Josie is a 29-year-old woman who has a long history of involvement with both the medical and the psychiatric treatment systems. At age 3, she developed recurrent seizures, requiring treatment with anticonvulsant medications. For a number of reasons, including side effects, Josie was taken off of the medication at various times, but the seizures eventually returned.
As early as preschool, Josie was seen as having some difficulties with learning and behavior, though not severe enough to require extreme interventions by the school. She was diagnosed with ADHD and various learning disabilities, but her family was unable to successfully advocate for services on her behalf.
During her early adolescence, Josie became much more disturbed, with paranoid ideas, threats, and aggression. She was hospitalized several times and given diagnoses that included bipolar disorder, schizophrenia, and Asperger's syndrome.
Only at age 18, when she was admitted to a state hospital, was she stabilized on clozapine, an antipsychotic reserved for patients with the most treatment-refractory illnesses due to the risk that it can induce bone marrow failure in about 1 percent of the people who take it. After becoming stable, she was placed in a group home; but she required more structure than they could provide, and she was hospitalized several times over the next few years.
During this period, her family moved to another state, but she remained committed to outpatient treatment in her home state of North Carolina, and could not move with them. Eventually, her family successfully advocated for her to join them in Maryland.
However, unknown to the treatment system in Maryland, her family was unable to obtain adequate treatment for her, and she spiraled downward behaviorally. Eventually, she was arrested for threatening to harm her neighbor, accusing her neighbor of raping her and attacking him with a knife. She was arrested, and eventually found her way to my hospital for a forensic evaluation.
Here are the lessons I learned in reading the hundreds of pages of her medical record:
1. Treatment staff in one setting rarely seek or obtain records from prior treatment providers. Thus, we are unable to modify treatment based on lessons already learned, or to build a coherent plan moving forward along a person's lifetime.
2. Families are often our strongest advocates, but as a rule, they are unaware of how to effectively advocate for their loved one. It is a rare case in which a patient or evaluee has a family member who is, say, a disability attorney, or a forensic psychiatrist.
3. As I have expressed in a prior blog, we have devised a system of care which is fragmented and in which we have a very difficult time serving the needs of individuals like Josie, whose deficits include serious medical problems, developmental and cognitive disabilities, and severe and longstanding mental illness.
What did we do? We spent many hours gathering Josie's prior treatment records, assisted her team in learning from those past treatments to develop an informed treatment plan, and informed the court of her many problems and how those problems impacted on her behaviors.
Josie is still in our hospital. It is my hope that we will be able to use the information gathered not only to provide the best treatment for her, but to leverage services that will meet all of her needs – psychiatric, cognitive and medical.
I anticipate a “battle between the systems,” which were designed with blinders on. I am hopeful that this case will be yet another of those that prove that we need to redesign our systems of care to be person-centered, and not disability or diagnosis focused.
Erik Roskes, a regular blogger for The Crime Report, is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. He welcomes readers comments. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes' employers or consultees, including the Maryland Department of Health and Mental Hygiene. He can be found a http://mysite.verizon.net/eroskes.