A unity of opposites: A prototypical case for the importance of primary-care providers in addressing mental health issues.

Primary-care providers are most often the first point of contact for patients presenting with mental illness. Highly stigmatized and with a litany of other medical issues requiring redress by providers, it may receive inadequate attention, despite its unintuitive consequences. Therefore, the purpose of this case is to demonstrate the potential catastrophic consequences of untreated mental illness by providers. As a result of a serious suicide attempt by a patient afflicted with bipolar disorder, this patient presented with significant blood loss secondary to multiple self-inflicted lacerations to the wrist, parasternal stab wounds, and a resultant hemopneumothorax. By juxtaposing this patient's mental illness with his other traditionally "more" concerning medical history (i.e., multiple myeloma, Factor V Leiden, and recurrent DVTs), we are forced to reexamine where mental illness resides in the hierarchy of treatment. Copyright:

Introduction

Mental illness can be debilitating, bearing with it, unintuitive long-term consequences. Associated with a high lifetime prevalence and a greatly reduced life expectancy (10.1 years),[1] mental illness is indiscriminate in who it affects, and it poses a significant threat to our patients.

Serving as critical pillars in the health-care network, primary-care providers (PCPs) are often the first point of contact for patients with mental health needs.[2] Unfortunately, mental illness is often underestimated and underprioritized by PCPs.[34] This case illustrates the potential deleterious consequences of unaddressed mental illness and the need for greater attention and priority by PCPs.

Case History

A 57-year-old Caucasian male with multiple myeloma, Factor V Leiden, recurring DVTs, bipolar disorder (Type 1), and a history of previous suicide attempts presented to the ED with self-inflicted lacerations to the wrist and stab wounds to the chest after being found by his wife in the bathtub upon returning home from work. Patient is a mental health provider who, due to medication side effects, decided to taper his medications in an effort to see if he could do well with fewer to no medications. This taper was done over the course of 1.5 years and without the knowledge of his PCP. The PCP agreed to manage the patient's psychiatric care over the years as the patient had not yet established care with a psychiatrist yet.

After tapering off his medications, the patient became manic, then depressed, and later sought electroconvulsive therapy (ECT). He had received a total of nine rounds of ECT over the course of a month and his last treatment was the day before his suicide attempt.

On arrival to the emergency department he was found to have a low blood pressure of 60/40, a heart rate of 60, respiratory rate of 24, and a temperature of 96°F. His depressed blood pressure and low heart rate were compounded by his appropriately prescribed propranolol and apixaban to treat his lithium induced tremor and recurrent blood clots, respectively. Review of systems was limited due to the patient's condition (hypovolemic shock with decreased brain perfusion). The patient appeared pale and diaphoretic. Breath sounds were reduced on the left, secondary to the hemopneumothorax. Multiple parasternal stab wounds were found on the chest with lacerations to left medial and lateral wrist. A chest tube and central venous catheter were placed and the patient was given two units of blood and fresh frozen plasma, respectively, and one L of normal saline. He was then transferred by aircraft to a level one trauma center for emergency surgical evaluation and chest tube management where he underwent surgery 12 h later.

After medical and psychiatric stabilization, the patient was then discharged 2 weeks later with appropriate aftercare arranged. The patient has yet to make a full psychiatric recovery, primarily due to persistent cognitive impairment from ECT.

Speaking with the patient postrecovery, the suicide attempt was precipitated by the ECT-induced cognitive impairment which caused severe distress. He expressed living with mental illness made it challenging to acknowledge his own need for treatment, even in spite of his professional background. Unfortunately, he reports continued anxiety over subsequent mood episodes and fears for his life. Consequently, the patient now exhibits avoidance behavior in an attempt to circumvent triggering his mental illness. Such behavior includes postponing elective surgeries. He firmly believes his mental illness poses a far greater threat to his life and health than his other medical conditions, including his cancer.

Discussion

Every year nearly 800,000 deaths worldwide are a result of suicide, an act with a well-recognized association with mental illness, and an issue afflicting mostly low- and middle-income countries.[5] Unfortunately, mental illness is among the most neglected of health issues.[4] Despite this, it has the potential to be a greater threat to health than traditionally “more” concerning conditions (i.e., multiple myeloma, Factor V Leiden, etc.), as seen objectively by this patient's presentation and subjectively as reported by the patient.

PCPs are often the first point of contact for patients, putting them into a pivotal position to address mental illness in their community. This is attributed to the closer relationship patients may have with their PCP,[2] ease of access, and the stigma associated with seeing a psychiatrist.[6] Therefore, the PCP plays a crucial role in breaking barriers to initial treatment but also in facilitating treatment by mental health experts for the more complex cases.[4]

With limited time for PCPs and numerous health issues to address,[6] delays in diagnoses are frequent.[7] Such delays can ultimately contribute to the development of various psychiatric and physical comorbidities, adoption of maladaptive behaviors, or even suicide.[8] As a result, it can be difficult to prioritize the needs of patients. However, given the significant mortality and morbidity associated with its neglect,[6] this case forces PCPs to reexamine where mental illness lies in their hierarchy of treatment.

Therefore, providers should not assume a patient's mental well-being or treatment adherence, irrespective of patient profession. Given the stigma of mental illness in the medical community,[9] it may be even more prudent to explore the mental health of one's colleagues.

Treating mental illness is foundational to the overall well-being of our patients. It can extend their life expectancy, improve their quality of life, and is integral to reducing the global disease burden.[1] The effect of suicide on families and communities is far reaching and good mental health is foundational to a healthy society. Afflicted by several very serious yet dichotomous medical conditions (mental vs. physical), this case offers a unique contrast between treating medical concerns and underprioritizing the treatment of mental illness. With its health-care consequences illustrated, untreated mental illness has the potential to be the most dangerous threat to a patient's health. Therefore, this knowledge should always command the attention of the PCP when presented with a patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.