He was young and suave. Like many educated metro-Indians, he spoke English more fluently than his mother tongue. I could see bandages around his wrists, which he tried to cover with a full sleeves shirt. His grandpa arranged his appointment a day before. He wanted to share things regarding the grandson in private. He did not want to reveal 'personal' things in front of the grandson to avoid embarrassment for everyone.
Basically his grandson had become a 'drug addict' and was using intravenous drugs. He was not seen in his college or the neighbourhood for a couple of days, when someone intimated the grandpa. His grandpa rushed to his college immediately on a taxi. The patient was found lying unconscious in his room. He was ALIVE! He was taken to a nearby hospital and was treated for sepsis with intravenous antibiotics. He had developed a major infection. All the points from which he had shot drugs were swollen and were oozing pus.
The patient's only concern was to find out if he had to continue antibiotics or not. We could connect well. He was young , English speaking gentleman, who felt no one is interested in him and I was a person interested in all aspects of his life if not personally at least professionally :-). I asked him to do a couple of blood tests. He readily agreed. I asked the lab technician to also do the HIV test. I had reasons to suspect a immuno-compromised state in him and also had the responsibility to protect our staff involved in his care.
I did not do the pre-test counseling or tell him about which tests were done. Reason- I did not want to rake up a emotionally disturbing issue in the beginning of a therapeutic relationship. I thought once I develop rapport and stabilized him, I would bring the topic, re-do the test and then declare the result to him.
I had few sessions with his grand father too. He was an old man of about 75 years. His wife had died when he was relatively young. He brought up three children. The eldest was a nurse, mother of the patient. She had a troubled marriage with an alcoholic man. She found peace in divorce. She brought up her son all alone and sent him to a metro city for his graduate level education. She was diagnosed of cancer and subsequently died. The old man had a paraplegic son who was dependent on him. The third child was a responsible one, who was single and worked in another part of the country. Grandpa had a comfortable pension, which was in addition to the pension the patient received. Their family income exceeded the salary of a consultant doctor of the hospital!
He came on a regular basis for two weeks. In the third week, I mustered courage to tell what had to be inevitably told.
"Ok" ,I added "also a child can get it from a HIV +ve mother during birth and people who share needles when they take drugs". I could see anxiety in his eyes.
Test was done. I already knew the report.
I nodded my head slowly. He understood. He did not mind me sharing this with grandpa.
" What should we do now?" they asked.
I still wonder, why is it that I did not 'break bad news' for two weeks!!! It looks so simple now 🙂 Was it my own anxiety that he being unstable, might do something drastic like commit suicide or less lethal step of relapsing into drug use? Was it my psychological voyeurism to understand a 'case' with multiple problems from many dimensions? Was it my fear to loose a psychotherapy client due to distress caused by a medical diagnosis? Was it me buying time to get the best information possible for his further management?
I do not know and might never know my own fears and motivations… I went by 'gut' and probably, was right. I feel timing was right in breaking bad news in this case. The reason is that the manner in which it happened and it's outcome was smooth, predictable and under control.
Why did they then stop following up??? !!! I do not know, and I have no guesses. I hope that he is following up in the center which gives them Anti- Retro-viral Drugs and that they a managing his psychological and substance abuse related problems.
He was sick from Makara Sankranthi season. He muttered to himself and beat his wife black and blue. He shouted obscenites and village people avoided him. He was suspicious of people harming him, so he kept aloof. He suspected hisown father to have a realtion with his wife. That was the reason that he was so irritated with his father and aggressive over his wife.
His beliefs overwhelmed him and he wanted to die. His father brought him one evening and he had to be given chemical restraints (pychiatric medicines in form of injections )before he could be admited. Injections are not painless. His backside was aching continuously after he recieved few shots. He understood that the hospital staffs are supportive. They give injections but also him give ice packs and comforting words. He started taking oral medicines.
He responded within a week. His hallucinations came down and his delusions were loosing their grip on him. He beacme very loving towards his wife and father too. He wanted to live, have children, educate them and do well. Nearly two weeks from admission, it was time to get discharged. His father wanted to pay 'full'. We offer people to pay prospectively too. A poor family becomes much poorer following a hospital admission. When we asked again he said he now had cash, so it was no problem. I asked him, how he got that cash. I could then smell the handia, the local rice beer from his breath. He said he promised off to sell 6 ghunt land for Rs 6000/- . This was to pay a bill of Rs 1800/- !!! When we did not mind it being paid in installments without interest !!! One could suspect the balance amount would run down his throat within a couple of weeks as alcohol. I told him to cancel off the deal and pay whatever he could from his own reserved. He had about Rs 1000/-. Rest was to be paid over 8 months as Rs 100/- per month.
There is less chance for a patient to leave psychiatric services here and go anywhere else as the over all costs are cheaper and quality of services provided are better. Quality measured in the 'time spent with patient' and 'time spent with family'.So there is less chance of losing to the competition.
Occupational rehabilitation is encouraged so patient becomes economically productive in ways such that in the long run cost of treatment is seen as an investment in generating income to the family.
She was 26 years old. A mother of a three year old child. She was well dressed and well kempt. An old patient of ours brought her to our OPD ( out patient department ) for vague somatic complaints that she had been having for the past 2 years. She was not keen expressing her problems as well. I usually enquire regarding stressors even in a general OPD. To me young hesitant woman ususally means- domestic problems with husband or mother-in-law.
She lived in a nuclear family and her husband was very loving. As I probed into her more deeply, I realized that the patient was quite severly depressed and was also having suicidal ideation. I encouraged her attender to admit as soon as possible indicating high suicidal risk. She wanted to come the next day. A hospital admission is not that simple.
Patient's families have to hand over their cows and hens to others to care for. They should arrange for someone to take care of their feilds. They also need to arrange for cash. Most payments are out of pocket in rural India. They need time to go and bring utensils, rice, dal and oil to cook nearby. Most importantly they should arrange for someone to stay as an attender.
She came the very next day for admission with her husband. I could see her in detail. She revealed that she had been hearing voices that others could not for the past two and a half years. She had also been suspecting few relatives of doing witchcraft against her. She was barely able to do her household work. She was managing well, due to her extremely suportive husband. Clearly her diagnosis was Paranoid Schizophrenia- continuous course.
I started her on antipsychotic Risperidone 2 mg. In the evening hours I spent time with her husband regarding her illness, its nature, course, treatment strategies, prognosis and outcomes. The voices in her ears came down within 3 days. I had planned to go up on the dose to 4 mg before discharge. I decided against it. Many a time we go up on the dose rapidly expecting results quickly. Thoogh many patients might respond at lower doses.
She bacame aware of her problem as an illness. She feels there is no reason to die if her voices go away. She has hope that treatment is helping her. Why go up on the dose? The patient is not going to run away anywhere. If she does not respond with 2 mg over 2 weeks then I would go up.
By increasing her dose to 4 mg would I not double her treatment cost? It she develops extra pyramidal side effects (tightness and rigidity), she would require medicines to control that. This would triple her cost. By being conservative in a relatively safe situation benefits are fewer medications, better compliance, lesser cost, lesser side effects and probably better effectiveness.