Crazy Or Not Crazy?

     Imagine looking in the mirror one day and realizing that you're 70 years old and have never been ill or injured. Realistically, your chances of making it to that age without experiencing some form of sickness or trauma are close to 0%. There are just too many ways to get hurt and too many bacteria and viruses floating around to avoid them for 70 years.

     Stepping away from illness and injury for a moment, what's the chance that you've lived to 70 and never had a mental health problem? You'd be surprised at how many folks would guess a ridiculously high percentage, like 80%. Why? Can being mentally healthy throughout such a long stretch of life also be close to impossible? There are a number of factors that play into this unusual mathematical mismatch.

     First and foremost is how we define mental health and mental illness. In my experience, far too many EMS providers associate the term "mental illness" with "crazy." Does that mean that someone who is mentally healthy is "not crazy"?

     Mental health actually has little in common with being crazy or not crazy. Many people struggle with their mental health, but are no closer to being crazy than I am to being a nuclear physicist. However, making that leap from mental illness to crazy can truly have a negative impact on how you care for patients with behavioral issues once you introduce this bias into your medicine.

     Far too often, I've watched providers going over a list of patient medications and seen the change in their demeanor when they find a medication used to treat a form of mental illness like depression or anxiety disorder. They suddenly look at the patient differently, and the patient's complaint of chest pain or shortness of breath gets discounted to almost nothing. The provider's facial expression says it all: "Yeah, sure, chest pain. Not likely; he's just crazy." How often does good medicine take a backseat when this kind of bias takes over?

     I'll never forget a call to transfer a patient from the ED for voluntary commitment to the psych unit of the local VA hospital. After picking up the transfer paperwork, we got the patient into the rig and, for close to a half-hour of transport, he and I had a great visit about current events and life in general. The patient was clearly well educated, well read and articulate. When we arrived at the VA hospital, I said, "Please excuse me for saying this, but you've got more on the ball than some of the people I work with on a daily basis. Why exactly am I taking you to the psych unit?" He replied, "Hey, I'm not crazy. I just can't cope sometimes."

     That was a career-changing call for me. Somewhere along the way, a bias toward mental illness had crept into my medicine. I know in my heart that when I heard the dispatch for a transfer to the VA psych unit, I thought to myself "just another crazy." But like a proverbial slap in the face, this patient showed me the error of my ways with his honest answer. I thought about what he said throughout the rest of my shift and made a commitment to try to eliminate, or at least greatly restrict, my use of the word crazy as a descriptive term, and to never let such a predisposition be part of my medicine again.

     In spite of the progress in many areas of medicine, being mentally ill still carries a significant social stigma. On the short list of things people don't want to own up to, having a history of mental illness has to be near the top.

     Putting a patient with a behavioral emergency into the crazy/not crazy algorithm is just bad medicine that devalues another human being. I've learned that there are people with medical and traumatic problems who have mental health issues on the side, and there are people who have a behavioral emergency as their primary problem and other medical issues or traumatic problems on the side. In some cases, it just comes down to "not being able to cope." The patients in that group deserve the same respect, professionalism and patient care as anyone else.

     Until next month...