Untreated Chronic Mental Illness

December 7, 2009

My interest in mental health began before I was a psychiatrist-it started in a small Central American country where I arrived as a primary care physician in the early years of the Peace Corps.

My interest in mental health began before I was a psychiatrist-it started in a small Central American country where I arrived as a primary care physician in the early years of the Peace Corps. My formal job was looking after the health of the 250 American volunteers. However, I had some extra time and asked the Minister of Health where I might volunteer my services. The minister suggested the large government mental hospital located on the outskirts of the capital.

Within a day, I found myself in charge of 300 chronically ill women who lived in one of the hospital’s fenced courtyards. All the patients had scarred faces and limbs. Some wore clothing that was dirty, disheveled, and ripped, and others wore none at all. They all had the same blank stare and most barely communicated verbally.

The courtyard consisted of numerous concrete benches and a large drainage ditch. The patients could also access the ground floor of a multistory building of which the upper floors had collapsed. What remained of the building was used as a cafeteria during the daytime and a dormitory at night. There were not enough beds for all the patients and no mattresses at all. Most of the patients spent their time fighting with one another, coming to blows over such things as a bit of food, shred of clothing, or shady spot. Screaming, moaning, praying, and bickering were ever-present sounds. Most patients paced the grounds in a haphazard way.

One nurse was available during the day to hand out medications and administer first aid, but none of the staff left the safety of the office. We communicated with the patients in the courtyard through a locked half door. In addition to me, there was one other physician. She was an intern, just out of medical school, who had responsibilities throughout the rest of the hospital as well.

Any patients needing medical help would be brought into the nurse’s office. The intern or I would treat and bandage open wounds to prevent infection or immobilize broken bones. Lacking any psychiatric training, we usually prescribed antiseizure medications, antibiotics, and medications to treat parasitic infections. The few antipsychotic treatments we could get from the hospital pharmacy, usually chlorpromazine, were mostly reserved for acutely agitated patients.

The intern and I wanted to do more, but we felt overwhelmed by the sheer number of regressed patients and the stench of the courtyard. We finally decided to set up a new unit to try to salvage at least a small number of patients. The intern proved to be an extremely effective solicitor of donations from the business community. In short order, she arranged for 15 cots with mattresses, basic clothing, towels, radios, clocks, a television, and even combs and cosmetics for our carefully selected patients. We put all of these things into a freshly painted area adjacent to the nursing station. Best of all, we arranged for food service from the employee cafeteria instead of the usual patient gruel.

After poring through the rudimentary patient records, interviewing staff, and soliciting volunteers, we introduced 15 patients from the courtyard to the new medical unit. Not only would they have a safe place to sleep and eat but they also would be allowed out of the unit into the hospital grounds during the day. The plan was to help them regain their ability to perform basic self-care tasks and gradually prepare for discharge. As a first step, we did blood counts and urinalyses and examined stool for parasites. In addition to treating anemia, urinary tract infections, and parasitic infections (such as those caused by amebas, hookworms, and digestive tract roundworms), we boosted dosages of antiepileptic medications, such as phenytoin and phenobarbital, to levels to help control seizures in patients with epilepsy. We also raised the dosages of antipsychotic medication, mainly chlorpromazine, to levels that began to stop delusions, hallucinations, and other psychotic symptoms.

What followed truly astonished me and probably accounts for my subsequent decision to change my career path from internal medicine to psychiatry. No doubt it affected the intern as well. She later became a child psychiatrist.

Within a few weeks, we were able to discharge a patient after much detective work on the intern’s part to find her family. However, that was our only success. All the others, with tears in their eyes, approached us one-by-one, every week or so to say that they wanted to return to the courtyard. They felt free there. The new surroundings demanded too much of them. They did not feel like going to sleep when the lights went out, eating at set times, or sitting quietly while watching television. There was no place to roam freely, discharge their anger in a fight, or just urinate where they wanted.

The patients cried (possibly because they knew that both the intern and I had put a lot of energy and hope into caring for them) but told us that they were lost causes. They had no family who visited them, had not talked to anyone on the outside in years, and had too much confusion in their heads to ever make it back to a society that they only remembered vaguely. All of their friends and lovers were in the courtyard.

Despite the danger and chaos, it was a lifestyle they had gotten used to and now missed. To behave was too hard, and to think of ever getting out of the mental hospital was frightening. They no longer had any expectations, nor was what they remembered of their prior life beckoning. Most had been very poor and had been rejected by their families and communities for strange behavior, such as epileptic fits or psychotic manifestations.

Sometimes we were able to talk patients into staying a few days or weeks longer in the special unit, but they kept beseeching us to leave until finally we would cave in and allow them back into the courtyard. Replacements fared the same way. Perhaps a total of 30 patients tried our program, some for several months, but all eventually wanted back into the courtyard.

To this day, I am not entirely sure why we were so unsuccessful, but unsuccessful we were. It was that humility and experience that brought me into psychiatry. Perhaps, chronic mental illness with institutionalization, allowed to fester, is untreatable.