I’ve worked in many different aspects of healthcare so I have an understanding of what’s meant by “different level of care”. You probably understand it too but you may not have thought about it.

There are different levels of care for all illnesses and situations. You may understand it better from a medical perspective. Have you ever had a relative who broke a hip? Perhaps they went from their home to an emergency department; the ED triages who needs admission to the hospital and who can be managed acutely and sent home with perhaps more supports in place. From the ED the broken hip is admitted for surgery. Perhaps after surgery they are in the ICU for a day because their vitals are not stable yet. From the ICU they go to a medical/surgical floor. Then from there they are not quite ready to go home but too well for the hospital, so they are sent to a SNF (Skilled nursing facility aka nursing home/rehab). From SNF they are sent home with perhaps in home physical therapy and skilling nursing visits once a day. From there they are then deemed able to go to physical therapy outside of the house and follow up at an office with an orthopedist.

The point of this is to demonstrate the multiple levels of care we have for people suffering from injuries or illness. At any point in that example did you think “Now that this patient is going to outpatient PT they are clearly the worried well”?

No. You didn’t. Because they had a diagnosed injury, surgery, and recovery.

What about the asthmatic who sees their pulmonologist once a year unless they are sick at which time the pulmonologist sees them daily until their 02 sat drops and they are not improving with outpatient care. They send them to the ED. Luckily the ED stabilizes them with IV steroids and they are able to return home and avoid admission.

Again- when the asthmatic is well and seeing their pulmonologist once a year for maintenance visits did you think to yourself, “They don’t need a pulmonologist, they are just the worried well,”?

No. You didn’t. Because they had a diagnosed medical illness, treatment plan, and exacerbation of illness which required an ED visit.

Please explain to me why, when I treat clients at an outpatient level of care in private practice I am told that I treat the “worried well”? A few people have said it to me over the years, more probably think it, but they know I will ask pointed uncomfortable questions and give a lecture on the stigma of mental healthcare.

Mental illness is the ONLY area of our healthcare where people who seek outpatient maintenance treatment are labeled the “Worried well”. Do cardiology patients have to deal with that bullshit? No. Their patient may never be hospitalized. They may never enter an emergency department. They may see their cardiologist once a year for their EKG, Echo, stress test, and renewal of their anti-hypertensives but they are never referred to as the “worried well”.

I’m about to get on my soapbox, in fact I think I’m already there. (But just so you have the mental image: imagine me standing left hand on hip, right hand waving around sometimes pointing and shaking sometimes running through my frizzy crazy hair looking passionate enough that you want to follow me into battle.)

People who seek outpatient psychiatric treatment are many things but they ARE. NOT. THE. WORRIED. WELL.

They are brave. They are survivors. They are people with diagnosed and treatable illnesses that originate in their brains.

They have Major Depressive Disorder Recurrent Moderate without Psychotic features (F33.2). They have Bipolar Disorder (F31.9) They have Postpartum Anxiety/Depression/Psychosis (There are a few codes for this- look it up). They have Generalized Anxiety Disorder (F41.1).They have Post Traumatic Stress Disorder (F43.10). They have Adjustment Disorders (F43.20-F43.24). They have Gender Dysphoria (F64.9). They have Dysthymia (cycling/irritable depression often co-morbid with trauma responds well to Lamotrigine now labeled as Cyclothymia F34.1). They have OCD (Not a billable dx any longer). They have Autism (Anthem BCBS says this is NOT a billable diagnosis. Add it to the list as to why I despise them F84.0).

These are a smattering of the diagnoses I treat on a day to day basis. We have over six hundred clients at my practice and six clinicians. Over six hundred people. But yeah they are totally all the “worried well”. I want to scream when I hear this. Because let me tell you maybe three of them are well enough to go a year without seeing me. A small percentage see me a minimum of every 3-6 months and the rest see me monthly, bi-monthly, and during acute crises weekly or more.

Private practice is the least acute setting. That doesn’t mean we see the least acute patients. And even if we do see the “least acute” that doesn’t make them the worried well. Are all the outpatient patients of every specialty- pulmonology, allergists, immunology, rheumatology, cardiology, endocrinology, etc.- the “worried well”? No. Most of them have moderate sometimes severe illness but they see skilled clinicians who work their butts off to keep them out of the hospital. Even then, some patients will end up hospitalized. Some will die. This is the nature of medicine. Psychiatry is no different.

We work hard to keep our patients out of the hospital, out of intensive outpatient programs, but we recognize when it’s out of our arena and they’ve reached a level of illness that requires a higher level of care.

Calling my clients the “worried well” infuriates me at a visceral level. Because I’ve seen their tears- even wiped them in some cases. I’ve encouraged them, listened to them, adjusted medications, changed medications, initiated, discontinued, met with families, done therapy, done visits in the parking lot for the autistic client who is too agitated to come inside, told them to put their knife away because even with a knife I’m not prescribing Xanax, tried to reason with psychotic people to take their anti-psychotic medication, watched as mania destroyed lives and supported through the first year after a manic episode while we stabilize, manage side effects of medications, and try to pull them out of the deep suicidal depression that follows the epic and destructive mania. I’ve treated during pregnancies that were planned, unplanned, and the result of rape. I’ve treated people postpartum and post-abortions and post-rape.

To call my clients the “worried well” insults them. Insults their illnesses. Insults their journey. Insults their ability to drag themselves into psychiatric treatment when our society and often their family members tell them that they are the damn “worried well” and to just do yoga and they will feel better.

Patients who seek psychiatric treatment and make it to maintenance treatment are not the worried well. They are healing. If they make it there without being hospitalized and without an IOP and they stay there until we get them off medication and they never need it again…they aren’t the worried well. They are lucky. Lucky we found the right medication the first try. Lucky they had a robust response. Lucky they found a good therapist who they engaged with weekly sometimes twice weekly for two years so they could work through all the despair they brought into treatment. They are lucky to live without a relapse in symptoms through acute future stressors. Those patients are rare. In fact I cannot think of one. Because mental illness IS. AN. ILLNESS. Maintenance is the goal. But there is always a risk of relapse and for women it is particularly risky if they have their illness controlled before having children- because having children is a risk for relapse or worsening of symptoms.

People who mention the “worried well” in regards to private practice in mental health brings to mind the term “toxic positivity”. It is always said with a smirk. It is discounting of every person’s journey into mental health treatment. It also discounts the skill of private practice clinicians who keep so many out of higher levels of care through finesse, clinical acumen, long term bonds and trust with patients, and generally being damn good at what we do.

Now you know. Never say this about mental health practices or patients. It is demeaning, inaccurate, and rude.

Sit with that discomfort. Process your emotions. It will help build resilience if you process negative emotions instead of ignore them or sublimate them. (Google toxic positivity). It’s not my job to take away the discomfort with a witty or heartfelt wrap-up. I want you to sit with the discomfort as I have. Examine it. Learn from it.