No, not me. While I have been and have even spent time on the inpatient psych unit, I am not currently even remotely feeling that way. To be honest, it took a bit to sort shit out, and while I was improving, It took some effort. Of course, I know people think I am still a tad, “not right in the head,” and they, of course, would be correct. I mean, take a look at my life; Military, Nursing School, Grad School, Burning Man, and being a raging queen. It stands to reason that I am not “right in the head” for many good reasons.

One of the things I hate about it when you are down is that people kept telling me, “You gotta pull yourself up by the bootstraps.” (Oh, this is helpful skippy, just how the fuck am I am supposed to do that?) I was taken aback until I thought about it a little. You are not singlehandedly pulling yourself out of depression (that is unrealistic). You can however, seek help, counseling, medications, and even hospitalizations. Pulling yourself up by the bootstraps is not just making yourself unsick; it uses whatever skill set you have to help you along the way. You alone are not going to make yourself magically better; you need help. A sound support system is a huge help (hopefully there are people near that have not been alienated or scared by your mental illness); without them, it is much more difficult.

That said, situations like this require a stretch of empathy like no other. Since the patient is a “frequent flyer (sorry no miles or hotel stays, just crappy hospital food and beds), he tests the staff’s patience in the fact that they feel that their help has fallen on deaf ears (kinda like your kids sometimes).

Our exciting patient, who had been out of the hospital for less than 4 hours, presented back to the emergency department with “suicidal ideation.” This patient just had a very long-term inpatient psych stay that has spanned several months and two separate facilities. He is using his same reasoning for requesting admission to the unit that he has for over a year (in other words, “what the hell have you been doing?). This is not to shame him, although he is either malingering, not working on his real issues, or is too dependent on the institutional setting. Honestly, I think there is a piece of each there. Each one fuels the other, and the patient gets nowhere. This is a provider empathy test to the ultimate, mainly because we just feel we are doing all the work. Yes, it is selfish, but like anyone, providers like to think they are doing their job effectively.

The real difficulty here is how do we break that cycle. We know he needs to help “pull himself up by the bootstraps” even just a little to help improve his condition (this is not him fixing the problem unsupported, this is him participating). In my assessment of the situation, the world is too much for our patient. Ok, maybe, but he has been given a shit ton of tools to help him get through things. Is he unable to use them? Not using them? Too co-dependent? Or are we as clinicians missing the point with him and have less than effective care modalities?

He is too dependent on the institution, and with any honesty, the only thing he is genuinely getting is “three hots and a cot” (although hospital food and our beds suck); beyond that, the therapeutic value of his stay is almost nil. As I said before, he has the tools he needs to use: otherwise, a medication adjustment or a different therapy modality.

But nursie poo, if they say they are suicidal, we need to put them in a secure unit until we are sure they are less suicidal and have the chance to commit suicide, so we need to bring them in.

But do we need to admit? Because of liability. We have to take a patient’s word that they are a danger to themselves and others. No provider wants to send a patient home that is suicidal because of liability. Plus, if they are truly capable of completing the act, it is horrible for the family and friends of that patient.
Ok, a lot of circular thinking to the point it sounds like a political speech. What is the answer? Honestly, a patient doesn’t always need a locked unit (they don’t) even with the liability looming over our heads. All of this backs a provider into the corner and forces us to place a patient like this in the most restrictive environment. They need an external support system; a follow up with a mental health professional or primary care or both, medication adjustments, and a safety plan. That alone can help start the bootstrap approach. The ultimate hope is a dependence on self and support network and less dependent on the locked door of the psych ward. Do patients need it sometimes? Yup, they sure do need it. The bottom line is the least restrictive setting.

Let’s be clear. I do not, nor have I believed that the patient alone is capable of just dumping depression. Depression is chronic, and there is no magic fix that works right now and keeps working. I know some folks might cite ketamine and a couple of other drugs that are supposed to have quick and long-lasting effects, but the science isn’t entirely there. We need to follow that science and not just do it the same old way. Effective treatments can be discovered and implemented and should be. Until then, we are stuck with the same old cycle, that is very tough to break (ya know like a beer bottle over your head). Tonight, as I came in, he is sitting in the same chair in the TV room and doing the same things he did during his protracted stay. Let’s hope that someone finds an approach that stops this behavior.

Oh well

Be the kind of person your dog and your mom hope you are.