Man with schizophrenia decides not to take his medication: how should social workers respond?

(pictured, social worker/AMHP Mark Sloman who handled this difficult case)

A social worker and approved mental health professional discuss a real case in which a man with longstanding mental health problems decides to live without his medication.

Case notes

Practitioner: Mark Sloman, a social worker and approved mental health professional (AMHP) in a community mental health team.

Field: Mental health.

Location: Somerset.

Client: Fred*, 55, who lives alone.

Case history: Fred was diagnosed with schizophrenia 30 years ago. Since then he has had several formal admissions to hospital under the Mental Health Act 1983. When he is living in the community, he receives an antipsychotic injection every fortnight. Within a few months he becomes symptom-free and believes he can live without this medication. He is now refusing his medication and unwilling to answer the door to professionals.

Dilemma: When Fred has refused medication in the past, his mental health has quickly deteriorated. Does the AMHP rush to convene an early mental health assessment or does he wait to see how the situation progresses?

Risk factor: If the AMHP convenes an early assessment he is likely to alienate Fred and risks damaging their working relationship.

Outcome: Having exhausted all options to engage with Fred, the AMHP obtains a warrant to enter the property. Fred is then assessed and detained in hospital under the Mental Health Act.

* Not his real name

Case commentary

Hospital admissions are the last resort when providing services for people in mental distress, writes Mark Drinkwater. However, when service users with severe conditions stop taking their medication they can become revolving-door patients, caught in a cycle of readmissions to hospital.

Mark Sloman, a social worker and approved mental health professional with a community mental health team, describes some of the problems encountered with one of his more complex cases, Fred*, who has a pattern of non-compliance with medication. “About six to nine months after hospital discharge he starts to become agitated about the need for medication because he’s not symptomatic and he’s not experiencing any auditory hallucination,” says Sloman. “He then believes that he is well and that he doesn’t need medication.”

Sloman explains that Fred’s mental decline post-discharge is a familiar scenario that has occurred several times in recent years. He says that when in the community Fred is not detained under the Mental Health Act 1983 and there is no way they can compel him to take his medication. “We’ve then got a dilemma because we know that for those with a schizophrenic-type illness that their situation is not going to improve without medication. His symptoms are only going to get worse, they’re not going to get better. He’s going to increasingly pose a risk in terms of his own welfare and also may well go on to pose a risk to other people.”

Sloman had considered a number of approaches in working with Fred, including advance directives. These enable service users to decide what mental health treatments they would wish, or not wish, to receive in the event of them becoming unwell and incapable of making decisions for themselves.

Sloman explains why this was not a realistic option. “He’s never set up an agreement with the staff when he’s well in terms of what should happen in this situation because he lives in the hope that it would never happen again. But the cruel reality is that any type of psychotic illness is subject to variation and episodes of poor health.”

Another alternative to break the cycle of readmission to hospital is a community treatment order, under which conditions are placed on service users’ treatment. However, Sloman says that this was unlikely to have made much difference in this particular case as these orders do not give professionals sufficient power to compel someone to take medication in the community.

On the latest occasion, having gone some weeks without medication, Fred became more aggressive to his neighbours and was particularly hostile to the community psychiatric nurses (CPNs) who visited. This presented a dilemma for Sloman. “Ultimately the decision is how long you leave someone to deteriorate before you intervene with a Mental Health Act assessment. You need to satisfy yourself that everything that could be done to avert a Mental Health Act assessment has been done. But that has to be countered with the person’s individual rights to try to go it alone and be independent of services.”

Sloman and his colleagues became worried about Fred when he refused to answer his door on several visits. Two important factors guided Sloman’s decision-making: Fred’s personal history and the typical progress of unmedicated psychosis.

“The general philosophy in working with people with psychotic illnesses is that the earlier that you can intervene and stabilise them on a medication regime, the better the outcomes for them and the quicker they are likely to respond to medication. And then less time is required for them to spend in hospital,” says Sloman.

In his role as an approved mental health professional (AMHP), Sloman chose to intervene early in this case. As Fred was refusing access to his property, he needed to obtain a warrant from a magistrates’ court. With the warrant issued, Sloman entered the property accompanied by a doctor and a police officer. Fred was then assessed and detained in hospital under the Mental Health Act.

Sloman acknowledges it is often difficult to decide whether to admit someone to hospital against their will. He recognises that such actions – obtaining a warrant, the assessment process, and the resultant detention in hospital – are all a huge intrusion into an individual’s circumstances and liberty. But he is confident that this early intervention resulted in the best outcome for the service user.

“We could have made the decision to leave him longer in the community,” he says. “But, of course, without medication his situation and his illness was only ever going to get worse. It was never going to improve spontaneously and his level of insight and understanding would have reduced over the coming weeks.”

Weighing up the risks

Arguments for taking the risk

● Increasing risk

Fred is not managing at home and he is likely to pose an increasing risk to himself and others. With little in the way of realistic alternatives, detention in hospital is the best option for him.

● Antisocial behaviour

Fred’s history indicates that his antisocial behaviour is unlikely to improve without his antipsychotic medication.

● Rapid response

The longer that service users with serious psychotic illnesses are left unmedicated, the longer the period of recovery. The social worker needs to act quickly to minimise any risks to Fred or others.

Arguments against taking the risk

● Gross intrusion

Detaining Fred in hospital will go some way to safeguarding him but it will inevitably be perceived by him as a gross intrusion.

● Working relationships

The legal framework is limited in its usefulness in cases such as this. Fred’s detention in hospital will damage the good working relationship that the social worker has built up with him.

● Last resort

Detention in hospital is the last resort. In a developed country, this approach seems draconian and an indication of a lack of humane alternatives.

Independent comment

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

This revolving door scenario is a common situation facing AMHPs. It can sometimes be very difficult for AMHPs to make a judgement about when to intervene, particularly when to execute a warrant given the subsequent impact this can have on privacy and liberty.

I would support the decision here to intervene. It was to Fred’s benefit to go ahead with the Mental Health Act assessment at an earlier stage rather than leave him until his health and safety, and perhaps the safety of others, was at significant risk. A further consideration was that in Fred’s case the historical evidence suggests his situation will only deteriorate.

The social worker has stated that the use of a community treatment order would not have been of use. However, I have seen patients who have really benefited from the use of CTOs. In our area we have seen cases where patients will respond to the boundaries of additional conditions, including requiring them to be concordant with their medication and other treatment, even though there is no power to immediately recall a patient if they stop their medication until risks are evident.

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This article published in the 21 October 2010 edition of Community Care under heading ‘Running out of options’