Public Psychiatry Fellowship

 

Work Site Case Study

 

 

 

Mr. Z

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Samuel Law

 

Nov 22nd, 2000

 

 

 

 

 

 

 

Introduction:

Mr. Z is an on-going case. This presentation may be viewed as a sort of running documentation. During the short time I have known about him, he has experienced much vicissitude, including two admissions to Bellevue. He is currently maintained as an out-patient by Gouverneur Hospital. His case illustrates well the inherent hardships faced by members from Mr. Z’s community of immigrants, the existing barriers of mental health delivery, the complexities of the service system, and to a degree, the triumph of a safety net mental health care system that ultimately catches some of those who are struck by mental illness under unfortunate circumstances that are hard to imagine.

 

 

Physical locale of Encounter:

Walk-in clinic at the Gouverneur Hospital, where a patient sees a nurse first, for triage (usual wait: approx. 20 min to 3 hours). After triage, persons requiring further care are to register at the cashier (usual wait: 5 to 30 min for revisit, 40 to 90 min for new patients), in order to see a physician or supervised physician aid (usual wait: 1 to 4 hours). Further waiting time required if labs involved.

 

 

Case Presentation:

August, 2000

Mr. Z was referred from the triage nurse of the walk-in clinic for psychiatric assessment. I took the call. Mr. Z. is an unilingual 30 year-old patient of Chinese descent. His main language is Fu-Zhounese, a dialect from the southern Fujian province of China. He spoke some limited Mandarin for the purpose of the assessment. He presented to the hospital accompanied by his older sister, who reported that Mr. Z was having problems sleeping and displayed increasing unusual behaviour - calling her incessantly at all hours, complaining that the police are chasing after him, and that he is worried about their parents in China, his arranged marriage, and money.

 

He stated that he was stressed, and that he did not understand why he is having such unwanted thoughts. He denied any unusual activities or any abuse of substances. He could not comment on whether he was suffering from auditory hallucination, but denied visual hallucination more unequivocally. He did not seem to understand questions on thought broadcast/thought withdrawal/thought insertion. He had no reported or observed manic symptoms such as increased energy, talkativeness, or pressured speech. He seemed genuinely disturbed at the sight of uniformed officers at the hospital.

 

His sister could not comment further on his symptoms beyond that he was acting bizarrely. She reported no protracted period of mood disturbances, and noting no clear precipitant. She gave a history that Mr. Z has had a previous episode of similar bizarre behaviour, but he had been ok since discharge from hospital and was in his usual/baseline level just a few days ago. She has been worried for her brother, however, who was a isolated man, worked at a restaurant 6-7 days a week, all over the country. Both he and his sister denied any use or knowledge of any substance abuse.

 

Past Psychiatric History:

During assessment, we requested information from Bellevue Hospital via the psychiatric crisis service where a psychiatry resident is on-call. Faxed copies of the following collateral information arrived within 15 min.

 

Mr. Z.’s first psychiatric admission was in Jan - Feb 99, at Bellevue. lasting 3 weeks. He was brought to Bellevue by NYPD after a bystander called the police for he was “running in Chinatown in his pajamas (winter), screaming that he was crazy”. Mr. Z. reported at the time that he was feeling increasingly confused after returning from a job as a cook in Connecticut. He reported throwing away his belongings, including his C8 Visa and $900 cash. He also admitted to command auditory hallucinations to hurt himself and paranoid delusions that the government (immigration) was out to get him because his C8 Visa was due to expire in 7/99.

 

He also later admitted to sleepless nights for two weeks prior to admission, coinciding with starting new job. He denied other manic symptoms, denied substance use, and denied family history.

 

Mr. Z’s social history at the time was that of a single person, living mostly in restaurants where he worked. He came to visit his sister during days off. His parents were in Fu Zhou. He had been in the U.S for five years, having worked in 20 different places.

 

His past medical history from Bellevue showed some WBC elevation. Further work up, including a lumbar tap, and CT of head, were negative. He received Haldol 5 mg IV twice, Valium 10 mg IV, twice, and Versed 2 mg IV.

 

While on the in-patient unit, he was under the care of a Mandarin-speaking psychiatrist. He gradually responded to treatment, with Haldol 4 mg qd, and Benedryl 50 mg for sleep. At the time of discharge, his paranoid delusions, auditory hallucination, insomnia, and thought disorganization were “completely resolved”. He was interacting in a meaningful way in groups and in sessions and showed no suicidal or homicidal ideation. His insight and judgment improved.

 

Mr. Z was diagnosed with Psychosis NOS, most probably schizophreniform disorder. His Axis IV was noted “stress at work, loss of job, impending loss of legal status”. His Axis V was 20 on admission, 75 on discharge.

 

Mr. Z’s discharge medications were Haldol 4 mg qhs, Cogentin 1mg qhs, Benedryl 50 mg, qhs. He was given a month’s supply and was instructed by a Chinese speaking social worker to follow up at a local psychiatrist’s office. He was to return home to live with his sister, who was aware of and agreed to implement the treatment plan.

 

 

Past Medical History:

No known acute illness. No current medication.

 

Family Psychiatric History:

No other known family psychiatric history, according to sister.

 

 

Social History:

Isolated, worked at restaurants all over the tri-state area and beyond. He “paid off” his “immigration”(smuggling) debt about a year ago. As an illegal immigrant, Mr. Z’s social history is integrally related to the onset and on-going stressors contributing to his illness and inability to seek treatment. His story warrants a closer look.

 

 

“Undocumented Alien” and others:

Mr. Z. is one of the 300,000 people from Fu Zhou thought to have illegally left China over the last few decades. A very large proportion of that group reside in the New York tri-state area; their community’s life center is East Broadway, a recent extension of the Manhattan Chinatown. Gouverneur Hospital is in the heart of this community.

 

We are probably familiar with the recent sensational stories about immigrant smuggling, from the Golden Venture (a dilapidated boat carrying hundreds ran aground with 10 deaths) in 1993, to the more recent 58 deaths by suffocation in a tomato container truck in England in 2000. For the long periods before and in between, there has been on-going smuggling of illegal immigrants form China. They are surprisingly mostly from a small area of China – Fu Zhou, in Fujian province.

 

Mr. Z was born in a small village near Fu Zhou. While illegal crossings from China to Hong Kong, or Macao, or other more prosperous neighboring regions of China has always been a known fact, for years the only way to come to the US directly was to become a seaman and then jump ship. However, with widening economic inequity, political oppression, lack of opportunity and jobs in China, and ties between the U.S and China warming up - opening trade, travel, tour and study links – more people have sought to escape from China to put roots in the U.S. They have achieved this through various methods. For example, some go AWOL from a tour, marry an American, seek political asylum, or refugee asylum; some use forged State or Business visitor documents, etc. Once a group has established here, it becomes the nucleus of a self-perpetuating flow of other compatriots to migrate to the U.S, through legal and illegal sponsorships.

 

Traditionally, smugglers are known as “snake heads” - with human cargo as the “snakes”. Typically snakeheads use Latin America such as Mexico, Belize, and Guatemala as stepping-stones to the U.S. More sophisticated operators provide forged papers such as Visas for plane arrivals. They also bribe of corrupt immigration officials, tour operators and other underground organizations, making this a multinational business. Mr. Z. came on the more traditional, hardy, sea route, at a cost of $US 35,000.

 

According to his sister, Mr. Z came first by boat to Central America, then to Mexico, crossed over the U.S border into Texas, then was driven to New York in a minivan. He had nothing but debt and hope when he arrived.

 

Mr. Z. paid off most of his debt after he came to the U.S. He obtained the down-payment from his family and relatives in Fu Zhou. Smuggled immigrants are typically found jobs at restaurants and factories upon arrival to pay for their remaining debts. Those who could not afford down payments can borrow from the snakeheads at a punishing 30% interest, effectively living an indentured life until they pay off the debt.

 

Mr. Z. was lucky to have a sister here in the U.S already to help out the first leg. Her role was typical of many immigrants in catalyzing further smuggling; she tapped into an extensive underground financial network. (Smugglers operate “bank services” in Chinatown where people can wire money back to Fujian. Money is delivered in hours and in U.S. cash, a superior choice over the poor exchange rate, 3-week process at the official Bank of China who delivers in the Chinese currency Yuan. This financial network was also instrumental in stimulating further smuggling. The symbol of success in Fu Zhou has become “who can get to the U.S and who can send more money home.” Money was Mr. Z’s major worries through out, and most likely a major precipitator of his illness.) Today, the smuggling fees to the U.S have soured to about $60-70,000.

 

For the community as a whole, there has been a major boom in the “undocumented community” after the amnesty granted by President Bush in 1989 after the Tiananmen Square massacre. The amnesty created a major base of legal immigrants who are able to sponsor their family from overseas, and/or afford the smuggling fees.

 

In the U.S., Mr. Z usually made around $1500 a month, and spent very little. He lived in single room apartments with other workers. He paid off his debt in about three years. This apparently is the norm if everything goes well and as planned. A booming U.S. economy meant plentiful jobs in restaurants and garment factories, further strengthening the conviction that there is sufficient opportunity in the U.S. to risk the process. After paying off the debt, Mr. Z. was thrilled to be able to start sending home money. He became preoccupied with it. Another stressor was his desperate wish to arrange for a female friend to come to join him, although it was also a source of purpose and hope. Mr. Z had some pre-existing friendship with a woman in China whom he envisioned joining him in the U.S. Of course, he would need to arrange for her smuggling – at least to pay for her down-payment. Then the illness started

 

Mr. Z tried to learn some English while in China. However, he never mastered much of the language even after a few years in the U.S., severely restricting his opportunities for employment and education.

 

Mr. Z had hopes to move up in the restaurant world. He wished to open or become a partner of his own place if possible. His future long-term plan also includes hiring a lawyer to seek asylum for him as a Falun Gong member, or for any other available and feasible reason. The legal fee may be as high as $4000 and the chance of success very low. At this point, in his view, he cannot afford to be too concerned about his illegal status. In his world, everybody is in the same situation – living on the margin of the society. He is not alone.

 

Family History:

Mr. Z’s only relative in the U.S. is his sister who came before Mr. Z to join her husband. She knows quite well the hardship involved when she prepared Mr. Z to come. She helped out with the down payment and once arrived, helped him to find a job. With the decompensation, she has felt guilty for bringing him here. She wondered if he would have been better off staying in China. Their parents are working on a farm in China.

 

Income:

“Undocumented” economy. Paid “under the table”. Public assistance available in the forms of shelters, soup kitchen, etc.

 

Legal Status:

Current exact legal status unknown. Was on a C8 visa, issued to those who are awaiting asylum or immigration hearing. After the onset of his illness, he missed his hearing, thus currently a “underground” or “undocumented” alien.

 

Health Insurance

None. Emergency Medicaid only, under the “don’t ask, don’t tell” rule. Basic care dependent on City Hospital system, community services, and traditional services in Chinatown.

 

 

Mental Status:

(At the walk-in Clinic) Mr. Z was a 30 year-old slim man who stood about 5’5”, reasonably groomed and appropriately dressed for the weather, and appeared younger than his age. His features were on the delicate side, suggesting that he was not used to hard labour. He started out looking quiet and apprehensive, with some psychomotor retardation. During the course of the assessment and administrative registration, he became increasingly agitated, with pacing, self-directed yelling, and later, an attempt to harm himself. He was guarded throughout, and suspicious of the hospital police, but more readily cooperated with the interview once we started speaking Mandarin. His affect was initially restricted, and anxious; his mood was “confused” - deteriorating later to agitation and gross confusion. He had some apparent thought blocking, disorganization, and delayed responses; he was unable to express himself clearly, which worsened over time. His thought content reflected delusions of persecution by the police, great concerns about his family in China, and desperation about the hopelessness of his arranged marriage. He reported that these thoughts were intrusive and debilitating. He uttered words of guilt and regret, as if he was tormented by his own failure (vis a vis his family, marriage), and he expressed expectation and willingness to be punished. This progressed to biting his own tongue in an attempt to punish or kill himself. He had no expressed intention or plan for suicide prior to this overt act. There was no homicidal ideation or plan. He did not report any auditory or visual hallucination, but he appeared to be preoccupied with internal stimuli. His insight was poor, with no understanding of his situation, and he drew no connection to his previous hospitalization. His judgment and behavior was disordered, but cooperative with assessment and appeared to be receptive to help initially. Ultimately, he was unable to carry out these initial intentions given his gradual descend into dyscontrol / decompensation. His cognitive ability was limited at the time, predominantly focused on his internal turmoil. No formal testing was done. His competence to make treatment decisions was severely questionable as the assessment processed.

 

 

Psychiatric Diagnoses:

Axis I               Schizophrenia - paranoid type

                        R/O Schizoaffective disorder

                        R/O Bipolar disorder

                        R/O Acute distress disorder

                        R/O Psychosis secondary to general medical condition or substance

Axis II              Deferred

Axis III            Unknown; non observed

Axis IV            Major social economical stressors: illegal immigrant, no English language skill, social isolation, financial hardship, lack of follow-up of illness, etc.

Axis V              20

 

 

Treatment Plan after Initial Assessment:

1.      Crisis management of agitation and confusion - IM medications given (Haldol and lorazepam)

 

2.      Emergency admission to Bellevue Hospital CPEP unit - with the assistance of hospital police and ambulance (usual procedure to call 911).

 

3.      Facilitate follow up by Asian Bicultural Clinic (ABC) for intake upon discharge from Bellevue.

 

4.      Psychoeducation and support for patient’s family.

 

 

Course in Hospital at Bellevue:

Mr. Z. was treated by his previous psychiatrist who speaks Mandarin. He became reasonably calm and oriented, after the emergency treatment with IM medication at Gouverneur. He felt safe in the Unit. A medical work-up showed elevated CPK and urine myoglobin, but no clinical evidence of extra pyramidal signs or neuroleptic malignant syndrome. Lab abnormalities were thought to be isolated findings, associated with physical struggle during his agitated state. He was medically cleared a day later. Psychiatrically, he revealed that he believed the police was chasing after him and that his father was sick in China because of him. He wanted to die, by biting his tongue, to make things better for himself and for his family.

 

He responded to his previous medications (Haldol) gradually. Clinicians learned that he has been under tremendous pressure to make money to send home, having worked in a few States, ranging from Indiana, to Florida in the last few months. He came back to Brooklyn with a few thousand dollars, hoping to be closer to his sister as his fear of the police and loneliness intensified. He was unable to find other employment in New York. A few weeks after his return, he decompensated to the point he was willing to come to hospital.

 

After three weeks in hospital, his intrusive thoughts and delusions lessened in intensity and he was no longer suicidal. He was discharged, on his previous medications, to the ABC clinic at Gouverneur.

 

 

Follow-up at Asian Bicultural Clinic (ABC)

Sept, 2000

The ABC, part of the Department of Behaviour Health, is an out-patient mental health clinic serving Asians, but predominantly Chinese, regardless of immigration status, in Lower Manhattan. It has three part-time psychiatrists, two full-time psychologists, and two social workers – probably the largest and more comprehensive and independent Asian services in New York. It uses an interdisciplinary approach. The clinic typically assigns a clinician and a psychiatrist for each patient, handling individual, group, and psychoeducation needs, as well as psychopharmacology. It also provides community education, and family support programs. It uses a sliding scale for fees, usually $10 to $40, a payment that would entitle patients to obtain medications (that are on the Hospital formulary) if prescribed.

 

The clinician and psychiatrist at ABC saw Mr. Z twice, from Sept to Oct, 2000. He appeared calm and cooperative during the visits, but had constricted affect. He had no hallucination or suicidal ideation. His medication remained the same as per Bellevue’s discharge plan. He found a job at a local restaurant and was to return for F/U in 4 weeks. But two weeks after his last appointment, he was readmitted to Bellevue.

 

 

Course in Hospital

Late Oct, 2000

Brought to Bellevue directly by sister, who reported that Mr. Z was suffering decreased sleep, decreased appetite, increased agitation, and worsening paranoia about Immigration and police over the previous two days. This occurred despite having been seen and followed up at the ABC clinic, reportedly on regular medications. He related that he was feeling very guilty about lending $2000 to a friend a few years ago, and that he gambled and lost a little bit of money (new information). No other obvious precipitant otherwise. No suicidal or homicidal ideation reported. No manic symptoms observed.

 

Medical work up was normal.

 

The impression was questionable compliance with medication and treatment. He had a history of believing that he was cured once he was well. He was placed on Haldol again, and responded in a few days, supporting the hypothesis that his deterioration was related to poor compliance. He was switched to Haldol Decanoate 150 mg IM q 4wks upon D/C. He tolerated the new medication well.

 

 

Notable points of this Admission:

¨      Social worker notes indicate that there was a communication problem, for patient spoke limited Mandarin and social worker was Cantonese speaking.

 

¨      There was miscommunication between ABC and Bellevue as ABC did not have record of patient when Bellevue initially called to enquire Mr. Z’s out-patient follow up status. Bellevue therefore operated under the assumption that patient had no F/U, or his medication had been reduced or changed.

 

¨      There was difficulty arranging F/U given that patient and his sister lived in Brooklyn, which is out of catchment area of Gouverneur, Bellevue’s usual choice. ABC clinic made an exception to continue to care for patient.

 

 

Current Clinical Situation:

Nov, 2000

Since discharge, Mr. Z has moved in with his sister, his primary care-giver at this point. There are some tension as his sister is working long hours and has to look after her child. Mr. Z. has come to two F/U sessions at the ABC so far. He appears more dysphoric, but mostly constricted in affect. His insight has improved slightly, and he has resigned to treatment and IM injection. He finds his daily routing boring and depressing, ashamed that he is unable to work or contribute to his sister’s and his parents. He is eager to find a job soon.

 

 

Last week

Mr. Z’s sister called ABC that he was again not sleeping well, having arguments with her. She wondered if she should bring him to the hospital. Mobile Crisis was called (where I also work, but not at ABC directly). I talked to his sister who the next day. She reported that he is doing better after taking an extra pill of this oral Haldol.

 

 

Some Known Barriers for Mr. Z to Access Services:

¨      Basic fear of as an illegal immigrant - “As illegal immigrants, they live in fear, often afraid to enroll children in school or visit a hospital”, reports E. Rosenthal of the NY Times. Mr. Z. is one of them. He came to the hospital only after great encouragement from the sister. His delusions have incorporated his fear of the police, fear of being sent home. When at Gouverneur, he was visibly disturbed when the Hospital Police walked by.

 

¨      Lack of knowledge of services and support  - Mr. Z did not know the difference between Bellevue and Gouverneur, or what services there is in Chinatown for mental health. For example, he did not know the ABC clinic at Gouverneur.

 

¨      Language – lack of English and other main Chinese dialects (e.g. Mandarin, Cantonese) skills dictate Mr. Z and other patients like him go for help in Chinatown, within his own community, which is relatively new and in great transition, often paying what ever the shop/doctor demanded.

 

¨      Cost – Mr. Z’s discharge plan in 1999 included a doctor whose fee was $200/visit. He never went.

 

¨      Lack of knowledge in mental health – mostly poorly educated individuals from a farming communities. A stoic disposition prevent many of them from recognizing illness and seeking help.

 

 

Other Resources / Services for Unilingual Chinese Immigrants:

(mostly Mandarin and Cantonese speaking, rare Fu Zhounese speaking staff in the City at this point)

¨      Henry Street Settlement Mental Health Clinic (out patient treatment for individuals and family, day-treatment, services in Chinese available) Accepts all Immigration status.

 

¨      Lower East Side Service Center, Mental Health Clinic ( for mental health and substance abusers, day-treatment, therapy)

 

¨      Hamilton-Madison House Mental Health Clinics (psychiatric consultation and counseling)

 

¨      University Settlement Consultation Center (individual and group therapy. Chinese and Spanish speaking staff )

 

¨      Chinatown Family Consultation Center  (general counseling services, no psychiatrist)

 

¨      Lutheran Medical Center Mental Health Clinic, Brooklyn  (comprehensive out-patient treatment; some Chinese speaking staff available)

 

¨      Fort Hamilton Mental Health, Brooklyn (out-patient  services with Chinese speaking staff available)

 

¨      Elmhurst Hospital Center, Asian Mental Health Clinic, Elmhurst ( comprehensive in and out-patient services with some Chinese speaking staff, city wide acceptance)

 

¨      Other private practice providers (charges ranging from $120 to $200, some with sliding scale.)

 

 

 

Some Relevant Questions:

1.      What is the responsibility and role of the “system” toward the caring of the “undocumented immigrants”?

 

2.      What is the role of “Public Psychiatry” toward this population?

 

3.      How to appreciate the mental health needs of this population?

 

4.      How to deliver mental health services to this population?

 

5.      What do we learn from this population in terms of public psychiatry at large? (of course, Chinese illegal immigrants are not unique, which leads to: )

 

6.      What can we learn from the experiences of other “undocumented” populations (e.g. Latinos, Canadians...?)