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Ask the Doctor: How do I respond to a hospitalized friend?


I have a friend who was hospitalized. When visiting someone who is having a break from reality (“they are trying to get me…”) do I play along with the fantasy or do I correct the person: “No there is no one out there doing that”.

It is frequently useless to correct the person and tedious to listen endlessly to the repetition of the same fantasy. You can often change the subject to something more immediate, e.g. “Food OK?”, “Making friends?”, “Plans when you leave?”, etc. Patients often are not able to tolerate visitors for very long periods of time during the acute turmoil and it is usually best to keep the visits short until the person reintegrates more and can carry on a conversation. The patient needs to be in control of who they see and when.

Ask the Doctor: Insomnia and Depression

Can Insomnia be a sign of depression?

Absolutely yes! Insomnia is a prominent part of the syndrome of clinical depression. Most typically it involves awakening in the morning before you’d like to and being unable to get back to sleep. Sometimes it also involves difficulty falling asleep, waking up in the middle of the night unable to get back to sleep, or less commonly — sleeping too much.

When a patient comes to any doctor, he or she usually comes with a symptom; say “cough”, or “insomnia.” Its the job of the doctor to look at the company which this symptom keeps, in order to discern a syndrome — or pattern of other symptoms. Cough, for example, may keep company with other symptoms like fever, or stuffy nose, or chest pain. Depending on the other symptoms, the fever could be the tip of the iceberg (or, as we say in medicine, the “presenting symptom”) of any number of syndromes — bronchitis, asthma, pneumonia, lung cancer, etc. The process of sorting this out in clinical medicine is called: a “differential diagnosis.”

Insomnia may be part of a variety of different syndromes, some medical, some psychiatric. So, its important to get it checked out. However, when it keeps company with some of the following symptoms, it is part of the syndrome known as “clinical depression:’

  • low mood or irritable mood
  • a change in appetite (up or down)
  • a change in weight (up or down)
  • a loss of interest in sex
  • low energy
  • difficulty concentrating
  • negative thoughts about one’s self
  • hopelessness
  • feelings of helplessness or ineffectiveness
  • blunted ability to experience pleasure in things that used to be pleasurable
  • thoughts of giving up on life
  • unexplained physical problems (bowel, back, headache)

This syndrome is pretty common. In fact, its one of the most important, and most treable , causes of insomnia. If this syndrome is present, merely using medication for sleep is NOT ENOUGH. It needs more extensive and more specific treatment.

The good news is that this syndrome, clinical depression, once identified is VERY treatable. The experts in treating it are psychiatrists who may use medication, or talk therapy, or often a combination of both, to treat it. Primary care physicians actually treat most of the simple cases –since there are far more of them than there are psychiatrists.

Whatever kind of doctor you go to, if you are having insomnia, get it checked out. Get a “differential diagnosis” and state-of-the-art treatment for whatever syndrome it represents.

Ask the Doctor: Antidepressants Not Working?

I don’t think my antidepressants are working. What should I do?

It is important to take an antidepressant for a long enough time, perhaps a month, before deciding whether it works. In general, all antidepressants have a similar rate of effectiveness but differ in the type and degree of side effects. This is true in a statistical sense, but research and clinical experience suggest that individuals may benefit from one antidepressant but not another. Increasing the dose may be the first thing to try, and if that fails it may be useful to switch to another antidepressant. Another option is to add a second medication that may augment the therapeutic effect of the antidepressant.

Unfortunately, a significant minority of patients do not benefit, or benefit only partially, from antidepressants. Sometimes this may be because the diagnosis is incorrect, and the patient has some problem other than a clinical depression. However, even when the diagnosis is correct, the medication may not work Psychotherapy is often as effective, or sometimes more effective, than medication. The depressed patient for whom medication is not the answer should be evaluated for the type of psychotherapy that may be the most appropriate for him or her.

Ask the Doctor: What If My Family Member Refuses Help?

A relative of mine clearly needs psychiatric help, but he refuses to see a doctor about this. What should I do?

Unfortunately, this is a very common problem. Sometimes people who are clearly suffering from psychiatric illness don’t themselves recognize that they are having problems, even when this is readily apparent to their families. In other instances, the person may feel ashamed to acknowledge that there is a problem, or feel afraid of what treatment might entail (including fearing possible hospitalization), or feel concerned about being stigmatized because of obtaining mental health treatment. There are many instances when people really know they need help, and may even want it, but can’t or won’t get it without guidance and encouragement from others.

If you have a close relationship with this person, the first thing to do is to try to discuss with him your concerns, gently giving examples of what he has said or done which have made you alarmed. Try to do this in a calm, supportive, and non-accusatory manner, and suggest that he see a psychiatrist or other appropriate mental health professional for an evaluation. Try and convey that you are only suggesting this because you care about him, and be reassuring that the professionals he sees will be knowledgeable and compassionate people genuinely trying to help.

If speaking individually with him doesn’t help the situation, or seems unfeasible, another approach would be to have several close family members or friends meet together with your relative to similarly express their concerns and suggest the need for evaluation and treatment. Sometimes it is helpful to offer to take the person to see a mental health professional, or to accompany him.

If you fear that your relative might be thinking of suicide, or might be violent, clearly there is much more urgency to his getting professional help. In these situations, or whenever serious psychiatric illness is suspected, one option is for you, perhaps accompanied by one or two others, to simply drive the person directly to an emergency room (where psychiatric evaluation is typically available). If you can’t do this, or you fear your relative wouldn’t cooperate, another option is to call the police. In Maryland and many other states, the police are legally obligated to take people with suspected mental illness who seem endangered or dangerous to a nearby emergency room so that a medical and psychiatric evaluation can be performed, and appropriate medical care can be provided.

Another option available in Maryland is to go to a district court and fill out a form called an Emergency Petition. Once this form is filled out, it is given to a judge or magistrate, and a hearing is held in which the judge may ask you some questions about your family member. If the judge/magistrate becomes convinced that your relative might have a mental illness, and might be in danger of immediately impending self-harm or violence, the court official can compel the police to take him to an emergency room for a medical and psychiatric evaluation.

Sometimes, when it seems very hard to know the best way to get help for a family member, it can be extremely helpful to make an appointment with a psychiatrist (without the relative being present), explain the situation, and receive professional guidance about how best to proceed.

Going the extra mile to get a relative needed help is an expression of great concern and love; frequently, at some point the family member realizes this, and ends up feeling extremely grateful.

Ask the Doctor: How can I help a “hoarder”?

I have a 34 year old daughter who neglects her home and it has come to the point of hoarding items. She never cleans her home and there are piles of stuff all over her home. When I try to condense things for her, she makes excuses as to why they should be kept. To make things worse, her father has been diagnosed with paranoid schizophrenia. Also, her husband seems to put up with it.

Please help me make the right decision to help her and her hubby. They have 2 minor children in the home.

The most important thing about this question is that your daughter needs a good psychiatric evaluation. Rather than focusing on what might be wrong with her, instead its important to focus on getting her evaluated by someone who has the expertise and experience to determine whether she has a treatable psychiatric problem, and how to approach her about that treatment. In light of the family history, and some of the hoarding behavior that you describe, it certainly seems likely that she may well have one of a few possible treatable conditions. So, how to approach her?

First you might wish to let her (and her husband) know that, like heart problems, psychiatric problems can run in families, based on genetic and other factors. There is certainly some family history of a disorder there, and that makes both your daughter AND her children at higher risk.

Second, you can tell her that psychiatric disorders are actually more treatable than most heart problems.

Third, you might want to let her know that untreated psychiatric problems in parents can take a significant toll on their children in terms of the childrens’ mental health, social adjustment, and academic performance. So, getting an evaluation would be a big favor to her children.

Fourth, you might want to do some homework before this conversation and identify a psychiatrist in advance who would be willing to see her. You could speak with your daughter’s family doctor about your concerns and get a recommendation from that doctor (as well as have him support the idea of a consultation directly in a conversation with your daughter). You can even speak with the identified psychiatrist in advance of talking to your daughter about this–either by phone or through an appointment with that psychiatrist yourself. It is actually quite appropriate for family members to consult a psychiatrist about their troubled loved one, and get some guidance from the psychiatrist about how to bring them into treatment, preparing the way in the most welcoming fashion.

You might want to include her husband in any or all of the above discussions, even before you approach your daughter. Getting him on board with the idea of at least a one-time consultation, might be easier to do first, before approaching her.

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