Category Archives: Issues & Debates

Adult ADHD?

Clinical Case Studies, Depression, Issues & Debates

This young Indonesian man came to us referred by a psychiatrist, in the referral letter it was written that he’s experiencing some psychological difficulties, poor sleep, mood swing, poor concentration, the diagnosis was dysthymic disorder.

When he came to the counter I can see his face in red and him in such an agitated mood, he said, “I’ve been trying to call you guys but something strange happened.” I told him to call us in front of us and so he did. There was indeed some weird sound coming up after he dialed, of course, as he called our fax numbers. So later he was registered and he took a sit, seemed to have calmed himself down listening music with his earphone in the waiting area.

He said his main objective to come to our clinic is to sort out his poor sleep and mood swing problems. He said even with medication from previous doctor, he can’t fall asleep deeply, he just doesn’t feel that he’s sleeping well. At one point he felt like he could no longer control his emotion. His appetite is considerably ok, acceptable as he said. But he said when he gets angry he feels dizzy in his head. The example he gave was the time he was coming to our clinic, but couldn’t find the place, and couldn’t reach us by phone (well, how to get to us with fax number, unless you’re sending a fax I suppose?). He said he was so angry and then he felt light-headed.

We don’t expect people to be flat in their mood (in fact being flat in mood is a negative symptom of Schizophrenia), so people can be sad, happy, angry, calm, depressed, elated… Yet his diagnosis was dysthymia, a disorder characterized by chronic, consistent low mood (just like depression, but less severe, more long-lasting). He didn’t appear so to us. He laughed when I joked. He was angry when he was frustrated. He managed to elaborate his problems with examples. He has interests- he listens to musics as he waits.

One main problem he has is his poor concentration, he’s a student. For a student to not concentrating, not focusing, not remembering, not memorizing, it’s like end of the world (especially if you do care about your studies!). He really wants to finish the study and graduate from it, as he doesn’t want to waste his father’s money.

So we’re suspecting Adult ADHD. I remember I got a copy of Adult ADHD scale just last week and was thinking “I won’t need this. Who’ll come to clinic for this problem?! Nobody.”

Now I realized one thing, it’s right, nobody will come for consultation and treatment for Adult ADHD. Not because nobody is suffering from it, but chances are it’s far under-diagnosed. If you look at the scale (Adult ADHD Self-report), you’ll realize people nowadays are likely to suffer from it (I can’t concentrate, I can’t sit still, I get distracted easily, I keep forgetting the deadlines, I feel restless…).

See here for more Psychological Rating Scales.

Consent to Treatment & Mental Health

Clinical Case Studies, Issues & Debates, Schizophrenia & Psychotic Disorder

I wrote a clinical case study previously (see here) and demonstrated under certain conditions it’s not always possible to gain the consent of treatment from the patients yet the family has some other options to help the patient if they want to.

Few days ago I spoke to a husband who all the while has been putting medicine in drinks for his schizophrenic wife. He has been cooking soup, buying Chatime, fresh milk etc at night, just to let his wife who thinks she’s well to take the medicine. (I wonder if married women who are reading this will become suspicious of whether their husbands are putting medicine in their supper drinks?!)

Recently the patient started to refuse to take supper at night. She got angry and asked husband not to let her eat anything at night. She goes out with friends till late night. Once she gets home she just wants to go straight to bed. She said those drinks are making her fat (she’s mostly right).

So husband started to fail giving her med and she started to demonstrate poor sleep, agitation, paranoia…

The husband said he’s really been suffering doing this (putting med in his wife’s drink/food). He said one day when he was dining out with the wife, while the wife was away to the washroom, he poured the liquid medicine into her drink, and guess what? Somebody saw it!! He was very embarrassed as if he was doing something illegal, wrong and sinful (imagine what the public would think about having seen that?).

It’s good to have consent to treatment from the adult patients, much easier for the clinicians and family members for sure, but when the patients think they are fine and completely healthy psychologically, guess it’s the family then, that have to suffer.

Bipolar Disorder

Bipolar Disorder, Depression, Issues & Debates

His family came for consultation on behalf, as he wouldn’t come no matter what. According to what his family (wife, son & daughter-in-law), he is in such a hypomanic stage, with spending spree, agitated mood, and not sleeping much day nor night.

However, we were surprised to know that the man has been taking anti-depressant himself. The son said that he was depressed few months ago, so he willingly went to the general hospital to see a psychiatrist, and got some anti-depressant medication. He has since then been taking it, and got better from depression.

Now that he’s in such a hypomanic stage, imagine he’s still continuing with the anti-depressant?! He gets even hyper and manic. He doesn’t listen to his family’s advice to stop the anti-depressant, as he feels good taking them, energetic, filled with drives, jovial… (but manic in others’ eyes).

So after consulting us, we’ve given advice to the family that they will have to find a way to stop the man from taking the anti-depressant but to start with our medicine. Few days later it was the date for the man to go for appointment in the general hospital, where he usually just collects medicine as the appointment bookings for the psychiatrist is always full. So when the son accompanied him there (he’d never accompanied his father to the hospital), again the nurse asked them to collect the same medicine as the appointment booking is full. This time, with the advice from us, the son refused. He said the man’s condition is no longer the same, he can’t take the same medication. They sent him to Accident & Emergency department where the man was asked to do blood test. Only with blood test result coming out few hours later, they got to see the psychiatrist doctor.

Here it shows the importance to regularly have follow ups and reviews with psychiatrist doctor rather than continuously collecting and taking medicine (which is very common in most government and some private practices, most likely due to the shortage of clinical staff and doctors). As people don’t usually get depressed all the time with medicine (other than dysthymic disorder which is another case), they do recover, so they shouldn’t really be taking anti-depressant for long term without medical review, even if it is just a maintenance dosage, review is still needed and important.

Physical vs Mental Health

Issues & Debates, Treatment Approaches

Background: Depression Following Stroke

When the patient was first admitted into the hospital due to stroke and was subsequently staying there to do physiotherapy, the doctors there had never wanted him to take any of those psychiatric medicine, despite being told by the wife that he has had a brother who committed suicide due to depression. The reasons given is that those medicine was causing him drowsiness and tiredness, so he’d be spending so much time in bed that he couldn’t do his physiotherapy and necessary exercise.

People often care only about their physical health, whether any part of their body is aching, body temperature is within the healthy range, diabetic or not, blood pressure is not too high, etc etc. This thought is possessed by many including clinicians, health professionals, doctors etc. So quite often when patients are admitted into hospital, for for example, gastric, intestine bacteria infection, fever, cancer, etc, they are advised by the clinicians to stop taking their psychiatric medicine.

So what happened when they stopped their antidepressant, anti-anxiety and/or anti-psychotic medicine? What happened when patients get slightly better in their physical health?

They can’t manage the stress and cope with the recovery process related to their physical illness. Some kick off, shout, throw things, self-harm, hurt others, restless, unable to sleep… They deteriorate so badly that they be treated for their physical illness. Some may be okay, but once they get recovered in their physical illness, their mental illness is again unmasked and has become even harder to treat as they have stopped medicine completely.

A lot of people need to take anti-anxiety/anti-depressant medicine to cope with their recovery from cancer, stroke or other illnesses. There is no point to recover from a stroke, being able to talk, mobile and function more normally, then have the patient to jump off the building or sea and lose their lives. Whether or not he is diabetic, immobile, body aching, has had stroke, gastric, cancer, high blood sugar… … if this person has had mental health problems, he then will have to take medicine for it.

Confidentiality Awareness

Issues & Debates

“What? You are just going to fax the letter over like that?” I asked, as my colleague was going to fax a letter regarding one of our patients to the patient’s company. The company requested it, and the patient was aware – he came to sign a consent form (ah wow such thing exists?!) but he isn’t allowed to even look at the letter. So yea, he gave consent for us to disclose his illness to his workplace, without quite knowing what his doctor wrote about him.

“Yes! The patient isn’t allowed to read it so we can’t give the letter to let him bring to the company! I’m just going to call to make sure that they get the letter” (they? who?!)

I guess most of us know where a fax machine is placed in an office in most companies. Usually anyone who walks past it can check and look at the incoming fax. Chances are the fax may then be passed from one to another (in a larger company, maybe office boy, secretary, some other “caring” colleagues). I feel so bad that this was done. I don’t blame my colleague or anyone in the clinic, but the whole awareness about confidentiality issue in Malaysia is just low, very low. When I was trained in the UK, confidential used to be such a big issue. In the uni we had one whole 5 credits module about ethics and confidentiality; At work, we had one whole hour training about protecting patients and staff confidentiality.

Having watch this, I will be so careful to sign any “consent” form in the future. I mean we all as patients or service users or some kind of participants should understand where those private information about ourselves is going and what they are used for. Remember you always have your rights, don’t be afraid to fight for them. It may take quite some time till we actually get there like in many developed countries, but it will not happen if nobody is fighting for it.

I hope people in the practice gain more awareness and give more respect too. Imagine this was you, would you be happy that your some sort of medical/financial report or ability test etc is passed around in your workplace or among some unknown people?

N.B. This post was first published at huibee.blogspot.com by the same author

What’s normal development?

Issues & Debates, Treatment Approaches

He is the eldest of his parents’ three sons, showing some delayed developmental milestones, usually withdrawn and unable to focus. By 5 or 6 years old, he could only use short sentences. He was sent to attend special school.

When he was 18 years old, the mother and his younger brother came to our clinic. For the past 2 years he had become more and more rigid, sensitive, with aggressive outbursts. Over 3 months mother was putting medicine in his food and drink and he slowly got better.

Few days ago the mother made a call to us. She said he seems to get more argumentative, bad tempered and demanding. He wants to learn driving because many of his friends are doing so. He wants things that his peers have. He is getting defensive when family speak to him.

Mother asked if the medicine can no longer control his illness, if her son is getting more and more ill. I explained to the mother, her son is at a stage where it’s normal for them to be argumentative, defensive, disobedient, rebellious, influenced by peers, having strong ego … What kind of expectation is she having? A son who listens to her completely? Never says no? Quiet and submissive? …?

We quite often overlook the stage of normal development and the environmental influences, and focus too much on the problems someone has. He’s bad-tempered, she’s irrational, he gets jealous all the time, she is disorganized, they’re lazy… But perhaps that happens to everyone at that stage of life, perhaps that happens to most people if they are under that level of pressure, perhaps there’s something else going on in that person’s life but we just don’t know, …

We don’t want to use medication to control one’s behaviour so much that this person loses the self, so much that this person lives how we want them to live but not how they want to live.