The Starving Surfer

He was known by the whole clinic as a tough patient.  He missed appointments, saying he was “busy,” but never explaining with what.

He looked like an obese surfer dude; blond, blue-eyed, always tanned.  He was quiet and polite and said little, very little.  His long-standing diagnosis was schizophrenia.

We knew that he lived with his mom.  She had once monitored his medications, but now she was ill. He did not take well to home visits, so there had been none for a very long time. Most anti psychotic medication makes folks put on weight.  I had seen many obese schizophrenics in many clinics, but his elusive nature made us wonder how sick he really was, what his life was like.  We even wondered if he sold the medicine on the street to make ends meet, as some folks do.

He lumbered in, if irregularly, to get his injection.  He always took it quietly. Mention him at a staff meeting, at least within the last three months during which I had called in to consultant, and every case manager turned their eyes heavenward, groaning.  Everyone agreed, he was frustrating, at the very least. Nothing could be done for him; he wouldn’t listen.  He told contradictory stories about his life. People told me he was a substance abuser –crack, cocaine, pot.  I saw no clinical signs of substance abuse when I visited with this patient.  However, I had only seen him twice, for he did not come to appointments often. “I am a busy guy.  I drive around; I do things.” He couldn’t tell me what.  “For my mother.  Sometimes, I like to be with my girlfriend.”

This was not sounding very schizophrenic.  Evasive, not schizophrenic. He said his mom, with whom he lived, was too frail to do much for him, so he had to do things for himself, including administer his medications. I had nearly despaired of getting him to say the same thing twice myself. My attention was first drawn to him, in a clinic full of unreliable patients with the diagnosis “schizophrenia,” when a doctor of pharmacy, a reviewer from a company hired by the state-run insurance for poor folks, called me. She told me that not only was he taking a large number of medications, but one of them was being given at twice the maximum dosage for which the medication had been approved by the Food and Drug Administration. Of course, I had not been unaware of this.  The patient had told me that any lower dosage left him hearing voices — horrible voices — that told him to harm himself. He seemed tired, listless, and hiding something.  The only way I could maybe figure out what was going on was to talk to him more. I asked him if he would come to visit me once a week if I could see if the clinic could do a better job of helping him figure out what was going on.  He seemed surprised that I cared.

He missed the first few weekly appointments.  I decided to try to get him some general medical care — something he had always avoided. I got case-management help — someone to make sure he went where I wanted him to go.  This was not simple.  I made sure he went to his medical doctor, a caring doctor at a local free clinic. At first I felt bad when I realized I had missed the first clue.

Nurses took vital signs when he came in for an injection.  He was in no pain and had no complaints.  But he had lost weight — about 20 pounds between the last two injections. Injections were one a month. He said the nurses had told him to lose weight, and that they praised him for doing this.  His girlfriend hugged him.  She would sometimes kiss him and that was the best thing in his life.

I got an electrocardiogram (EKG) mainly because I figured if I could show that the high dose of Geodon (arapiperazone) — the price of which the insurance reviewer had questioned — had not produced any EKG changes which could possibly be interpreted as harbingers of harm.  Maybe that kind of evidence would help me convince the state insurance bean counter to keep getting him this dosage of medication that seemed to be his only relief from voices. Besides, if I could get him to increase the amount of food he ate when he took the medication, I could increase the medication in his blood level — and lower the dose and make the bean counter happy.

Such is the public medical system – satisfy the bureaucrats – rather than help the patients. The EKG did not show any changes that were from the medication.  I decided to focus on the food.  I got blood work and it looked pretty normal.

He told me at first that the ate only a bowl of cereal at breakfast, and there was no question of his eating more. I kept seeing him on a weekly basis because I had no idea what was going on.  At each visit, his skin looked grayer, he looked more tired.

He told me he was really worried about his mother. Finally, a light bulb popped on over my head.  I had been looking at medication causes or underlying disease.  The simple and elegant answer was — he could not eat because he had no money to eat.  He admitted first to skipping dinner, since that was the most expensive meal.  Then, some other meals occasionally.  In fact – more and more frequently. He was starving himself to death.

I do not think he had been eating at all, maybe for weeks.  I could not get a straight story about eating habits.  He bowed his head and could not look me in the eyes. What I got was a sad young man who, on the fourth of the month, told me he had paid his mother’s rent for the apartment where they lived, and that the utilities would not be shut off, at least for this month. He pulled some crumpled bills from his pocket — $127 in cash, and told me that was all he had until the end of the month.

There was no money for food. I immediately enlisted some kind of social services assistant to give him a list of local food banks, and we tried to figure out what he was capable of preparing, whether cooking, opening cans or whatever.

We worked hard on how he and his mother could both eat.  The social assistant was charged with the follow-up, but my time at that clinic had come to an end.

I doubt our hungry patient was easy to monitor and maintain. He is proud and change is tough. Fortunately, he was able to see me once a week, because he did not have to pay for that. And he said it always felt good to see me because he knew that I cared and was trying to help.  At least that is what he said. Lack of nutrition can be at the bottom of a lot of problems, and often those problems can appear to be psychiatric as well as medical.

Basically, the starvation had something to do with his problems with recent memory and his avoidance of most appointments.  His “lies” were covering up for the loss of pride and self-esteem. At that clinic there were not usually case presentations in a staff meeting setting.  This is one change I instituted because I thought everybody had to hear about this case.

I made sure that everyone understood that since they had jobs, they all had a normal life expectancy.  The patients they served would live – on average — twenty or thirty years less.  Although chronically mentally ill, they would die of medical causes.  We probably wouldn’t die of the same ailments that killed our patients because we had better monitoring and medical care.

This is the sad truth about psychiatric patients. I told the staff to routinely start to find out who else is starving.  From then on, it was import to ask patients about what they ate and if they had enough food.  If there was any suspicion they did not, the state could provide food stamps when needed. It was the duty of the staff to take care of this.

But to be fair to the staff, it is hard to tell who has too much pride to tell about this. The nurses thought an appropriate screening was asking somebody what they had for breakfast the day before.  However, I pointed out that since I did not remember what I had for breakfast the day before, that probably was not a very good screening. Many psychiatric patients have trouble communication, socializing and relating to people. Too many questions makes anyone, especially a patient feel more like a subject of torture than someone who is a valued member of a clinician-patient relationship. The skilled clinical interview alternates questions with “empathic” statements.  This helps the psychiatric interview sound — and feel — like a “real” conversation between just plain folks. Maybe chatting about how rotten the economy is and how a lot of people could not buy healthy enough food could open a discussion by lowering the pride factor.  After all, many patients at this particular clinic had commented to me on how I seemed to have a steady job and seemed immune from financial worries. I did ask the nursing staff to focus on getting vitamins for the patients, something not usually paid for by medical insurances.  However, the same companies that made prescription drugs and sent representatives to the clinic  often manufactured vitamins, and could perhaps be persuaded to offer vitamins for the indigent. What a concept – let’s manipulate the pharmaceutical companies for once.

After I presented the case of the starving surfer, one doctor told me about a patient who lived on dog food.  I have many patients who buy “bombs,” big cheap burrito available at a major chain of convenience stores.  You can imagine, these are low on nutrition, even if filling in the short term.  I’ve even heard of those who will fry the left-over portions in whatever oil they can get.  That might be the entire food for one day. Clinical signs of vitamin deficiencies abound in the population I see now.  I generally tell patients that any kind of vitamins they can buy would be helpful, but I do not think they spend their money on this sort of thing. Neurotransmitters, the molecules that transmit messages in the brain and nervous system, are basically made out of amino acids, which are in protein, and protein (fish, poultry, red meat, soy) is usually more expensive than carbohydrates (bread, pasta, rice, potatoes).

Maybe the patient who eats dog food gets some meat.

In the past few weeks, I have learned of two publications, one French and one British, both of which suggest that diets with an excess of processed foods promote depression, while a diet rich in fish and vegetables seems to prevent depression.

Nobody seems to want to write or research much about starvation; perhaps, because it is hard to imagine how it could be done in an appropriately humane manner.

There is a little more about malnutrition.  Most research involves very young animals and how their brains develop poorly.  There is some suggestion that the problem is increasing among older people.

It seems politically correct to speak of developing countries, which often have these problems. It does not seem politically correct to say this is happening in the United States. I am not surprised that neither of the recent studies on diet and depression was done in pharmaceutical-dominated American research. I do not think that people who prescribe antidepressants regularly gave a lot of time to check out research.  I do not think they know a great deal about what they are doing. Sometimes, I become angry about these things. One thing I can do about hunger is to write — as I am doing here – and speak out, as I do in public appearances throughout the nation.

Resources exist in all communities, I do believe, since this is a ubiquitous problem. Luckily good people who solve problems are ubiquitous, too. The most important step is to cultivate communication with the potential victims of starvation.

The more you can gain the confidence of a fellow human being, the more likely that human being is to share the truth about their problems and to give you — whether you are a clinican, clergy or someone else who interacts with and tries to help other people — the pleasure of helping another human being.