptoms now included recurring episodes of elevated or depressed mood, with significant distortions in perception. Her symptoms affected cognition and emotion. She demonstrated auditory hallucinations, paranoia, bizarre delusions, disorganized speech, and social and occupational dysfunction. 

Stacey gave birth to a second son. Again, due to her disability, she was unable to care for this child, and Stacey’s parents gained legal guardianship. Over the next few years, Stacey would give birth to two other children, who were subsequently adopted, and an additional pregnancy was terminated by abortion.  

Once, Stacey showed up at her parents’ house and in front of two of her children attempted to cut her wrists. She was taken to the urgent psychiatric care center and hospitalized. She checked herself out 72 hours later. This became a recurring pattern. She would have outbursts, be hospitalized, then check herself out—back to the streets. 

Unable to manage her Social Security checks, Stacey frequently went to casinos to spend her money rapidly; she would then have no money for food, clothing, or transportation. She has been banned from most casinos because of outbursts and inappropriate behavior. 

Her parents believe Stacey has become a danger not only to herself, but also to the lives of her children and siblings. Her behaviors have escalated to include threats to harm others. 

Recently, Stacey was found wandering around town and talking to herself. She was again admitted to the local psychiatric facility. Her intake examination revealed she was undernourished, with poor hygiene. Her drug screen was positive for cocaine, and a pregnancy test was positive. A hearing took place, and she was committed for 30 days for evaluation and treatment. An assigned caseworker explained to her parents that, due to financial constraints, they would not be able to hold Stacey past the 30 days, despite her pregnancy.  

There is no doubt that Stacey is suffering from a serious mental illness that has severely impaired her functioning. Caseworkers, counselors, and physicians all agree that Stacey’s health and well-being, particularly now that she is pregnant, can only be maintained by the most restrictive psychiatric setting. Unfortunately, the long-term psychiatric hospital has denied a request for admission. Stacey will be returned to outpatient treatment where she will, undoubtedly, be lost to follow-up and treatment. The risks to the fetus and to Stacey are extreme.

It has become commonplace to see and hear media reports about police interactions with mentally ill people. Yet it is not uncommon for correctional officers and officials to voice concerns that our jails have become de facto mental health hospitals, with more people than ever before incarcerated with—and sometimes because of—mental health problems. Correctional personnel continuously remind us they are neither trained nor funded for these types of responsibilities.

Mental health funding has faced the budgeting sword in many states over the past couple of years. While the social implications are tragic, there is also a significant cost. Law enforcement and emergency services are not designed to provide mental health services to patients on a prolonged basis. The needs of the chronically mentally ill quickly overwhelm those systems and become very expensive to address.     

Releasing patients from the psychiatric wing of a jail, a crisis center, or a psychiatric hospital without ensuring that treatment is continuously maintained is a profound medical error, with risk to patient and community—not to mention a waste of taxpayer’s money. There is an astonishing recidivism rate among repeat offenders with serious mental illness, even though parole or probation conditions usually mandate follow-up treatment. Even when effective medications are dispensed, many patients suffer from anosognosia (impaired awareness of illness) and subsequently do not continue their medications or follow-up care.  

According to the Treatment Advocacy Center, anosognosia is the single largest reason that individuals with schizophrenia and bipolar disorder do not take their medications. It is caused by damage to specific parts of the brain, especially the right hemisphere, and affects approximately 50% of individuals with schizophrenia and 40% of individuals with bipolar disorder.³ 

Another major factor in noncompliance is alcohol and substance abuse; this further complicates treatment of the seriously ill. Commonly, such patients revert back to abusing drugs or alcohol. It is clear that abuse of these substances mars one’s ability to appreciate symptoms, to make proper judgments, and to have the insight necessary to recognize one’s dysfunctional behavior.

The National Alliance on Mental Illness estimates the cost of untreated mental illness to be more than $100 million annually. Ignoring the needs of the mentally ill contributes to and fosters:

• An inability to maintain employment

• An increased burden on law enforcement

• Overcrowding of cases in an already strained legal system

• Stressed jail facilities

 • Overburdening of local crisis centers 

• An increase of the homeless population in our communities.⁴

The plight of mentally ill patients in this country is heartbreaking. Of course, no single answer or approach will fix this problem. It will take multiple funded agencies working together with clinicians and caseworkers to provide the necessary continuation of care for the chronically mentally ill to correct this catch-22. 

I’d love to hear from you if you have comments about this editorial. E-mail me at PAeditor@qhc.com.            CR