Post by Admin on Sept 18, 2020 17:31:52 GMT
Cherry-Picking Psychiatric Patients Must Become Illegal
January 19, 2020|malingering, mental health law, psychiatric treatment, psychiatry, psychosis
lynnnanos.com/blog/f/cherry-picking-psychiatric-patients-must-become-illegal?blogcategory=malingering
Hospital administrators allow their inpatient psychiatric units to discriminate against aggressive and uncooperative patients. Do administrators believe such discrimination is perfectly acceptable? Do they believe selecting cooperative patients who feign illness before highly agitated and floridly psychotic (really brain-diseased) patients is okay? We do not hold inpatient units legally accountable for such discrimination because there is no law against it. My book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, exposes this practice and asks legislators to eradicate it.
Emergency psychiatrists reported about their suspicions and findings of malingering among 405 patients for one month in New York City recently. The psychiatrists suspected one-third of these patients were malingering and twenty percent of them were malingering. Clinicians can have difficulty finding evidence of malingering when suspicion arises, especially when they encounter highly proficient liars. All clinicians have is suspicion when there is no evidence. I have never refused to grant inpatient to any patient solely due to suspicion of malingering and have refused to grant inpatient only when I saw evidence of malingering. When evidence exists, the best clinical practice is to not grant inpatient because enabling the inappropriate behavior will guarantee a re-entry to emergency services.
Psychiatrist Jacob Appel accurately writes, “Malingering is not a victimless crime. Every hospital bed squandered on a healthy patient is one fewer that’s available for someone who’s tormented by voices of schizophrenia or who’s in the throes of severe depression. As a result, ill patients sometimes have to wait hours in emergency rooms or, when hospitals are at full capacity, travel elsewhere for inpatient care. Because Medicaid picks up the tab for some of the treatment received by malingerers, taxpayers are indirect victims of this fraud.” The reasons for malingering vary–seeking food and shelter, avoiding legal problems, building a case to secure government benefits for “disability,” hiding from the threat of getting murdered because of an illicit drug-deal-gone-wrong, and seeking controlled medication to abuse. Regardless of the reason in an emergency psychiatry case, there is already a severe shortage of inpatient beds throughout the United States. Compounding the problem of excessive waiting periods in the emergency setting with discrimination is substandard and reprehensible.
A pattern emerges in the hundreds of inpatient bed searches for patients I conduct as an emergency psychiatric clinician. A certain subset of patients languishes in hospital emergency departments awaiting inpatient placement far longer than other patients. Because a history of violence is one of the best predictors of future violence, inpatient units are less inclined to accept patients who were physically aggressive toward other people.
Seriously mentally ill people who are not undergoing treatment typically refuse to accept help because they lack awareness of their illness, called anosognosia. They believe they don’t need help because, from their perspective, they’re not ill. When this occurs, they are more likely to become symptomatic, which can involve aggression and agitation. This is especially true in psychosis.
Malingering patients are on the opposite end of the spectrum as they take limited bed availability away from psychotic people. Mental health professionals often find them pleasant and cooperative. Admissions staff are tempted by the prospects of revenue and easy clinical management. No wonder inpatient units quickly accept the less challenging cases for admission to the detriment of those who are most sick.
Jason, 29 years old, well-groomed, walks into my mobile emergency psychiatric office. Everything he owns is with him. He’s not psychotic, doesn’t present with any risk of seriously harming anyone else, but claims to be suicidal. (Empathy is used regularly in actual practice and is not included in the following vignette for ease and flow of reading).
Jason: I don’t feel safe. I’m going to die if I don’t have somewhere safe to stay. If I don’t get into a program, I’m going to relapse on heroin.
Lynn: What do you mean by "safe"?
Like I’m going to hurt myself if I don’t get help.
How would you hurt yourself?
I don’t know! I just need help! I can’t sleep outside again. Everything gets stolen, including my medications. I owe $100 to the guy who hooked me up with heroin a couple weeks ago and I can’t pay him back. I hear he stays at the shelter. I don’t want to go there anyway because everyone shoots up in there and I’m trying to stay clean (off heroin).
When did you last use heroin?
Last week.
What was your pattern of using, or not using, heroin before this?
Every day until on and off for years until I went to detox.
What’s the longest time you stayed away from it since you started using it?
I don’t know, a couple months like a year ago.
What was your life like in those couple of months?
Great! Much better than now. I had my kids, started working.
Were you in any treatment then?
No.
I’m still not clear about what you mean by “safe.” Have you ever thought about killing yourself?
Yes.
When was the last time you thought this?
Today.
Is this more wishing you were dead or planning a way to kill yourself?
Wishing.
Did you ever try to kill yourself?
Yes. I overdosed on a bottle of Tylenol 5 years ago.
Any other suicide attempt?
No.
Is there anything in your life that makes you want to continue living?
I want to be allowed to see my kids again.
What medications were stolen?
Klonopin, gabapentin, seroquel.
When did you last take these?
I don’t know 2 or 3 weeks ago.
Who had prescribed these?
The last hospital (inpatient) I was in.
How would you feel about admission to the crisis stabilization unit?
I won’t be safe there.
How so?
I just won’t! It’s a joke there. I’ll just walk out. If I sleep outside again, I’ll kill myself by overdosing on heroin!
I expect Jason's health insurance to resist inpatient approval and to push for diversion to the less expensive and less intensive crisis stabilization unit. He had been admitted to eight inpatient psychiatric units and to our crisis stabilization unit four times in the last six months. There were plenty of recent opportunities for him to stabilize. His suicidal intensity suddenly increases upon hearing my suggestion of diversion to the crisis stabilization, among other clues indicating the likelihood of malingering. I find no history of a suicide attempt noted by other clinicians. Did he neglect to tell them? Did they not ask him about this? What is a well-meaning crisis clinician to do? Grudgingly, I grant inpatient to Jason.
If there is no law against discrimination against the most challenging cases, inpatient admissions staff will continue to prefer cooperative over uncooperative, insured over non-insured, calm over agitated, insightful over encompassing anosognosia, mildly mentally ill over floridly psychotic, and malingering over ill. Prioritizing the patients who need the most psychiatric help is the ethical, moral, and right thing to do.
en.wikipedia.org/wiki/Malingering
January 19, 2020|malingering, mental health law, psychiatric treatment, psychiatry, psychosis
lynnnanos.com/blog/f/cherry-picking-psychiatric-patients-must-become-illegal?blogcategory=malingering
Hospital administrators allow their inpatient psychiatric units to discriminate against aggressive and uncooperative patients. Do administrators believe such discrimination is perfectly acceptable? Do they believe selecting cooperative patients who feign illness before highly agitated and floridly psychotic (really brain-diseased) patients is okay? We do not hold inpatient units legally accountable for such discrimination because there is no law against it. My book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, exposes this practice and asks legislators to eradicate it.
Emergency psychiatrists reported about their suspicions and findings of malingering among 405 patients for one month in New York City recently. The psychiatrists suspected one-third of these patients were malingering and twenty percent of them were malingering. Clinicians can have difficulty finding evidence of malingering when suspicion arises, especially when they encounter highly proficient liars. All clinicians have is suspicion when there is no evidence. I have never refused to grant inpatient to any patient solely due to suspicion of malingering and have refused to grant inpatient only when I saw evidence of malingering. When evidence exists, the best clinical practice is to not grant inpatient because enabling the inappropriate behavior will guarantee a re-entry to emergency services.
Psychiatrist Jacob Appel accurately writes, “Malingering is not a victimless crime. Every hospital bed squandered on a healthy patient is one fewer that’s available for someone who’s tormented by voices of schizophrenia or who’s in the throes of severe depression. As a result, ill patients sometimes have to wait hours in emergency rooms or, when hospitals are at full capacity, travel elsewhere for inpatient care. Because Medicaid picks up the tab for some of the treatment received by malingerers, taxpayers are indirect victims of this fraud.” The reasons for malingering vary–seeking food and shelter, avoiding legal problems, building a case to secure government benefits for “disability,” hiding from the threat of getting murdered because of an illicit drug-deal-gone-wrong, and seeking controlled medication to abuse. Regardless of the reason in an emergency psychiatry case, there is already a severe shortage of inpatient beds throughout the United States. Compounding the problem of excessive waiting periods in the emergency setting with discrimination is substandard and reprehensible.
A pattern emerges in the hundreds of inpatient bed searches for patients I conduct as an emergency psychiatric clinician. A certain subset of patients languishes in hospital emergency departments awaiting inpatient placement far longer than other patients. Because a history of violence is one of the best predictors of future violence, inpatient units are less inclined to accept patients who were physically aggressive toward other people.
Seriously mentally ill people who are not undergoing treatment typically refuse to accept help because they lack awareness of their illness, called anosognosia. They believe they don’t need help because, from their perspective, they’re not ill. When this occurs, they are more likely to become symptomatic, which can involve aggression and agitation. This is especially true in psychosis.
Malingering patients are on the opposite end of the spectrum as they take limited bed availability away from psychotic people. Mental health professionals often find them pleasant and cooperative. Admissions staff are tempted by the prospects of revenue and easy clinical management. No wonder inpatient units quickly accept the less challenging cases for admission to the detriment of those who are most sick.
Jason, 29 years old, well-groomed, walks into my mobile emergency psychiatric office. Everything he owns is with him. He’s not psychotic, doesn’t present with any risk of seriously harming anyone else, but claims to be suicidal. (Empathy is used regularly in actual practice and is not included in the following vignette for ease and flow of reading).
Jason: I don’t feel safe. I’m going to die if I don’t have somewhere safe to stay. If I don’t get into a program, I’m going to relapse on heroin.
Lynn: What do you mean by "safe"?
Like I’m going to hurt myself if I don’t get help.
How would you hurt yourself?
I don’t know! I just need help! I can’t sleep outside again. Everything gets stolen, including my medications. I owe $100 to the guy who hooked me up with heroin a couple weeks ago and I can’t pay him back. I hear he stays at the shelter. I don’t want to go there anyway because everyone shoots up in there and I’m trying to stay clean (off heroin).
When did you last use heroin?
Last week.
What was your pattern of using, or not using, heroin before this?
Every day until on and off for years until I went to detox.
What’s the longest time you stayed away from it since you started using it?
I don’t know, a couple months like a year ago.
What was your life like in those couple of months?
Great! Much better than now. I had my kids, started working.
Were you in any treatment then?
No.
I’m still not clear about what you mean by “safe.” Have you ever thought about killing yourself?
Yes.
When was the last time you thought this?
Today.
Is this more wishing you were dead or planning a way to kill yourself?
Wishing.
Did you ever try to kill yourself?
Yes. I overdosed on a bottle of Tylenol 5 years ago.
Any other suicide attempt?
No.
Is there anything in your life that makes you want to continue living?
I want to be allowed to see my kids again.
What medications were stolen?
Klonopin, gabapentin, seroquel.
When did you last take these?
I don’t know 2 or 3 weeks ago.
Who had prescribed these?
The last hospital (inpatient) I was in.
How would you feel about admission to the crisis stabilization unit?
I won’t be safe there.
How so?
I just won’t! It’s a joke there. I’ll just walk out. If I sleep outside again, I’ll kill myself by overdosing on heroin!
I expect Jason's health insurance to resist inpatient approval and to push for diversion to the less expensive and less intensive crisis stabilization unit. He had been admitted to eight inpatient psychiatric units and to our crisis stabilization unit four times in the last six months. There were plenty of recent opportunities for him to stabilize. His suicidal intensity suddenly increases upon hearing my suggestion of diversion to the crisis stabilization, among other clues indicating the likelihood of malingering. I find no history of a suicide attempt noted by other clinicians. Did he neglect to tell them? Did they not ask him about this? What is a well-meaning crisis clinician to do? Grudgingly, I grant inpatient to Jason.
If there is no law against discrimination against the most challenging cases, inpatient admissions staff will continue to prefer cooperative over uncooperative, insured over non-insured, calm over agitated, insightful over encompassing anosognosia, mildly mentally ill over floridly psychotic, and malingering over ill. Prioritizing the patients who need the most psychiatric help is the ethical, moral, and right thing to do.
en.wikipedia.org/wiki/Malingering