Disclosure, How and When?

By: Pamela P. Siller, MD

“Hello doctor, this is Mrs. Goldman. I just wanted to let you know that Shmuel Rosen, his mother, or the Shadchen will be calling about Rivky. Such a wonderful boy, truly Bashert, but he has some questions for you. Just let them know my Rivky is fine, and all should be good, Kol Tuv”.

Voicemails such as these, or any variations thereof, may instill fear, or at the very least, some degree of unease in many practitioners as there are no easy answers to the complex situation represented.

Although boundaries in small communities can become blurred, the HIPPA guidelines are straightforward. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, was enacted on August 21, 1996.  The HIPAA Privacy Rule protects all individually identifiable health information that is held. PHI includes:

1. a patient's name, address, birth date and Social Security number;
2. an individual's physical or mental health conditions,
3. any care provided to an individual;
4. information concerning the payment for the care provided to the individual that identifies the patient, or information for which there is a reasonable basis to believe could be used to identify the patient.

 Any release of information must be accompanied by a document signed by patients over 18 years of age or by their parents if they are minors. Therefore, in the above situation, Mrs. Goldman cannot authorize the release of information for her daughter, provided that Rivky is over 18 years of age. Only Rivky can do so, and must name the specific individuals to whom she wishes the information to be disclosed.

The complexities continue, as disclosure of information may have implications on multiple levels. The topic of mental illness is emotionally charged, and can have many repercussions. It affects not only the patient, but the potential spouse and potential children as well. Additionally, in some communities where marriages are arranged, the marriageability of the patient’s siblings may be affected. Therefore, decisions to disclose information must not be taken lightly. 

However, disclosure can be very important. Mental illness can affect one’s marriage, job, finances, and ability to both have and parent children. Although the origin of mental illness appears to be multi-factorial, there is little doubt that genetics plays an important role in the etiology of mental illness. This is broad based, as one specific disorder can predispose a person to a number of different mental disorders. For example, one parent with schizophrenia confers a 10% risk that their child will have schizophrenia, as opposed to 1% in the general population.  When one parent has bipolar disorder, there is a 25% risk for the child, which increases to 50-75% when both parents are affected.  

Additionally, when a parent has bipolar disorder, this also increases the risk of depression, and other affective disorders. When one parent is depressed, the child has a threefold increase of depression.

As demonstrated, many factors must be taken into consideration.  If the patient is truly stable, there is no reason to think that they cannot have a successful and happy marriage. However, many mental illnesses are chronic, with exacerbations and remissions, which need to be navigated as they may place obstacles in marriage. Although most successful marriages utilize open communication, with both parties providing mutual support and encouragement, at first the patient may be conflicted about how much to disclose, and when, as they may risk losing their potential spouse. 

During Rivky’s next session, her excitement was palpable. She described the courtship in detail, and extolled the virtues of her Shmuel. She was agreeable to sign consent for disclosure to him and his mother, but then began to set parameters, “only say I was on medication for a month, and I do not need it anymore… no, just say I have depression… that does not sound as bad right?” After explaining that the truth could not be stretched, her enthusiasm began to wane. “What if he does not want to marry me, maybe I should not tell him about it.” After extensive discussion, it was decided that Rivky would speak with him herself, and then assess the situation. I could then speak with him by myself, or if she preferred to be present, they could attend a joint session, together.

Rivky returned for a follow up session a month later. She explained that after she disclosed her struggles with bipolar disorder, her fiancé felt comfortable enough to confide that he struggled with depression as a boy, and took Prozac for 2 years. He was also able to admit that he was again feeling overwhelmed, and was considering returning to treatment. The wedding date was set for 7 weeks away. However, Shmuel still had some questions regarding how her medication could affect her and their life together, particularly regarding fertility, pregnancy, and children.  After extensive discussion, and written consent, Rivky was able to call Shmuel in session, and we were able to allay his concerns. She continues to be happily married.

In general, as a psychiatric practitioner, I have always felt that less is more. There are no guarantees in this life, especially with sickness and health, regardless of predisposing conditions. The truth cannot be stretched or changed. If handled incorrectly, it can be perceived as a betrayal, and have disastrous consequences. Therefore, I always advocate for the patient themselves to disclose only as much information as they feel comfortable with. If further questions come up, they could be discussed and answered either in a joint session or individually with additional clarification by the mental health provider. Patients often feel more comfortable if they know in advance what will be discussed and disclosed. When an open, honest discussion occurs, it often brings both parties emotionally closer and sets the foundation for mutual respect and understanding, the cornerstones in a happy and successful marriage. 

 Pamela P. Siller, MD is a Board Certified Child, Adolescent and Adult Psychiatrist who provides medication management as well as individual and family therapy to both children and adults.  She maintains a private practice is in Great Neck, New York.  Dr. Siller is also the Director of Child and Adolescent Psychiatry at the Interborough Developmental and Consultation Center in Brooklyn.   She is an Assistant Professor of psychiatry at New York Medical College. She can be reached at 917-841-0663