Let’s say you’re a doctor with a patient who presents with an infection. You examine the patient, determine that the infection is bacterial, and prescribe basic antibiotics. You start with a base standard of care that’s usually effective, and you send the patient away with clear instructions on how to use the medication, what kinds of side effects to watch out for, and what to be particularly alert to; like a significant rash, for example, which might indicate an allergy. You may make a followup appointment to check in at the end of the course of medication to see how your patient is doing.
Two days later, your patient calls the front office. Your triage nurse pops into your office to say that the patient’s infection is spreading, that the patience is experiencing side effects, or that some other problem has occurred. Maybe you call in a prescription for a different antibiotic, assuming that the infection is resistant to the first line (a growing problem in medicine). Maybe the information the nurse collected concerns you enough to bring the patient in and take a sample so you can get a culture. Perhaps the second round of treatment works, the patient is cured of the infection, and all is well.
But maybe the infection persists. Even with two rounds of different antibiotics, it’s still ravaging the patient. You try a third, maybe a fourth. You keep trying until you find the right medication; or maybe, you never find it at all. Maybe an infection is so robust, or your patient is so frail, that you’re effectively out of treatment options.
This isn’t just a hypothetical; it happens to doctors on a regular basis. But it doesn’t just happen in physical medicine. It’s also an apt scenario for mental health care. A patient comes in complaining of, say, depression. You perform an assessment and determine that the patient is depressed. You provide the patient with some treatment options. Maybe the two of you decide on medication, paired with therapy.
Maybe the medication does’t work. Maybe the therapy doesn’t work! You play around with medication levels and different drugs. You recommend that the patient explore the option of seeing another therapist, or consider switching modalities; maybe your patient needs intensive daily psychotherapy, maybe your patient would benefit from the structure of cognitive behavioural therapy, maybe your patient actually needs electroshock (still used, though modern treatments are less brutal and more targeted) or magnet therapy (it sounds like woo woo hokum, but it’s actually effective). You work with your patient — in this case you’re not looking for a cure, but to the key to unlock management of the mental illness, but the goal is the same. You want your patient to have the best possible quality of life.
We recognise and accept that patients with physical conditions, like infections, may need to go through several treatment options to find one that works. Maybe treatment starts with antibiotics and then the patient has to go to surgery because an infection is so aggressive. We acknowledge that these things happen, that medicine isn’t always right off the bat, and that patients can get misdiagnosed, that they may need several rounds of different treatment to address an issue, that they may need referrals to specialists or a switch to a different doctor to get the treatment they need. This is so widely accepted that it’s almost reflexive; ‘oh, I have severe persistent headaches, so my GP referred me to a neurologist.’
Yet, when it comes to mental health care, people seem to struggle with this. The idea that mentally ill people have equally complex conditions that may require some shuffling and experimentation to find the most effective course of treatment and maintain stable mental health is apparently utterly alien. Evidently, mentally ill people are supposed to walk into a psychiatrist’s office (because it’s so easy to get an appointment), be correctly diagnosed on the first try (because you can test for mental illness with a little test strip, like pH), and then receive an effective treatment modality that just works, with no further intervention necessary. Maybe the patient needs to take pills or talk to someone, but that’s tangential: Mental health care is easy!
Setting aside the larger issues within the mental health system that make it extremely difficult to access care, and to have that care paid for, assuming we lived in a magical world where all mentally ill people could access the treatments they needed without having to worry about paying for them or enduring stigma, mental health care is just not one size fits all. Like an infection, mental illness can seem easily treatable, and sometimes it is, but other times, it’s not. Sometimes it’s grown deep to the bone and the patient needs multiple rounds of treatment, maybe even surgery (a stay in a residential treatment centre, say, or daily outpatient therapy for a while). Mental illness presents in many ways, sometimes it is not diagnosed correctly, sometimes a patient’s diagnosis shifts — a coinfection sets in, if you will, complicating the original issue.
A greater understanding of mental illness is key to building acceptance and respect for mentally ill people. Such an understanding often seems lacking in conversations about mental health subjects, with people refusing to acknowledge that it is more complicated than taking some pills and calling it a day. Mental health is complicated, managing it is demanding, and it is very rarely simple. A simple prescription for antibiotics is not enough to kill this infection.
Image: Psychiatry_2., Emmm Weee, Flickr