A Life Lost
A mother's grief, a system's failure, a culture's complicity.
Posted Apr 02, 2014
Daily tragedies occur with psychiatric disease. Simplistic critics often ignore the risks of some of these conditions, if untreated or ignored. The following story is true, with some changes made to ensure confidentiality. It is one life lost, a life few recall now except a mother and a father, for whom the pain never leaves. It could have been a life saved, perhaps, if our mental health care system was less stigmatizing and more honest, - perhaps, if we all, in the larger culture, were less stigmatizing and more honest about these conditions.
The email message was cold and pitiless:
“Dear Dr Ghaemi: Last week, Thomas hanged himself. I knew you would like to know. Thank you for everything you did for him. You were one of the few people who tried to help. Thank you so much for everything.”
I had just returned from a visit to my wife’s terminally ill grandmother. I thought back to Tom. I remembered most his long lumbering steps, the steps of a gangly 17 year old when I knew him. In those days, he was alternately depressed and manic, but not, to my recollection, especially suicidal. But time had not been kind to him.
I first met Tom and his mother when a colleague referred them to me, and they agreed to participate in a research study with me, followed by clinical treatment. He had classic bipolar illness, with obvious and clear manic episodes alternating with depressive episodes. The research study was brief and uneventful. Tom entered the hospital meeting standard diagnostic criteria for mania; he left two weeks later no longer meeting those criteria. When the study ended, we gave him standard mood stabilizers, and he seemed better for a while. Later he became depressed again, and we made some medication changes. He gained some weight, and we made other changes. All in all, he remained ill, but not as severely ill as he had been. I moved away and the family took Tom to local psychiatrists, along with recommendations from me about treatment options.
Three years passed. Then, first with email and later with telephone calls, his mother reestablished contact with me. In the intervening years, Tom’s condition had worsened. His parents had separated, largely under the pressure of his illness. Sometimes he was psychotic, with paranoid ideas that others wanted to hurt him. He had strong homicidal urges, wanting to kill alternately strangers, or men whom he thought were courting his girlfriend, or his mother. Then he would become scared, and, to prevent himself from hurting someone else, he would become suicidal. He had made a number of attempts, including overdosing and cutting his wrists. But these actions would lead to short hospitalizations, a few days to a week at best, since he would always convince his doctors that he was no longer suicidal. Sometimes, after an attempt, he wouldn’t even be hospitalized. The crisis team, set up by the state to screen and triage psychiatric patients, would send him home, relying on his explanation that he did not mean to actually kill himself. After a while, he would cut himself and his mother would not even bother calling the crisis team.
Tom had become a Medicaid client. Despite coming from an upper middle class family – his father was a successful businessman, and his mother worked for a university– his family’s resources didn’t allow for private insurance payment for his many brief hospitalizations, or for long-term psychotherapy, or even for regular psychopharmacology treatment with one of the small group of experts in bipolar disorder. Tom was treated with the same care and attention given to the poorest, homeless client - which means very little. After one of his many brief hospitalizations, the doctors told his mother that there was no treatment for him; he might as well take no medications and receive no treatment of any kind. It was convenient advice, since she couldn’t afford to pay for much treatment. After a while, Tom lost faith in his doctors; he took them at their word: they said there was nothing to be done; he concluded they didn’t know what to do.
He refused all medications.
At this point, his mother contacted me. You are one of the few doctors he trusted, she said. I knew it was more complex. When Tom had seen me, his illness was less severe. But I also knew the other part of the truth, which his mother implied: as a poor, ill patient, Tom would get good care only by luck. He wasn’t lucky.
I offered to bring him to a prestigious psychiatric hospital, near where I worked, where at least we could try to get him on some medications in a supervised setting over a few weeks. The hospital agreed, and even went so far as to go through the paperwork needed for Medicaid reimbursement out of state. But Tom refused. He wouldn’t go along, even at my suggestion. He did not believe medication would help any longer.
We couldn’t force him to go, because he would deny any immediate wish to kill himself, which is the criterion of involuntary treatment in most states.
We had one other hope: the courts. In the course of some of his rages, Tom had assaulted various people, and had previously been convicted of various misdemeanors, never leading to imprisonment. He had another court date soon. His mother planned to ask the court to mandate treatment for her son against his will. Lawyers who were friends, as well as some court officials, had intimated that the judge would likely help her. We hoped, with some court intervention, to force Tom to take lithium or some other mood stabilizers, which at least had made his illness less severe in the past. Where Tom lived, outpatient commitment was possible, though highly limited in use.
The court date came and went. The judge let him go.
His mother was demoralized.
On Mother’s Day, she prayed that the Lord would take her son.
A week before his death, Tom’s mother informed me of this turn of events. Finally, I asked her to contact a local advocacy group to see if they could help her influence the courts or the state mental health system to initiate more intensive treatment for Tom. She made some calls, but it was too late.
One night, Tom was in a rage. He burst into the living room, telling his mother that he was going to kill himself. She slumped in her chair. “I felt exhausted,” she later told me. “I knew he could kill himself, but I didn’t have the energy to call the crisis team one more time, to see nothing done, or to see him held for a day at most. I was tired.”
She stayed in the house. He went into the backyard.
The next morning, she found him hanging from a tree.