The .Plan

I.

“It’s all bipolar,” he declared. “It’s all due to ‘the’ bipolar.”

Mr. Smith had “degrees from prestigious institutions” (bachelor’s from Idaho State [*], culinary certificate from a private school of hospitality in Montana), however, despite having “the natural abilities” that would suit him for “really important positions” he felt his illness was “keeping me from getting a job”. In particular, his “bipolar” has caused “anger outbursts” that have made it hard for him to get along with people. He had been serially fired from several jobs and had now been unemployed for nearly a year and a half. When queried about “anger outbursts” that had occurred in the past month, Mr. Smith described one incident that occurred at the public library last week as he was filling out a job application online (”for a really important job”) and asking the desk secretary for help, and I could not help but think to myself that his tantrum — which eventually necessitated a mild response from library security — far outweighed the magnitude of the infraction, real or imagined.

But, he added, “I know it’s ‘the’ bipolar”.

Careful review of his past history did not reveal any events that were even suggestive of distinct mood episodes, nor was there any (quasi-) objective evidence of disability such as emergent psychiatric hospitalization or workplace absenteeism. To my examination, his “bipolar” appeared to be invoked (rather, conjured), prodded by an intrapsychic strategy designed to defend his narcissistic self against the crushing realization that, now homeless and looking every bit his 58 years of age, he had not achieved the lofty goals he had set for himself; and, moreover, this was an invocation reinforced by the prescribing behavior of poorly trained, uncritical psychiatrists and covertly blessed by an approving, disease-mongering pharmaceutical industry. (For more, see “The Latest Mania: Selling Bipolar Disorder” by David Healy.)

Sigh. The previous psychiatry resident had already started him on Abilify(R) (aripiprazole). He expected me to increase the dose. The attending expected me to increase the dose. Clearly the medication wasn’t “working” because it had been quite loosely prescribed. But what else could I do?

I scribbled on my notepad.

“Plan: 1. Increase aripiprazole to 30mg PO QD. 2. Return to clinic in one month.”

I hate my job.

II.

Mr. Parker first encountered the mental health care system some 10 or 20 years ago, when the city police had to drag him from his apartment kicking and screaming. His landlord had called the police because the rent had been overdue and there was a terrible smell emanating from the apartment. And his mother had become increasingly worried about him. Over the course of the year he had turned to drinking, but what worried her more were the increasingly bizarre things he would tell her during their sporadic telephone conversations, many of them occurring in the wee hours of the morning. In order to enter Mr. Parker’s apartment, the police needed to cut through some 3 or 4 types of razor and barbed wire that he had strung up around the door. The inside of the unit was littered with trash, urine, and feces, and the report made it sound like Mr. Parker hadn’t eaten in a month. He was muttering aloud and clearly responding to internal stimuli.

Now in his 40s, Mr. Parker has been doing as well as one could expect for someone with a chronic, debilitating mental illness characterized by extreme cognitive deficits and poor social functioning. He has been clean and sober for many years; he lives in a single room occupancy hotel one block away from the downtown street corner where “you can get anything you want” (according to my actively heroin-injecting, Vicodin-popping, alcohol-drinking patients); he has no friends; he spends most of his time in his room, but when he is able to tolerate it he will take the bus to the outpatient mental health building and participate in a “board games group”; and he has a case manager who meets with him weekly, safeguards the meager check he receives from the state, and sometimes helps him buy things like bread and milk (at one of the three bodegas in the entire downtown area that do not sell alcoholic beverages). He is very disorganized and rarely able to fully track with a conversing adult.

I hate the one-patient-per-30-minutes, assembly-line attitude that my outpatient clinic instills in me. I only have a few elementary tools to combat it. Beyond the cookie-cutter questions that medical students are taught to ask their patients (”hearing any voices lately?”, “have you had any thoughts of hurting yourself?”), I try, when appropriate, to ask about the experiential aspects of mental illness.

Today, Mr. Parker’s reply was stunning (although I’ve only seen him twice).

“I bought milk — gave him a twenty. He gave me change for a five.”

What is it like to be cognitively debilitated, yet to have a glimmer of insight that something is rotten in Denmark and therefore to live in the shadow of the knowledge that if you raise a fuss in a clearly unjust situation, your assailant will call the police and have you carted off to the hospital?

I love my job.

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[*] All names, dates, and other HIPAA non-compliant details have been confabulated.