This piece was written in March 2020
You are being kept inside. It is for your own safety, and for the safety of others. This is the unprecedented message we are being told by the UK government, but for people currently detained on mental health wards against their will, it is a sentiment that rings all too familiar.
In lockdown as in mental health law, the competing interests of individual freedom and collective safety have to be carefully weighed. These are deep issues of political philosophy, upon which grand ideologies have been built and wars waged.
For the patients of my psychiatric ward they are tangible daily realities. Some have lived their lives constantly bouncing between hospital and home, even with the best community support. They might, quite understandably, harbour bitter feelings towards NHS services that have deprived them of their freedom over months or even years. Lockdown is small fry.
Anne is not one of these patients; this is her first admission and she has never previously required the input of secondary mental health services. She has led what is by most accounts a fairly ‘normal’ life; a stable office job at the local council, a supportive husband, two young children. There have probably been psychological troubles bubbling under the surface for many years, but all of this fades into the background as I set eyes on the distressed and agitated woman I find bouncing around the ward.
“Doctor, just the person,” she begins.
It is another half hour before she stops. In the intervening period Anne fires a scattershot salvo of her jumbled thoughts in my general direction. She jumps between topics that at times seem to be associated only by rhyme or pun. A few themes emerge. The coronavirus pandemic, she tells me, is a serious threat that requires a serious response. She tried to tell her colleagues about social distancing, but they wouldn’t listen. She found a solution to coronavirus, and even cured herself of the disease. But her workplace said she was getting too stressed, and advised her to take some time off. Perhaps they were jealous, she worries – planning to steal her ideas and pass them off as their own. Maybe, as a doctor, I could understand the seriousness of the situation. Maybe I could help get her ideas out.
Her plans to defeat coronavirus are bizarre and seem to involve a network of traffic lights that the council will install nationwide. For whatever reason Anne decides to entrust me with this information, but she is convinced that her conspirators are hard at work trying to steal her ideas. They have even started listening in on her thoughts.
That is Anne’s reality. To our medical eye, she has entered a state of acute psychosis; her mind had become detached from the real world. Anne’s psychosis has a strong flavour of mania, with the typical features of tangential speech and grandiose delusions.
Without treatment, Anne’s mental state will only worsen. It already poses a serious risk to her physical wellbeing. Despite her husband’s best efforts, she has barely eaten, slept or washed in days. She only came to our attention after being brought in by the police, dishevelled and acting bizarrely in a public place. Public spaces have developed a whole new character in the last few weeks; mentally unwell patients may contract or spread the virus if disinhibited, and this has added a whole new dimension of risk to consider.
Like the vast majority of patients with psychosis, Anne’s greatest risks come from misadventure, self-neglect and exploitation. Contrary to the damaging depictions often seen in popular culture and certain media sources, psychotic individuals rarely pose a risk to other members of the public.
Anne is able to recognise that she is on a mental health ward, but reasons behind this remain mysterious to her. She feels insulted that we would even suggest she has a mental illness, and asks to be let out immediately. She certainly does not want any of our medications, thank you very much.
No amount of debate can shake the beliefs of a psychotic individual. The mind has become fixed on a strange and often threatening worldview that has one foot in reality, and the other in the fantastical. One man, totally convinced his brain was wired with tracking devices, took his spotless brain scan as proof, not of his mistaken belief, but of the medical conspiracy against him. In such cases talking therapy might be part of a longer-term recovery, but it is only medications that can reverse the immediate disease process.
Psychotic illnesses provide an unpleasant paradox – at their most sick people lose insight into their illness and refuse to be treated.
In rare circumstances and as a last resort, doctors can detain and treat patients against their will. In matters of physical health, the law is clear that anyone of sound mind can decline a treatment, even when that decision results in harm or death. But for mental disorders the law is more complex, and compulsory treatment may be necessary in certain circumstances. The legal bar is set appropriately high, and no health professional takes this decision lightly.
Anne’s mind gradually cleared as the medications kicked in. After a week or so her special curative powers and paranoid delusions were a strange and foggy memory. We held coherent conversations for the first time, her insight slowly returned, and her family breathed a sigh of relief as she sparkled back into her normal self. Anne was appreciative for the care provided, if a little bemused by the whole situation.
Had we acted paternalistically in our treatment of Anne? Without a doubt. It almost goes without saying that paternalism can be a dangerous thing in the world of medicine, and psychiatry in particular has its own dark history to contend with. But I also believe we acted with her best interests at heart.
In some comparatively small way, people across the globe have found themselves in a similar situation to Anne. We are compelled to follow restrictions that are being imposed with the aim of our protection. Government authorities sit in the position of mental health professionals, having to draw arbitrary lines and decide which risks are unacceptable, which restrictions too burdensome.
I have no doubt that many more people like Anne will pass through our doors during this crisis, shaken by the combined effects of social isolation, disrupted community services, and inherently uncertain and stressful times. Most of our patients are not as fortunate as Anne in their social circumstances, and will be the first to fall through the gaps when services are stretched. People with serious mental illnesses may end up overlooked in our efforts to protect vulnerable groups. A respiratory condition might hamper your chances of survival in hospital, but a serious mental health disorder may prevent you accessing care altogether. Physical and mental vulnerabilities feed into one another, and neither should be viewed in isolation. We have all heard the slogans declaring parity between mental and physical health. Now is the time to live up to that maxim.
Tom Ronan 