Case Studies of Mental Health in General Practice(24)
——Who Cares for the Carer of A Mentally Ill Patient?

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Some years ago whilst working in my practice on a Saturday morning I received a distressed phone call from a patient of the clinic requesting an urgent home visit.He informed me that if I did not attend promptly the next call would be to the police to notify a homicide.Although distressed,he sounded like a reasonably rational elderly gentleman which made the threat of a homicide most unusual.He told me that the potential victim of the homicide was his 94 year old demented mother in law.

During the home visit I was confronted by the couple caring for the old lady.Her daughter was aged 68 and greatly disabled with rheumatoid arthritis.The son in law was 71,had ischemic heart disease and had undergone triple vessel by pass surgery 12 months ago.The daughter Mrs.G was tearful and very upset.Her mother had been diagnosed with dementia 5 years ago and was now spending much time in bed.She weighed 94 kg and was extremely difficult to move,wash,toilet and feed.District nurses came once a week to assist with bathing and check medications.She had been on the waiting list for a nursing home for 2 years.She now had a cough and a fever and I suspected left lower lobe pneumonia.This gave me an excuse to arrange a hospital admission and avert the threatened crisis.It also taught me the significant role played by carers be they family or close friends,and the pressures both physical and mental,experienced by carers.

As our community ages and chronic disease,both physical and mental absorb greater proportions of the health care budget,community care and by implication home based care involving family and close friends is a necessity.Young adults with congenital and acquired brain disease are living much longer and remain in the care of elderly parents for a greater part of their life span.The same applies to adults crippled by chronic mental illness,in particular schizophrenia,bipolar disorder,chronic mood disorders and certain personality disorders.Caring is not limited by age or nature of illness.

General Practitioners provide comprehensive care to individuals and families in community settings.In the case of mental illness the perceived interests of the individual,when unwell and thought disordered,may be at odds with the interests of the carer caring for the mentally ill and often irrational family member/patient.GPs are obliged to act in the best interests of the mentally ill patient whilst taking into account the needs of the carers who may also be their patients.The carer′s needs include care for their own physical and mental wellbeing as well as access to community support services,respite care for the patient to enable carers to have a holiday,legal advice and counseling.

The case study below illustrates some of the issues faced by carers as they try to act in the best interests of their loved one afflicted by a mental illness.

1 Case study

Mrs.H,a 53 year old widow and school teacher has been a patient of your clinic for 20 years.She has 2 sons Adam aged 23 and Roger aged 19.Her husband died 2 years ago of the complications of pancreatic cancer.Adam has left home and lives with his girlfriend.He is a computer programmer and seems happy with his work and with his relationships.Roger was a very bright student at school,topped his final year and commenced a combined biomedical science/engineering degree at University.He struggled through the first year of his course and seemed to spend increasing periods of time in his room,or at the local gym,missing classes and losing contact with friends.When questioned by his mother he indicated that he was working on a new project involving the recent discovery of a novel neuroendocrine pathway that controlled the release of gonadotrophic hormones and hence testosterone which could transform muscle growth and revolutionize the body building industry.He felt that his own body needed transformation as it had too many feminine features.

On one occasion when he was away from home his mother searched his room and found a range of tablets and injections with unusual names as well as various scientific and body building magazines.She also noted that he recently seemed to have gained a considerable amount of weight,largely muscle bulk,developed acne and seemed more intolerant and at times aggressive.

Concerned about his behavior and changing appearance she arranges an appointment with you.She appears tearful,distressed and concerned.

2 Questions

2.1 How would you approach the consultation with Mrs.H,given that you have known the family for such a long time?

2.2 What thoughts do you have about Roger′s problems as conveyed to you by his mother?

2.3 Mrs.H would like you to see Roger.How can this be arranged and what will be your approach when you do see him?

2.4 How will you manage ethical issues of consent and disclosure,given your responsibilities to both Mrs.H and her son Roger?

3 Answers

3.1 You should acknowledge her obvious distress.Doing so may immediately lead to an outpouring of her problems and her feelings.This requires active listening on your part and demonstration of empathy.Although you may know the family,you may not have seen Mrs.H or her sons for some time.Much may have happened since the death of Mr H so general questioning about Mrs.H′s health and well being is required.This includes questions about her mental health particularly with regard to depression.In this context further questions about the family (including psychiatric history amongst family members),and more details about Roger are in order.Given the changes which have occurred in her life over the past 2 years it is likely that Mrs.H may not have had a check up during this time.Having listened to the presenting problems and taken a relevant medical history,it may be necessary to stress the importance of Mrs.H looking after her own health and in this regard a brief physical examination and checking dates of her last Pap smear,mammogram,lipids and blood glucose are in order.Arrangements may be made for these to be repeated and follow up consultation arranged.This will in any case be necessary based on her concerns about Roger.

3.2 It is most likely that Mrs.H will ask you for an opinion about Roger and possibly even a diagnostic formulation based on the information she has provided.She may have her own ideas and fears about his diagnosis.In a patient centred way you should ask her what she thinks the problem is.As a school teacher she may well have experienced such problems amongst her students and their families.You should point out that it is difficult to reach a diagnosis without meeting Roger and even then the diagnosis in these circumstances may not immediately be clear.The concerns are that he is developing a psychotic illness.This may or may not be drug related,but other conditions including depression need to be considered.His withdrawal from social life,increasing isolation and inappropriate concerns about his appearance may suggest a psychotic illness in evolution with some somatic delusions.You should stress to Mrs.H the importance of early diagnosis and reassure he about the possibility of a favourable outcome if Roger is agreeable to receiving help.Of course this may not be easy and Mrs.H will need much support along the way.

3.3 Convincing Roger that he needs medical help may be difficult.Mrs.H,having discovered that he is using anabolic steroids and possibly human growth hormone injections,may be able to convince him that medical tests are in order to ensure that these substances are not causing metabolic or liver problems and that he should have a check up.He may be reluctant to see the same GP as his mother is seeing.Assuming he does see you care will be needed to gain his trust so a non judgmental but honest approach is required.During the consultation Roger questions you about your knowledge of neuroendocrine pathways and provides numerous references confirming his deficiency in growth hormone and testosterone.He presents complex biochemical pathways that demonstrate his need for hormonal supplements and believes that food additives have interfered with his hormones.He plans to sue some of the food manufacturing companies.He agrees to have a series of blood tests but indicates that these routine tests will not detect deficiencies of the sort that he has.He asks for scripts for anabolic steroids and human growth hormone which you refuse to supply.This angers him but he agrees to have the blood tests and return at a later date.

3.4 GPs may find themselves in potentially difficult situations ethically when managing several members of a family where requests for non disclosure of information are made by a particular family member.In the case of serious mental illness the rights of the carer to information needed to support the patient are protected under State laws as is their right to convey information to clinicians looking after the patient[1].Carers are in constant often 24 hour contact with the patient and therefore able to notice subtle changes which need to be reported to the care team.

4 Further developments

Some 6 weeks later you receive an urgent call from Mrs.H.Roger became quite violent during the night,claimed that he was being followed and that his discoveries on neuroendocrine pathways were being stolen and that his mother was sabotaging his work.He smashed a considerable amount of furniture,woke the neighbours who called the police.Roger was taken into custody and then transferred to the acute psychiatric ward of the local hospital.You arrange to see Mrs.H that afternoon.She feels guilty and blames herself for not giving Roger as much attention over the past 3-4 years whilst caring for her sick husband.She feels that Roger is now punishing her for this.She tried to see him at the hospital but he refused.She is not sure how long he will stay in hospital and is unclear about his diagnosis or prognosis.She would like him to come home but is unclear as to how she will be able to cope if he becomes violent again.She is also concerned about her own career as she is losing time from work due to recent events.

5 Further questions

5.1 What is the nature of the support you can provide Mrs.H at this stage?

5.2 What advice can you provide for long term care in event that Roger returns home？

6 Answers

6.1 Despite Roger′s reluctance to see his mother,it is likely that the treatment team at the hospital will have spoken to Mrs.H.Roger may have been certified so under this section of the local mental health act he may be kept in hospital against his will for 3 days and then reviewed (Laws governing this form of certification will vary from State to State and country to country).As both his GP and his mother′s GP you should contact the hospital to determine their thoughts about diagnosis and treatment.You should arrange to see Mrs.H and explain the nature of the illness and the proposed treatment.

It is likely that Roger has a form of schizophrenia with both somatic and paranoid delusions.The drugs he is taking may have exacerbated the condition,in particular the violent behaviour.Whilst in general terms you might reassure Mrs.H about the prospects of improvement with treatment,it is likely to be a long and at times difficult journey and she will need much support.You should assess Mrs.H′s understanding of the condition and how she feels about living with Roger and looking after him.In addition to explaining the condition and correcting any misunderstandings about the illness,you may provide some literature,web sites and information about carer support services[2-4].Given the stress that she is under it may be appropriate for her to have some time off work so a medical certificate is in order.

6.2 Assuming Roger returns home he will need to be managed by the local mental health service with your support,unless of course if Roger chooses another GP.Compliance with treatment may be problematic and the possibility of his continued use of anabolic steroids remains real.Mrs.H will need to monitor his well being and note and report any early signs of deterioration.Mrs.H will need your ongoing support and that of carer support groups in the region.Should his behavior deteriorate,in particular if he becomes violent again Mrs.H should have access to the Mental Health Crisis Assessment Team(Nurses trained in mental health supported by psychiatrist) and if necessary the police.Under these circumstances it may be difficult for Mrs.H to continue caring for Roger and he may need to move into supported accommodation.

During this time Mrs.H may experience episodes of anxiety,depression and guilt.Balancing her job and caring for,Roger (who may also be prone to depression) will not be easy.It is important that you monitor her emotional state and if necessary specialized psychological support may be needed.Having a break from her caring role may be required and under these circumstances alternative arrangements may need to be made for Roger′s supervision.

1 School of Psychiatry and Clinical Neuroscience UWA,the Mental Health Division,the Office of the Chief Psychiatrist and Carers WA.Carers guide to information sharing with mental health clinicians:Communicating for better outcomes [EB/OL].http://chiefpsychiatrist.health.wa.gov.au/docs/guides/Carers_Guide_Information_Sharing.pdf.

2 Victorian Government Health Information.Mental health - information for families and carers[EB/OL].http://www.health.vic.gov.au/mentalhealth/carer.htm.

3 Blashki G,Judd F,Piterman L.General Practice Psychiatry[M].McGraw Hill，2007.

4 Carers Victoria.Supporting family carers[EB/OL].http://www.carersvictoria.org.au.