The Q&A below is transcribed from a phone interview with Dr. Alison Swigart, psychiatrist on the Intensive Treatment Unit at Butler Hospital, for Honest Conversations.
What do you do at Butler Hospital?
When I was in medical training I really enjoyed working with patients with severe mental illness, who were more ill than our average patient. So when I joined the staff in 2013, I took the opportunity to become part of the intensive treatment unit.
We treat a variety of different types of illnesses, but the main focus of our work is on people who have severe and persistent mental illness. We primarily work with people who have diagnoses of schizophrenia, schizoaffective disorder, bipolar disorder, and major depression as well as severe personality disorders. We also do sometimes work with adults who have serious developmental disabilities and associated behavioral problems such as aggression, or self-injury. I work as part of a multi disciplinary team including social workers, nurses, activity therapist, occupational therapists, and mental health workers to do a complete evaluation of people who are admitted to our unit and start a course of treatment that is often then continued in the outpatient setting.
What drew you to work with severe mental illness?
When I did my psychiatry rotation in medical school, I rotated at a state hospital in New York where I saw people who had very severe and chronic psychotic illnesses. I think I was really drawn to those people because they’re vulnerable in so many ways and if you can just imagine yourself in their shoes, the world suddenly seems like a very terrifying place. So I think I was drawn to that because I wanted to help make the world seem less scary to these people. And the other reason is that, I think it’s an area where psychiatric treatment can really make a huge difference, both in the short-term, in terms of days or weeks, but also in the long-term, potentially impacting the trajectory of a person’s whole life.
Can you define schizophrenia, personality disorders, and bipolar disorders, in a way so that the average person would understand what’s happening?
The interesting thing about these illnesses is that I use different terms when referring to them, depending on who I’m speaking with. I usually use one term when speaking with a fellow medical provider, but different terms when speaking with a family member or with a patient.
For many patients with these types of disorders, part of their illness is a lack of awareness of their illness. So with patients, I try to use terminology or the descriptive terms that the patient themselves use. For example, someone with schizophrenia that has paranoia might say they have anxiety or fear, and so it’s often not really useful to try to force that person to accept a diagnostic label of paranoia because it’s something that they’re not really going to identify with. So I try to use whatever terms they use.
In terms of defining these illnesses for a family member, I would define schizophrenia, for example, as a neuro-developmental disorder: so it really is a disorder of the brain that we think starts before people are born. I explain that it takes some time for the symptoms to show themselves, which usually is in later adolescence or early adulthood. It’s a disorder where people typically have a break from reality where they often exhibit delusions and hallucinatory experiences—like hearing voices, or seeing things that other people can’t. I think that the piece that many people are unaware of is that in addition to those sort of glaring psychotic symptoms, these people have significant cognitive problems. So they’re simultaneously experiencing problems with their ability to think, with their memory, and with their ability to plan and organize. This makes it very difficult for them to function in the same way that someone without this illness does. And those tend to be fairly persistent symptoms.
Is there a test for predisposition to schizophrenia?
There is not a definitive test at this point in time. We know that there’s a significant genetic risk component, so if you have a first degree relative, meaning a parent, or a sibling with schizophrenia, your risk is increased about ten fold. Still, there are certainly plenty of people whose parents or brothers or sisters have schizophrenia yet they themselves do not ever develop it. We think that most likely you’re born with a significant genetic predisposition to having it, then through a series of events or environmental influences that are not understood, that predisposition in the brain is sort of activated and you develop psychotic symptoms. It could be from traumatic experiences, or substance abuse, for example.
How is bipolar disorder different?
Bipolar disorder is what we call a mood disorder, and includes periods of depression, where people have a very low mood, low energy, often difficulties with sleep and motivation, and they have thoughts of suicide; alternating with periods of what we call mania, which is a period of days to weeks of an abnormally elevated mood with abnormally high energy. People sometimes describe mania as being driven by a motor. They don’t need very much sleep, and often engage in risky or impulsive behaviors that they wouldn’t normally do.
How do you define personality disorder?
That’s probably the most complicated to explain. Personality disorders are a group of illnesses where people have persistent difficulty managing their emotional states, forming and maintaining interpersonal relationships, and functioning in terms of maintaining their abilities as a student or in a job. It’s really a disordered way of how people view themselves and their identity, and how they view the world and other people. There’s a wide range of personality disorders. Many people who have a personality disorder seem to have more difficulty regulating their emotions than other people. Perhaps they haven’t learned that as a child, and that leads them to have unstable personal relationships, and view the world as menacing or unfair, or somehow against them.
How do you treat chronic psychiatric illnesses?
Typically the gold standard for treatment is a combination of medication and therapy, though each individual’s treatment is tailored to their needs. The focus of treatment in the hospital setting is usually getting people stabilized on an effective medicine so that they can be safe enough to be discharged and be back in the community and engage more in outpatient services, where the focus is on both medication and therapy. We do offer group therapy on the unit, but there isn’t really intensive individual therapy. We’re primarily focused on getting people started on the right regimen of medicines that helps get the severe symptoms of their illness under control and helps get them to a point where they’re safe to leave the hospital.
How do those medicines work and how do you see them affecting the person?
We have many different categories of medicines, depending on the type of illness that we’re treating. Many of our medications and treatments are useful for different diagnoses. As an example, an anti-psychotic medicine may be effective not only for schizophrenia but also for bipolar disorder, major depression, and anxiety. A lot of these medicines have been studied across a range of diagnoses. Most psychiatric medicines do take up to three months for the full effect of the medication to be seen. So unfortunately we don’t often get to see the full effect of the medicine but we may start to see effects within about a week if the medicine is going to work.
What’s the greatest cause of relapse?
I would say, among the population that I treat, the biggest relapse has to do with the lack of insight into having an illness. People might accept medicine in the hospital setting because they know it’s a way to get out of the hospital. But once they leave, and they don’t have a nurse bringing them their medicine everyday and the doctor educating them everyday, and reminding them of the need to take the medicine, I think many of them don’t believe that they need it.Not necessarily that they think they’re better, but that they might think that there was nothing wrong with them to begin with. And then I think there’s a whole bunch of other factors that intervene, and that are often hard to predict, like, how much does the medicine cost? Does their insurance cover it? Does it require a prior authorization? Will they make it to an appointment with an outpatient provider who can continue the prescription for the medicine? Do they have transportation to the pharmacy to pick up the medicine? The infrastructure and support can really influence the trajectory of a patient’s success after discharge.
Do you think we need more support systems for this population of patients?
In my opinion the goal should be to treat people for mental illness and have them live in the least restrictive setting that they can. For most people that’s being in the community. But I think there’s definitely a subset of patients with severe mental illness who don’t respond completely to treatment with medicine or don’t comply with treatment because they don’t think they have a problem. These people are not able to function on their own in the community and many of them have burned bridges with family, so they have very few supports and often little financial means. I think we have seen, even over the seven years that I’ve been here as a psychiatrist in Rhode Island, that the safety net in the community has been defunded, and it’s making it more difficult for those people with severe mental illness to live successfully in a community. We do have patients who we are attempting to get into group home facilities, and the number of beds have been cut so much that those people can be stable and ready for discharge from the hospital, but there’s no place for them to go and they have to wait three, four, six months.
In the time you’ve been in psychiatry, how have things changed for the better?
I think stigma around treatment for mental illness has been reduced over the last ten years or so; it’s more acceptable for people to seek out treatment and to talk more openly about seeking out treatment.