How one word may have harmed my patient [PODCAST]

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“With this single word, mom had now completely altered her willingness to see the deep suffering of her child. This single word watered all of this child’s five years of depression, crippling anxiety, history full of ACEs, and very significant struggle down to a simple, selfish, flippant choice.

Furthermore, mom said that the nursing staff asked her about the medications. Mom informed me that: ‘The nurse said maybe it’s the Wellbutrin making her this way. Maybe she is suicidal because of this?’ If the team had spent five minutes doing a real assessment of suicidal thinking, they would have learned her suicidal thoughts started years prior to her being on medications and have actually decreased in frequency since starting these meds in the hospital.

I could see in mom’s eyes. She now did not trust me when I spoke about the importance and urgency of treatment. Her child was now an inconvenience, my medication recommendations could be damaging, and our work together was now a waste of their time. Mom declined my recommendation to titrate up meds because of her concern about them now brought on by the nurse.”

Shivana Naidoo is a child psychiatrist.

She shares her story and discusses her KevinMD article, “How one word may have harmed my patient.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Shivana Naidoo. She is a child psychiatrist, and she wrote the KevinMD article “How one word may have harmed my patient.” Shivana, welcome to the show.

Shivana Naidoo: Thank you so much, Kevin.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Shivana Naidoo: I’ve wanted to be a doctor for as long as I can remember. When I was 14, my dad died of cancer, and that made me want to become a doctor even more, not to do oncology, actually, but to do palliative care, because I felt like the way he died and passed in the hospital could have been better. That really pushed me to pursue medicine even more.

But in third year, you explore everything, right? So I explored psychiatry as a third-year medical student. I was on call with a resident, and there was this six-year-old child who had been really aggressive. She had been fighting, and we were called to do a consult on her. So as a lowly med student, I had to go talk to the six-year-old. I sat in the room with her, and you could see in her eyes that she had just been through a lifetime of trauma. You could see that she was yellow and green and fiery and hurt.

When I went into the room with her, I didn’t know what to say. I didn’t know how to talk to her, and I didn’t know how to engage her. So we just sat in silence and looked at each other. What was interesting is that in those 10-15 minutes, which felt like an eternity, I could feel her anger, I could feel her pain, and I could feel this defiance, this courage, and this audacity to just live. I left the room feeling like a failure because I didn’t do much, but I also left with a conviction that this is what I needed to do. I needed to go into this field of medicine to reach these kids, to help these kids, to empower these kids, and to give them a voice.

So then I pursued child psychiatry, and I’ve been doing it for about the past five years, living the dream in outpatient child and adult psychiatry. Now I work at an exclusively outpatient child psychiatry nonprofit, where I have tons of support. I have case management and therapists, and it’s really a utopian place because I have everything at my fingertips to help kids. And yet I still feel really limited, and I feel like I have not been doing as much as I could do to really help kids.

So that has really helped force me to expand myself even further. I have become a life coach, and I am signing up to do integrative psychiatry to further subspecialize. I wrote this article for KevinMD, and I also started a podcast called Thinking It Through with Dr. Naidoo, Child Psychiatrist, which is really to provide education and information for parents and for young people going through their own mental health crises, to really give them the tools to think through how to get their best mental health care. So that’s where I’m at.

Kevin Pho: So tell me some of the typical cases that you see on a daily basis. Without getting into too much detail, what are some common scenarios that you find yourself in?

Shivana Naidoo: Because I work at a nonprofit, there’s a certain type of patient that will come to me. They tend to have lots of socioeconomic challenges and lots of ACEs, the adverse childhood experiences, so lots of trauma, but also very typical ADHD, concerns for bipolar, concerns for mood disorder, and oppositional defiant traits. But my type of patient now, because they’ve had so much trauma, is really kind of delving into how physical trauma, neglect, and sexual trauma may come out looking like ADHD or ODD, these labels that we put on kids, when really the root is some kind of trauma or neglect. But I also get a fair share of bread-and-butter anxiety and depression as well.

Kevin Pho: And of course, we’re in the midst of another wave of the pandemic, right? So can you comment on how the last couple of years have affected some of the cases that you’ve seen?

Shivana Naidoo: What’s interesting is that I think the pandemic has really hit hard those of us who are performing at or above level, those of us who are used to performing well in how society typically functions. I think my population of kids, who have always been challenged, have actually done kind of well with the pandemic. My OCD kids have had it confirmed that the world is scary. My anxious kids don’t have to go outside and go to school. The kids I’ve seen come in have been the higher-functioning kids, where taking away the social interaction has really reduced their coping strategies.

But I think that the level of uncertainty that’s come about now, the misinformation and the confusing information from the medical community and the media, has really provoked a lot of fear in a lot of people across the board about what to know, what to expect, and who to trust. I think that shakes the grounding and foundation of security that a lot of kids have. There’s been a lot of economic instability for parents, and there have been a lot of changes in routine, which for kids on the spectrum has been really challenging. So it’s strained us all, I think, in and outside of the mental health care system. We’re still going through it. There will be PCSD, post-COVID stress disorder, I think.

Kevin Pho: All right, let’s transition into the KevinMD article and the story that you shared. It’s titled “How one word may have harmed my patient.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Shivana Naidoo: Sure. As an outpatient psychiatrist, I see kids who come out of the inpatient medical hospital, the inpatient mental health hospital, and ERs. Throughout my career, I’ve seen kids this way. We intersect with kids who have been in the medical ER, received some kind of treatment, and come back to outpatient care.

In this particular situation, I had a 14-year-old whom I worked very hard with, who came out of inpatient psychiatry. She had made a suicide attempt. I tried to help build an alliance with her, and I referred her for therapy. Then, after a couple of visits with her working hard on this, she had another attempt. She ended up back in the ER, and within a couple of hours she was at my virtual visit.

When mom talked about the ER experience, of course, most parents have a tough time with bringing their kid to a medical ER or inpatient psych, but the parent was very frustrated with me because of the information that was shared in the ER. Namely, someone in the ER said that the patient’s suicide attempt was behavioral. That term “behavioral” really shifted my parent’s and patient’s understanding of her suicide attempt, and that created a lot of challenges for me. This patient was actually lost to follow-up; she has not come back to me. I think it really crystallized how valuable words are and how powerful we as medical professionals are in terms of the weight of our words and how they affect people. I just really wanted to share the story of how we need to be mindful of what that is.

I have so much respect for ER doctors and ER staff. They have worked so hard, it’s been such a tough year, and they get everything. And I know from working as a consult psychiatrist that psych patients are not the favorite of the ER, right? We know that they’re pretty difficult and challenging, and I know that sometimes when my patients walk in the door, there is some eye-rolling, right? There’s some frustration because they’re going to be a challenge. But I really wanted to express that I have that empathy for ER staff.

But I think especially with suicide, and knowing that there’s been an increased rise in suicide attempts in young people, it’s the number two cause of death in ages 0-35. And we know that really the greatest predictor for completed suicide is a suicide attempt, whether that is downing a bottle of Tylenol or scratching yourself with a paper clip. Any of those attempts count as a precursor for a completed suicide, so we have to take all of that seriously.

In the article, I said that there used to be something called pseudo-seizures, where young people would have seizure-like activity, and we’d find out it was actually linked to a psychological underpinning versus being epileptiform. We renamed that in the DSM as functional neurological symptom disorder. And I think when we have people come in with suicide attempts that seem not as great or serious, we’ve now started using the term “behavioral” in the same way, but it really is not. I think that if we just call suicidal behavior suicidal behavior, whether or not it’s severe, it would be much more powerful for that young person, the parent, and the family, to underscore the significance of this attempt and to continue to take it seriously and work with outpatient mental health care. So that was basically the impetus for the article.

Kevin Pho: So if this scenario were to replay itself again, what should the emergency room staff have done? What would have been an ideal way to handle that situation?

Shivana Naidoo: There are so many people working in the ER, right? There are so many levels of education and training, and of course it depends on what time of your shift it is, right, whether you start your shift or end your shift with a patient like this. But I think it’s just being consistent in calling suicidal behavior suicidal behavior.

In the article, I also touch upon the fact that someone had told the parent that a medication I prescribed could have provoked suicidal thoughts, which is possible. But I think it’s raising it as a question versus “This is what I think is going on,” because you don’t really know what’s going on, right? You see a snippet of what’s happening in the story of this person’s life. We can’t really theorize about what’s happening throughout their whole life. So I think just being compassionate and underscoring the significance and importance of a suicide attempt as suicidal behavior, not “behavioral,” would have been helpful. And reaffirming to the mom and the patient how significant this is, and to continue to get mental health care, would have been important.

But what’s challenging is that what we say may not mean what they hear. It could have been that the doctors and staff there did all the things I’m saying, and the parents just latched on to that word “behavioral,” which is why I think we have to be mindful of the words we use, because we don’t know which one is going to catch their ear, which one they’re going to latch onto, and which one will effectively change the behavior.

Kevin Pho: So tell me, in the immediate aftermath, what did you try to do to remedy the situation? And did you have any follow-up with the ER staff to further discuss this?

Shivana Naidoo: Oh, wow. The collaboration between different organizations is so challenging. When I get patients from inpatient psych, it’s very hard to have a doc-to-doc, and the same is true with the ER because the shifts are constantly changing. So no, I did not have a discussion with the ER docs, but maybe the KevinMD article will reach some ER staff and inspire them to think about this.

But I did talk to the parent, of course, and the patient, and I had two follow-up visits with them before they were lost to follow-up, where I tried to problem-solve. In the article, I say that everything we do is behavioral, but that means that everything we do has a reason and everything we do has a purpose, and we want to make sure we understand what that purpose is and take it seriously. Our goal really is to effectively change her behavior and her choices and empower her to make better choices versus reaching for the Tylenol bottle. But that takes time, and that takes work, trust, and an ongoing relationship, and “I’m here for you if you need me.”

I also told the parents that they did the right thing to go to the ER. She made a suicide attempt. There are times to go to the ER and there are times not to go to the ER, especially for psych, because our ERs are as stressed and stretched as they are, and not all psych needs to go there if you have established psychiatric care. That’s something I address in my podcast, in one of the episodes, called “Connecting to Care.”

So it’s about knowing when to utilize these resources. Across the country, there are different teams called mobile crisis teams. Instead of going to the ER if you have a psychiatric crisis, you can look up your county’s mobile crisis team number online and call them, and they will send a team to your home to do an assessment to determine whether you really need to go to the psych ER or not. Now, in the case of an overdose, you should go to the ER regardless. But there are many other subtle situations where you may be thinking of bringing your child to the ER, and we know what happens in the ER. You wait and you wait, you may not get a bed, and you may not be appropriate for admission. It may be helpful to call these other teams and support systems to really do another triage and sort out whether you need to take that extra step of going to the medical ER.

Kevin Pho: We’re talking to Shivana Naidoo. She is a child psychiatrist, and she wrote the KevinMD article “How one word may have harmed my patient.” Shivana, we have a lot of general pediatricians and primary care physicians who listen to this podcast. From your perspective as a child and adult psychiatrist, are there any messages you want to share with your primary care colleagues, any tips and advice on what they could do better to treat some of the cases that you see in a primary care setting?

Shivana Naidoo: My hats are really off to the pediatricians and primary care physicians. All of my good friends were in family medicine, and they do 75 percent psych. I mean, depression is one of the number one causes of disability in this country, so primary care sees the bulk of psychiatry: depression and anxiety, bread-and-butter anxiety and depression.

What I would say is that we know that we have to keep following these patients, and we know that they don’t always really want the help, right? They don’t want to come to me as a psychiatrist; they want to come to you as their primary care doctor, who knows them and trusts them. So we value your assessment, and I value it when you think it is beyond your scope and when it’s not. I think a lot of the pediatricians and primary care physicians are really doing their best and doing a stellar job with starting SSRIs and referring for therapy, but we know it takes time. And for your patients who have comorbidities, diabetes, high blood pressure, cancer, and all sorts of chronic medical conditions, we know that depression can compound their ability to heal from these chronic medical conditions. So continuing to remind your patients to reach out to us for help would be wonderful.

The other thing I would consider is that we know that every medication has side effects, and especially in young people under the age of 25, SSRIs have that black box warning, right? They can upregulate some suicidal thinking, not necessarily behavior and action, but thinking. So ask those questions and be on top of that. If they are started on an SSRI and they have the symptom of irritability, anger in particular, that is really a red flag to get them to see a psychiatrist ASAP, or reduce the medication and talk to a colleague who’s a psychiatrist if you can’t get them in. Irritability can really be a big warning sign for action of all sorts, self-harm and aggression, and it really can be an adverse reaction to SSRIs, what we call SSRI activation, or even an unmasking of bipolar. So watch for the symptom of irritability, as well as suicidal thinking, ideation, intention, and plan.

I had a supervisor in residency who would say, “You can bring a horse to water, but you can’t make it drink.” Of course, we know that adage, but she’d add on, “But if you follow the horse long enough, it will get thirsty.” I think that’s our job in primary care, and I lump myself as a psychiatrist into primary care. We are supposed to follow that horse no matter what their problem is. If they have a mental health condition and they don’t want to come to psychiatry, keep following them and keep reminding them that there are good psychiatrists here who want to help you and who are ready for them when they’re ready for us.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Shivana Naidoo: My take-home message would be that for physicians, medical professionals, PCAs, and parents, all of us, our words carry weight, and our words carry worth. So think about these words when we talk to our patients and our families. If a psych-ish feeling, smelling patient comes your way and walks through your door, just remember: If the idea of “behavioral” flashes through your mind, if that word comes into your background, take pause. Take pause and remind yourself that everything we do is behavioral. Everything we do has a reason and has a purpose, and we need to call that behavior what it is. It could be confusing, concerning, worrisome, inconsistent, or interesting, but if that concerning piece has suicide in it, please don’t call it behavioral. Please call it suicidal behavior, and emphasize the suicidal piece, because that is very serious.

And if you like what you hear, please come listen to my podcast, Thinking It Through with Dr. Naidoo, Child Psychiatrist. You can find that on Apple and Spotify, and I would love to hear from you. My email address is [removed by the editor]. You can find me on Instagram, and I’m happy to hear from you and help in any way I can.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Shivana Naidoo: Thank you so much, Kevin.

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