Introduction: A Lexicon of Complex Patients in Psychiatric Practice

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THE COMPLICATED PATIENT

It’s complicated.” When we say this in everyday conversation, we usually mean we don’t want to talk about the subject because we either don’t have the time or we don’t have the inclination to explain to the person asking about it. Not so with our intrepid authors of this Special Report. They were willing and-as you will see-able to respond to our invitation to deploy their unique expertise to write about several different types of complicated patients.

When, as the Chair of this Special Report, I virtually sat down with the editorial staff of Psychiatric Times to brainstorm topics we took a phenomenological approach rather than an analytic one. We used our collective experience to intuit areas of psychiatric practice where complicated patients would likely be encountered without restricting our imaginations or those of our authors with a definition. Let me work backwards here and circumambulate a definition not discursively but descriptively using synonyms.

One of the more basic entries the Oxford English Dictionary gives us is “complex” as in “compound” and the opposite of simple. My favorite thesaurus, Roget’s Words for Intellectuals, lays out a verbal feast for the close cousin, “complex”: anfractuous. Full of windings and intricacies. Convoluted. Complicated; intricate; twisted and coiled. Daedal. Extremely intricate and complex; skillfully made. Inextricable. Incapable of being disentangled or united: hopelessly complex. Involute. Intricate; involved. Tortuous. Winding; full of twists and turns.¹

It is certainly true that none of our articles in this Special Report deal with simple kinds of patients; and all of our authors had to assemble many moving parts for their coherent, comprehensible pieces.

We often make the mental health treatment world convoluted for those patients who are deaf or hard of hearing in ways those without hearing loss often do not appreciate. Fortunately, the article by Kimberly Mathos, DO, MPH, raises our cultural competence in being able to communicate professionally with persons who are deaf or have hearing loss so that we can make a better diagnosis and treatment plan.

Diabetes is a systemic chronic disease, and though as physicians we are well aware of the detrimental effect of diabetes on the heart, kidney, nerves, and eyes, we often forget that it is inextricably bound up with psychiatric symptoms. Awais Aftab, MD, Sidra Qadir, MD, and Muhammad Hasnain Abbas, MD, provide a primer on the management of anxiety disorders in individuals with diabetes.

Finally, these days many of the most exciting new research articles are on pharmacogenetic studies. It may be that my brain is just getting old, but I find these to be very torturous articles. Alessandro Serretti, MD, PhD, and Chiara Fabbri, MD, PhD, untangle two of the most cutting-edge areas in psychiatry: treatment resistance and pharmacogenetics. Their overview of how pharmacogenetics can be a powerful tool to overcome the obstacles of treatment resistance is user-friendly for old and young psychiatrists alike.

These thumbnail sketches of the articles in this Special Report produce an impressionistic sketch of the meaning of the word complicated in psychiatric practice.

A patient can be complicated because of an unusual presentation we were not trained to assess, such as a deaf person. A patient can be complicated for one practitioner and yet not for another: a psychiatrist who has a strong basic science background such as our new Editor-in-Chief probably finds subjects like pharmacogenetics to be easy reads whereas a medical psychiatrist like myself would feel far more able to understand an article about diabetes patients who have anxiety.

Treating a patient may be complicated because of a lack of resources in the community or knowledge of how to access those resources. And last but not least, a patient may be complicated as a result of having too many cooks in the prescribing kitchen who are faced with a multi-symptom patient in an era in which medication management is both our blessing and our curse as clinicians.

We hope these perspectives on different types of complicated patients will improve your ability as practitioners to understand and treat these complex patients in your own practice.

Disclosures:

Dr Geppert is Professor, Department of Psychiatry and Internal Medicine, and Director of Ethics Education, University of New Mexico School of Medicine in Albuquerque, NM; she is also Health Care Ethicist, Ethics Consultation Service, VA National Center for Ethics in Health Care. She is also an Editorial Board Member of Psychiatric Times.

References:

1. Olsen D, Bevilacqua M, Hayes JC. Roget’s Thesaurus of Words for Intellectuals: Synonyms, Antonyms, and Related Terms Every Smart Person Should Know How to Use. Avon, MA: Adams Media; 2011.