On the difficulties of psychiatric assessments

The quality-of-life of an individual patient with mental health issues is more important than a diagnosis

I had just pressed send on the last prescription when the phone rang. The caller introduced himself as Jack O’Donnell, the new key worker for one of my patients, Stuart Baxter. Jack spoke quickly, earnestly spilling out his story like a medical student in a clinical exam. The patient, Stuart, well known to me, suffered from schizophrenia. A couple of months earlier Stuart had stopped his medication. He had become withdrawn, irritable, was not eating, or sleeping. That afternoon when Jack had called to see him, Stuart had been sitting on his bed muttering to himself, stopping occasionally to smile or grimace in the direction of a chair in the corner. Jack was applying for compulsory admission and Stuart needed a psychiatric assessment.

In the opening chapter of his book In Search of Madness, Prof Brendan Kelly recounts the tale of Nathaniel Lee, an exuberant playwright, who in 1684 was committed to Bethlem (Bedlam) ‘lunatic asylum’ in London. Lee objected to his committal declaring, “they called me mad, and I called them mad, and damn them, they outvoted me.” Kelly goes on to say that three centuries later, Lee’s words still resonate. Who is ‘mad’? Who is not? And who decides?

Hoar frost silvered the grass verges along the roadside as I drove to Stuart’s home, an old farmhouse at the end of a narrow country lane, that he shared with his mother. When I arrived, Jack was already parked outside.

“He doesn’t know we are coming,” Jack said. “I was afraid he might abscond if I told him.”

I looked around at the frosty moonlit fields. Even if Stuart had bolted, he would not have gone far on such a night.

“I can do the talking,” Jack went on. “Just go through the usual questions.”

I had almost forgotten the tick-box history taking that I had been taught in medical school. Stories reveal so much more. I wondered if Stuart would be able to construct a narrative that Jack and I might understand.

Stuart’s mother held the door open. Behind her, Stuart peered out from the dim light of the hallway. I greeted him with a hesitant smile. To my relief, his face lit up and he grinned back.

“Dr Gannon, you’ve come to see me.”

“Yes. I hope that’s alright. I hear you haven’t been well.”

“Yeah, but I’m fine again,” Stuart replied. “A bit of a stomach bug, I think.” He put his hand to his belly as if to demonstrate the source of the illness. It was clear that he had no idea of the purpose of my visit.

Jack and I followed Stuart into the kitchen. A small room with a table and four chairs. I sat down on one of them. Jack settled into another. Stuart remained standing, moving from one foot to the other, still looking a little bewildered. It felt like a terrible invasion of privacy.

“Can you tell Dr Gannon about the voices you have been hearing?” Jack said.

Stuart glanced at me, his eyes suddenly fearful. 

“I’m not going to hospital,” he said. “Is that why you’re here?”

“Nobody said anything about the hospital,” I said. “I just came to see how you are.” I wasn’t lying, but neither was I telling the truth and this bothered me.

In In Search of Madness, Kelly explains that mental health and mental illness exist on opposite ends of a spectrum. There is a point of diagnosis somewhere along this spectrum, but the quality-of-life of an individual patient is far more important than a diagnosis. Occasionally, when Stuart attended the surgery for a repeat prescription or routine blood tests, I would ask him if his voices still spoke to him. He always answered “no”. But in the gap between the question and response, I suspected that they did. I turned to Stuart.

“Just tell me what’s been going on.”

The story emerged. Stuart had stopped working out and going for walks. People were talking about him. The nurse was trying to poison him, so he had to stop taking the medication. I suggested that he might benefit from a brief hospital stay, just to get his medication right. He declined. We left it at that. In the dim light of my car, I signed the committal form.

“So, what happens now?,”  I asked Jack.

“I’ll be back in the morning,” he replied, “with another member of the team to escort him to the psychiatric unit.”

The following Monday I had a call from Stuart’s mother. She told me that the morning after our visit, Jack had arrived early with a colleague. Stuart looked at them both then went to his room, packed his bag, got his jacket, and willingly got into the car to go to the hospital. She had no idea why he had changed his mind.

The names in the above scenario have been fictionalised.