© 2008 Patricia Iyer
By Patricia Iyer, MSN, RN, LNCC
• A physician who is named as a defendant in a medical malpractice suit commits suicide.
• A plaintiff who loses his ability to work after a car accident becomes depressed.
• A woman who is injured by a defective product loses her ability to control her bipolar illness and spirals out of control.
• A child custody battles focuses on the mother’s history of schizophrenia, which has been well controlled with medication.
• An attorney’s erratic behavior exasperates her colleagues, clients, adversaries and the judges.
Every year 40 million Americans experience some form of mental illness, including major depression, schizophrenia, bipolar disorder, obsessive-compulsive disorder and anxiety disorders.  Attorneys may be involved in representing, deposing, counseling and suing mentally ill people. Mental illness may complicate the litigation process, affecting the basics of obtaining information and gaining cooperation.
Major depression, a response by many to the stresses associated with litigation, is marked by a loss of interest and pleasure in daily activities. A depressed person may sleep too little or too much, eat too little or too much, and feel slowed down or too agitated to sit still. The individual may be extremely tired — getting out of bed is an effort. Lack of motivation, difficulty performing tasks, withdrawal and isolation from others, and lack of attention to hygiene and appearance may be noted. The individual may blame herself for the way she feels and dwell on guilt feelings and personal failures. There may be difficulty thinking, remembering and concentrating. The person may have a heightened sensitivity to noise, light and stress. The psychotic phase of this disorder, which affects 10-25% of those who are depressed, is marked by grossly disorganized behavior, incoherent speech, hallucinations and delusions.
Even a person who is not psychotically depressed may lack insight into the severity of the problem. Consider how one person well-acquainted with major depression symptoms described her depression: “When you are lost in the woods, it sometimes takes you a while to realize that you are lost. For the longest time, you can convince yourself that you’ve wandered a few feet off the path, that you’ll find your way back to the trailhead any moment now. Then night falls again and again, and you still have no idea where you are, and it’s time to admit that you have bewildered yourself so far off the path that you don’t even know from which direction the sun rises anymore.” 
The severely depressed person may have recurrent thoughts of death and impulses, thoughts or plans to commit suicide. Risk factors for suicide include being unemployed, unmarried, having a problem with substance abuse, having a mood disorder and a history of previous suicide attempts. Other risk factors include a change in personality such as being sad, withdrawn, irritable, anxious, tired, indecisive or apathetic. There may be a change in behavior such as an inability to concentrate on school, work or routine tasks, or a change in sleep patterns characterized by oversleeping, insomnia or early waking. Additional symptoms include a change in eating habits, loss of interest in people and activities previously enjoyed. Suicidal patients may be worried about money or illness (real or imagined), feel like they are losing control, going crazy or want to harm themselves or others, or have feelings of overwhelming guilt, shame or self-hatred. They may have no hope for the future or have experienced a recent loss of relationship, marriage, house, job or money. They may have nightmares and express suicidal impulses, or make statements or plans. A classic warning sign is giving away favorite things. The suicidal patient may be agitated, hyperactive or restless.
Healthcare professionals should be alert to the risk factors and signs of suicidal intent. Suicide in a healthcare facility is the second most common sentinel event reported to the Joint Commission, an accrediting body for hospitals.
The attorney or records reviewer should keep in mind a few points when reviewing medical records of a depressed patient. First, detailed notes about the content of psychotherapy sessions are likely to not be supplied by a therapist. General comments about the course of therapy may be turned over, but the intimate notes of sessions may be kept in a separate file. Secondly, it is common for a psychiatrist to define the patient’s problems along five axes, as laid out by the DSM IV-TR. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is an American handbook for mental health professionals that lists different categories of mental disorders and the criteria for diagnosing them, according to the publishing organization the American Psychiatric Association. The DSM is used worldwide by clinicians and researchers as well as insurance companies, pharmaceutical companies and policy makers. The DSM, including DSM-IV TR, is a registered trademark belonging to the American Psychiatric Association. The DSM-V is currently in consultation, planning and preparation, due for publication in approximately 2011. 
The five axes are as follows:
• Axis I: Clinical disorders. These consist of all relevant major psychiatric disorders such as schizophrenia, bipolar disorders and major depression.
• Axis II: Personality disorders and mental retardation. Personality disorders as defined in the DSM IV-TR are deeply ingrained maladaptive, lifelong behavior patterns.
•Axis III: General medical conditions that are identified on the basis of a comprehensive history and physical examination, evaluation of symptoms, mental state examination and supplementary assessment instruments. These include any medical condition such as diabetes, hypertension, cystic fibrosis and so on.
• Axis IV: Psychosocial and environmental problems. These can include stressors such as a recent death of a loved one, being a victim of a crime, going through a divorce or losing one’s job, among others.
• Axis V: Global assessment of functioning (GAF), written as numbers (0–100) meaning “current functioning”/“highest level of functioning in past year” with 100 being the highest optimization of functioning and 0 being the lowest. 
Thirdly, the attorney can be of value to his or her clients by mentioning resources, such as NAMI, available to help the depressed patient or family. NAMI (National Alliance on Mental Illness at www.nami.org) has chapters in all states and in many counties. NAMI offers an array of peer education and training programs and services for consumers, family members, providers and the general public. NAMI’s education and support programs provide relevant information, valuable insight and the opportunity to engage in support networks. These programs draw on the lived experience of mental health consumers and family members who have learned to live well with their illnesses and have been extensively trained to help others, as well as the expertise of mental health professionals and educators.
There are several effective antidepressants on the market that bring relief of symptoms for those challenged by depression. There is no need to suffer through a major depression. Lives can be saved by confronting depression. •
Patricia Iyer is president of Med League Support Services, a legal nurse consulting firm established in 1989. Pat is a past president of the American Association of Legal Nurse Consultants and was the chief editor of both the Principles and Practices of Legal Nurse Consulting and the online LNC course offered by AALNC;email@example.com.
1. NAMI Family to Family Education Program 2/03e.
2. Gilbert, Elizabeth, Eat, Pray, Love, Penguin Books, 2006.
4. Mohr, W. “Psychiatric Medical Records,” in Iyer, P., Levin, B. and Shea, M.A., Medical Legal Aspects of Medical Records, Lawyers and Judges Publishing Company, 2006; available through www.medleague.com.