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Vol. 5, No. 12 / December 2006

In “10 delirium myths debunked,” (Pearls, Current Psychiatry, October 2006) Dr. Mitchell Levy promulgates a dangerous myth about psychiatric illness. He states that a patient—a postoperative middle-aged attorney with psychotic symptoms—“is not mentally ill, but has delirium.”

Delirium, like schizophrenia, is a mental disorder. The idea that a mental syndrome with an identifiable physical cause is not a psychiatric disorder is antiquated and obviously incorrect but is not understood by many medical personnel. We need to educate our colleagues about this misconception.

This myth dehumanizes mentally ill individuals. By distinguishing the middle-aged attorney from what might be considered a typical schizophrenia patient, Dr. Levy propagates the idea that mentally ill persons come from a class beneath successful professionals. This mistaken idea contributes to misdiagnosis and inadequate treatment and disproportionately low financial allocation for treating mentally ill patients.

Ira Handler, MD
Butler Memorial Hospital
Butler, PA

Dr. Levy responds

As a psychiatrist in a large university hospital, I advocate for the mentally ill daily and would never denigrate their condition.

A differential diagnosis via DSM-IV-TR, however, requires determining that “symptoms are not due to the direct physiological effects of a substance or general medical condition.” The best way to advocate for our patients is to render proper treatment, and the standard of care for treating delirium addresses causative medical issues.

Delirium is a mental disorder just as depression is a physical disorder caused by disrupted neurobiological mechanisms. However, as most psychiatrists—but not all internists—are aware, a high-functioning person rarely suffers a first schizophrenic break in middle age. Conversely, bypass patients are at risk for cognitive and perceptual changes—which mimic schizophrenia—caused by delirium.

My article described a situation I encounter frequently in consultation-liaison psychiatry when non-psychiatrists attempt to admit their delirious patients to the psych unit instead of treating the underlying medical cause. I hope that we can advocate for our patients across multiple venues and not at the expense of any group or population.

Mitchell Levy, MD
Assistant professor in psychiatry
University of Washington, Seattle

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