Sickle cell psychiatry: don’t give up
Date: July 15, 2011
In medical school, the feedback other doctors gave Patrick Carroll about his wanting to work with sickle cell patients wasn’t favorable. “If you’d say sickle cell,” he remembers, “their eyes would roll back in their heads. The impression that’s out there is that these patients are very tough, that there’s lots of bad behavior, that they’re too interested in opiates.”
Sickle cell disease (SCD) is marked by pain crises—times when misshapen red blood cells turn blood to syrup. The resulting oxygen starvation brings searing pain that only IV opiates and fluids can relieve. So, yes, many of these patients are more than a little interested in opiates. And, yes, the crises’ unpredictability and what that does to a career or raising a family makes the disease a sieve for depression or other psychiatric illness.
Carroll came to Hopkins as “an addictions doc,” he says. But asked to see some troubled patients who came to its new Sickle Cell Infusion Center for medical therapy, the psychiatrist found “an assortment of psychiatric illnesses, as well as problems in relating to doctors and the very occasional genuine case of addiction.” He signed on right away.
Rather than viewing SCD as a crisis-based disease, Carroll sees it as a chronic condition that requires treating the whole person. His work begins when clinicians notice something going on with an infusion patient—maybe it’s missed appointments or someone just looking burned out. Then Carroll meets with the person, separating demoralization from depression, checking for anxiety or other psychiatric ills. He draws up a comprehensive plan to address problems and settles in for what may be the long haul.
It’s the rare sickle cell patient who has everything going for him except the disease itself, Carroll explains. Many people he sees are like a current patient—a young man who had dropped out of high school and who remains unemployed due to his sickle cell pain. His family—many members crammed into a tiny, drafty house—relies on his meager disability check to pay the bills. He doesn’t have a car, so he has to walk to his appointments, a journey that could take two hours because of his chronic pain. The patient’s previous doctors complained that he frequently missed appointments. But from the patient’s point of view, the situation was hopeless—he was in chronic pain and no one was helping.
“He was depressed out of his mind, but he had never been diagnosed with depression,” says Carroll. “We started working on that.”
Carroll sees patients take better care of themselves and their sickle cell disease once their underlying medical and/or psychiatric issues are addressed—a process that can take months, rather than a few hours or days. “At a really pragmatic level, it’s just irrational to give up,” he says. “If you do something, there is some chance it will work—maybe it’s slim, but if you give up, you’ve decided on certain failure.”
The young man has made significant progress, Carroll adds. He’s now coming to more appointments—for him, a sure step in the right direction.
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