The DSM is written mostly by academics, which is why it gets so excited about distinctions like schizoid personality versus schizotypal personality. If it were written by clinicians, it might better reflect the sort of cases that make it into a hospital.
There would, for example, be an entire chapter on the scourge of ‘My Boyfriend Broke Up With Me’ spectrum disorders. More attention would get paid to the plague of chronic ‘I Got Angry At My Dad And Told Him I Was Going To Kill Myself To Freak Him Out And He Overreacted And Called The Cops And Now Here I Am In Hospital But Honestly I Didn’t Mean It’. Society would finally wake up to the epidemic of ‘I Wanted To Take My Medicine But My Hand Slipped And I Somehow Took The Entire Bottle All At Once Even Though I Would Never Do Something Like Intentionally Overdose’. And the sufferers of ‘This Patient Probably Has Some Kind Of Complicated Neurological Problem But Neurology Is Tired Of Trying To Figure It Out So They Have Declared It To Be Psychiatric’ might at last get some relief.
But the biggest change to the medical lexicon would be the introduction of ‘Poverty NOS’.
I recently got a patient, let’s call him Paul…
(all of my patient stories are vague composites of a bunch of people with details changed to protect privacy)
…who was in hospital after trying to hang himself. He said he was so deep in debt he was never going to get out. He’d been involved in a messy court case, had to hire a lawyer to defend himself, lawyer ended up running to the tune of several thousand dollars. He was a clerk at a clothing store, barely made minimum wage, maxed out his credit cards, then maxed out other credit cards paying off the first credit cards.
He didn’t seem to have major depressive disorder, but when someone comes in admitting to a serious suicide attempt, procedure says he gets committed. He wasn’t thrilled about this, saying if he missed work then he might lose his job and this was just going to make him further behind on his payments, but I checked with my attending and as usual the answer was “admit”.
Something especially bothered me about this case, and after thinking about it I’ve figured out what it is.
It’s not just that the psychiatric hospitalization won’t help and might hurt. That’s pretty common. The ‘My Boyfriend Broke Up With Me’s, the ‘I Got Angry At My Dad’s, unless they have some underlying disorder all of these people get limited value from the psychiatric system and tend to just sit in hospital for a couple of days, go to some group therapy, get asked a hundred times if they’re depressed, then go home. And then they’re still broken up with their boyfriend or still have a terrible relationship with their dad and the same thing’s going to happen again.
In this case, it was that – well, the guy is a minimum wage worker from inner city Detroit. He didn’t tell me exactly how much money this debt was, but from a couple of numbers he mentioned I got the impression it was in the ballpark of $5000. That might not seem like an attempt-suicide level of money to some people, but to this guy with his job the chance of ever paying it off seemed low enough that it wasn’t worth waiting and seeing.
So what bothered me is that psychiatric hospitalization costs about $1,000 a day. Average length of stay for a guy like him might be three to five days. So we were spending $5,000 on his psychiatric hospitalization, which was USELESS, so that we could send him out and he could attempt suicide again because of his $5,000 debt which he has no way of paying off. And probably end up in the hospital a second time, for that matter.
I assume that since he was poor, Medicaid paid his hospital bill. I’m not complaining that the cost of the hospital bill was added to his debt, I’m pretty sure it wasn’t, although in some other cases it would be. I’m complaining that here’s this guy, so desperate for money that he wants to kill himself over it, and he has to sit helplessly as we throw thousands of dollars at getting a parade of expensive doctors and nurses and social workers to talk to him, conclude that yup, his problem is definitely that he’s poor, and then throw him back out. I feel like this fails to be, as the buzzwords say, “patient-centered care”.
Problem is, you don’t have to be an economics PhD to realize that “give $5,000 to anyone who attempts suicide and says they need it” might create some bad incentives.
I have no good solution to this. Offering people who are so poor they want to kill themselves very expensive psychiatric care seems maybe a little better than doing nothing. But it also seems insulting, patronizing, paternalistic, wasteful, and occasionally heartbreaking.
And this is why I can never decide whether to identify as a libertarian or a liberal. On the one hand, top-down institutionalized bureaucracies seem so ridiculously inefficient at solving problems that it’s an outrage and a disaster. On the other hand, there are a lot of problems that really need solving, they don’t seem to have solved themselves yet, and governments are the only entity with enough coordination power to attempt the task.
Solution there, it seems to me, is to create unimpoverishable populaces. I think if we were to implement a Basic Income Guarantee we might save more money in psychiatric care than we think – since we compete with the prison system to be the warehouse for people who can’t make it out in the world and nobody knows what to do with. It might produce some of the same kind of savings as giving the homeless people houses. If I got fired because we’d solved all the problems relating to poverty, and the population of seriously mentally ill people was too small to support the current number of psychiatrists, that would be a pretty neat way to go.