Friday, June 02, 2006

Salt Mines

[posted by dinah]

I'm stealing a thought from Shiny Happy Person (and I do hope she is), the psychiatrist who blogs at Trick-cycling for Beginners.

SHP wrote:
Why, when so many of my patients are adamant that they do not have an illness, are they so keen to demand Disability Living Allowance, Incapacity Benefit, and free bus passes for those with a disability?

I've been perplexed for years about the relationship between mental illness and the ability to work. It's not that I don't think people with disabling mental illness shouldn't get benefits: I do. What I don't get is how we know when people can't work versus when they won't work, and I haven't observed a great correlation between severity of symptoms and ability to work. So, I see patients who are on disability for Depression or Bipolar Disorder who, on mental status exam, report that their mood is euthymic, their sleep and appetite normal, there are no psychotic symptoms, the medicines are working, and they are busy with a number of activities. Now, granted, these are chronic and intermittent illnesses; some of these patients have been hospitalized, all have had episodes of severe illness, but they also have periods of stability. This is not to be a comment that they should be working, just an observation.

On the flip side, some of the absolute sickest patients I have seen have worked despite their illnesses. One woman's anxiety clamped down her life such that she could tolerate no social events outside her home at all. She couldn't go to a movie or a restaurant (funny, she did have a pet but this was years ago, in the era before Emotional Support Animals, but she also had a family so if they couldn't get her out in public, would a Duck have helped??? Okay, I'm straying here, forgive me). Still, she got to work every day. And the happy ending to that story is that when SSRI's came out, her social life resumed.

The most depressed patient I have ever seen lived with constant misery, non-stop suicidal ideation, extreme guilt, constant self-criticism, and the only symptom that really responded to medication was her extreme irritability and sleeplessness. Still, this was a medical professional who repeatedly won awards and raised a family.

The most psychotic patient I have ever treated spent years in a state hospital. She is plagued by delusions and hallucinations, her symptoms dictate her every move. The symptoms here are so extreme and so unique that confidentiality concerns limit my ability to fully discuss this case, or even to distort it. In the years I've treated her, she has always had a job....well, almost, there was one brief period where she was too ill to get to work and she's left a job or two for reasons that probably haven't related to reality. A trained professional, she's at times taken positions well-beneath her abilities just to pay the bills. I would recommend she apply for disability in a flash, but it's never come up.

And finally, I once treated a man who had never worked. He'd been receiving psychiatric care since he was 10, lived with his father, never finished school despite a documented IQ in the 150 range. He struggled after the father's death, living in his dilapidated childhood home, intermittently doing chores or running errands for neighbors. He told me he didn't believe he could maintain a job at Burger King, that it might fly for a while, but he had periods where he just couldn't do anything. With decades of failures behind him, no stories of success, I believed him. The Disability folks did not, and his final appeal was denied. And so, when I see a patient who left work a few years ago, whose symptoms are now controlled with medication, who says they can't work and gets regular payments, I'm often left wondering.

Just my thoughts, no answers here, and I'm sure some of you will have great references to post, I won't steal your thunder.