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Key points
- Events leading to hospitalization vary from person to person.
- Psychostimulant use is often a contributing factor.
- The context is important for understanding the illness.
My intention in writing this blog is to share the experiences that I went through with my son, starting with the first manifestation of his illness and our journey through numerous subsequent episodes. Also, my purpose is to provide commentary as a parent and psychiatrist on issues that these experiences bring up, such as how the diagnostic process works in mental health, and how to work with treatment providers and medication issues. My hope is that reading this may be helpful for people with mental health issues and also their families and friends.
Events Leading Up to ER Visit
Events leading to hospitalization vary from person to person and from one situation to the next. Understanding how these events unfold can give overall context to a person’s illness. For my son, the events happened quickly. The day prior to his first hospitalization, Bill gathered his belongings together to move into a shared apartment. We pieced together later that he was following a friend in his car when he suddenly made an abrupt turn and disappeared. Several hours later, I got a call from him in jail.
The sergeant described the events: The police received a call after a stranger had been seen vandalizing cars parked in back of a local business. Apparently, he was using a rock to smash the windshields. When the police arrived and asked him what he was doing, he said, “I’m the parking attendant and these cars have no business being here.”
Hearing this was horrifying and confirmed my fears that Bill was far more ill than he admitted. Later, after he had recovered from this episode, Bill was able to tell me that he thought he was being tested for a job as head of the FBI and this was part of the test.
But that day, I drove from work to the jail, frantically calling his former therapist and some of my friends who could help me think through options. Bill had been in therapy during his junior year of high school, when he had some oppositional behavior. His psychiatrist told me they had discussed his drug use, which caught me by surprise.
Confidentiality Regarding Drug Use in Minors
Asked why I hadn’t been told—since Bill at age 16 was a minor—the therapist said, “It would have damaged the therapeutic alliance.”
I was stunned that he hadn’t considered it important to include the family in his decision making. There is a gray area about disclosing information about adolescents to parents. The law is clear that as guardians, parents have a right to request treatment information: Minors can’t consent to treatment; a parent or guardian consents on the minor’s behalf. But from a clinical perspective the situation is more complex.
An aspect of treatment is fostering the individual’s autonomy, including privacy. However, psychologists may disclose confidential information without consent to protect the patient or others from harm (standard 5.05). Thus, a therapist cannot promise a minor that information will be kept from a parent who has legal custody. My opinion is that drug use is not merely part of rebellious behavior but represents a clear and present danger because of the risks for lasting brain damage leading to a psychosis predisposition or the risk of impulsive behavior that can be dangerous.
Effects of Psychostimulants on Future Psychiatric Illness
Statistics on THC in adolescence show widespread use from age 15-25, with 25% reporting frequent use and 31% abstaining. Comparing frequent users with abstainers showed, overall, that frequent use lowers school performance and raises rates of behavior problems. There is accumulating evidence that all mind-altering drugs, including cannabis, increase the risk for psychotic disorders as well as decreasing educational and vocational achievement. This is particularly important for post-secondary education where it has been shown that given the strong relationship between post secondary education (PSE) completion and entry into career-track jobs, the influence of recreational drugs is critical. Studies comparing marijuana abstainers to frequent users in adolescence found that frequent use was associated with closed opportunities to enter PSE and even occasional use could create delays in starting or completing PSE.
I thought about the de-motivating effects of THC and about students who smoked weed in my college days. Some of them could smoke a lot with no apparent ill effects, while others seemed to get caught up in an endless cycle of using and then being too wasted to do much of anything. Although Bill did well in school up until he developed bipolar disorder in college, another problem associated with using THC in adolescence is higher rates of developing psychiatric illness. Many of the observable symptoms of psychosis—paranoia, heightened anxiety, and thought disorder—are essentially the same in a drug-induced psychosis and in schizophrenia or manic psychosis. For the clinician this creates a diagnostic dilemma, trying to sort out what the underlying issue is.
