Articles: Medical Topics
More Than The Blues
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A physician who is named as a defendant in a medical malpractice
suit commits suicide.
• A plaintiff who loses his ability to work after
a car accident becomes depressed.
• A woman who is injured by a defective product loses
the ability to control her bipolar illness and spirals out
of control.
• An attorney’s erratic behavior exasperates
her colleagues, clients, adversaries, and the judges.
Every
year 40 million Americans experience some form of mental
illness, including major depression, schizophrenia, bipolar
disorder, obsessive-compulsive disorder and anxiety disorders.
[1] Attorneys may be involved in representing, deposing,
counseling, and suing mentally ill people. Mental illness
may complicate the litigation process, affecting the basics
of obtaining information and gaining
cooperation.
Major
depression, a response by many to the stresses associated
with litigation, is marked by a loss of interest and pleasure
in daily activities. A depressed person may sleep too little
or too much, eat too little or too much, and feel slowed
down or too agitated to sit still. The individual may be
extremely tired—getting out of bed is an effort. Lack
of motivation, difficulty performing tasks, withdrawal and
isolation from others, and lack of attention to hygiene
and appearance may be noted. The individual may blame herself
for the way she feels and dwell on guilt feelings and personal
failures. There may be difficulty thinking, remembering,
and concentrating. The person may have a heightened sensitivity
to noise, light and stress. The psychotic phase of this
disorder, which affects 10-25% of those who are depressed,
is marked by grossly disorganized behavior, incoherent speech,
hallucinations, and delusions.
Even
a person who is not psychotically depressed may lack insight
into the severity of the problem. Consider how one person
well-acquainted with major depression symptoms described
her depression: “When you are lost in the woods, it
sometimes takes you awhile to realize that you are lost.
For the longest time, you can convince yourself that you’ve
wandered a few feet off the path, that you’ll find
your way back to the trailhead any moment now. Then night
falls again and again, and you still have no idea where
you are, and it’s time to admit that you have bewildered
yourself so far off the path that you don’t even know
from which direction the sun rises anymore.” [2]
The
severely depressed person may have recurrent thoughts of
death and impulses, thoughts or plans to commit suicide.
Risk factors for suicide include being unemployed, unmarried,
having a problem with substance abuse, having a mood disorder,
and a history of previous suicide attempts. Other risk factors
include a change in personality such as sad, withdrawn,
irritable, anxious, tired, indecisive, or apathetic. There
may be a change in behavior such as an inability to concentrate
on school, work, or routine tasks or a change in sleep patterns
characterized by oversleeping, insomnia, or early waking.
Additional symptoms include a change in eating habits, loss
of interest in people and activities previously enjoyed.
Suicidal patients may be worried about money or illness
(real or imagined), feel like they are losing control, going
crazy, or want to harm themselves or others, or have feelings
of overwhelming guilt, shame, or self-hatred. They may have
no hope for the future or have experienced a recent loss
of relationship, marriage, house, job, or money. They may
have nightmares and express suicidal impulses, or make statements
or plans. A classic warning sign is giving away favorite
things. The suicidal patient may be agitated, hyperactive
or restless.
Healthcare
professionals should be alert to the risk factors and signs
of suicidal intent. Suicide in a healthcare facility is
the second most common sentinel event reported to the Joint
Commission, an accrediting body for hospitals.
The
attorney should keep in mind a few points when reviewing
medical records of a depressed patient. First, detailed
notes about the content of psychotherapy sessions are likely
to not be supplied by a therapist. General comments about
the course of therapy may be turned over, but the intimate
notes of sessions may be kept in a separate file. Secondly,
it is common for a psychiatrist to define the patient’s
problems along five axes, as laid out by the DSM IVTR. The
Diagnostic and Statistical Manual of Mental Disorders (DSM)
is an American handbook for mental health professionals
that lists different categories of mental disorders and
the criteria for diagnosing them, according to the publishing
organization, the American Psychiatric Association. It is
used worldwide by clinicians and researchers as well as
insurance companies, pharmaceutical companies and policy
makers. The DSM, including DSM-IV TR®, is a registered
trademark belonging to the American Psychiatric Association.
The DSM-V is currently in consultation, planning and preparation,
due for publication in approximately 2011. [3]
The
five axes are as follows:
-
Axis I – Clinical disorders consists of all relevant
major psychiatric disorders (such as schizophrenia, bipolar
disorders, and major depression).
-
Axis II – Personality disorders and mental retardation
(Personality disorders as defined in the DSM IV-TR are
deeply ingrained maladaptive, lifelong behavior patterns.)
-
Axis III – General medical conditions that are identified
on the basis of a comprehensive history and physical examination,
evaluation of symptoms, mental state examination, and
supplementary assessment instruments. These include any
medical condition such as diabetes, hypertension, cystic
fibrosis, and so on.
-
Axis IV – Psychosocial and environmental problems
(these can include stressors such a recent death of a
loved one, being a victim of a crime, going through a
divorce, or losing one’s job, among others)
-
Axis V – Global assessment of functioning (GAF),
written as numbers (0–100) meaning “current
functioning”/“highest level of functioning
in past year” with 100 being the highest optimization
of functioning and 0 being the lowest. [4]
Thirdly,
the attorney can be of value to his or her clients by mentioning
resources, such as NAMI, available to help the depressed
patient or family. NAMI (National Alliance on Mental Illness
at www.nami.org)
has chapters in all states and in many counties. NAMI offers
an array of peer education and training programs and services
for consumers, family members, providers, and the general
public. NAMI’s education and support programs provide
relevant information, valuable insight, and the opportunity
to engage in support networks. These programs draw on the
experiences of mental health consumers and family members
who have learned to live well with their illnesses and have
been extensively trained to help others, as well as the
expertise of mental health professionals and educators.
There
are several effective antidepressants on the market that
bring relief of symptoms for those challenged by depression.
There is no need to suffer. Lives can be saved by confronting
depression.
Med
League assists attorneys by summarizing mental health records,
among other kinds, and locating expert witnesses.
References
1. NAMI Family to Family Education Program 2/03e
2. Elizabeth Gilbert, Eat, Pray, Love, Penguin
Books, 2006
3. http://en.wikipedia.org/wiki/DSM-V
4. Mohr, W. “Psychiatric Medical Records”, in
Iyer, P., Levin, B. and Shea, M.A., Medical
Legal Aspects of Medical Records, Lawyers and Judges
Publishing Company, 2006.
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