I saw a patient today that I can't seem to shake from my mind. He is a 25 year old African American male who is homeless on the Sacramento streets. He was clean shaven, wearing new jeans, a clean sweatshirt and clean shoes. He was polite and well-spoken and had intelligent eyes. He told the intake people that he came to clinic for his "diabetes". When I and another medical student began to talk to him, he clarified that he wanted his blood sugar checked because he was afraid of getting diabetes. He had never been diagnosed, had never had his blood sugar checked and did not have a history of diabetes in his family. He had no history of health problems except for depression, which he said he had been treated for. I asked him how he ended up on the streets. He said that he used to live with his parents but now that he was 25, it was time for him to leave. He said: " You know, I was 25. It's not like I could live there forever. I can understand that."
As he said this, I felt like we had been walking with him through an empty narrow hallway and he had suddenly brought us to a door and told us to look through a small keyhole in it. Inside, it was too bright to see anything, but you could tell that there was an entire world behind that door, if we just had the patience and compassion to open it. I think this is a position doctors encounter every day. I know I have already encountered it many times and have let the moment pass because a 15 minute visit does not allow you to explore the ghosts of someone's life. But this was a Saturday and we were learning, and this man didn't quite fit into this homeless setting: he was educated and from a loving home - yet he had been lost to the world of the unlucky, sick and abused.
I asked him what he did for money and he said he did "service jobs." Do you use any drugs? "No, I stay away from those. They can really mess with your head. You know, I have to keep my focus, stay in focus, I keep things centered. That's what I'm workign on right now. I just got to keep my mind in that one place. Like in Peter Pan, that 'happy place', you know. Because you need to keep your focus and keep center and keep your mind calm and when things don't they just don't work then the center needs to be kept. And it really needs to be something I do and that's what I'm doing right now..." He kept going for a while, talking in this diverging, hard to follow thought pattern, occasionally switching to passive tense and looking away from us and then back again, trying to summarize and make a point, but not really getting anywhere. For the first few seconds, when his eyes lost focus, I though he may be on a heroin high, but his focus came right back and he looked straight at us, over and over, as his mind grasped to make a point. This was the first time he had show any sign of mental illness since we had met him. Before that, he could have been any guy you talked to at the store or a social gathering. As he talked, our minds were spinning. So this is pure, unromantacised schizophrenia, I thought. I saw the other medical student's body language change; he had had the same thought.
"Sounds like you have a pretty good system for keeping your mind in check," I told our patient, trying not to blatantly interrupt him, " So what happens when it doesn't work for you?"
"What do you mean, it doesn't work?" He asked, soberly back from his diversion.
"Well, do you ever feel like sometimes you head says one thing and then the next moment it says something different and then you're not quite sure what's going on?"
"Oh, yeah", he kind of laughed, "that happens a lot. That's why I have that happy space".
"Has anyone ever tried to help you with that?"
"Yeah, my family says I have all sorts of things -depression, schizophrenia, biopolar- and they tried to get for me. I was in a program once an they gave me pills, but they made me sleep 8 hours a day and I just couldn't do that. I had to stop."
We talked with him for a few more minutes and his story just spilled out. For years, his family has been trying to get him help. When the medication was making him sleepy, they took him back to county health care system but the doctors wouldn't give him a different drug. The mental health treatment was costing him $20 a month and he said that he quit once he couldn't afford it anymore. And it was only making him feel worst, he said. His family then tried to get him to qualify for disability so that he could get insurance for his mental health treatments. He said he went through a long enrollment process, but eventually failed the tests that would prove he had schizophrenia. Having not suspected mental illness when we were first talking to him and seeing his moments of clarity, I am not surprised. If indeed he has bipolar disorder on top of his schizo, he may be quite capable of pulling things together long enough to take the test. He then tried enrolling in programs in another state, and they wouldn't take him either. After awhile, he ended up on the streets.
We talked to him about bipolar disorder and schizophrenia because he wasn't really sure about what those diagnoses meant. With bipolar disorder, you can have these moments of delusion and gradiosity, where you feel you can do anything. When they pass, you feel horrible and you feel like you don't deserve the people and things you have in life. "Oh man," he said, "I definitely get that!" I know you feel like you may be able to control it, I added, but the problem with these illnesses is that the longer you have them, the more your brain gets used to acting like that. It will start to do it more frequently and more intensely, and you may not feel like you can control it after a while. The only thing that can really help that is medication, but you need someone who will know what to give you and see if it is helping.
We referred him to a new program through the county. A volunteer counselor who used to be homeless and mentally ill will get in touch with him and try to get him reenrolled in the county program. Hopefully, someone will make more effort in providing him care this time.
There has been a lot in the news lately about schizophrenia because of the mother who tossed her babies into San Francisco Bay. I find it really sad that people and the media have the time and energy to lament such a tragedy but do not have the heart and compassion to fund programs for the mentally ill. One in a hundred people have schizophrenia. That means that in your office building or classroom, for every 99 people there, there is one person missing and very likely, on the streets. There are also millions suffering from bipolar disorder and crippling depression. The numbers are appalling. It is a critical, but invisible, mass of illness. Much greater than the number of people dying from AIDS or diagnosed with skin cancer every year. It can affect anyone's child, sibiling or parent, tear a family apart, and send people on the fast tract to poverty and crime. And it's mostly treatable. If only we were willing to pay for it.
As I left the clinic, it was still morning, and some of the Sacramento central valley mist was still in the streets. I pulled out of the parking lot onto the street. There were no cars - this is the empty wherehouse district - but in every direction I saw dozens, maybe even hundreds of the city's homeless pushing their carts and carrying their large bags, trying to live another day with the cards they were dealt.
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