Hard Cases: The Personal Loss and 4 a.m. Awakening That Transformed My Career – and My Life



Omar Manejwala, MD, MBA | 10.09.2019 | LinkedIn Hard Cases | Posted in Insights

Like many who do this work, I didn’t choose the mental health profession -- it actually chose me. In fact, I never had any intention of treating addiction. How I arrived at where I am today has more to do with my frustration on behalf of people struggling with addiction and their families -- and with experiencing personal loss in the face of a deeply broken healthcare system.

I had setout to become a neurosurgeon. I attended the University of Maryland School of Medicine and completed two neurosurgical sub-internships. It was during my 4th year as I was rounding on my 5th comatose patient at 4 a.m. that I became keenly aware that I was more attracted to the idea of neurosurgery than the actual work itself. I realized that it was the mind that fascinated me most. After a series of thoughtful conversations, I found myself on a new path at Duke studying what really interested me -- psychiatry.

As a practicing psychiatrist in Charlotte, I still had no intention of focusing on addiction. When I saw a patient or a family struggling with substance use disorders, I would refer them to a specialist—often they’d have to travel hours to find one. They were suffering with issues that were destroying their lives and their communities. Of course, I was frustrated every time I tried to get them help, but that paled in comparison to the frustrations they were feeling -- abandoned by a system that treated them at times like they weren’t really sick -- they were just bad people.

Then it hit me personally. My best friend Greg died of a heroin overdose. I had revived him once before using Narcan, but this time, he succumbed -- and it was nothing short of devastating. I realized I could no longer send these patients and their families to other practitioners. So I responded in the only way I knew how, by listening, learning and treating these misunderstood patients myself.

Fast forward to today. My close friend Chris passed away of an overdose in January of this year, 14 years and 5 months after I lost Greg. The same treatable, preventable disease that killed Greg, killed Chris. What has really changed in the almost 15 intervening years? We do have newer medications to treat opioid addiction -- but most facilities don’t even offer them -- and over 90% of people with addiction don’t receive any treatment at all. So what’s really changed in that timeframe?

People suffering from substance use disorders -- and their families -- are struggling with a healthcare system that simply isn't built for them. Even though we understand that rapport, empathy, understanding and relationships are fundamental to mental health outcomes, we still deliver care in sterile, transactional units -- if at all. And, overwhelmingly, mental health solutions are offered in a one-size-fits-all approach. When that doesn’t work, the next step is often to blame the patient. The stigma we still attach to addiction and mental illness make it far too convenient to blame outcomes on patients who ‘don’t know better’ or ‘don’t care.’ We still have many facilities that will kick people out of treatment for relapsing. Imagine if you were discharged from your doctor because your diabetes or heart failure symptoms returned! Yet this is exactly how people with substance use disorders are treated (that is, not treated) every single day.

An immediate shift is needed. We must redirect our healthcare innovation energy and resources where they will make the biggest impact for this silently suffering population. These innovations should be guided by five key principles:

  • We need to acknowledge that what matters to people is far more important than what is the matter with people. What matters to people is what drives engagement, and most behavioral health interventions fail to effectively engage. So how can we engineer systems for scale that value understanding and learning rather than purely system or provider-driven knowledge transfer?
  • We need to make getting help the path of least resistance not the result of the most coercion. In other words, it should be easier to get help than to get high. So how can we identify and partner to solve the unique barriers and challenges that each person faces in getting well, and how can we do this at scale?
  • We need to meet patients where they are. Since most of what drives health and happiness occurs outside of the healthcare environment, how can we better understand and ultimately support members where they are—geographically, emotionally, mentally?
  • We need to help patients customize plans that evolve with their needs. So how can we leverage technology to deliver the right care and support to the right member at the right time?
  • We need to lose the stigma. So how can we remove stigma and give patients a safe way to seek help?

To help answer these challenges, I joined the team at Catasys, where we work with people who may be on the verge of suicide, are dependent on intoxicants or face crippling anxiety or depression. Some are ashamed to admit to food insecurity; others face loneliness, intimate partner violence, unstable housing, poverty and other challenges to health. As a result, their medical conditions are worsening, and they are landing in emergency rooms and hospitals. Nearly all have lived their entire lives without ever having received help for mental health conditions.

We take this group of silent sufferers and engage them in flexible approaches that work for them, helping them get well and driving down the overall costs of their medical care. By allowing them to teach us about their lives and what matters to them, we become better suited to offer fingerprinted solutions that can solve their problems.

It would be easy to be despondent thinking about the friends we have lost and the patients who are still flailing in a system that isn’t architected to care for them -- and to be sure, at times I am. But more often, I’m filled with gratitude to be part of a team that is solving these systemic injustices and helping people who have been suffering for far too long to get the care they so desperately need.

Omar Manejwala, M.D. is the chief medical officer of Catasys, one of the nation’s leading experts on behavioral healthcare and the author of “Craving: Why We Can’t Seem to Get Enough”. He is also a Distinguished Fellow of the American Psychiatric Association and a fellow of the American Society of Addiction Medicine.