Physical and mental health in the community

CrossCurrents

DR. ERIC SOLWAY is a physician at the Queen-Dufferin Treatment Centre in Parkdale, an area of Toronto with a large population of people with psychiatric and substance use issues. Solway and one other physician see approximately 40 clients per day. Most clients come for addiction treatment and approximately 25 per cent of them have a major psychiatric diagnosis. The clinic also has two support staff who function as receptionists and laboratory technicians but who also do case management, crisis intervention and supportive psychotherapy.

What led you to practise physical medicine with people who have mental health and addiction issues?
My training is in family medicine. During my residency I had planned to join a physician with a well-established practice in Thornhill: a typical suburban family practice, with lots of kids, earaches and sore throats. Not long before I finished my training, the physician bought a practice in Parkdale. He felt motivated by the degree of illness and pathology he was seeing, things he hadn't seen since medical school. Given the area of the city, he also saw a lot of substance abuse. One day on his way into work he literally tripped over the body of someone who had overdosed in the alley behind the clinic, someone who had sought his help in getting methadone treatment. At that time there was very limited access to methadone and patients would spend years on waiting lists to get methadone, if they survived that long. This doctor decided to prescribe methadone in the community, which at that time was almost unheard of. He quickly developed a clinic that provided methadone to more patients than the established hospital-based programs. He needed doctors to help him manage the patient load and that's where I came in.

Although I was interested in addiction medicine, I wasn't ready to narrow the scope of my practice that early in my career. I insisted on doing general practice as well as addiction medicine. I was seeing a lot of patients with major mental health problems, primarily schizophrenia and bipolar affective disorder. Over time I developed a reputation among psychiatrists and mental health support workers as a doctor who was willing to take on the role of family doctor for their patients. As people with psychiatric illnesses were being de-institutionalized, there was an increased demand for community doctors to manage their general medical care. Patients found the clinic to be a place where they felt comfortable going for their medical care. And I found my niche in an area of medicine where my skills were put to good use.

What physical health problems do you commonly encounter among your clients?
I see an overwhelming rate of diabetes in this population. The majority of these patients are smokers and many lead very sedentary lives. So they are at particularly high risk for cardiovascular disease.

Some patients are referred to me by their psychiatrist because they haven't had their physical health checked in years or because the psychiatrist has identified a medical concern that would be more appropriately managed by a family physician, the most common ones in addition to diabetes being hypertension and high cholesterol.

I am often asked by the patient or referring psychiatrist to manage symptoms that may be side effects of psychiatric medication, for example, constipation, dizziness, diabetes and kidney failure. Patients who have not seen a family physician in years often need their immunizations updated or they may need preventative medical care, for example, PAP smears and mammograms. And they also need advice about diet and contraception, as well as referrals for dental and eye care.

Patients are often not able to commu-nicate the reason for their visit, or they will ask me to deal with the voices they are hearing, the people who are out to poison them or where they can get their money or cigarettes. In these cases, the community support worker who accompanies them is invaluable in explaining the medical purpose of the visit.

How do the physical health needs of clients living in the community differ from clients living in psychiatric institutions?
Patients in the community will often need more assistance with reminders regarding medication, follow-up testing and other medical appointments. Patients in the community may also need more reassurance and tolerance of behaviours that may deviate considerably from social norms. In institutional settings, staff are usually trained to deal with these issues. But in the community, where medical professionals and support staff may not be trained to deal with psychiatric issues and symptoms, dealing with these patients can be very challenging. I am very fortunate to have staff at my clinic who have the training and understanding to be able to embrace the differences in our patients.

What is the biggest challenge for you in attending to the physical health of people with mental health or addiction issues?
Many of the challenges are basically exaggerated versions of those I encounter with the general population: denial, lack of understanding or insight into the medical condition, non-compliance with treatment and not considering their medical problem as seriously as I do.

Also, many of these patients are cognitively impaired as a result of their mental illness, so they may require more reminders, written instructions and sometimes simplified treatment regimens. Patients may be less able to recall the names of their medications and their prior medical history, so my record-keeping must be that much clearer and I more frequently rely on corroborating information from psychiatrists, previous doctors, community workers or family members. In one instance I sent a patient for a series of consultations and investigations only to find out that he had had all the tests done before. In another case, a patient couldn't recall whether she had had a tubal ligation and because she may be sexually active, which was also unclear, I am providing her with a contraception injection until I can obtain the records of her tubal ligation from the hospital where the procedure would have been done.

It's my role as their doctor to try to make medical sense of the symptoms with which patients present. Patients with mental health issues may have particular difficulty interpreting their internal cues, which adds to the challenge of making a diagnosis. They also may be clearly delusional regarding a particular symptom. But the symptom may be based on some physical pathology that can be addressed. I had a patient who complained about the radio implanted in the back of his head that was causing him pain in his ear. When I examined him, I discovered that he had an ear infection that could account for the pain.

I find that it is often futile to confront patients about a fixed delusional belief that they may have. Instead, I may try to show them how my treatment recommendations are still consistent with their beliefs. Recently, I had another patient who had a paranoid delusion that he had been injected with something while he was in hospital and that this accounted for his current gastrointestinal symptoms. He wanted to be tested to find out what had been put into his system. I did feel that blood tests were indicated to help diagnose his condition and he agreed to do the tests in the hopes of finding out what was wrong. The tests didn't find anything, but they were important in ruling out any significant pathology that would require treatment.

In many instances I rely much more on the physical exam and on corroborating information I may get from the commu-nity support worker who accompanies the patient to the clinic. Depending on their level of functioning, some patients attend appointments on their own. But most need reminders from the office or their support workers. Many patients won't attend without their worker, or if they do attend on their own, they may not know why their worker made the appointment. These support workers are also invalu- able in helping the patient adhere to the proposed treatment and following up for additional investigations and appointments.

For some patients, the challenge is getting past their anxiety and paranoia. It is often difficult for them to sit in the exam room with me for even a brief assessment. They may be more comfortable if their support worker accompanies them. Some patients need to take a break from the exam room because of their anxiety, but most come back to complete the exam. During the first visit I always try to check blood pressure. I do this because screening for hypertension is important, but more significantly because it is a relatively non-threatening way to break the ice in establishing a doctor-patient relationship. Recently, a patient expressed reluctance when the lab technician in the office tried to obtain a blood sample. He was concerned that the sample was going to be used to clone him. But after considerable reassurance, he finally agreed to provide the sample.

What supports do you find valuable in dealing effectively with the physical health of people with mental health and addiction issues?
Some medical professionals have the same attitudes as the general public toward people with mental illness. They may assume that someone with a mental health issue who has a physical complaint is delusional, that their symptoms are not real or that they can't be helped. My informal associations with community support services and the psychiatrists at the nearby institutions, such as the Centre for Addiction and Mental Health, have greatly increased my comfort level and ability to deliver care to these patients. Psychiatrists have actually made "house calls" to my office to assess patients who weren't comfortable being seen anywhere but in my office. Recently a psychiatrist referred a patient who was having episodes of shortness of breath that had caused him to go to the emergency department several times without a cause being identified. I found it invaluable to discuss with the psychiatrist the differential diagnoses that included both psychiatric and medical causes for the symptom. I have also found that providing additional information and being accessible to the consultants to whom I refer my patients has enhanced their ability to effectively manage patients. Dentists and surgeons are particularly grateful when I am involved in the management of post-operative pain in patients with addiction issues who may be predisposed to abusing painkillers.

The community support workers that accompany patients to the clinic are an invaluable source of information. And the front-line medical staff, for example, receptionists and lab technicians, are key because their interactions with patients can be equally important in establishing a successful therapeutic relationship.

What gives you the greatest satisfaction in your work?
I find it gratifying when a patient who may initially been very apprehensive about attending what may be their first non-institution-based medical appointment returns for a follow-up visit. Many of these patients have had very unpleasant interactions with the medical profession, for example, being involuntarily admitted or restrained. Or they may have paranoid delusions about the clinic or me. Or, like many patients, they may just be scared to find out what might be wrong with them.

I've found that many patients like to have their own doctor, who they can see on their own and who can deal with the concerns that are important to them. It's rewarding when a patient who was previously disconnected from the medical system is now engaged in an ongoing medical relationship.

In terms of addictions, I have found that helping patients break free of a chaotic and destructive existence can have more of an impact on their lives than anything else I do in medicine. Many of the patients I see have spent much of their adult lives on the street or in jail as a result of their drug habit. Those patients who respond to treatment often go to school, tend to their families and get a job. Being a part of such a dramatic life change is extremely rewarding.

Hema Zbogar