Thursday, January 10, 2013

Never Crazier

I have worked at this hospital almost 35 years.  I have never seen a unit with more deeply sick people than who we have now.

We usually complain when we are cluttered with people we believe we shouldn't have: drug users seeking abusables, small-time criminals hoping to avoid court dates or parole violation hearings, developmental services clients who are acting up, borderline personality disordered people who are nearly always disregulated, and thus nonacute. (That last is a debatable category. Some states treat those in psych hospitals, others don't.)  There is none of that on my current caseload.  Drugs are a factor in a few, but every single one of them is/was psychotic.  The exceptions would be that some may be dementing or brain injured (we are still testing).  Terribly broken people, many of whom we will not be able to fix, only manage them below level of dangerousness.  We have also an unusually high percentage of people who are not only violent, but unpredictably violent - always our biggest fear.

One of my patients who comes from a line of conspiracy theorists, and has inspired a few posts, came in today. He has hung out at times with the tax-protestor and sovereign-citizen movements, but mostly, it's about him personally, not any larger group. 


james said...

How stable are the conspiracy groups? If they were driven by a significant amount of paranoia I'd expect them to quickly fission, and I gather they don't.

If they are driven by a gnostic hunger for being in the elite who know the deep secrets, I'd expect them to morph over time, acquiring new worries and shelving others.

At any rate, it sounds like you have a rough few months ahead.

Assistant Village Idiot said...

They are mostly unstable. The joke has been that the SPLC claims that the number of hate groups is increasing, not noticing that it's the same guys joining similar groups after getting sick of each other. The explanations overlap.

I am now convinced that the idea that "something is up" precedes all data.

jaed said...

It seems to me there are at least two variables here:

1) Absolute number of seriously crazy people in your base population;

2) Likelihood that a given seriously crazy person will be hospitalized at your facility.

So a couple of questions immediately occur: are there other facilities that might deal with someone seriously crazy in your area, that are overloaded/closed down/whatever, and thus you're seeing overflow you normally wouldn't? Are families/loved ones/the crazy person himself less likely to be able to manage without hospitalization? (A sour economy, for example, can limit people's ability to cope at the margins. The crazy person can't keep a job because employers are pickier; the crazy person is under more stress and thus crazier; family members likewise; family can't dedicate one member or hire someone to care for the crazy family member, or pay for an apartment to keep him or her safely away from the family home. Result: more very problematic patients.) Have formal or informal policies about commitment changed, such that it's easier to have someone forcibly mental-healthed? (I'm not sure you've said, but I assume most of your patients aren't there willingly.) Etc.

Assistant Village Idiot said...

Fewer beds is a reality - other hospitals have gradually closed their psych services, and we closed a unit last year for budgetary reasons. That keeps us mre full, so that any problem seems magnified. But that doesn't explain why this diagnostic set is more concentrated. It may be just law of averages. The other units may have more typical populations.

jaed said...

Makes me wonder whether, with the lack of beds, triage is happening somewhere before they get to you. At another time, more of the less-sick patients might be referred (or binned) by social services, doctors, etc.