Thursday, 21 January 2010

The Problem with Relatives

Relatives and carers of people with mental illness need to be heard and respected. They are frequently good informants, and often bear the considerable burden of caring for a mentally ill relative without complaint, and for far longer than they necessarily ought.

However, relatives are not always good informants. Sometimes they can be actively malicious – I have had several nearest relative requests for assessments (to which, under Sec.13(4) MHA, we have to respond) from ex-partners complaining that their wives/husbands are behaving in an irrational and unbalanced way, when the only “irrational” behaviour is that they no longer wish to live with an abusive partner. And sometimes they become just too sensitised to the relative and interpret innocuous or normal behaviour as signs of mental illness.

Ivan’s GP phoned me one afternoon. He had had a call from Ivan’s mother saying that he was becoming unwell again. She reported that he was threatening her and neighbours, and that the police had been called on one occasion. Although the GP had not recently seen Ivan, he was nevertheless requesting a formal assessment under the Mental Health Act. He had noticed that Ivan had not ordered a repeat prescription for his antipsychotic medication for about 6 months. On the basis of this information, I agreed that I would undertake an initial assessment with the GP, and the GP arranged for Ivan to visit the surgery the next day.

I did know Ivan. He was a man in his 40’s who lived alone. I had assessed him under the Mental Health Act about 7 years previously, again on the information of his mother. In fact, she had often reported that he was displaying gross symptoms of mental illness, but when assessed had been found to be largely asymptomatic. On the previous assessment, he had admitted to an unusual somatic hallucination or delusion, which was the feeling that someone was pressing down on his head. He admitted that the only way he could find of relieving this symptom was to bang his head on the wall, and indeed he had a few contusions and abrasions as a result of this practice. He had also lost a lot of weight and complained of having no appetite.

That assessment had been inconclusive, and the psychiatrist and I had not felt he was detainable under the MHA. However, he did agree to an informal admission, and he was checked out medically to exclude any physical causes for these symptoms. He was discharged on a small dose of antipsychotic medication, had remained very well for several years and had eventually been completely discharged from the Community Mental Health Team.

In view of this previous history, and despite the reported concerns, I somehow doubted that the assessment would result in an admission to hospital.

I was right.

I saw Ivan on his own initially, as the GP had had to see another patient. Ivan remembered me from my previous contacts with him, and was friendly and appropriate throughout the conversation. He told me that for the last few years he had been doing a part time Open University course leading to a degree in Astrophysics. He had attended short courses and summer schools, and had even spent a week working at an astronomical observatory on Majorca.

All this was true. Since cosmology is something I am quite interested in, while we waited for the GP to join us, we had an illuminating and interesting discussion about String Theory, the Large Hadron Collider, and the nature of black holes, and even got into an argument about whether or not the Higgs Boson existed.

He showed not the slightest evidence of psychosis or any other signs of mental illness. He said that he was still taking his medication, and had not collected any recently because he was on such a small dose he still had a supply. This was plausible. He had insight into his disorder, recognising the ill effects of not taking the medication on the occasions when he forgot it. He denied any problems with the neighbours, although agreed that he had fallen out with his mother a couple of months previously because she had been trying to convince him that he was unwell. He had not seen her recently. There was no evidence of head banging, and he had even put on weight since I had last seen him.

He shook my hand as he left, and I wished him luck with his degree.

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