After Discharge, a Psychiatric Patient May Still Be Unable to Manage

Source: Alexandra_Koch from Pixabay

My intention in writing these posts 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. It's also 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.

Understanding definitions of “remission” and “recovery” is key to interpreting data presented in the literature on time course of remission in psychosis. Traditionally, patient management has focused on symptomatic remission involving the assessment of positive and negative symptoms. However, this does not encompass the need for functional recovery, including psychosocial, occupational functioning, and family dependency that can be detrimental to patients’ quality of life. The average time to recovery from a psychotic episode varies depending on factors such as underlying diagnosis, treatment adherence, and access to care, but studies suggest that remission from acute symptoms typically occurs within 6 to 12 weeks with appropriate antipsychotic treatment. However, full functional recovery—defined as sustained symptom remission along with social and occupational functioning—can take significantly longer, often extending over several months or even years.

How long it takes to fully recover from a psychotic episode depends on the illness and the affected individual. In schizophrenia, by definition, the person has ongoing deficits as well as acute psychotic flare-ups. In mood disorders with psychosis there may be cumulative impairment from repeated episodes of illness, especially if psychosis is involved. A study (Robinson) that separated clinical recovery (medically defined symptom remission) from personal recovery found that for personal recovery (defined by patients themselves) measures of empowerment, hope, affective symptoms, occupational function, duration of untreated illness and social and cognitive symptoms predicted personal recovery. Thus, when patients are stable, or at least not psychotic, they intrinsically are oriented towards a functional recovery. However, during psychotic episodes this understanding may not be possible.

In the case of my son, Bill, trying to help with his recovery long distance was challenging. When we finally made the connection with the Social Security Insurance agency (SSI), they stated that they did not have Bill’s W2 form and paystubs, which they would need, including his final paystub, in order to re-open the case—but Bill was in no condition to be able to fulfill these requests. The step-down unit released him, even though he was still paranoid and worried about being “monitored.” Typical of psychosis, he had numerous delusions, believing that various devices such as computers and drones were following him, and that because of his special mission, his movements were being tracked.

While he was being treated at the step-down unit, Bill’s car was towed and had been accumulating storage charges. I called the towing facility to see if someone else could pick up the car, but they would only release it to Bill, a frustrating condition that only piled on more complications. I wished that the county’s mental health system had instituted the Program in Assertive Community Treatment (PACT) model for all its patients, and not just their lone demonstration project. In PACT, the workers assumed responsibility for helping with daily living tasks when the patients couldn’t do them for themselves.

As it became clear that Bill couldn’t manage all the tasks he needed to complete—figuring out a new treatment plan, getting SSI reinstated, getting his car out of the tow lot, finding an apartment he could afford—I realized I needed to travel to Madison to intervene however I could. I was frustrated at having my life perpetually at risk of being upended by Bill’s struggles. But he was clearly so sick that my only choice was to go to help him. How was I going to accomplish everything necessary to get him back on track? Was that even possible, or was it hopeless?

I arrived the day after he was discharged home. For all my previous visits, Bill had picked me up. I was staying at a local inn, a short drive from Bill’s apartment.

When he opened his apartment door, I immediately detected the faint stench of garbage and cat litter. He looked gaunt and frightened.

“Hi Mom, how was your trip?”

Discarded take-out containers and unwashed dishes were strewn everywhere, and litter boxes for three cats hadn’t been emptied. The alarming mess didn’t seem to register with him.

Clearly, he wasn’t managing to take care of the apartment, which wasn’t really a viable option for him anymore since he had no means to pay for it. His SSI allotment had been reduced when he started working several years earlier and wouldn’t cover food and rent without a paycheck to make up the difference. He needed to be in a less expensive place, since we couldn’t assume he would be back on his feet any time soon, earning a paycheck. He had to be out of the apartment by the end of the month because he had no way to cover rent. I pondered all this silently as I cleaned up the dishes.

“Bill, we need to find a different apartment for you that you can afford,” I told him. “I’ve been paying for the apartment for several months now—I can’t cover the costs indefinitely.”

“Mom, please, I can’t move now. Please cover the cost until I can figure out a plan.”

“But Bill, you say that every month; why is this going to be any different? The real problem is that you’re not taking your medicine. If you would take the medicine as prescribed, you would stabilize and be able to work again, and then affording the apartment wouldn’t be an issue.”

Psychosis Essential Reads

High-Profile Violence and How We Can Be Effective for Change

Assisted Outpatient Treatment Keeps People Out of Hospitals and Jails

“But Mom, I just can’t move now.” He was sincerely pleading with me. I felt terribly guilty at insisting that he move, but I also knew he had to be back in a situation where he could have his SSI reinstated with enough money to cover his medicine and living costs.

“Bill, we’ll look for a new apartment together,” I assured him.

He finally acquiesced, and we started an internet search. Painful though it was, it seemed logical at the time to give him an ultimatum. It seemed clear that the only way to move forward was for him to take his meds. But in hindsight, did my ultimatum put too much pressure on him? For patients who are marginally stabilized, emotional stressors can help trigger acute illness. About 80 percent of acute depressive episodes, for example, include a major stressor. For psychosis the contribution is less clear, but stressors are thought to contribute in a significant number of cases, particularly when there are more than one simultaneously, as was the case for Bill. He was already psychotic, but did the apartment hunt push him into further decompensation (worsening of his illness)? Should I have continued to cover the costs of the apartment indefinitely? Would that have made a difference? While I could have afforded it, continuing to cover the costs seemed like enabling his refusal to take his meds, and ultimately sabotaging his chance for recovery.