“Climbing up the tower, just a boy, and his computer…”  Weezer’s “Feels Like Summer”

A 50-year-old white male presented for a check on his new glasses, complaining that they just didn’t work. There was a cylinder change of a half diopter on each eye. The doctor put the new Rx in the phoropter, and said, “Let’s start here, and remeasure.” As the phoropter was put into place, the patient slid off the chair and assumed the fetal position on the floor. He offered the explanation as “THAT is what the new glasses do to me.”

If you are thinking that a bizarre behavior might be simply an isolated episode, don’t. 

Experience tells us that bizarre behaviors are more likely to be part of a pattern. You can do a patient the greatest favor by making this observation and acting accordingly. Our patient above has an affective disorder, and is likely to be a difficult character in Sears, Applebee’s, and just about everywhere else. While the retail environment is not the place to produce a mental health referral, the compassionate optometric practice should be.

Here are some thoughts on how I decide to ask for the mental health consult:

*Psychotic ideations get an automatic referral. Loss of touch with reality indicates that they go “out” without question.

*Violence, either a suggestion or action is also an automatic criterion. This includes potential suicide and potential harm to others. Suicide rates seem to be on the rise (Footnote 1), so our actions can be timely if not critical.

*Quality of life issues, as they pertain to depression, anxiety, mania, and other neuroses should get strong consideration.

*Evidence of drug abuse, including alcohol and marijuana, should be referred automatically.  It’s beyond our scope to define abuse here, but a patient who appears under the influence is showing inappropriate behavior and needs help.

This topic has increased importance as suicide rates are on the rise and we seek better integration in the health care system. Our sensitivity to mental health, in general, could have an impact, and we can’t count on government requirements to steer us in the right direction. Talk about “meaningful use!” Wouldn’t it be interesting if this could be achieved by having the patient do a basic questionnaire on mental health? Compare this to our ability to “opt out” on some of the requirements by performing a questionnaire screening on CERVICAL CANCER, which we did!

Should we have a required course on this? I am torn on the idea. Education never hurts, but our curricula are so overwhelmed with new technologies and expansion of scope that we may reach critical mass at some point. Using the guidelines above, I feel like I can screen patients informally and provide the wonderful service of referring for a mental health evaluation. I’ll make the argument that mental health issues are difficult to define, but I’ll know them when I see them. 

The identification is virtually intuitive, but it’s that action that presents the challenge.

My own approach is a simple one. When I am about to confront a patient with a mental health issue, I take a deep breath, face him or her directly, and fold my hands on my lap.  I’ll say, “I am concerned about XYZ behavior that you have shown. Have you talked this over with your family, friends, or trusted family doctor? Have you tried to do anything about it? If not, would you mind if I shared my concerns with your doctor?” Unless the patient is totally psychotic, I’ve never had trouble with this approach.

Do I make a direct referral to a mental health professional?

I do not unless there is a clear psychiatric emergency. (These are best handled by the local EMS.) Put the patient in touch with a trusted family doctor, who may have better insight into the history and best professional to consult. It is better to maintain the “team” approach that the family doctor has assembled, especially in mental health cases.

Follow-up is difficult, as mental health issues have a stigma attached, and I wonder if compliance for treatment is low. Further, the mental health problem itself may make it difficult for the patient to comply. Our best effort can make a huge difference in the patient’s well-being and shows caring for the patient as a whole person. Isn’t this value at the core of what we do?