Fieldwork notes, ongoing case report 1

Medical negligence and system failure: personal and collective consequences

Summary presentation: This case involves a patient who has been overworking for years, leading to extreme exhaustion and health issues. The patient's responsibilities increase with the birth of a second child, while the family faces economic challenges. The healthcare system mismanages the case, resulting in the patient being secluded in a mental health facility for over a month and prescribed expensive neuroleptic drugs with adverse effects. The financial burden and side effects further worsen the patient's ability to find work again, and thus care for the family, leading to significant negative consequences.

Treatment plan: based exclusively in the prescription of valproic acid (Depakine, primarily used to treat epilepsy and bipolar disorder and prevent seizures), aripiprazole depot (Abilify Maintena, atypical antipsychotic primarily used in the treatment of schizophrenia, obsessive compulsive disorder and bipolar disorder), and Trihexyphenidyl (Artane, antispasmodic drug used to treat stiffness, tremors, spasms, and poor muscle control), for a total cost of 2,954.08 euros per month, covered mostly by the public health system (tax-payer money).

The patient was under treatment for about four years before the case was revised and all prescribed drugs tapered and gradually discontinued to avoid further harm

Analysis and Observations: This case raises several concerning issues regarding the Spanish healthcare system's response and its impact on the patient and the family.

1. Lack of Proper Diagnosis and Treatment: The patient's chronic fatigue and stress-related disorders, including silent migraines and other signs of extreme tiredness resulting from overworking, were not adequately addressed. Instead of addressing the root cause and providing appropriate treatment, the healthcare system mismanaged the case by secluding the patient in a mental health facility, neglecting the underlying physical health and socioeconomic needs. This approach fails to address the root cause and prevents the patient from receiving appropriate treatment and support, exacerbating the overall situation.

2. Deterioration of Health: As a result of the unnecessary treatment and prescription, the patient experiences severe deterioration of his health. Symptoms such as akathisia, permanent numbing, and difficulty speaking are indicative of the adverse effects caused by the prescribed medications. These symptoms further impair the patient's ability to function and negatively impact their quality of life, including potential dependency on anti-parkinsonian medication. The prescription of this sort of drugs, likely due to the side effects of previously prescribed drugs, represents a concerning development.

   It is distressing that a young man, at the age of 40 as this patient was, is forced to take medication typically associated with older individuals. This dependency on medication not only affects the patient's health but also impedes their ability to care for themselves and work effectively to support their family.

3. Impact on the Patient and Family: The patient's deteriorating health and dependency on medication have significant consequences for both the patient and their family. The patient's reduced capacity to care for themselves and contribute to their family's well-being places an additional burden on their spouse and children. This situation compromises the family's stability and hampers their ability to thrive.

4. Financial Burden and Misallocation of Resources: While the prescription costs are primarily covered by taxpayers, the high expenses and costs associated with iatrogenic harm and disability further exacerbate the family's financial challenges. This situation not only hampers the patient's recovery but also prevents the allocation of those resources to provide social support and aids for the young family. Taxpayer money should be used efficiently to address the family's economic difficulties and ensure their overall well-being, not contribute to their distress. The excessive prescription bill amounts to a significant portion of the family's income before the seclusion and drugging occurred, which not only affected the patient but also put a strain on the entire family, making it difficult to meet their basic needs and potentially leading to long-term negative consequences.

5. Inefficient Use of Resources: The decision to seclude the patient in a mental health facility for an extended period seems disproportionate to the situation. Instead of addressing the underlying issues and providing comprehensive support, this approach isolates the patient and adds unnecessary costs to the healthcare system. These resources could have been better allocated towards providing the patient with appropriate medical care, counseling, and assistance in managing their workload and family responsibilities.

6. Adverse Effects of Medication: The prescription of neuroleptic drugs with parkinsonian effects further compounds the patient's challenges. These medications not only drain the patient's energy but also impede their ability to work and care for their family once discharged. It is crucial for healthcare professionals to consider the potential side effects and weigh the benefits against the risks, ensuring that the chosen treatment supports the patient's overall well-being and functionality.

7. Inadequate Support for the Family: The patient's wife, an unemployed immigrant with still limited local language skills, faced significant challenges in managing herself and the children without sufficient support. The healthcare system should recognize the family's circumstances and provide assistance, such as social services, language support, and financial aid, to help them navigate their difficulties.

Cost of medication in this case hit thrice the national minimum salary for a full time job, among those fortunate to be employed (~10-20% unemployment rates)

General Remarks and Critique: this case reveals the failures in diagnosing and treating the patient's condition effectively, the adverse consequences of mismanaging the healthcare system's response, and the severe consequences of unnecessary treatment and prescription of multiple drugs on the patient's health and well-being. The high cost of prescriptions, primarily borne by taxpayers, as well as the overall cost of disability, exacerbates the family's financial burden and hinders the allocation of resources to social support and aids. The deterioration of their health, the dependence on anti-parkinsonian medication at a young age, and the resulting inability to care for themselves and support their family are distressing outcomes. A comprehensive reevaluation of the patient's condition, proper diagnosis, and appropriate treatment strategies are essential to restore their health and well-being, following an approach that addresses the root causes, provides appropriate support, and ensures the efficient use of taxpayer, all the above being crucial to avoid further harm to individuals and their families while promoting their overall well-being.

Suggestions and proposals: neuroleptics, also known as antipsychotic medications, are commonly prescribed to manage symptoms of various mental health conditions, particularly psychosis. While these medications may be beneficial for some individuals, it is important to acknowledge their potential for toxicity, side effects, and impact on overall quality of life. Here are some considerations:

1. Side Effects: Neuroleptic medications can cause a range of side effects, including sedation, weight gain, metabolic changes (such as increased risk of diabetes and dyslipidemia), movement disorders (such as parkinsonism and tardive dyskinesia), and hormonal imbalances. These side effects can significantly impact an individual's daily functioning, physical health, and overall well-being.

2. Reduction of Life Expectancy: There is evidence suggesting that long-term use of certain neuroleptic medications may be associated with a reduction in life expectancy. Factors contributing to this reduction may include increased risk of cardiovascular diseases, metabolic disorders, and other adverse effects of the medications. It is important for healthcare providers to regularly monitor and manage the potential health risks associated with these medications.

3. Impact on Quality of Life: Neuroleptic medications can have a profound impact on an individual's quality of life. While they may help manage psychotic symptoms, their side effects and adverse reactions can limit social interactions, cognitive function, motivation, and overall emotional well-being. It is crucial to strike a balance between symptom management and minimizing the impact on an individual's quality of life.

4. Individual Variability: The impact of neuroleptics can vary from person to person. Some individuals may experience minimal side effects and find significant symptom relief, while others may struggle with adverse reactions that significantly diminish their quality of life. It is essential for healthcare professionals to engage in regular monitoring, individualized treatment planning, and open communication with patients to ensure the best possible outcomes.

5. Shared Decision-Making: Given the potential toxicity and side effects of neuroleptic medications, it is important for healthcare providers and patients to engage in shared decision-making. This involves a collaborative approach where patients are informed about the potential risks and benefits of treatment options, allowing them to actively participate in deciding the most suitable course of action based on their unique circumstances and preferences.

While neuroleptic medications can be helpful in managing certain mental health conditions, their potential toxicity, side effects, and impact on quality of life should be carefully considered and monitored. Regular assessments, open communication, and a focus on holistic care are essential to minimize risks and ensure the best possible outcomes for individuals receiving these medications.

Collective Level - Improving the Healthcare System:

1. Comprehensive Healthcare Reform: Implementing reforms that prioritize holistic and patient-centered care is crucial. This includes improving access to primary care, mental health services, and reducing barriers to receiving appropriate treatment for chronic conditions like fatigue and stress-related disorders.

2. Enhancing Diagnosis and Treatment Protocols: Develop and implement guidelines for healthcare professionals to accurately diagnose and effectively treat conditions related to chronic fatigue and stress. Emphasize the importance of addressing root causes and providing comprehensive care rather than focusing solely on symptoms.

3. Improved Coordination and Communication: Enhance coordination and communication among healthcare providers, ensuring that medical professionals across disciplines work collaboratively to develop personalized treatment plans for patients. This includes regular follow-ups, evaluations, and adjustments to the treatment regimen as necessary.

4. Focus on Preventive Care and Health Education: Prioritize preventive care initiatives to raise awareness about the dangers of overworking, stress management, and the importance of work-life balance. Offer educational programs to individuals, families, and employers to promote healthier lifestyles and reduce the likelihood of similar cases occurring in the future.

Individual Level - Improving the Patient and Family Situation:

1. Comprehensive Support for the Patient: Provide the patient with cognitive remediation programs and therapy to help alleviate the cognitive deficits caused by the adverse effects of medication. Focus on improving cognitive function, memory, and speech abilities to enhance the patient's quality of life and their ability to reintegrate into society.

2. Social Support and Financial Aid: Offer social support services to the patient's wife, who faces language barriers and unemployment. This can include language training programs, job placement assistance, and financial aid programs to alleviate the family's economic burden and improve their overall well-being.

3. Rehabilitation and Vocational Training: Facilitate the patient's rehabilitation process by providing vocational training and reintegration programs. This can help the patient regain their work skills and find suitable employment opportunities that accommodate their health condition.

4. Reparations and Compensation: Consider providing reparations or compensation to the patient and their family to acknowledge the harm caused by the mismanagement of their case. This can help alleviate some of the financial burdens incurred and support their efforts towards rebuilding their lives.

5. Long-Term Follow-up and Monitoring: Ensure long-term follow-up and monitoring of the patient's health to address any ongoing challenges and provide necessary support. This includes regular check-ups, mental health assessments, and access to healthcare professionals who can assist in managing the patient's condition effectively.

Practitioner Level - Improving the Discipline Standards:

It is important to emphasize that these proposals aim to rectify the situation and mitigate the harm caused to the patient and their family. They should be implemented in a manner that promotes justice, fairness, and the well-being of all parties involved.

The psychiatrist's lack of knowledge about important details of the patient's life and professional situation, as well as the circumstances that led to their seclusion in a mental health facility, is a clear failure of the healthcare system and a reflection of a lack of professionalism and thoroughness on the part of the psychiatrist. This situation is unfortunately not an isolated incident but a generalized problem that highlights the shortcomings of the mental healthcare system.

1. Importance of Comprehensive Assessment: A thorough and comprehensive assessment is essential in understanding a patient's condition, determining appropriate treatment, and considering the broader context of their life. Without knowledge of crucial details such as the number of children, job situation, and circumstances leading to seclusion, the psychiatrist cannot adequately develop a treatment plan that addresses the patient's specific needs and challenges.

2. Patient-Centered Approach: It is crucial for healthcare professionals, especially psychiatrists, to adopt a patient-centered approach. This means actively listening to the patient, taking into account their unique circumstances, and involving them in the decision-making process regarding their treatment. By neglecting important details about the patient's life, the psychiatrist fails to uphold this patient-centered approach and risks providing ineffective or misguided treatment.

3. Collaboration and Communication: Effective healthcare requires collaboration and communication among all members of the healthcare team. The psychiatrist should have sought to gather information from various sources, including the patient, their family, and relevant healthcare professionals involved in their care. This collaborative approach ensures a comprehensive understanding of the patient's situation and facilitates better decision-making.

4. Professional Responsibility and Accountability: Psychiatrists, like all healthcare professionals, have a responsibility to provide competent and ethical care to their patients. This includes conducting thorough assessments, maintaining up-to-date knowledge, and actively engaging in ongoing professional development. The lack of knowledge demonstrated by the psychiatrist in this case suggests a failure to meet these professional responsibilities.

5. Systemic Issues: The case highlights broader systemic issues within the mental healthcare system. These issues may include time constraints, heavy caseloads, and a lack of resources or support for healthcare professionals. Addressing these systemic issues is crucial to ensure that healthcare professionals have the necessary time, resources, and support to provide quality care and conduct comprehensive assessments.

Conclusions: to address these problems, the healthcare system should prioritize ongoing training and professional development for healthcare professionals, promote a patient-centered approach, and ensure effective collaboration and communication among healthcare teams. It is essential to hold healthcare professionals accountable for providing thorough and knowledgeable care and to address systemic issues that hinder their ability to do so. By addressing these shortcomings, the mental healthcare system can work towards providing better and more effective care for patients in need.

The fact that Spain ranks as one of the leading countries in the world in terms of expenditure on neuroleptic drugs raises several questions and concerns.

1. Prescribing Practices: High expenditure on neuroleptic drugs may indicate a significant reliance on medication as a primary approach to treating mental health conditions in Spain. This raises questions about prescribing practices, including whether non-pharmacological interventions and alternative treatment modalities are being sufficiently explored and utilized.

2. Access to Mental Health Services: High spending on neuroleptic drugs may reflect a greater prevalence of mental health conditions and a larger population in need of treatment. It could also suggest challenges in accessing appropriate mental health services, resulting in a reliance on medications rather than comprehensive care. Addressing the underlying issues of mental health provision and accessibility may be key to reducing reliance on medication.

3. Influence of Pharmaceutical Industry: The high spending on neuroleptic drugs also raises questions about the influence of pharmaceutical companies in the healthcare system. Pharmaceutical marketing practices and financial incentives provided to healthcare professionals can potentially influence prescribing patterns, leading to increased medication usage and expenditure.

4. Evaluating Cost-Effectiveness: While spending on medication is not inherently negative, it is important to assess whether the benefits justify the costs. Evaluating the cost-effectiveness of neuroleptic drugs, considering their efficacy, potential side effects, and long-term outcomes, is crucial to ensure that taxpayer money is being used wisely and that patients receive the most appropriate and effective care.

5. Comprehensive Mental Health Approach: It is vital to promote a comprehensive approach to mental health that incorporates non-pharmacological interventions, psychotherapy, and social support. By expanding access to these services, the reliance on medication as the primary treatment option may be reduced, resulting in more holistic and personalized care.

Ultimately, a deeper analysis of the factors driving the high spending on neuroleptic drugs in Spain would be necessary to fully understand the situation. Addressing the underlying issues, such as prescribing practices, access to mental health services, and the influence of the pharmaceutical industry, is crucial for optimizing mental healthcare, avoiding iatrogenic practices to eliminate associated personal and societal costs, thus ensuring the most effective and cost-efficient use of resources.