The diagnosis that makes you invisible to doctors

How is it possible for a man to be quadriplegic, and to die of cancer at 68, with doctors from six different medical facilities totally unaware of either condition?

Unbelievable, I know. But Kenneth had the answer, even while he was dying.

“Once they find out you have a mental illness, it’s like the lights go out.”

Medicine has a massive blind spot when it comes to treating people with mental illness. Research and anecdotal records point to several factors that contribute to this.

The bottom line, though, is that Americans with mental illness die 13 to 42 years earlier than the general population. And we’re not talking about suicide here.

This is a phenomenon that’s been described for decades. Take schizophrenia as an example.

In the 1970s, persons of any age who had schizophrenia were 1.8 times more likely to die than people without mental illness. By the early 2000s, that number had increased to 3.7.

In other words, if you have schizophrenia, you have almost four times the chance of dying from causes not related to your mental illness than people without schizophrenia. But it’s not far-fetched to think the same life-threatening bias could plague you following an anxiety or depression diagnosis.

What’s behind this troubling statistic? Or, as Dr. Dhruv Khullar of New York-Presbyterian Hospital calls it, “the largest health disparity we don’t talk about”?

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Doctor bias plays a role

Doctors get trapped in two types of bias that can prevent them from adequately addressing the medical needs of patients diagnosed as mentally ill:

Therapeutic pessimism.
Dr. Lisa Rosenbaum of Brigham and Women’s Hospital describes this as an internalized directive to order a test or procedure only if “there’s something you can do about it.”

The pessimistic view of mental illness often justifies doing nothing, says Dr. Rosenbaum. “Why biopsy a breast mass if the patient will surely refuse mastectomy or chemotherapy?”

Diagnostic overshadowing.
A patient’s physical symptoms are often attributed to their mental illness when in fact they are purely physical. This was the case with Kenneth.

His paralysis was blamed on psychotropic medications and later on the “psychomotor retardation” of depression. The real cause was severe spinal cord compression, the result of progressive deterioration following the car accident that first got him admitted for psychiatric treatment.

Fear of legal issues also interferes with proper treatment

Doctors also fear being sued and are often caught between the proverbial rock and a hard place.

Nicholas Bagley, a health law professor at the University of Michigan, points out that doctors can be sued for negligence if they fail to provide necessary treatment to someone who did not actively refuse care.

But they can just as easily face accusations of battery if they override the wishes of a patient because they mistakenly thought the person lacked the ability to make that decision for themselves.

This double-edged sword gives doctors pause when it comes to treating mentally ill patients for medical conditions they present.

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Beginning to address the problem

Kelly Irwin, a psychiatrist at Massachusetts General Hospital, piloted a program aimed at improving cancer care for seriously mentally ill patients. Most of these patients receive cancer diagnoses much later than average.

Dr. Irwin offers several pointers for helping people with mental illness access the medical system:

Make it concrete.
Those with mental illness often need to see concrete evidence of the need for treatment. Showing them their chest x-ray, for example, can convince them to cooperate more readily than just telling them they need surgery.

Don’t overwhelm.
Present information in small chunks, rather than trying to explain everything at once to the distressed person. Respect their need to cope in the way that works for them.

One step at a time.
Don’t fail to take the first step with someone who’s sick just because you don’t know if they’ll follow through or cooperate with treatment. Talk to them and take one step at a time.

More psychiatry education.
Dr. Rosenbaum makes the point that psychiatry should be a bigger part of medical education, and not just theory, but practical application with people who have mental illness.