The Movie Unsane is Insane in its Portrayal of Mental Health Care

A recently released movie, Unsane, starring the remarkable Claire Foy, highlights the plight of Sawyer Valentini after she’s been involuntarily committed into an inpatient psychiatric hospital.

This post does contain spoilers to the movie so stop reading if you don’t want to know more about the film.

The crux of the story is that Sawyer believes her stalker has made his way into the psychiatric unit where she is a patient— whether or not that is the case is the mystery.

Unfortunately, the way that psychiatric care is highlighted in the film is disturbing at best. At worst, I hope it doesn’t deter anyone from seeking mental health treatment if they need it.

Problem One: Not disclosing to a patient why she’s being admitted. The genesis of Sawyer’s admission into the psychiatric unit stems from a visit with a counselor where she discloses at times she thinks about hurting herself. She’s left unattended (a no-no if you think someone is suicidal) and the next scene is a nurse escorting her into an intake room. The nurse never fully explains to the patient the reason for the admission and leaving it out doesn’t really increase the drama of the scene— it just makes the nurse look mean and uncaring. Simply, a nurse could say, “Your mental health provider has placed you on an involuntary hold because she’s concerned you’re going to hurt yourself. ” Then the heroine can argue with her about why she feels the admission is unnecessary.

Problem Two: Having the patient undress but allowing her to keep her bra. A bra is considered a ligature risk and patients can’t have anything on their person that they might use to hurt themselves. Hair ties, piercings, and other jewelry are all removed.

Problem Three: Drug injection sites. Emergency drugs for agitated patients are usually given IM (intramuscular) and not IV (intravenous) to the neck or arm. Can you imagine trying to start an IV on an agitated patient? It’s much easier to land a needle in a large muscle group then to try and finesse a tiny IV catheter into a moving target.

Problem Four: Leaving a patient alone in restraints all night. There are very specific regulations around restraints and significant documentation that goes along with it. Patients in restraints are continuously observed by a staff member and circulation to their extremities is checked often. Also, the patient must be offered bathroom breaks at a minimum of every two hours and you can’t deny them food as punishment. The goal is always to get patients out of restraints as soon as they can be safe— and that doesn’t always imply that they are calm.

Problem Five: A mixed gender open unit. Need I say more?

Problem Six: That psychiatric care is an insurance scheme for money and that patients are intentionally kept until their insurance money is exhausted. This is a large crux of the movie to the point that one of the patients is actually an undercover police officer trying to uncover the scam. This is the most disappointing aspect of the film. There are so few mental health beds around the country right now that it is not difficult to fill them. Here’s a news article here, here, here, and here— which all posted within one week. Trust me, mental health facilities can keep their beds full without perpetuating insurance schemes.

Overall, an interesting movie, but portraying the current state of mental health care in this country would have only increased the tension and drama for this film.

Author Question: Treatment of Teen Suicide Victim (2/2)

Today, we’re continuing our discussion of the medical treatment of a fifteen-year-old male suicide victim who slit his wrists at school. You can find Part I of the discussion here. In this post, we’ll focus on more of the mental health aspects over the medical treatment.

Pink Asks:

Upon examining a patient, and if sexual abuse is suspected, what is the hospital protocol? How do the hospital staff work with police and the victim’s family?

Jordyn Says:

If outward physical exam of the skin shows injuries concerning for sexual abuse, this can be handled several ways. In order to answer this best, I’d need to know what kind of hospital your patient/character is at in order to give advice as to how that community would likely respond but I’ll give thoughts as to how my institution would handle it—which is a large, urban pediatric medical center. A rural hospital would likely handle it much differently.

One thing I want to say is that no sexual assault exam would be done without the patient’s consent (or parental consent—a court can order if needed)—so this would not be done on an unconscious person. What you can see from the outside would be the limit. For instance, in girls and women no internal vaginal exam.

There might be an extreme outlying caveat to an internal exam if the patient were near death, concern for loss of evidence, or other victims were at risk, but it would have to be VERY PRESSING circumstance and likely the courts/law enforcement would be involved in order to move forward.

Regarding the suicide attempt, the next thing to keep in mind is that the patient’s medical needs are always addressed first. In fact, the patient must be “medically cleared” by a physician before they can participate in a mental health evaluation.

If there is a concern for sexual abuse, we would first contact social work through our hospital to develop a game plan. If a sexual assault exam needs to be done, we have health care professionals that are very experienced in doing these with kids/teens and we want the most experienced professional to do the exam and collect any evidence. Social work will do a couple of things if they think the concerns are valid. One, report it to the state (Department of Children and Family Services—something along those lines depending on the state) and second, report it to the police if they believe a crime has occurred. The incident is reported to the police jurisdiction where the crime took place and not the location of the hospital where the patient is receiving care.

As an example, if a woman is raped in Anchorage, AK, flies to Seattle and seeks treatment there, the hospital in Seattle is going to have to call Anchorage, AK police to report the crime. Local police can help determine the appropriate jurisdiction if it’s not clear.

The timing of the sexual assault is important in collecting evidence. If a person was just raped, we’d be very anxious to encourage the person to have a sexual assault exam done ASAP. If they are reporting something that happened more than three days prior (it’s 72 hr for us)—it’s not as pressing that an exam should be done immediately but plans can be made with the patient and family for follow-up exam and care.

Larger police departments typically have victim advocates that can help families through processes like this, but it is up to them to call that person in. Contrast this with a more rural hospital that may “hotline” the concern for abuse to the state, call the police, and depend on state social workers to determine the course of action.

Pink:

Are patients who attempt suicide always sent to a mental health facility for treatment? I know patients speak with a crisis counselor, but what if the attempt wasn’t caused by being under the influence of drugs, or a mental illness, but due to a desperate situation (domestic violence)?

Jordyn:

The most important determination about whether or not someone will receive psychiatric care is whether or not they are a current danger to themselves (and/or others) and how likely are they to act on it. This is determined by a mental health professional and not the medical staff. The reason for the attempt doesn’t necessarily differentiate potential lethality—it’s what the patient is thinking about in their mind and how at risk they are to act on it.

I think you’re trying to make a distinction that a desperate situation caused by domestic violence leading to a person’s suicide attempt would be seen as less lethal and it wouldn’t. If a person is trying to kill themselves because their home situation is driving them to do that—that is very significant and taken as seriously as someone who swallows pills, or slits their writs, or is having a psychiatric break. Someone attempting suicide due to domestic violence will likely have other co-existing mental health issues like anxiety and depression.

This is a very serious topic and definitely worthy of fiction to help foster discussion of suicide. Good luck with this novel.

Criminal Minds: Can a Patient be Admitted for Psychological Distress?

In a recent episode of Criminal Minds, a woman was nearly shot and killed by a madman operating a drone. She is saved and uninjured, but is admitted to the hospital just in case she begins to suffer some psychological distress.

Can this really happen?

The situation as portrayed on television— no.

When admitting someone emergently for a psychiatric problem, one of two things needs to be a concern. Either the person is a threat to themselves, to another, or both. You might hear a provider ask, “Is the person expressing HI or SI?” which stands for suicidal ideation or homicidal ideation.

If a person is expressing either or both of these concerns then a couple of things happen. The patient first must be medically cleared by a physician to ensure that there are not any coinciding medical concerns. Once this takes place, they then are put through a mental health evaluation.

Once a mental health evaluation is complete, it is decided what type of psychiatric services the patient may require. Sometimes, it is admission under an involuntary hold. Other times, the patient may be connected with outpatient services.

Think about the many events that have happened just in the US where people will be suffering psychological distress, but are not expressing suicidal or homicidal thoughts. The  devastating hurricaines. The mass shooting in Las Vegas. Put simply, if we admitted every patient that we were concerned for the potential of psychological distress outside of expressing HI or SI— we’d quickly run out of hospital beds. Plus, patients expressing these concerns should not be placed on a medical floor unless they also have co-existing medical problems that they need treatment for. Also, in that case, they require one on one observation.

Although a nice thought, you do have to have a mental concern other than psychological distress from surviving a potentially life-ending event to be admitted into the hospital.

Author Question: Small Town Care for Complex Medical Patient

Holly Asks:

In the very first chapter of the story I’m working on, the main character gets sent to hospital. The character in question is a sixteen-year-old female who has been missing for eleven years. She is found in the woods surrounding the town it’s set in and presents naked, severely malnourished, heavily pregnant, and with a gunshot wound to her leg. There are other superficial injuries that one might get when attempting to flee nude through dense woodland. The town and hospital are relatively small. The hospital has seventy-five doctors and forty-five nurses on staff and it’s in a fairly isolated location.

I’ve got a few questions:

1 – Would the hospital I’ve  described be able to treat a patient in this condition? What would be the basics of this treatment?

2 – Is there a procedure hospitals have in place for patients who act violent? My character hasn’t been around people for eleven years. She’s borderline feral and she attacks a doctor when she wakes up. Since she’s pregnant, I wasn’t sure if they’d be able to sedate her.

3 – Can doctors share information about patients with police officers? Since she’s a missing person and a minor, the police are going to be involved but I’m not sure how much doctors can share.

Jordyn Says:

Hi, Holly! Thanks so much for sending me your questions. These are complex ones for sure.

Question #1: Could a small town rural hospital be able to care for this patient? Maybe. One thing I want to clear up is your ratio of doctors to nurses. Usually, there are many more nurses in a given area than physicians so maybe adjust your numbers if you’re making a point about this in your novel.

When I first read your question, I thought the medical care aspects might be cared for by a rural hospital, but it was going to be a tough undertaking. This victimized teen is going to need, at a minimum, five services to be in place to stay in a rural hospital— a good general practitioner (to manage her overall care), a nutritionist (for the malnutrition), a surgeon (surgical evaluation of the gunshot wound), an OB/GYN (for the pregnancy), and a psychiatrist and/or psychologist (just because she’s been held hostage for eleven years.) Already that list is going to be tough and likely insurmountable for the area you mention.

What tilts the balance for me in saying she would have to go to a large, urban center are the psychiatric issues you mention in your second question.

Question #2: Yes, hospitals have procedures in place for violent patients, but the staff and mental health care specialists who will be required to manage her care are likely to be found at an urban center.

Violent patients are generally managed in a step-wise fashion. Can talking to them de-escalate their behavior? Is there something they’re requesting that we can give them to get them to calm down? Does she have some sort of object (like a stuffed toy) that giving her would help if it was safe for her to have?

If it’s more a fight response because of what she’s been through and she’s a danger to herself and others then she’d have to be restrained and placed under one on one observation. This type of patient can tax staffing resources which is another reason why transfer might be best.

Each drug is given a category related to its potential to harm a developing baby that is easily searchable via the internet. The categories go from Category A to Category D. Category A is deemed safest to D which has proven adverse reactions in humans. Just because a drug is listed as Category C or D doesn’t mean it might not be used. Several things would be taken into account— what we call risks versus benefits.

For instance, if she was late in her pregnancy, the doctors could risk it because the baby is fully developed. This is tough, though. Many physicians will err on the side of what’s safest for the pregnancy. However, you can’t leave a patient restrained forever and some form of psychiatric medication could be warranted here.

Question #3: Can doctors share information with police officers? Yes, they can. There is actually a special provision listed in HIPAA (the law that rules over patient privacy) that allows for this. Police officers mostly need to document what “serious bodily injury” the patient has suffered so they can determine what criminal charges to bring against a perpetrator.

The other thing to consider is the size of the local police department. Small towns may not even have their own police department but rely on the county sheriff’s office and/or state police to handle the investigation of this crime.

I actually think the best place for this teen would be the closest children’s hospital. Children’s hospitals have specialized teams in place to manage issues particularly around crimes against children. The caveat would be her pregnancy— for which she would likely deliver at an adult center.

Hope this helps and good luck with your story!

Men Who Kill Women

Regular followers of my blog know that my medical nerdiness can reach into other areas of science like forensics and psychology. I was actually doing a search on women who kill men when I came across this very interesting article on the opposite— men who kill women. Information in this post comes directly from the Vice article entitled Inside the Minds of Men Who Kill Women posted August 10, 2015.

Married couple and criminologists from the University of Manchester, Rebecca and Russell Dobash, spent a decade interviewing men serving life sentences in seven different British prisons. According to the article, this was the largest study done to the date of the posting. They have also published a book on the subject (photo right).

There were some consistent similarities that pertained to these men. “They found that many women are murdered by jealous, possessive, and controlling men.”

Here are some of the highlights.

1. In the majority of cases, men kill out of sexual jealousy. They are possessive. And this possessiveness can also lead these men to kill others close to their victim like her children, family, and friends.

2. Many had problematic childhoods and adulthoods that consisted of alcohol use and unemployment. The authors suggest that the use of alcohol is common to Britain and doesn’t necessarily mean illicit drug use as perhaps is the case in the US. Though they don’t specify this difference.

3. Many are sexual predators.

4. Older women, over the age of sixty-five, are considered vulnerable and therefore worthy targets. Living alone does add risk.

5. The murderers were largely not remorseful of their crimes.

6. Surveillance programs that force violent men (before they murder) to understand denial, remorse, and empathy could prove helpful. Also suggested are developing youth programs to teach people how to handle breakups.

I also highly recommend all women read The Gift of Fear by Gavin de Becker. I think it should be required reading of all girls over the age of fourteen. The sooner they can learn these skills the better.

Guest Author Gillian Marchenko: Living Through Depression

Today, I’m hosting author Gillian Marchenko. Her book on living with and through depression called Still Life really struck me on several levels and so I asked Gillian if she would stop by Redwood’s Medical Edge and answer a few questions. I’m also giving away a copy of Gillian’s book. All you need to do is leave a comment on this blog post by Saturday April 8, 2017. I’ll post the winner here on Sunday, April 9, 2017. Winner must reside in the U.S.

Thanks so much for stopping by Gillian!

Jordyn: What do you find are some of the common misconceptions about depression? 

Gillian:
Common misconceptions include:

Depression is not a real illness.

A person is lazy and can ‘break out of it’ if she really wants to do better.

For Christians, many still believe that depression is a spiritual issue. She should ‘pray away depression.’ That depression has more to do with the individual’s sin issues than an actual illness.

Jordyn: Do you feel like these misconceptions are perpetuated in the media? Books, television, and film? If so, how?

Gillian: Yes. People with depression (and other mental illnesses) are often portrayed as ‘crazy’, and disregarded as valued members of society who have dignity and purpose. Countless media outlets use mental illness as comedic material or objects of pity. If a person on the street shows signs of mental illness (talking to themselves or psychosis), people throw a few dimes in their cup and move on. Individuals are put into one box: mental illness. Because of misconceptions, inconsideration, and lack of education, they are not taken seriously. I also want to say, though, that I get it. Mental illness can be scary. Many don’t know how to help or what to do, or even fear for their safety. So, they do nothing. Education helps with these things. But I don’t fault their emotions.

Jordyn: What do you feel like are some frustrations you have in dealing with the medical community?

Gillian: I relied on my primary care physician to help manage my depression for years. The problem was that the doctor did not specialize in psychiatry and therefore, did not know enough to treat me. Once I started seeing a psychiatrist who knew how to evaluate needs and address them accordingly, my treatment became much less of a ‘throw meds against the wall and see what sticks.’ I wish my doctor would have seen that my symptoms were more than a few bad days and referred me to a psychiatrist much sooner.

Also, I’ve found that both my doctor and psychiatrist have gone straight to medication without also encouraging a holistic approach towards health; things like talk therapy, cognitive behavioral therapy, diet and exercise, and spiritual components. After investing in a lot of personal education out of desperation, I’ve sought these various helps out personally and had to inform my doctors on the positive effects produced in my journey through health.

Jordyn: What would you change about our mental health care system?

Gillian: This is a hard question. I’d love to say that I know enough about how the health care system works to provide an educated answer. But I can only go by what I hear from other people and their families who are battling illness.

I’ve heard that families typically have no say regarding a loved one who clearly needs their help in medical decisions unless they have a power of attorney. A lot of times their hands are tied and the person who is sick is in charge. Bad decisions abound. One should be hospitalized, but unless there are claims of self-harm and attempts at suicide, he or she can discharge themselves at any time. I have a friend right now whose husband believes he is a prophet from God. But every time he is taken in for his psychosis, he is lucid enough to play the doctors. They see no reason to commit him long-term and he is released.

I also, think that many doctors, sadly, still don’t take mental health symptoms seriously and buy into misconceptions. But I don’t have data and statistics, so I’m not sure I can concretely contribute to this claim.

Jordyn: What advice do you have for friends or family members who have a loved one with a recent diagnosis of depression?

 Gillian: I recently wrote a blog post about this very topic.

In you are an acquaintance, help a depressed friend by:

Reaching out via text or with a card letting her know you are praying for and thinking of her.

Leaving a small gift or a meal (without the expectation that she will open the door).

Praying for them regularly.

 If you are a close, help a depressed friend by:

Doing all of the above.

Noticing when she is withdrawing (no longer attending church, events, or other activities he previously participated in).

Taking a little more intentional action when you notice. Call once a week. Text more often. Let her know she is loved and not alone.

Inviting her out without the pressure of acceptance. If you are refused, try again but give it time. It may feed into her guilt and anxiety.

Dropping off a book or another thoughtful gift. For instance: a small box of encouraging quotes and verses.

If you are a very close, help a depressed by:

Doing all of the above.

Reminding her that getting out will help her get out of her head.

Standing there. Don’t give up on her. She needs support in and out of depressive episodes. While depressed, that support may be from afar. When she is doing better, she needs to know that she still has friends, that she isn’t judged, or considered a lost cause.

Being more specific with Bible verses, direct encouragement, and gentle reminders of things that have helped her in the past during particularly difficult episodes. You’ve earned her trust to speak into her life. If you aren’t close enough to her, she will resent it.

Telling someone. If she talks of self-harm or suicide but doesn’t want you to tell anyone, tell anyway.

Thanks so much for your insight, Gillian. I found your book so insightful and it really helped give me new perspective into those who struggle with depression. I highly recommend Gillian’s book, Still Life.

Netflix Suspense Movie Clinical: Treatment of the Suicidal Patient

Proper Treatment of a Suicidal Patient. 

clinical-netflixNetflix recently released a psychological suspense (perhaps some would call it horror) movie called Clinical. It surrounds the story of psychiatrist Dr. Jane Mathis who is an expert in dealing with PTSD. She is recovering from her own traumatic experience, a patient attempting suicide in front of her, and has vowed to not care for these types of patients until her own issues are resolved. However, the work of regular psychiatric problems doesn’t seem fulfilling enough so she takes on the case of a facial transplant patient named Alex.

In one particular scene, Alex calls Jane and states he “took too many pills”. I don’t know how this could be viewed other than a suicide attempt. Instead of calling 911, she goes to his home. Once there, Alex is first scene barely conscious, but is evidently able to stand up and answer the door. From that point on, the conversation goes something like this:

Alex: “Did you call an ambulance?”

Jane: “What did you take? If you don’t tell me, I’m going to have to call 911.”

Alex eventually becomes unconscious. Jane then administers a drug via IM injection. In the next scene, Alex is vomiting.

Jane is holding a prescription bottle in her hand. “How many of these pills did you take?”

Alex: “I just wanted to sleep for a while. What did you give me?”

Jane: “It’s called naloxone. I only use it for emergencies.”

Just. Awesome.

Issue One: I can’t imagine how many ethical and legal lines it crosses that this psychiatrist did not have this patient involuntarily committed to the hospital under an M-1 hold when he clearly tried to commit suicide. I’ve seen M-1 holds placed on patients for far less than an actual attempt.  Clearly, this is a big medical no-no and really doesn’t do the patient any favors. Just because the patient’s worried financially about an ambulance ride doesn’t mean he doesn’t get one.

Issue Two: Let’s discuss the medical drug naloxone or Narcan. This is a reversal medicine for drugs that contain opiates. This would include drugs like morphine and heroine. It’s not clear what drug Alex took— all he says is sleeping pills. To me, sleeping pills would more than likely contain some kind of benzodiazepine, of which there is no reversal a doctor would personally carry, though one is available in the hospital setting.

Issue Three: The scene where the patient is vomiting after the Narcan is administered. I’m not sure if the writers are portraying that the drug induces vomiting so that the patient throws up the pills. If so, that’s not medically accurate. Narcan reverses the effects of opiates at the receptor level. It immediately brings the patient out of their high and they’re usually not very happy about that. Most often, we don’t want to fully reverse the drug as this can put a patient at risk for seizures so we may titrate the dose just to reverse the diminished (or lack of) breathing induced by taking too much of the drug.

I actually think it’s okay the doctor did these things if it would have been pointed out by her mentoring/treating psychiatrist that she acted inappropriately and he was going to report her to the Board of Healing Arts because of her actions.

That would have ramped up the tension/conflict on many levels.