Vegetarian diet

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

whopper

Former jolly good fellow
20+ Year Member
Joined
Feb 8, 2004
Messages
8,026
Reaction score
4,146
http://www.nutritionj.com/content/pdf/1475-2891-11-9.pdf
http://www.ncbi.nlm.nih.gov/pubmed/20515497

OK vegetarian diets improving mood are half the reason why I'm bringing this up.

I've found this a very effective method to wiggle out malingerers. If I suspect malingering, I offer a vegetarian diet, mention the alleged benefits, mention that there's data showing it can improve mood, and guess what? So far every single person I've offered it to demanded to get out of to the hospital and sign out AMA.

Here's what typically happens. We get a patient, patient alleges to be suicidal, may even show vegetative sx, tell me that they've been on every antidepressant and nothing works. I tell them something to the effect of, "Sir maybe a new approach is needed. We can try a vegetarian diet. Please allow me to show you some articles showing why it can help." Then the patient becomes irate, all of a sudden loses all of their vegetative sx, then demands to leave the hospital, even a lot of them saying they faked all of this when I tell them that if they are suicidal I got to keep them in the hospital against their will. While waiting to sign out AMA, they are told to wait a few hours just so we can check collateral data about their safety and during this entire time we see no signs of depression. Some of them even say they're going to a neighboring hospital because the food is better.

I don't see anything unethical with this. First off, I'm offering them the data showing why it can help. This is evidenced-based data. There is a theory to why it works considering the arachadonic acid/omega 3 ratios in the brain, I've already done a malingering assessment and I have significant reasons to believe they are malingering that meet reasonable medical certainty.

I've not yet had a patient with vegetative signs that when offered this diet maintain their presentation, in which case I would've believed they were depressed. It could also be that because I'm not trying with this those I don't believe to be malingering, I'm not getting non-malingerers to try this approach. I've spent years doing M-FASTs and SIRSs so it's to the degree where I can almost do it in my head based on an interview.

Thoughts?

Members don't see this ad.
 
  • Like
Reactions: 4 users
your post made me laugh. excellent strategy. unfortunately this seems geographically dependent, even our malingerers here are gluten-free, vegan granola munching heart sinks who are more likely to complain the food isn't organic!
 
  • Like
Reactions: 3 users
That's funny, but also interesting. I became vegetarian when I was 2-3 years old, hard to remember exactly. My grandmother in Sweden was a psychiatrist and she was very concerned about me being vegetarian. When she would come to visit from Sweden she would be very upset that my parents gave us 2% milk. She believed in lots of butter and whole milk and meat! It's been suggested to me by quite a number of people throughout the years that I might feel more "solid" if I ate meat. For health reasons I've wanted to eat meat at times, but at this point eating meat to me would be like eating a snake for most people; it's just too gross. I do take fish oil capsules daily and I feel really gross for the second it's in my mouth before I swallow it. So I'm no longer, as I was as a child, a vegetarian for ethical reasons. As a child I would have never had fish oil or the gelatin capsule containing it. That leads me to wonder if it were possible to swallow a steak in pill form whether I would do it for possible health benefits, and I'm inclined to think maybe I would.
 
Members don't see this ad :)
I've noticed this approach didn't work well while I was at U of Cincinnati but there we had a psych ER so the psych ER attempted to weed out the malingerers by holding them for about 20 hours of the required 24-hour maximum hold, where the person could only eat pretzels and water. Yes we had more food options but if we thought they were malingering they only got pretzels. The malingerers by then usually after a few hours started yelling "what no real food?!?!?" and they opted to leave on their own.

One time a patient complained that pretzels weren't real food and I opened a bag of pretzels, put it in my mouth and chewed it and said," oh oh oh that is soooo good! President Bush almost choked to death on one of these. This is presidential food."

She demanded chicken and lost all of her signs of mental illness. I told her that for someone seriously psychotic she seems to have a lot of passion in her choice of food and all of her demands for food were coherent, rational, goal-oriented, and she appeared to be able to care for herself given that nutritional intake is of concern to her.

And just like my SLU people, there was an intentionally insulting comment "You people don't have real food here, I'm going to Christ Hospital! I'll get real food there!"

So the ones that got past that initial filter were a bit more resilient than the ones I see at SLU. We have no psych ER at SLU so they're usually not weeded out.
 
  • Like
Reactions: 1 user
I don't like this at all. If you believe the vegetarian diet may help depression, then you should be offering it to all your patients.

It sounds like you are only offering it to certain patients to agitate them enough to make them leave. If you already have determined as best you can that they are malingering, then deal with that in the appropriate manner --why go through this diet thing?
 
Actually, and I am correcting myself, I did offer it to two inpatients that I did believe were mentally ill because I did think it could help their mental health. One was a TBI patient that was violent despite being tried on several meds and I do believe the violence was due to TBI. The other was a depressed patient but he refused and I told him I'd honor his request.

The TBI patient after about two weeks on the diet opted to go back to a regular diet because he told me he felt no difference and I honored his request.

As for the "why the offer?" Cause IMHO the likelihood of violence will be less when they choose to leave vs us telling them to leave. I'm sure you've seen people in the ER or inpatient unit start acting-out such as screaming, throwing chairs, etc when told to leave. With this approach they seem to want to get out ASAP.

I got the idea after reading the article but also seeing a specific patient in the psych ER throw a fit and security had to escort the patient out. The patient threatened to harm someone (not due to Axis I but due to Axis II and a threat to be hospitalized or else). The police were called but refused to show up. Security literally physically picked the patient and threw him (yes threw like he was a physical object to be thrown) out that IMHO would've been avoidable with this diet approach That patient started clutching onto heavy objects and objects that were stuck into the ground. That patient could've been hurt.

As for my outpatients I've always entertained the idea of including diet as a therapeutic approach, and I've presented omega 3 and vegetarian diets as options.

But yes, the ER patients suspected of malingering were often only give pretzels (not by me-it was the nurses) but I can also tell you this. The other food options consisted of white-bread + baloney or chicken sandwiches on the order of what you'd see in a vending machine and I'd rather eat the pretzels.
 
Last edited:
I thought about this more. At first I thought it was funny and clever, but then I started thinking about how I would react to hearing this, from the perspective of believing the doctor was serious. It would make me angry because it would be a red flag that the doctor was a nut. When you have severe mental illness, diet might possibly change your direction by a degree or two but it's not going to get you even in the right ballpark. If I felt a doctor couldn't get me in the right ballpark, I might be irate, as well.

I am not sure what it feels like to be a malingerer, so I can't speak to that. But if I were desperate for help and some guy came in talking like Dr. Oz that some fad diet would help me, I'd be even more desperate.
 
It's brilliant and harmless.

Offering Vegan might be a little over the top, though.
 
I thought about this more.

And this is what I'd like to hear. A reason why I brought this up is since this idea is new and I've been cutting and dissecting it myself I want this to go through the thought-experiment lab to so speak of other clinicians.

but then I started thinking about how I would react to hearing this,

Now let's be fair. If someone told me they were going to force a diet on me I didn't want I'd be pissed too....but here's my counter-argument.

1-Several standards exist where doctor can clearly go beyond just recommending but actually forbid behaviors.
Are not patients forbidden to smoke despite that this is what they may want? Why? It's because it's better for them. It's the law. Too bad if they want to smoke. If a patient has high cholesterol aren't we supposed to give them a low fat diet even if they want ice cream? If a patient is NPO and wants food are we supposed to cave in?

Where exactly are we supposed to cater to the patient even if it's not in their own best interests? The standard of care clearly points to them not being allowed to smoke or even eat under certain conditions such as being NPO even against their wishes for a GI procedure.

Shall I give a patient Xanax, Oxycodone, or any drug of abuse simply because they want it and the assessment within reasonable medical certainty shows they don't need it?

2-You're forcing it.
No I'm not. I never told the patient they would get a vegetarian diet no matter what. I'm telling them that if they truly have a mood disorder that food is an important component to mental health and I want them to consider a vegetarian diet. I also offered them the journal articles for them to consider this diet for themself and I wanted them to read it. The patient from there took the idea and ran with it---to a discharge.

As for the word "fad" I believe this is not fair. As I said there's evidence this diet can have benefits. is it faddish to offer fish oil? Faddish to offer milk thistle for a liver patient when study after study shows it benefits the liver? Faddish to tell patients to exercise to improve mood?

3-If I didn't use this approach and the patient didn't opt to leave, we would be kicking them out anyway, by force if necessary.

Remember, this patient was already assessed for malingering and was found within reasonable medical certainty to be so. This is not someone that would've stayed in the hospital anyway and would've been given a diet they didn't want against their will. I think most people would agree it's safer for everyone including the patient for them to walk out willingly vs security guards literally picking up the patient and tossing them out of the hospital onto a concrete sidewalk.

4- This type of cat & mouse testnig is unethical.
Is it? Several accepted practices in medicine are based on diversion. E.g. distracting a patient while injecting them to reduce pain. As I said there's evidenced-based data showing a vegetarian diet could work. I am not presenting false data.

Malingering testing-every single test of it is based on this type of approach. You ask the patient questions about their mental illness with the complete intention of seeing if their symptoms fall within a category of realistic vs highly unrealistic. You watch them to see if their signs match their symptoms. The SIRS, the M-FAST, the TOMM, you think this is unethical you must also state those tests are so too. You must also state that someone ordering a BMP on a patient alleging to have renal problems but no signs of it to double check is being unethical because we're not placing 100% faith in the patient. We are testing them. Yes-repeat we are testing them to see if what they claim to have matches the science.

If one were to argue this is unethical then IMHO all malingering testing would be and we'd then have to accept that we are to keep anyone in the hospital as long as they want even if we do not believe they are in need of our services.

The entire point of testing is to see what is REALLY GOING ON regardless and/or in addition to what the patient is telling us.

I'm not saying this to be defensive or sanctimonious. I want some people here to really critically think about it and tell me if they agree or disagree because this is an out-of-the box approach. I welcome and opposing points of view so long as it's based on something reasonable that does not deny the reality that malingering goes on and sometimes quite often in some clinical scenarios and that we physicians have a duty to not enable such behavior.
 
Last edited:
  • Like
Reactions: 1 user
1-Several standards exist where doctor can clearly go beyond just recommending but actually forbid behaviors.
Are not patients forbidden to smoke despite that this is what they may want? Why? It's because it's better for them. It's the law. Too bad if they want to smoke. If a patient has high cholesterol aren't we supposed to give them a low fat diet even if they want ice cream? If a patient is NPO and wants food are we supposed to cave in?
These are not examples of doctors forbidding behaviors. It's the law, not the doctor, stopping patients from smoking. And while we can recommend patients eat a good diet or be NPO, anyone who's worked on the floors knows that patients will do what they want regardless of if we think we're forbidding it.

If one were to argue this is unethical then IMHO all malingering testing would be and we'd then have to accept that we are to keep anyone in the hospital as long as they want even if we do not believe they are in need of our services.
No, this is a clear strawman. The other malingering tests are validated and accepted. This vege-diet test is not. So it's not unreasonable for us to want to treat them differently.

Anyway, I'm wondering what happens if someone calls your bluff? Will you admit the person you've already determined to be a malingerer? I really feel it's best to be direct and upfront. Playing games like this wastes time and invites trouble.
 
It still doesn't make sense to me. Granted, I'm not familiar with malingering, but people malinger in order to get something, such as out of work or a place to stay, for example. So, say your main goal is to not go to work. Would being suggested to take on a vegetarian diet be so horrible that you'd go to work instead? Or say you're homeless and want a place to stay–what homeless person would say no to a vegetarian meal? The idea that a malingerer--a person without a mental illness--would become irate seems strange to me.

It seems more likely that a person who is mentally ill would be concerned that their psychiatrist is also mentally ill if he's going on about a vegetarian diet for aiding mental illness. And that's coming from a vegetarian.

The other possibility is that there isn't such a direct line between malingering and mental illness. That's how you're approaching the patient. It's unlikely that a patient, even a malingerer, would see himself in such a clear cut way. When we do things for secondary gains, we're not always aware of it. We tend to believe our own stories. Isn't that a big thing in psychology? That it's difficult to believe anything that goes against what the ego needs/wants.
 
It still doesn't make sense to me. Granted, I'm not familiar with malingering, but people malinger in order to get something, such as out of work or a place to stay, for example. So, say your main goal is to not go to work. Would being suggested to take on a vegetarian diet be so horrible that you'd go to work instead? Or say you're homeless and want a place to stay–what homeless person would say no to a vegetarian meal? The idea that a malingerer--a person without a mental illness--would become irate seems strange to me.

It seems more likely that a person who is mentally ill would be concerned that their psychiatrist is also mentally ill if he's going on about a vegetarian diet for aiding mental illness. And that's coming from a vegetarian.

The other possibility is that there isn't such a direct line between malingering and mental illness. That's how you're approaching the patient. It's unlikely that a patient, even a malingerer, would see himself in such a clear cut way. When we do things for secondary gains, we're not always aware of it. We tend to believe our own stories. Isn't that a big thing in psychology? That it's difficult to believe anything that goes against what the ego needs/wants.

Second guessing a Forensic Psychiatrist's evaluation of a malingering patient that he has seen in person and you haven't.

The fact is someone so mentally ill to be in a true vegetative state shouldn't even be able to snap out of it if you offered them a plate of pocket lint for a meal.

I'm not sure where these opinions are developing from.
 
  • Like
Reactions: 1 user
Members don't see this ad :)
http://www.nutritionj.com/content/pdf/1475-2891-11-9.pdf
http://www.ncbi.nlm.nih.gov/pubmed/20515497

OK vegetarian diets improving mood are half the reason why I'm bringing this up.

I've found this a very effective method to wiggle out malingerers. If I suspect malingering, I offer a vegetarian diet, mention the alleged benefits, mention that there's data showing it can improve mood, and guess what? So far every single person I've offered it to demanded to get out of to the hospital and sign out AMA.

Here's what typically happens. We get a patient, patient alleges to be suicidal, may even show vegetative sx, tell me that they've been on every antidepressant and nothing works. I tell them something to the effect of, "Sir maybe a new approach is needed. We can try a vegetarian diet. Please allow me to show you some articles showing why it can help." Then the patient becomes irate, all of a sudden loses all of their vegetative sx, then demands to leave the hospital, even a lot of them saying they faked all of this when I tell them that if they are suicidal I got to keep them in the hospital against their will. While waiting to sign out AMA, they are told to wait a few hours just so we can check collateral data about their safety and during this entire time we see no signs of depression. Some of them even say they're going to a neighboring hospital because the food is better.

I don't see anything unethical with this. First off, I'm offering them the data showing why it can help. This is evidenced-based data. There is a theory to why it works considering the arachadonic acid/omega 3 ratios in the brain, I've already done a malingering assessment and I have significant reasons to believe they are malingering that meet reasonable medical certainty.

I've not yet had a patient with vegetative signs that when offered this diet maintain their presentation, in which case I would've believed they were depressed. It could also be that because I'm not trying with this those I don't believe to be malingering, I'm not getting non-malingerers to try this approach. I've spent years doing M-FASTs and SIRSs so it's to the degree where I can almost do it in my head based on an interview.

Thoughts?

I thought about this more. At first I thought it was funny and clever, but then I started thinking about how I would react to hearing this, from the perspective of believing the doctor was serious. It would make me angry because it would be a red flag that the doctor was a nut. When you have severe mental illness, diet might possibly change your direction by a degree or two but it's not going to get you even in the right ballpark. If I felt a doctor couldn't get me in the right ballpark, I might be irate, as well.

I am not sure what it feels like to be a malingerer, so I can't speak to that. But if I were desperate for help and some guy came in talking like Dr. Oz that some fad diet would help me, I'd be even more desperate.

I'm with Whopper on this one, malingers waste valuable time and resources that could be used helping others who actually are sick and really do need help. If there's a harmless way to get the person out of the hospital (he's not giving false advice to anyone who is actually sick, and as stated it's not really false advice anyway because there is some evidence basis for suggesting a vegetarian diet) without serious incident (the patient choosing to leave means they remain in control of the situation, and would probably be more likely to storm out with a string of expletives in their wake than have to be forcibly removed with a possible result of violence or injury) then it should be done - that's a bed that is being taken up by someone faking a reason to be there, whilst a genuinely suicidal/psychotic/distressed person is forced to wait for the help they actually need. So f**k 'em, they get no quarter from me. And yes I do know what it's like to be poor and desperate enough to line up at soup kitchens, or beg for a meal, or to have to go knocking on shelter doors hoping there's a bed available for the night, and my prior comment still stands.
 
To what extent do people think a hospitals going strict vegan would save money on frequent flyers? As a student, we see quite a few people who mysteriously improve (i.e., cease feeling suicidal or voices quiet down) when their benefit cards are reloaded.
 
To what extent do people think a hospitals going strict vegan would save money on frequent flyers? As a student, we see quite a few people who mysteriously improve (i.e., cease feeling suicidal or voices quiet down) when their benefit cards are reloaded.

This sort of concept is one of the things thats most frustrating about inpatient to me. For the patients who really genuinely need to be there, the units are often so sparse and spartan that I feel terrible for the patients. I would be super irritated if I had to give up all my electronics and share living spaces with several folks who don't bathe.

But then on the other hand, for the patients who don't really need to be there its like a luxury spa. They are living the high life with unlimited graham crackers, fuzzy socks and not having to constantly look over their shoulder watching for the drug dealer they owe money.

So for the patients who need to be there the units seem less than adequate, but for the malingers the units are too nice.
 
The ethics of malingering and consuming a limited resource warrants the technique. Which I think is creative and harmless. A diet with variety is healthy. Fasting is good for you. 24 hours without the compressed floor scraps of a meat packing facility is not an ethical outrage.
 
  • Like
Reactions: 1 user
The idea that a malingerer--a person without a mental illness--would become irate seems strange to me.It's unlikely that a patient, even a malingerer, would see himself in such a clear cut way. When we do things for secondary gains, we're not always aware of it. We tend to believe our own stories. Isn't that a big thing in psychology? That it's difficult to believe anything that goes against what the ego needs/wants.

They're trying to pull a scam for their own benefit, and someone has called them on their BS, of course they're going to become irate. There's a difference between knowing how to utilise the system to your best advantage, and taking advantage of that system. Malingers aren't these poor lost ego driven souls acting on a subconscious level, they know exactly what they are doing.
 
In defense of the malingerer: If I were in the situation that many of these wretched souls are in you can be sure as hell I would be malingering too. Most people malingering psychiatric illness do actually have some mental illness or substance use problem, which is how they learnt to malinger in the first place. Often psychiatrists fall in to the trap (especially junior residents) of trying to "get the goods" on these patients and derive some fleeting satisfaction for catching them out, this ultimately leads to dissatisfaction, anger, and burnout. I can tell you we did not see malingering very often in the UK (but with cuts to welfare it's on the rise). Medical and mental health services bear the brunt of the failings of social care in this country. Even if medical or psychiatric help is not what is needed, it is sadly what's on offer. And so of course people are going to avail themselves of it. I think that is incredibly adaptive. Within limits I will try and help these individuals as far as I can, maybe giving them some extra food, a place to shower or stay warm for a few hours or occasionally days. I do not typically confront them. I have had security escort malingerers out where they have been threatening or hostile and saying they would kill themselves in the hospital. But if they are willing to let me help them in some way, then I do what I can. And this is an infinitely more satisfying approach. (but they aren't getting any xanax, adderall, oxy or suboxone from me).
 
  • Like
Reactions: 1 user
In defense of the malingerer: If I were in the situation that many of these wretched souls are in you can be sure as hell I would be malingering too. Most people malingering psychiatric illness do actually have some mental illness or substance use problem, which is how they learnt to malinger in the first place. Often psychiatrists fall in to the trap (especially junior residents) of trying to "get the goods" on these patients and derive some fleeting satisfaction for catching them out, this ultimately leads to dissatisfaction, anger, and burnout. I can tell you we did not see malingering very often in the UK (but with cuts to welfare it's on the rise). Medical and mental health services bear the brunt of the failings of social care in this country. Even if medical or psychiatric help is not what is needed, it is sadly what's on offer. And so of course people are going to avail themselves of it. I think that is incredibly adaptive. Within limits I will try and help these individuals as far as I can, maybe giving them some extra food, a place to shower or stay warm for a few hours or occasionally days. I do not typically confront them. I have had security escort malingerers out where they have been threatening or hostile and saying they would kill themselves in the hospital. But if they are willing to let me help them in some way, then I do what I can. And this is an infinitely more satisfying approach. (but they aren't getting any xanax, adderall, oxy or suboxone from me).

I feel the same way. But as a diagnostic move recommending a diet plan change and incurring an indignant response that results in a voluntary discharge is reasonable. Not everyone that malingers is a bad customer. But why clog a busy unit with those who think they're at a restaurant and who want to speak to the manager about the menu. Like now! That guy can take a hike.
 
i very much like whopper's suggestion, i just cant use it here myself, except maybe at the VA. One problem is that some people who really need to be on an inpatient unit balk at having more of their rights taken away and no longer agree to hospitalization when they discover they cant smoke or go out or that it's a locket unit etc.
 
I agree completely about feeling empathy towards the plight of those malingering, and I agree that given the same circumstances I would absolutely do the same to get a safe, warm place to get fed. But thats exactly why its so important that we consistently don't allow those who are malingering to get what they want by malingering. As a society we can't afford to treat homelessness in a psychiatric hospital. Allowing the malingers to stay in the hospital takes up beds needed by the acutely ill and is furthermore a short term band-aid that a community uses as a crutch instead of having having to face the reality of the social problems facing it. Honestly, if a provider feels so strongly about wanting to help someone in this sort of situation I would much rather a couple people chip in $10 to get them a hotel room, instead of allowing them to stay in the psych hospital overnight at the cost of thousands to society.

Obviously the easiest and most comfortable thing for a psychiatrist to do is turn a blind-eye towards the malingering and give them temporary shelter at the hospital. But I don't find it particularly noble for a physician to dishonestly use society's resources (at no real expense to yourself) in the name of their own personal altruism.
 
I agree completely about feeling empathy towards the plight of those malingering, and I agree that given the same circumstances I would absolutely do the same to get a safe, warm place to get fed. But thats exactly why its so important that we consistently don't allow those who are malingering to get what they want by malingering. As a society we can't afford to treat homelessness in a psychiatric hospital. Allowing the malingers to stay in the hospital takes up beds needed by the acutely ill and is furthermore a short term band-aid that a community uses as a crutch instead of having having to face the reality of the social problems facing it. Honestly, if a provider feels so strongly about wanting to help someone in this sort of situation I would much rather a couple people chip in $10 to get them a hotel room, instead of allowing them to stay in the psych hospital overnight at the cost of thousands to society.

Obviously the easiest and most comfortable thing for a psychiatrist to do is turn a blind-eye towards the malingering and give them temporary shelter at the hospital. But I don't find it particularly noble for a physician to dishonestly use society's resources (at no real expense to yourself) in the name of their own personal altruism.

What's the situation like in the US then? Are there just not enough resources to assist the homeless or people in poverty, or is it a case of resources being available and not enough advocacy groups to help people access them? Because from my point of view I can definitely empathise with the reasons people might feel driven to malinger, but not the malingering itself because to me it seems there are so many other options available, especially if you've spent some time experiencing hardship and/or living on the streets.
 
What's the situation like in the US then? Are there just not enough resources to assist the homeless or people in poverty, or is it a case of resources being available and not enough advocacy groups to help people access them? Because from my point of view I can definitely empathise with the reasons people might feel driven to malinger, but not the malingering itself because to me it seems there are so many other options available, especially if you've spent some time experiencing hardship and/or living on the streets.

I think its a combination of inadequate resources for the acutely homeless in combination with general social problems that lead to chronic poverty and homelessness. In addition to the general crappy social support systems here, there is the ease of assess if you get in a unexpected jam. Most of the homeless shelters around here you need to stand around and wait to get a spot and even then your not guaranteed anything if its busy that night and the next shelter may be a very long walk away. But if you walk to the road, wave down a cop/ambulance, tell them your suicidal and were about to jump in front of traffic you will get a free ride to the psych hospital and a place to stay that night.
 
What's the situation like in the US then? Are there just not enough resources to assist the homeless or people in poverty, or is it a case of resources being available and not enough advocacy groups to help people access them? Because from my point of view I can definitely empathise with the reasons people might feel driven to malinger, but not the malingering itself because to me it seems there are so many other options available, especially if you've spent some time experiencing hardship and/or living on the streets.

I consider myself progressive, and while it's usually a conservative stance to say that government is inefficient and wasteful, I think that is a huge problem in the US. We do have resources available, but they come through organizations that are very difficult to navigate. If you are disabled or mentally ill and poor and need public assistance, you basically need a lawyer or a very committed family to help get public support. Getting a bed in a long-term residential care facility can take years. Most care is outpatient-based, and there are community care workers at the municipal level, but they are often just a stop-gap. I received those types of services for a while, and I heard some horrible things about other clients who were worse off than me. These community care workers would check in on people a few times a week in their homes. If they were decompensating and couldn't get into their psychiatrist, the care workers would have to take them to the ER. It was just a bad cycle of the right level of care not being there, so everything is treated with stop gaps: insufficient community care and ER visits. This is from the state I live in: http://en.wikipedia.org/wiki/Creigh_Deeds#Stabbing And that was the son of a wealthy politician.

I'm less familiar with people who are homeless and not disabled or mentally ill, but if it's so difficult to get mental health care as a person who is mentally ill, I can't imagine there's much help for people in general. There's not a lot of general welfare available as far as I know. In the winters, churches open up so people can avoid freezing to death, but they can generally only stay there overnight. My sister teaches elementary school here in the US and has students who are homeless or live in houses with tens of people in them.

The US is one of the most unequal developed countries, which I believe calls into question what the meaning of being developed really is.
 
I think its a combination of inadequate resources for the acutely homeless in combination with general social problems that lead to chronic poverty and homelessness. In addition to the general crappy social support systems here, there is the ease of assess if you get in a unexpected jam. Most of the homeless shelters around here you need to stand around and wait to get a spot and even then your not guaranteed anything if its busy that night and the next shelter may be a very long walk away. But if you walk to the road, wave down a cop/ambulance, tell them your suicidal and were about to jump in front of traffic you will get a free ride to the psych hospital and a place to stay that night.

I consider myself progressive, and while it's usually a conservative stance to say that government is inefficient and wasteful, I think that is a huge problem in the US. We do have resources available, but they come through organizations that are very difficult to navigate. If you are disabled or mentally ill and poor and need public assistance, you basically need a lawyer or a very committed family to help get public support. Getting a bed in a long-term residential care facility can take years. Most care is outpatient-based, and there are community care workers at the municipal level, but they are often just a stop-gap. I received those types of services for a while, and I heard some horrible things about other clients who were worse off than me. These community care workers would check in on people a few times a week in their homes. If they were decompensating and couldn't get into their psychiatrist, the care workers would have to take them to the ER. It was just a bad cycle of the right level of care not being there, so everything is treated with stop gaps: insufficient community care and ER visits. This is from the state I live in: http://en.wikipedia.org/wiki/Creigh_Deeds#Stabbing And that was the son of a wealthy politician.

I'm less familiar with people who are homeless and not disabled or mentally ill, but if it's so difficult to get mental health care as a person who is mentally ill, I can't imagine there's much help for people in general. There's not a lot of general welfare available as far as I know. In the winters, churches open up so people can avoid freezing to death, but they can generally only stay there overnight. My sister teaches elementary school here in the US and has students who are homeless or live in houses with tens of people in them.

The US is one of the most unequal developed countries, which I believe calls into question what the meaning of being developed really is.

Here we have several different types of benefits people can claim if they're eligible (although I'm not sure how much that has changed since the new Government came in, I know they were planning a lot of funding cuts and extra restrictions, and so on)...There's Youth and Newstart Allowance (for the unemployed looking for work), Sickness Benefits, Disability Support Pension, Family Allowance, Austudy & Abstudy (for those in full time study), as well as Health Care Card Benefits if you're on any sort of pension or benefit. Now these payments don't exactly have people raking in a healthy wage, they are pretty much still bare minimum payments, and of course those who have mental health and/or substance abuse issues aren't always the best at managing their finances. I know back in the 90s when I ran into trouble a few times (no money for food, on the streets at one point) there was the Church on Wednesday morning you could go to the back of and get a bag full of still fresh bakery products donated by local bakers outlets, and then Thursdays you could walk 20 minutes up the road to another Church and get a hot cup of tea or coffee, cake and biscuits, as well as a basic food pack (long life milk, bread, baked beans, etc) no questions asked. There were advocacy groups you could go to as well that would assist you in getting a 'temporary hardship' voucher that either allowed you an actual voucher to a certain value you could take to a supermarket to be redeemed for food and basic living items, or to access other charity services like the free supermarket the Salvation Army used to run in the city, or the Food Bank in the City's West (where everyone would get a weeks worth of basic groceries and then we'd all sit round in a big circle and have a swap meet - 'I'll trade you a tin of ravioli, for that tin of canned soup you've got' - 'I've got more than one carton of milk here, anyone want to do a swap for a loaf of bread?'). St Vincent De Paul ran night time meals (roast and veg with gravy) for $1.50 at their city drop in centre, and then there were the soup kitchens that were always parked at certain times around the various parks, or you could even get yourself a free three course vegetarian meal at the Hare Krishna restaurant if you were willing to wash some dishes, or wipe down a few benches. If you wanted a hot shower you could go to the University shower rooms and use them, if you tidied yourself up a bit you could sometimes pose as a hotel guest in one of the hotels and gain access to the enclosed, and heated pool area and catch yourself a bit of kip there, or if you got to know some of the security guards that worked guarding empty buildings/buildings in development, and developed a bit of a rapport with them they'd sometimes let you crash inside as long as you didn't trash the place. And then of course you could always turn an extra trick to pay for a cheap motel room for the night and maybe get some take away once you'd made enough money to get your fix if you were an addict. It certainly wasn't what I'd call an easy life at times, and sure you had to learn how to hustle to a degree, but not once did I ever have to abuse something like the hospital system by making up some fake complaint just to get a meal and a bed. I know some people might say 'but you were forced to prostitute yourself', and well hey no one held me down and forced a needle in my arm and made me become an addict against my will, and I'd much rather have been out there peddling my ar5e than to waste time, space and resources that someone else, who was genuinely ill/struggling/in distress, actually needed.
 
Last edited:
Wow,. so many posts. Don't know if I can respond to all of them.
These are not examples of doctors forbidding behaviors. It's the law, not the doctor, stopping patients from smoking. And while we can recommend patients eat a good diet or be NPO, anyone who's worked on the floors knows that patients will do what they want regardless of if we think we're forbidding it.

The smoking thing is the law. True-Hamstergang. But the NPO thing I'm right on. A patient cannot have certain things done such as a GI procedure if they don't follow the rules. If a patient, for example started eating food, procedure is cancelled. They can then leave the hospital if they don't want it cause there's almost no point in them staying there.

No, this is a clear strawman. The other malingering tests are validated and accepted. This vege-diet test is not.

No. The vegetarian test is not simply being used as a malingering test, although the patient's response could further reinforce the notion they are malingering (E.g. completely inconsistent signs vs sx). As I mentioned several times, they already were assessed for malingering and found to be so before I offered the diet.

I argued the futility of being against malingering testing not to defend the vegetarian diet I offered but to defend the practice of malingering testing and assessments in clinical practice. The vegetarian diet offer is akin to a PT Barnum, "This way to the egress" maneuver to elicit a response where the patient will want to voluntarily leave on their own vs security physically picking them up and throwing them out.....a more dangerous scenario for everyone including the patient.
 
Last edited:
This sort of concept is one of the things thats most frustrating about inpatient to me. For the patients who really genuinely need to be there, the units are often so sparse and spartan that I feel terrible for the patients. I would be super irritated if I had to give up all my electronics and share living spaces with several folks who don't bathe.

This is actually an unintended but very good effect of the thread I mentioned.

Malingering and how to deal with it are no-nos that people avoid as a taboo in professional debate. For psychiatry this is an issue we see often but no one wants to talk about the ethics of kicking malingerers out vs keeping them in cause no one wants to publicly admit which side they are on.

In the meantime the issue, because it is not being debated, just goes on with no one really tacking what to do.

It is nonsense that malingering evaluations aren't taught in general residency and I find it pathetic it's only taught in some forensic fellowships, not even all of them. It should be well taught in all residencies.

For the people who disagree with me, I'm not against them on this in terms of anger. I think if anything this issue needs to be pushed to the forefront of our profession for more debate, all sides.

. Most people malingering psychiatric illness do actually have some mental illness or substance use problem, which is how they learnt to malinger in the first place.

Completely agree. IMHO many malingerers should get some type of mental health treatment, but most of them (repeat most, not all) should definitely not be in the hospital.

Someone pushed to malingering is either antisocial, in which case that doesn't get better even with treatment, or in such dire straits with other personal issues such as personality disorder traits and that latter category is definitely one where they can benefit from a mental health provider.

The problem here is that given that the person is malingering, the provider trying to get to the real heart of the issue may never ever be able to do it within a reasonable time unless the malingerer drops the malingering.

This post is already too long but in trying to explain the case in a nutshell, I had a forensic case of a kid that was bludgeoned by the cops to the degree where he needed brain surgery and his skull drilled to relieve brain pressure or die. He alleged his memory was so bad and permanently so. He was suing the city for millions.

Turns out he was malingering. Memory testing with the TOMM among other tests showed he was very much fabricating or exaggerating his problems. On interview, after pretending to remember nothing I told him....
"You realize that if your memory is as bad as you're making it out to be and you win your lawsuit you'll have to have a guardian assigned to you and won't be able to control any of the money you win. What is your response to that? I'm going to report to the court that if your memory is as bad as you make it out to be you don't have the capacity to control your money."

The kid immediately started acting normal and told me he could remember very well. He showed me 30 minutes of behavior where his cognition and memory showed no deficits.

You can likely figure out what my opinion was. Of course I told the court the kid was malingering. The testing and the clinical presentation beyond a shadow of a doubt supported he was malingering.

Here's the problem and it points to exactly SPLIK wrote. The guy IMHO really did have a memory problem. His brain damage after the cops bludgeoned him was visible on brain scans. I'm convinced it did something bad to him, just that because he was malingering and wanted to get several millions, we couldn't tell just exactly how bad it was. It might have been minor to moderate. It could have entitled him to some reward.

I even mentioned that to the judge. I and 3 other doctors wrote that we believed there was some type of potential memory problem, just that this kid was so hell bent on trying to win and get as much money as he could we couldn't figure out just how bad it really was other than that it wasn't severe cause when he was able to do ADLs and maintain himself well when he dropped his fake presentation when we saw him through a one-way mirror.

The judge dropped the kid's case. There's legal precedents showing that when a plaintiff lied on anything, I mean anything, the entire case is thrown out the window. That's what happened to this kid and I still wonder to this day that maybe he did legitimately deserve something.
 
No. The vegetarian test is not simply being used as a malingering test, although the patient's response could further reinforce the notion they are malingering (E.g. completely inconsistent signs vs sx). As I mentioned several times, they already were assessed for malingering and found to be so before I offered the diet.
Right, so there is a difference between the malingering tests and this vege-diet-maneuver (to be known as VDM for now). Therefore, one could easily be in support of one and not the other. You said, "If one were to argue this [VDM] is unethical then IMHO all malingering testing would be," but as they are different things for different purposes with different levels of evidence, that really does not logically follow.

I'm a little upset that you left out responding to the part of my post that I was most interested in -- what if the malingerer calls your bluff?
 
Therefore, one could easily be in support of one and not the other

Fair and logical. And given that I gave some very long posts it can mislead the reader as to my intentions.

What if the malingerer calls my bluff? I'll talk with the treatment team and decide what to do. Still throwing them out in a literal physical sense onto a concrete sidewalk is still an option. We want to avoid that. Not even considering the well-being of the malingering patient, such an event could traumatize the non-malingering patients. The goal then is to kick them out in a manner that requires the least amount of conflict. I've also only kicked patients out when there's a real potential for conflict if I was over 95% certain they were malingering. (Based on a combination of gutt-check experience, actual documented evidence, plus actual studies that could point to the statistical possibility).

I should also mention that if one person on the team doubts the malingering I usually give the patient another 1-3 days for us to figure this out. I also should add that when I was at U of C, the nurses yes only gave pretzels but only if this patient was a known malingerer--e.g. we saw them several times and had hospital records strongly supporting malingering, or it was blatantly obvious (e.g. they are heard telling another patient they are faking their problems).

But as I said with the food in the psych ER, the other food aside from the pretzels, yuck, I'd rather just eat the pretzels.
 
Not directly related but I just kicked out a malingerer a few days ago and I found out today that he broke into the home of one of my current patients. He duped her into revealing her address while in the unit. The patient's case manager went to the home and found the malingerer patient drunk and he allegedly invited several homeless people in there and gave away her booze among other things.
 
Last edited:
Too gamey for my taste.

And there are ethical issues to it (though on the softer end of the scale). For this to work, it has to assume that the vegetarian diet is noxious stimuli to most people and that it will dissuade malingering by being noxious to the point that only individuals who are truly ill will tolerate it and those who are malingering will not.

This is the same game that used to be played by not alleviating pain in folks suspected of malingering or other forms of punishment ("therapeutic wait," refuse blanket requests, subject to noise, etc.). It's unethical because you are providing negative stimuli to patients who are undeserving of this maltreatment (those who are not malingering) as a diagnostic tool.

If you are sure they are malingering, give them the door. If you're not sure, negative stimuli on potentially legitimate patients is unethical.

4- This type of cat & mouse testnig is unethical.
Is it? Several accepted practices in medicine are based on diversion. E.g. distracting a patient while injecting them to reduce pain. As I said there's evidenced-based data showing a vegetarian diet could work. I am not presenting false data.
True. But applying this technique only to some patients and not others is unethical.

If one were to argue this is unethical then IMHO all malingering testing would be and we'd then have to accept that we are to keep anyone in the hospital as long as they want even if we do not believe they are in need of our services.
The reason I disagree with the approach is that it's not a true test. You have one of four results:

1. A legitimate patient who accepts the new diet and stays, tolerating what they view (and you are using) as negative treatment
2. A legitmate patient refuses the new diet and leaves, not tolerating the negative treatment
3. and 4. You will have the same results with malingering patients

So you can't call this a test, because the results don't tell you anything useful. Well, I suppose it tells you whether or not their disdain for vegetarian diet over-rides their desire for treatment, but this will capture both legitimate and malingering patients, though it sounds like you would assume malingering, which could be faulty.

Non-sensitive, non-specific, and dodgy ethically. I vote no.
 
I don't like this at all. If you believe the vegetarian diet may help depression, then you should be offering it to all your patients.

It sounds like you are only offering it to certain patients to agitate them enough to make them leave. If you already have determined as best you can that they are malingering, then deal with that in the appropriate manner --why go through this diet thing?

Probably because most providers think that the study is BS...but since it is there...they can use it to their advantage.
 
If you are sure they are malingering, give them the door. If you're not sure, negative stimuli on potentially legitimate patients is unethical.

Still disagree but I do think your points merit more discussion.

Is it noxious? Vegetarian food could be delicious. Being more realistic, in a hospital, it's probably not going to be that, then again the regular food likely isn't going to be either.

Let's cut into it even more. A regular diet in most hospitals isn't healthy. A typical breakfast: Whole milk, pancakes, coffee with half-and-half, sugar, a side of potatoes and eggs-not egg whites, I mean whole eggs, toast with butter or margarine. I wouldn't call that healthy. In fact I would downright say it's unethical we're giving that as "regular."

Here's a breakfast I eat usually 7 days a week. A protein shake. It's vegetarian. I'm not a vegetarian. I'm an omnivore who was a vegetarian for weeks at a time but stopped not because I hated it but because every darned time I went to someone's house I felt I was imposing on them for having to re-arrange their dinner for me. About 1-3x a month I'll eat real food cause I'll cook up some pancakes for my family on a weekend and want to bond with them while eating it.

The dictionary meaning of "noxious" is....
http://www.merriam-webster.com/dictionary/noxious
1 a : physically harmful or destructive to living beings<noxious waste>

b : constituting a harmful influence on mind or behavior;especially : morally corrupting <noxious doctrines>
2
: disagreeable, obnoxious
nox·ious·ly adverb
nox·ious·ness noun

It certainly is not #1. In fact a regular diet fits more of the category of #1. One could even argue offering a regular diet is unethical since we are health care providers and we are not giving them a healthy meal.

In fact, IMHO a "regular" diet should automatically be low-fat, low salt, high fiber because that is a healthy diet and we're talking the hospital here, not the McDonald's.
E.g. egg-white omelet with chopped scallions, low fat cheese, skim milk or maybe 1%, whole wheat toast, orange juice or decaf coffee.
It doesn't HAVE to be that. It could also be a Mediterranean diet. E.g. Olive oil for dip, toast, hummus, etc.

On no! Now I'm offering them a noxious diet! While I'm being sarcastic, the word "noxious" was being used in the context I used it in the last sentence.

Now, being fair does it fit #2? Disagreeable? Yes it does. Then again a lot of what we do in the hospital is that. We make the patients wear gowns, take away their shoes even against their will, take away their belt, put them in a room with a roommate even if they don't want one, turn off the TV when they go to group. Some people find exercising noxious. Shall I refuse to offer it? Some people find fish oil noxious because it causes a fishy burp.

I can't honestly see how offering a vegetarian diet for several is on a scale significantly worse than telling a guy he can't have his own room. Further the vegetarian diets I've seen in three different hospitals were not IMHO aesthetically worse. E.g. curry sauce with vegetables and rice, or nachos with multi-layer dip, blackbean burger with a side of sweet-potato fries, for breakfast-pancakes with vegetarian sausage, heck on some days the vegetarian menu is better than the regular. I'm not being sarcastic at all.

I do think it is "disagreeable" but in a category no worse than what is done for safety and healing purposes in a hospital unit.

So you can't call this a test, because the results don't tell you anything useful.

I wrote this before and I'm repeating myself for clarification. The vegetarian diet itself is not the "test," though the patient's reactions should be noted. The patient was already determined to be malingering. The goal is already determined to be to get the patient out of the hospital. It's a "this way to the egress" technique to avoid what could become a physical altercation that is more dangerous for everyone including the patient.

And by the way we do offer the patient referrals for what I believe what is really the heart of the matter. That is referrals to homeless shelters, rehab facilities and outpatient services.

Too gamey
Well a psychiatrist certainly has a right to pick their style of treatment so long as it's evidenced-based, well-intentioned, and leads to positive results. Yes it is gamey. I understand if this turns you off. I still adhere, however, to the argument that as scientists we do have a duty to figure out what is really going on, and that as physicians, in our effort to avoid causing harm, we avoid enabling pathological behaviors such as fabricating or exaggerating illness for personal gain.

If you find it more palatable to simply kick the patient out, hey I respect that but I really do think it's more dangerous to do that.
 
Last edited:
My brief experience thus far has been that malingerers no longer fake psychosis, they simply fake SI with a plan, and state they have a firearm at home. My psych patients in the ED all have some variation of this story and use it at the various ED's in the city without fail.
 
Is it noxious?
You spend way too much time on this question and arrive at a conclusion contradictory to the rest of what you post in this thread. If you don't think the patients will view the vegetarian diet as 'disagreeable' then it wouldn't work at all to get them to leave in order to avoid that diet.
 
No one has yet to explain why a malingerer would care about the quality of the food given what she/he is already avoiding. If this is only to get them out the door and not a test, what malingerer would decide that whatever is so horrible about there in the world (homelessness, going to a job) is better than vegetarian food? Hospital food is going to be terrible either way. By definition the malingerer has gone to a hospital because something in their life was so detestable they'd rather be in a hospital. Slightly worse hospital food is worse than what led them to seek shelter in the hospital?

I'm not taking a moral position on this; I just don't think it makes sense.
 
Usually it has to do with the individual feeling like society or more popularly the VA "owes" them something...the VA owes me a nice hot meal and a cot, the va owes me a stipend, the VA owes me benzos etc. etc. Once they feel they are owed something, then they will do everything in their power to get it.
 
This is bringing back so many memories of hostile interactions with malingerers on the units. This is why I don't do inpatient psychiatry. Let's eliminate all accountability, recreate the womb, and hope nobody sneaks in wanting in on the umbilical cord. It's unethical to be "aversive"... but no pain no gain. Almost everything we do in life to get ahead "hurts" ie. exercise, a good diet, trying new things, experiencing failure, studying for a test, working, raising a family, giving to others. I remember a great quote from a surgeon in med school "if you're not in pain, you're not alive". Is it ethical to make depressed patients walk on reverse conveyor belt to get to the cafeteria? No. Would they feel better? Probably.
 
You spend way too much time on this question and arrive at a conclusion contradictory to the rest of what you post in this thread. If you don't think the patients will view the vegetarian diet as 'disagreeable' then it wouldn't work at all to get them to leave in order to avoid that diet.You spend way too much time on this question and arrive at a conclusion contradictory to the rest of what you post in this thread.

I didn't say it's not disagreeable for the patient.

I said IT IS (well at least for many of them).

Just as I mentioned that several things are disagreeable in a usual hospital stay.

If you don't think the patients will view the vegetarian diet as 'disagreeable' then it wouldn't work at all to get them to leave in order to avoid that diet.

Again I said it is disagreeable for many. Some will want to leave once they don't get Xanax or Ativan, others will if they can't watch the Superbowl. Others will if not able to determine their diet even if it is a diet unhealthy for them.

. Let's eliminate all accountability, recreate the womb, and hope nobody sneaks in wanting in on the umbilical cord. It's unethical to be "aversive"... but no pain no gain.

A foundation approach in DBT is the patient is to experience the natural consequences of their actions and as health care providers, we are not supposed to block them because in doing so we are enabling the pathological behavior that got the person in the bad predicament to begin with.

E.g. if someone gets drunk, has a hangover, and calls us up asking us to write a sick excuse note to the employer and not mention alcohol use, we tell them that we can write a note, so long as it tells what's truly going on otherwise we're not writing one at all.

IMHO malingering whether you disagree with me or not needs to be openly debated more and this thread proves it. There are no clear guidelines being offered in residency training programs on this. We got Linehan on one hand telling us to be firm with cluster B patients on the other hand, we got several psychiatrists openly keeping patients in the hospital that they don't even believe are mentally ill in the sense they are reporting but writing a false dx down.
 
Last edited:
  • Like
Reactions: 1 user
A foundation approach in DBT is the patient is to experience the natural consequences of their actions and as health care providers, we are not supposed to block them because in doing so we are enabling the pathological behavior that got the person in the bad predicament to begin with.

E.g. if someone gets drunk, has a hangover, and calls us up asking us to write a sick excuse note to the employer and not mention alcohol use, we tell them that we can write a note, so long as it tells what's truly going on otherwise we're not writing one at all.

IMHO malingering whether you disagree with me or not needs to be openly debated more and this thread proves it. There are no clear guidelines being offered in residency training programs on this. We got Linehan on one hand telling us to be firm with cluster B patients on the other hand, we got several psychiatrists openly keeping patients in the hospital that they don't even believe are mentally ill in the sense they are reporting but writing a false dx down.
It is important to keep in mind that a core DBT principle is to minimize hospitalization. The worst thing we do is keep the Cluster B patient until they get comfortable in the setting. Also, to have the patient recount in "painstaking detail" the precursors to the behavior. I have the patient go over it and over it until they say they are sick of talking about it, then they are ready to be discharged.
 
Also, to have the patient recount in "painstaking detail" the precursors to the behavior. I have the patient go over it and over it until they say they are sick of talking about it, then they are ready to be discharged.


And such therapy is considered noxious and inappropriate by some providers despite that this is considered an acceptable and appropriate DBT technique.

Linehan, by the way, does have training courses where some of the most difficult scenarios are presented. She doesn't poo-poo difficult patients. She also doesn't believe in revolving door treatment where we enable pathological behavior but at the same time encourages outpatient providers to truly take up these difficult patients and deal with their immature defense mechanisms for real.

A problem in psychiatry is we get borderline PD patients all the time and most of us don't get training on how to deal with it. So when we get them in outpatient we don't do anything appropriate. E.g. psychiatrists often-times put borderlines on medication gumbo regimens and keep them on it despite that it doesn't work, or just refer them back to inpatient.
 
And such therapy is considered noxious and inappropriate by some providers despite that this is considered an acceptable and appropriate DBT technique.

Linehan, by the way, does have training courses where some of the most difficult scenarios are presented. She doesn't poo-poo difficult patients. She also doesn't believe in revolving door treatment where we enable pathological behavior but at the same time encourages outpatient providers to truly take up these difficult patients and deal with their immature defense mechanisms for real.

A problem in psychiatry is we get borderline PD patients all the time and most of us don't get training on how to deal with it. So when we get them in outpatient we don't do anything appropriate. E.g. psychiatrists often-times put borderlines on medication gumbo regimens and keep them on it despite that it doesn't work, or just refer them back to inpatient.
Yup. See it every day.
Also, it might seem noxious and inappropriate and the patient wants to talk about everything else but what caused them to cut or attempt suicide, but I make it very clear to them that if we don't then it will just keep happening again and again and again.... They are as tired of the same old painful cycle as everyone else is. Well not true, actually, they are much more tired of it because they have to live it. We get to go home our relatively stable and happy lives.
 
I didn't say it's not disagreeable for the patient.

I said IT IS (well at least for many of them).

Just as I mentioned that several things are disagreeable in a usual hospital stay.



Again I said it is disagreeable for many. Some will want to leave once they don't get Xanax or Ativan, others will if they can't watch the Superbowl. Others will if not able to determine their diet even if it is a diet unhealthy for them.
Yes, but you view the vege diet as more disagreeable than the other things patients have to do in the hospital (else, why come up with something new to drive the malingerers away?). You are suggesting to offer the vege diet for the purpose of it being noxious, which is not why we do the other noxious things we do in a hospital.
 
Yes, but you view the vege diet as more disagreeable than the other things patients have to do in the hospital (else, why come up with something new to drive the malingerers away?). You are suggesting to offer the vege diet for the purpose of it being noxious, which is not why we do the other noxious things we do in a hospital.
We have a similar issue at our hospital where the administration has decided they want to keep hospital stays brief. I quote, "if we make it too comfortable for the patients, then they won't want to leave." It really raises the question of why we can't treat all of our patients with dignity and respect regardless of how "real" their psychiatric illness is. I don't think functional people are trying to fake their way into our facilities so why do we need to keep these people out? In our community we have one PMHNP and one counselor and one case manager at the community mental health center and we have a population of 20000 which means we have about 200 people with schizophrenia and another couple hundred with Bipolar I and the usual mix of other more difficult to classify cases. Maybe that's why our ER is overloaded.
 
Yes, but you view the vege diet as more disagreeable than the other things patients have to do in the hospital (else, why come up with something new to drive the malingerers away?). You are suggesting to offer the vege diet for the purpose of it being noxious, which is not why we do the other noxious things we do in a hospital.

Certainly a fair argument. I didn't agree with your previous post because it wasn't factually accurate. To the malingerer that doesn't want a vegetarian diet, why would that turn them off and not getting something that's been going on before not turn them off?

Well first off, and I am making presumptions here, some of the usual things do turn them off. Ever see a malingerer freak out when we don't give them Ativan or Xanax? I see it with newer ones. The experienced malingerers, however, have come to expect that and are willing to tolerate it.

It's the old, put a frog in boiling water, it'll jump out but put it in water that's slowly heated, it'll tolerate it. It's a new step in a different direction and foreign to the patient.

The vegetarian diet, however, is a new experience for even the experienced malingerers often called "frequent flyers" and "professional patients." In fairness several truly sick people are also termed "frequent flyers" because they have severe mental illness such as schizophrenia and are frequently non-compliant.

A geographical-specific factor I'm noticing is I'm being told by several clinicians that another hospital in the area will take patients without any blow-back. In fact when I've discharged a lot of patients they've even told me, "if you don't give me Xanax (other hospital I will not name) will give it to me!" and then leave. As I mentioned, the diet is a "this way to the egress" strategy. Not only am I making it less appealing to stay, the patient is also being offered a carrot by the other hospital. I personally don't think they should be doing that but it is what it is.

Another aspect about the vegetarian diet is that in our world where poor and uneducated people often times eat horrifically fat-laden diets, e.g. making McD's the norm, instant TV/frozen pizza dinners, etc, the person could be automatically assuming something not true. That we're going to offer them rabbit-food. E.g. salad 3-meals a day

No.

As I've mentioned, in most hospital systems I've seen the vegetarian diet is something on the order of something I or most people wouldn't mind eating at all and in some cases is actually preferable to the regular diet, not just in terms of heath, but in terms of taste.

IMHO the huge emotional turn-off is based on ignorance and an American mindset on diet that meat and high fat equates with being "real food."

And to clarify, the newer malingerers are often allowed in, even by myself. Why? Because I don't determine if they're a malingerer and proceed on that unless I'm very certain. By day 3, or their 2nd + hospitalization/visit to the ER, I'm usually very certain. By then we usually have several notes supporting that the person is not mentally ill, seen by several clinicians reporting consistent data that the person is not showing signs of mental illness, I've done a malingering evaluation, and we've contacted collateral and have a fairly nice picture of what's going on with the person.
 
Last edited:
As others have stated already, its pretty clear that the core reason for this veg diet isn't for treatment of any psychiatric d/o, but to encourage malingerers out. I'm just an amateur nutritionist, but I think vegetarian/vegan diets are not healthy. Yes, ALA, a form of Omega-3 PUFA can convert to EPA/DHA, but does so in a very inefficient manner. You're better off getting your EPA/DHA from marine/animal sources and/or supplements. Furthermore, theres more evidence supporting the benefits of not just Omega-3 PUFA, but saturated fats in maintaining cardiovascular, neurological, and mental health.

As for malingering, I think there are better methods. But yea, it sucks that EDs have been the place to go when people get kicked out of housing. Usually its because they simply don't want to follow certain rules such as...not being high or drunk.

How sad it is that there are people who are willing to get stuck, change into paper scrubs, and be forced to lie to a bunch of people so they can get shelter and food. What an existence.
 
I wrote this before and I'm repeating myself for clarification. The vegetarian diet itself is not the "test," though the patient's reactions should be noted. The patient was already determined to be malingering. The goal is already determined to be to get the patient out of the hospital.

I don't get it. Are you saying that, as the treating psychiatrist, you do not have the authority to discharge a patient you've determined to be malingering?
 
Top