The provision of inpatient psychiatric care is some-times complicated by the need to treat patients who are unable or unwilling to identify themselves or who provide false identities. While treatment plans may be organized under these circumstances, prompt identification of these individuals helps reunite patients with their families, enabling faster recovery and establishment of a behavioral and cognitive baseline against which to judge the extent of illness and the efficacy of treatment. Successful identification also enables recovery of records detailing past hospitalizations and information on successful previous treatments. In addition, name, birth date, and social security number are required to procure the social services that are often needed for the long-term care of patients with chronic mental illness.
There is a paucity of literature describing the process by which such patients are usually identified. However, available methods include searching local residential listings, contacting local police departments and homeless shelters,1 checking missing persons notifications in local newspapers, and checking national missing persons registries. While helpful, these methods sometimes fail; they may also run counter to patients' wishes or expose patients to adverse legal consequences.
In this article, we describe a relatively non-intrusive method used to determine the identity of and obtain critical clinical information about three poorly identified patients.
Mr. A was a patient in his early forties who was found without identification in southern Connecticut after having been expelled from a commuter train originating in New York City. He exhibited poor hygiene, malnutrition, and psychotic ideation and behavior. The patient spoke accented English and was very disoriented, able only to state a name, birth date, and a residential address without state or country name. Because he was indigent, Mr. A was referred to our mental health center for evaluation and care. He was diagnosed with and treated for schizoaffective disorder and responded well to therapy over the course of several weeks. His condition stabilized, with improved interactivity and decreased psychosis after administration of risperidone and citalopram, as well as lorazepam as needed.
Preliminary efforts to identify Mr. A at the time of presentation were unproductive, with staff searching missing persons registries and white pages listings in the states of New York and Connecticut in print and online without success. The team then initiated efforts to have the court appoint a conservator for the patient, because, despite some symptomatic improvement, he was unable to serve as his own clinical decision-maker.
At this time, the treatment team revisited Mr. A's initial presentation. The staff noted that the name the patient had given when he was first brought in was uncommon and non-Anglicized and wondered whether Mr. A might have provided the name of a well-known personality outside the United States rather than his own. The internet search engine Google was used to look up the name given by our patient, with the first and last names he had provided entered in quotation marks. The search engine returned a link to the New York City Police Department's Missing Persons web-site, where a picture of Mr. A was posted, along with his stated name and information that his family was looking for him. The detective in charge of the case was notified and he in turn contacted the patient's family to tell them where he was located. A few days later, Mr. A was reunited with his family. According to his family, the patient had had a prolonged history of psychiatric illness, including psychosis, and his family had relocated him to the United States 5 days before his disappearance so that he could receive more comprehensive mental health care. His recent arrival in this country was a possible factor in his becoming lost and not being able to identify where he lived.
Mr. B was a monolingual Spanish-speaking patient in his early twenties who was brought by police to the emergency room of another institution after exhibiting bizarre behavior and being found to have no identification. He was reported to have been staring at a magazine rack for 2 hours, laughing intermittently, and apparently responding to internal stimuli. He was transferred to our institution, where he stated on admission that his name was "Mr. B" and that he was 38 years old, although he gave a birth date that was incongruent with his stated age but proved later to be in fact his correct birth date. Mr. B admitted to being an undocumented immigrant, but was disoriented to date and unable to give a place of birth or residence more specific than a country. He also told the treatment team that all of his family members had been murdered within the last few years.
Mr. B was treated for psychosis with various antipsychotic medications, to which he initially had a poor response. He was then treated with clozapine, which led to gradual improvement. At this point, the patient became increasingly able to provide some information about his background. He revealed that he had been looking for a job in New York City, but was unsure when or why he had come to Connecticut. As time passed, Mr. B was able to provide the treatment team with his exact foreign residence and full names of his close family members. With this additional information and the patient's permission, the treatment team contacted the Office of Citizens' Aid at the New York embassy of Mr. B's birth country. However, the team was told that the patient's birth place and place of residence would need to be confirmed by independent means before the embassy would intervene.
The Internet search engine Google was then used to consult residential directories in the patient's home country. The name Mr. B gave for his father was entered in quotation marks. The directory returned the exact name given by the patient as well as a telephone number. Google was used again to confirm that the telephone number that was listed corresponded to the city and country information given by the patient. After obtaining the patient's permission, Mr. B's father was contacted via telephone. The patient was reunited with his family, who were alive and well. The embassy subsequently arranged for the patient to be transferred to a psychiatric hospital in his country of origin.
Ms. C presented to our institution with psychotic mania, giving a name that did not match the social security number she provided. She had no identification with her and apparently had no ties to the local area or its mental health facilities. Ms. C volunteered a great deal of information about her background, including professional training programs she claimed to have completed, names of relatives, and names of treating psychiatrists and hospitals. She gave various last names, stating that she had been married multiple times.
In an initial attempt to identify Ms. C, the treatment team contacted the Social Security Administration; however, the Social Security Administration would only disclose that the social security number the patient had provided did not match any of the last names she had given. The Internet search engine Google was used to search for the patient's first name in combination with each of the last names she had given, but these searches were unproductive.
During the course of treatment, Ms. C mentioned that she did not want the treatment team to contact her brother, whose name she mentioned. A member of the team recalled that name as one that had been on the list returned by the search engine during the initial Internet search of the patient's various putative last names. The team searched Google for the presumptive name of Ms. C's brother and located an obituary notice for him, which contained dates that corresponded roughly to important events in the patient's life. The treatment team contacted the funeral home in the obituary and was given the telephone number of Ms. C's presumed sister-in-law. The patient gave the team permission to contact this relative after being shown her brother's obituary notice. Ms. C's sister-in law provided the name of a mental hospital where Ms. C had previously been treated, and a conservator was then appointed to coordinate care for the patient. In reviewing the patient's initial presentation, the conservator determined that the initial social security number given by the patient had been incorrect by one digit.
Treating patients whose identities are unknown is a recurrent concern for clinicians who provide psychiatric care, particularly since a number of psychiatric conditions, such as schizophrenia, dissociative disorders, and dementia, may sometimes cause patients to be unable or unwilling to provide identifying information. In addition, patients may sometimes have a conscious determination to withhold identification, for example, in cases of substance abuse, antisocial personality disorder, or merely because of a desire to maintain anonymity. A number of problems can arise from lack of identification, such as difficulty arranging long-term care for these patients, who may need to apply for governmental assistance to finance placement, as well as difficulty selecting appropriate pharmacotherapy without having any treatment history available.
Clinicians have several tools at their disposal when trying to find patient identities. These include accessing community resources that have frequent contact with the indigent, checking telephone directories, searching registries of missing persons, and enlisting the help of law enforcement officials. Contacting police departments, however, is potentially problematic as it may expose patients to arrest and/or incarceration.
Another tactic is the use of court-appointed conservators, who may have access to data not accessible to the healthcare team, such as being able to match names and social security numbers. According to the Social Security Administration, written authorization is required to match names and social security numbers; for patients who do not provide authorization, the conservator or legally authorized representative is the only person who may access this information (personal communication with Social Security Administration). In a fourth case at our hospital, a patient's identity was revealed when her conservator matched the social security number she gave as her own to one of the patient's relatives. Establishing that link enabled the team to identify the patient and obtain vital clinical information.
The methods discussed above are time-intensive and, even when used, may not succeed in determining the identity of some psychiatric patients. The cases presented here illustrate the use of another method that can be used to determine the identities of persons with psychiatric illness-the use of online search engines to research important names, dates, or places given by patients whom caregivers have been unable to identify. In all three cases, the Internet was instrumental in reuniting patients with family members and in securing long-term services.
The Internet is especially useful for such identity searches for several reasons. First, it allows one to rapidly search digitized versions of familiar resources such as residential and business address and telephone listings and missing persons registries. The Internet is also a repository of a tremendous amount of information, such as genealogical relationships, organizational affiliations, photographs, and criminal records, that were either previously inaccessible or very difficult and time-consuming to access. The Internet is a public information resource, much like a telephone book. Accessing the data contained within it, therefore, is, in one view, no more intrusive than consulting a telephone directory or a newspaper archive to verify information given by a patient. On the other hand, the Internet differs from these more traditional resources in that information on individuals may be listed without their knowledge or consent. Examples include postings of family trees, sex offender names and addresses, and the more recent phenomenon of weblogs, or "blogs"-online diaries that are widely read, unedited, and unverified.2
Although questions remain about appropriate limits on accessing personal patient information, the Internet's potential utility in caring for unidentified psychiatric patients is clear. Specifically, the use of online search engines may produce outright identifying information or clues to identity, such as family names and relationships or important dates and events. Searches conducted more than once at different time points may be especially helpful, as the Internet is a dynamic network in which data are continuously updated. Although the identities of many of these patients are eventually revealed, it is to the patients' and clinicians' advantage to expedite this process and minimize costs of investigation where possible. It is our hope that detailing this experience may facilitate the identification of similar patients admitted to psychiatric institutions.
1. Irwin RS, Rippe JM, eds. Irwin and Rippe's intensive care medicine, 5th edition. Philadelphia: Lippincott Williams & Wilkins, 2003.
2. Gallagher DS. Invasion of the "blog": A parallel world of web journals. New York Times 28 December 2000, late ed: G11.