When patients with a history of mental health disorders begin to decompensate mentally, many providers automatically assume that the problem is related to the mental health diagnosis and either refer the patient to a psych/mental health provider or, if they are managing the psych meds, increase the doses of psychotropic medications. Patients with mental health problems whose condition is suddenly becoming poorly controlled require a medical work-up to first look for physical health problems that may be exacerbating the mental health issues.
I examined a woman with schizophrenia who had been admitted to a board-and-care facility after a nine-month commitment at a state psychiatric hospital. Numerous types of psychotropic medications had been tried with no real improvement in her psychiatric symptoms, so she was discharged. She was very intrusive, following the staff around the nursing facility, and was complaining of back pain.
The patient agreed to an exam to evaluate the back pain. From five feet away, I was able to diagnose the reason for both the poor control of her schizophrenia and her back pain. Her right breast was red, grossly enlarged, and misshapen, with peau d’orange skin changes and puckering around the nipple. Palpation revealed a 5 x 5–cm hard mass. Her diagnosis was inflammatory and ductal breast cancer with metastasis to the spine.
The sad part of this story is that she had two exams by an NP and two by an Ob-Gyn for some vaginal bleeding issues during the preceding nine months, and there was no documentation of a clinical breast exam being performed or the patient’s refusal of an exam. I unfortunately have had at least 20 of these cases, which I use to teach my NP students about managing the care of patients with mental health problems.
The bottom line here is that this kind of care, or lack of care, is unacceptable. The story that you shared in your editorial goes on all day, every day, all over the country. Primary care providers, and those who educate them, need to make a commitment to Stacey and the thousands of patients just like her to do better. We do this by educating ourselves regarding psych/mental health care, advocating for our patients and their families within the systems where we practice, and holding our legislators accountable for policies that protect the human rights of those who suffer from mental health disorders.
Ruth Staus, DNP, RN, CNP, St. Paul, MN