Will early discharge hinder long-term recovery?

CASE NOTES

PRACTITIONER: Helen Durdy (pictured above), a social worker in an early intervention in psychosis team.

FIELD: Mental health.

LOCATION: Manchester.

CLIENT: Anna*, 28.

CASE HISTORY: Anna was admitted to a psychiatric hospital for assessment under section two of the Mental Health Act 1983. She had been smoking cannabis heavily and had suffered from psychosis and depression. Her stay in hospital was traumatic because she was often sexually harassed by another patient. A decision was made to release her from hospital after the section two assessment period.

DILEMMA: Although psychiatric hospitals ought to be therapeutic, Anna’s time in one was so distressing that remaining there was likely to hinder her recovery.

RISK FACTOR: There is a risk that Anna will be discharged before she is resilient enough to cope at home. This could jeopardise her long-term recovery or, worse, she could end up being readmitted to hospital again if her mental health deteriorates.

OUTCOME: Anna struggles initially after leaving hospital. However, her mental health improves with support from her family and the early intervention service.

*Not her real name

Helen Durdy, a social worker in an early intervention in psychosis (EIP) service, found that one client referred to her, Anna*, had experienced an incredibly distressing time while in hospital, after being admitted for assessment under section two of the Mental Health Act 1983.

Durdy describes the circumstances leading up to Anna’s discharge: “She was coming up to the end of her section two and they were considering a section three the following week [under which she would be admitted for treatment for up to six months]. But the family were really against it and Anna was desperate to leave hospital. She said she felt it was ‘making her mad’.

“She was also being sexually harassed by a male patient. So they ended up discharging her when her section two ended.”

In the six months leading up to her admission Anna’s life had taken a sudden downturn. She lost her job and her boyfriend left her. In addition, Anna had endured a number of distressing events in the preceding years, including her parents’ break-up and the murder of her first boyfriend. These experiences had greatly affected her and continued to haunt her.

After Anna was discharged, she went to stay with her father because she did not want to be on her own.

“She wouldn’t stay at home,” says Durdy. “She couldn’t bear to be on her own and that’s why she couldn’t bear to go back to her flat.

“She became quite worried about mortality and about the fact that she was relying so much on her parents and what if something happened to either of them. Anna became quite morbid.”

Her father found that Anna was reluctant to take her medication because she was unhappy about the side-effects. Durdy realised that Anna had perhaps been discharged prematurely and that this was hindering her recovery in the community.

Although Anna did make some progress by giving up smoking cannabis, without the drug she realised that her life was not going to plan. She was also troubled by her new-found identity as a user of mental health services and felt as though her life had fallen apart.

“At first she desperately wanted to be out of hospital and that was all that she wanted. And quickly she became quite low, realising everything that she had lost,” says Durdy.

Concerned about Anna, Durdy visited her regularly. However, the visits were not as regular as she would have hoped because Anna’s father’s home was some distance from Durdy’s patch. Anna was also now miles from her GP. However, on balance it was decided that, for the sake of continuity, Durdy would remain involved in the case.

Over the next few weeks, Durdy became increasingly worried about her client’s low mood and her reluctance to take her medication.

“I was really concerned for her because she was saying she couldn’t stick to the medication because of the side-effects,” Durdy says. “She was anxious and was saying she was feeling suicidal. She wouldn’t take the medication and said she didn’t care whether she went into hospital again.”

Anna’s mood continued to deteriorate and she had become so low at one point that Durdy was on the brink of asking the local crisis team to intervene.

Eventually, things did turn around for Anna when Durdy helped convince medical staff to change her medication to a different combination that treated her psychotic symptoms and low mood. This new arrangement controlled her symptoms with far fewer adverse side-effects.

With her new medication, Anna’s mood stabilised. Working closely with the family, Durdy was able to address other social aspects of recovery. In particular, she helped Anna with her vocational aspirations by securing her a place on to a back-to-work course for people recovering from mental health problems.

Durdy feels that the alternative options were limited in this case. “With hindsight, she would definitely have settled down quicker if she had stayed in hospital longer. But you’ve got to weigh that up. She was adamant that she wanted to go home and her parents, one of whom would have been her nearest relative, were saying that they didn’t want her to stay [in hospital],” she says.

Despite the difficulties, Durdy is pleased with the outcomes in this case and the progress that Anna has made so far.

“She’s really improved,” Durdy says. “She’s definitely becoming less and less dependent on services and more settled. But it’s still early days.”

Independent comment, by Lance Carver

This is a success story. Anna was discharged early and, with support in the community, could recover from her mental health problems.

It is clear that the therapeutic benefits of hospital admission had run their course. Ongoing and sustained sexual harassment may have proved more traumatic and problematic for her long-term recovery. These kinds of incidents can leave a damaging and lasting effect on anyone, let alone somebody who is acutely vulnerable.

Recovery is a complex process, but at the centre of it must be the desires and will of the service user. In this case, Anna was desperate to leave institutional care and this needed to be balanced with the potential risks both to her and others when discharging the section.

Regular follow-up and support enabled these risks to be mitigated and allowed Anna the chance to rebuild her life. Although this was not easy, and nearly resulted in readmission, it may have enabled her to develop the skills to work through this kind of difficult situation should it occur again.

Lance Carver, head of adult services, Vale of Glamorgan Council

Weighing up the risks

Arguments for taking the risk

● Hospital stay counterproductive

Anna’s stay in hospital was far from therapeutic. Even though her discharge may appear rushed, her continued stay in hospital was likely to be counterproductive for her recovery.

● Relationship with family

The relationship between Anna and her family was seen as key. Anna wanted to return home and it was felt that the family could offer her much of the support she needed.

● Community support

With help from the early intervention service, Anna could continue her rehabilitation on returning to the community. The social worker could ensure that she was able to access further community resources, such as vocational courses.

Arguments against taking the risk

● Vulnerability

Anna is a vulnerable individual who has had difficulty coming to terms with loss arising from several traumatic experiences. Her short stay in hospital may not have been long enough for her to learn to deal with these.

● Distance from services

Anna was unable to cope on her own without family support. When she moved in with her father she was then far from the support of her GP and the early intervention service.

● Costly readmissions

Readmissions to hospital are costly, both for her as an individual and in terms of hospital resources. Further admissions would also be likely to exacerbate the distress experienced during her initial detention.

Contact mark.drinkwater@rbi.co.uk to submit your Risk Factor case studies