Patient in the Spotlight

Are they trying to self-medicate?
That's one of the theories, yes. If somebody has a mood that is very unpleasant for them, they not uncommonly try to do something to relieve that mood. It might be use of a stimulant or alcohol. This does not apply to most people with a mood disorder, but people with bipolar disorder or major depression are more likely to use some kind of substance, either to try to get them over their mood problem or, again, because they are more impulsive and might be showing poor judgment.

If someone has a problem with substance abuse and addiction, could his or her behavior be mistaken for a mood disorder?
That's why we want to examine somebody before coming to a conclusion about what's driving what. It is possible for somebody to appear to be severely depressed or manic, and it could be primarily a result of [this person] having a substance abuse problem. So in the absence of taking a careful history, and sometimes having what we call collateral sources—friends or family members who can tell us what else is going on in somebody's life—it's really hard to come to any conclusion about the source of somebody's problems.

If somebody has a family member, an adult child or a spouse who is exhibiting behavior indicative of a mental disorder or substance abuse, what can family members do if that person is reluctant to get help?
That is one of the most vexing kinds of problems for families. I get calls about this all the time. I got one over the weekend from a family going through this. In our society, because we do have very strong protections for individual civil rights, it can be very difficult to compel somebody to get help they need. If one is an adult suffering from major mental illness, [and] if one doesn't want to get help, it's possible to avoid getting that help. And it can be very difficult to push somebody to get help until they get to the point where they can't care for themselves. So, in California for example, unless one is a danger to oneself, a danger to others or gravely disabled, one cannot be compelled to receive any kind of treatment. Even then, one may have to go to court in order to get the court to order specific types of treatment.

If a patient such as Spears is brought in involuntarily but is released within the 72-hour window allowed under California's 5150 code, does that mean she does not have a mental disorder?
When somebody is confined involuntarily, one is supposed to be reassessing them on a regular basis. If at any time it's the judgment of the treating physician that the person is no longer a danger to self, a danger to others or gravely disabled—whatever it is that brought them in—then they should be released. Sometimes we can find that people exhibit bizarre behavior or are a danger to themselves because they are intoxicated or high on something. And once that situation is cleared, we find they no longer meet the criteria to be held.

But if somebody is released in the middle of a 72-hour hold, that does not necessarily mean they don't have a mental disorder?
Correct. The great majority of people, more than 99 percent of people, with some kind of psychiatric diagnosis, would never be held against their will. Psychiatric disorders are extremely common, and with most psychiatric disorders people are able to function day to day. Most people with depression and bipolar disorder lead normal lives [usually with treatment, which usually includes a combination of psychotherapy and medication].

What is the best thing for a family to do if a relative is exhibiting bizarre behavior but is not in a situation that might require hospitalization?
The most effective intervention is to encourage [them] to get help. Clear, consistent feedback on, "You know, I think you have a problem. I think you need help." Getting other family members to step up and give the same clear message, looking for the opportunity. Sometimes the only time to convince somebody to get help is when they are in crisis.