Risk factor: Establishing a mental health diagnosis

Case notes

PRACTITIONER: Helen Durdy, a social worker in an early intervention in psychosis team

FIELD: Mental health

LOCATION: Manchester

CLIENT: Steve*, a 23-year-old man with mental health problems

CASE HISTORY:  Steve was malnourished and suffering from auditory hallucinations. His exact diagnosis was difficult to determine as he had stopped talking. He was refusing to take his medication and was eventually admitted to hospital under the Mental Health Act as he was deemed a risk to himself.

DILEMMA: Now that Steve’s physical and mental health has improved, should he return to live with his sister, who has a mild learning disability?

RISK FACTOR: Steve’s sister has support needs of her own. There is a risk that returning to live with her might jeopardise his recovery or cause problems for his sister and her child.

OUTCOME: Steve returns to live with his sister with a support package in place. This enables him to take his medication regularly and his physical and mental health continues to improve.

Establishing an accurate mental health diagnosis is important for people experiencing psychotic symptoms because early treatment has been shown to dramatically improve the long-term prognosis of the condition, writes Mark Drinkwater.

However, Helen Durdy, a social worker in an early intervention in psychosis (EIP) service, found one client particularly difficult to engage with as he had stopped talking entirely.

The client, Steve*, had suspected psychosis, but this was difficult to ascertain because of his mutism. He lived with his sister, but she also needed support because she had a mild learning disability. She could not read or write and her recollections about significant events in Steve’s life were unreliable as her memory and sense of time were poor.

Durdy found that Steve’s lack of communication presented her with significant problems. “Steve was very uncommunicative and would nod or shake his head in answer to questions,” she says. “He had been having some psychotic symptoms for a long time, but he’s not someone who easily fits into services. It had been difficult to gain an accurate diagnosis of his condition as he did not speak to anyone.”

Her unease grew as Steve became increasingly uncommunicative and it was evident he was malnourished. What Durdy observed on a visit gave her further cause for concern. “I went with another worker to encourage him to take his medication,” says Durdy. “Steve chucked the glass with the medication at the wall. It was quite scary. He didn’t want to take the medication.”

She decided to carry out a mental health assessment with a doctor. “The first time we went, Steve locked himself in his room and we were unable to see him. But we did manage to assess him when we went back later in the week and he was admitted to hospital on a section two [of the Mental Health Act 1983].”

In hospital, Steve’s medication was changed. This led to a slow, but gradual improvement in his mental health. He became more confident, started to speak and ate with others for the first time in months. Professionals’ thoughts then turned to Steve’s options on leaving hospital. Mindful of her role as the approved mental health professional who had assessed him for his hospital admission, Durdy arranged an independent mental health advocate (IMHA) to advocate impartially on Steve’s behalf.

Some professionals expressed concerns about the possibility of Steve returning to his sister’s flat. This included his sister’s housing support worker who suspected that Steve’s support needs would be too great. Durdy was, however, convinced that he could continue to improve on returning to live with his sister. “He gets on well with his sister. She wanted him live with her and he felt the same way. While she has a mild learning disability I was confident that she was capable of looking after him,” she says.

Steve returned home with a care package that included social activities. A year on, he continues to live with his sister and attends a local day service. “He’s a lot happier now that he is accepting his medication,” says Durdy. “He talks to people and takes part in day services. It’s made a massive difference and his sister says ‘this is the best he’s been for years’. It’s been a struggle, but things are a lot better now.”

*Not his real name

Weighing up the risks

Arguments for taking the risk

● Independent advocate
The social worker arranged for an independent advocate to help Steve determine what was in his best interests. This support enabled him to participate in decisions about his treatment and where he wanted to live after leaving hospital.

● Relationship with sister
Steve improved substantially while in hospital. Both he and his sister wanted him to return to live in her flat. He values the mutual support they provide for each other and she feels safer with him living there.

● Relationship with sister
With continued support from the EIP service, Steve should be able to continue with his rehabilitation on returning to live in the community.

Arguments against taking risk

● Less support
Living with his sister, Steve would receive less support than in a specialist housing project. He might fail to build on the improvements in his physical and mental health.

● Relationship with sister
Steve is close to his sister. There is a risk he is putting her needs before his own by choosing to live with her.

● Medication risk
There is always the danger Steve might stop taking his medication. When this has happened in the past, he became aggressive.

Independent comment

PRACTITIONER: Rachel Morley, approved mental health practitioner (AMHP),Essex Council

This case reveals the difficulties involved in communicating with clients experiencing their first psychotic episode. There was little option in these circumstances but to detain the patient under the Mental Health Act.

This illustrates the importance of the IMHA role in supporting service users subject to the act to understand their rights and to support them to participate in decisions about their care and treatment. Many AMHPs can struggle with the power relationship when care co-ordinating service users they have been involved in detaining. The IMHA service, which came as a result of the Mental Health Act 2007, provides a vital independent safeguard for rights.

Steve has returned home and is now both a lot happier and accepting medication that contributes to the improvement in his mental state. This illustrates the importance of positive risk taking on such occasions on behalf of his social worker and the EIP team. His care package has also acknowledged his social needs, demonstrating the importance of holistic assessments when implementing care plans.

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This article is published in the 24 June 2010 edition of Community Care magazine under the headline Is Steve Ready to Return?