Our country, and the world, is beyond exhausted by COVID-19 and the utter chaos and destruction of lives it has caused. All people, including physicians, are being pushed beyond capacity, resulting in collateral damage. What do I mean, collateral damage? Originally, this phrase related to war, meaning the unintended result of a terrible, unprecedented event or action. We may not be in a traditional war but make no mistake, we are in a war.
Imagine – you have a child or young adult with life-altering or threatening mental health issues (not mild anxiety or depression). On a good day, navigating mental illness is challenging.
1) inadequate care (only 40% of people diagnosed with a mental illness received care last year in the United States)
2) associated stigma and shame
3) little understanding by the medical community at large, even less awareness in the general public
4) the very nature of these very complex, challenging, confusing diseases
When we hear “cancer,” patients and families are supported by the community with meals, compassion, and understanding. However, when we hear of mental illnesses like eating disorders, psychosis, or suicide attempts, we run and hide. It’s 2020, yet mental illness remains one of the most stigmatized, misunderstood, and discriminated diseases — even by physicians, those that pledge to provide care to all people.
Bring on COVID-19. Hospitals are locked down, family members are isolated from ill loved ones, and overtaxed front-line medical staff attempt to provide care in stressful conditions. All of this in a system already biased against mental health patients, especially adult patients. What could possibly go wrong?
Enter: patients too mentally compromised to advocate for their own well-being and safety. Brains being held hostage by mental illness. Yet, these patients are left alone in an ER with no one to advocate for or support them while they struggle with an illness poorly understood by medical professionals. It’s a recipe for disaster.
Three different cases illustrate the atrocity and reveal the same theme: lack of sound resources and knowledge, as well as a lack of compassion in a system already biased against their disease.
Patient 1: A 19-year-old with severe chronic anorexia with acute weight loss and prolonged caloric restriction, in need of medical stabilization due to her malnutrition, presents to the ER, a repeat scenario for many years. Her mother, a physician, and intimately knowledgeable of her extremely complex history, is not allowed to be present to give appropriate history. The patient refuses to be admitted despite being medically and psychiatrically unstable, as well as meeting admission criteria. The ER doctor discharges the patient because “she wanted to be,” without much consideration of the above. And, the ER was “busy.” Her parents feel powerless, knowing when she decompensates to this point, only NG tubes can stabilize. The following day, she presents again to the ER, on the precipice of discharge once more, despite worsening vital signs and labs. This time, her desperate physician mother knows the “right buttons” to push. The patient is finally admitted. Non-medical people would not have had that “insider knowledge” for their ill loved one.
Patient 2: A 22-year-old is admitted with acute new onset severe mania and psychosis, who is a danger to himself and has a history of mild intermittent anxiety. He’s been having increasingly progressive mental and emotional stress due to social isolation/distancing and reduced hours at his job. Over the course of only five days, his parents took him to no fewer than three ERs and three psychiatric hospitals, but they were not allowed to be present to advocate for appropriate intervention. He was discharged each time, “stable.” Despite a signed release of information, his parents’ repeated attempts to speak to doctors were ignored. The parents were forced to rotate shifts 24/7 to attempt to monitor their son’s safety. Eventually, he was admitted but discharged after less than 48 hours into 90-plus degree weather, without an ID or cell phone or a call to his parents, still psychiatrically unstable. Within less than 24 hours, the patient became physically violent with his parents and was transported to the state psychiatric facility.
Patient 3: A 21-year-old with a history of an eating disorder and severe depression presents with suicidal ideation and a plan. She has a history of previous suicide attempts. Parents are not allowed in the ER with the patient to provide context. No family history or past medical/psychiatric history is obtained. She is discharged home. “Not a danger to herself and the hospital is full of COVID-19 patients.” Parents set up a rotating schedule to monitor her and remove all possible harmful objects from home.
All three of these scenarios are real, and have occurred in just the last few weeks. Imagine how many more there are. It is sobering how many things are coming undone in our health care system due to COVID-19. The disparities in care, the lack of a seamless public health system, and politicians getting in the way all contribute. Mental health is the forgotten stepchild in the U.S. health care system. And yet, mental illness affects more Americans than almost any other disease, and the numbers are growing. At least 30 million Americans are affected by eating disorders, with the grim statistic of one death every 62 minutes and the highest mortality rate of any mental illness. General mental illness lifetime prevalence is 46%. Half of all mental illness begins by age 14 and 75% by age 24.
COVID-19 has brought the woeful inequities of appropriate mental health care front and center and it cannot be ignored any longer. Mental illness is a brain-based neurologic disease. It is time to treat it as such. It is time for physicians to be educated on mental illness and to have the same compassion and urgency we have for cancer patients or other “physical” diseases. The brain is indeed a part of the body; brain illnesses should be treated with the same conviction, compassion, and attention as other physical illnesses.
Mental health care is the not-so-silent collateral damage of COVID-19. We can and must do better for our mentally ill patients. They deserve it, their families deserve it. As physicians, we took an oath to care for all people.
All names and identifying information have been modified to protect patient privacy.