For those with schizophrenia the problem is not so simple. After months of taking dopamine blockers, a person may feel cured and no longer in need of drugs, which can have nasty side-effects. Yet those who fail to receive regular medication are likely to relapse into madness. As they become sicker, they lose grip on reality and on their insight into the illness. Increasingly deluded, they may refuse help and drugs. Caught in a spiral of decline, they will almost certainly end up in prison, hospital or dead. A few may kill.
Twice in the past month the Old Bailey has heard cases of people with schizophrenia who killed strangers. In both cases the accused had been discharged into the community with inadequate psychiatric support. According to the National Schizophrenia Fellowship, more than 40 people have died at the hands of diagnosed schizophrenics or otherwise mentally ill people in the past two years.
A video of Ben Silcock, a 27-year-old schizophrenic who was savaged by a lion after jumping into its den at London Zoo in January, graphically demonstrated the dangers that mentally-ill people can themselves face. .
It is in response to these cases that proposals have been drafted that could force even non-psychotic psychiatric patients into hospital if they refuse medication. Virginia Bottomley, Secretary of State for Health, has backed the introduction of 'community supervision orders'. But the House of Commons Select Committee on Health yesterday rejected the idea, arguing that the law was already strong enough to commit difficult patients to hospital.
Changing the law may well not help. Many families tell how they have pleaded with doctors to admit a relative with schizophrenia, only to be turned away. There are not enough beds. The NHS, not the patient, seems to be 'non-compliant'.
James, a 60-year-old schizophrenic, shows how the system fails and how it could be improved. Three years ago he was living on the streets of London, drinking heavily and psychotic. He had been homeless since being discharged, after 20 years, from a mental hospital in 1980. No one followed up his case. Then, in 1990, James walked into London's Great Chapel Street medical centre for homeless people.
'We started him on medication and eventually found him accommodation in flat where a warden keeps an eye on the residents,' explained Dr Simon Ramsden. 'He comes back three times a week for a cup of tea and a chat. He can't manage his money, so we help with that. Once a fortnight he comes for his injection. He still has psychotic symptoms and needs a lot of help, but he is coping. We were able to provide the type of care that he found acceptable, together with the social and psychological support.'
James is typical of those who might be subject to a compulsory supervision order. Yet his case, and many others at Great Chapel Street, shows that most patients, even when experiencing delusions, will accept treatment provided services are sympathetic. Of the 200 people with serious mental illness attending the centre each month, only about two require admission to hospital.
What happened to James in 1980 should not occur today. Since 1991, hospitals have been required to discharge psychiatric patients only when proper care exists for them in the community. But the spirit of these rules is often flouted. 'It is unusual for someone to be discharged on to the streets,' said Dr Ramsden. 'But it is being done by the back door. If you send a recovering schizophrenic to a hostel full of drinkers and give him an out-patient appointment in a month, what do you expect?'
The debate over community care of mental illness in Britain mirrors argument in America about how to deal with an epidemic of tuberculosis. People with TB need to take medication for about a year, but more than half never complete the treatment in cities such as New York, where 4,000 new cases are expected this year. So people experience multiple relapse and are the hosts for new drug-resistant strains of the disease, which spread rapidly and fatally.
Tuberculosis has finally come to the attention of the American middle-classes following the deaths of prison warders and hospital workers. These deaths served the same purpose as the recent high-profile murders in Britain. In each country there is a danger of reacting with too much haste and too little thought.
In America there are also plans to confine these so-called 'non-compliant' patients, even after they cease to be infectious. Kept in hospital, they would complete the course and be fully cured. But this is an expensive option. It is much cheaper and as effective if the system changes to meet the needs of the patient.
In some cities, health workers go out to find people with active but non-infectious TB and give them their drugs daily. A local person may also agree to keep an eye on someone with TB to ensure they comply with their treatment. Meanwhile clinics offer incentives, such as money for travel and food.
The results are encouraging: as at Great Chapel Street, the Americans have found that this 'directly-observed therapy' has resolved the issue of non-compliance. Most people take their medication.
With tuberculosis and mental illness there will always be the need to confine the most difficult and dangerous patients for their own good and that of society. But most people, even those suffering mental illness, want to feel well and healthy. Neglecting them and then reacting to their collapse with fear and anger is not the answer.
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