25-year-old Sam is brought in by the police due to public concern regarding some bizarre and distressed behaviour in the city centre. The police say Sam will only speak of being “scared of ‘them’ ”. He’s currently curled up in a ball over in the corner of the room.
Mental health act
Section 136 allows police to bring a person from a public place to a place of safety.
The place of safety can be A&E, a police station or a specific ‘136 Suite’.
A person can be held under Section 136 for a maximum of 72 hours.
During this time an assessment of the individual should take place by a mental health professional.
If a person:
- has/is deemed to have a mental disorder which requires assessment or treatment
- is suffering from a sufficiently serious disorder that means admission is necessary for either the health and safety of the patient themselves, or the public
- requires hospital admission for assessment/treatment
- is unable and/or unwilling to agree to admission
Two registered medical practitioners (one of which must be Section 12 approved) and an Approved Mental Health Professional (AMHP – usually a social worker) submit reports which support that the case satisfies the above criteria.
“They’re after me…they’re going to get me. I’ve heard them talking about me.”
“They know what I’m doing, they know where I am. They follow me everywhere. They put a tracker in my head while I was asleep a year ago. Now they know where I am and what I think.”
“They know what I’m thinking, and they make me think about hurting my family. I don’t want to hurt my family, but I keep getting these thoughts…It’s getting worse.”
“The chip was put in my brain last year. They’ve been getting louder ever since.”
It is not possible to obtain any more of a medical history from Sam.
- Acute psychosis
- Drug-induced psychosis
- Schizoaffective disorder
- Psychosis due to a medical condition
- Bipolar disorder
- Delusional disorder
- Schizotypal personality
- Third person auditory hallucinations
- Thought insertion
- Thought broadcasting
Routine drug screening – urine & blood – typical suspects are cannabis, amphetamines & LSD
FBC – white cells/infection markers
U&E – electrolyte disturbances may indicate an underlying medical cause
Random blood glucose/fasting blood glucose – diabetes
Medication history – can get this from the patient’s GP
Neurological examination – to rule out organic causes – space-occupying lesions etc
CT/MRI head – to rule out organic causes
EEG – if seizure activity suspected
The story continues…
You return to Sam to discuss the need for blood tests and find a lady sat with him. Jane introduces herself as Sam’s mother and explains that Sam usually lives with her. She explains that Sam is known to have schizophrenia. This was diagnosed during university and has been somewhat turbulently managed since. He has been on several different antipsychotic medications in the past 4 years, none of which have seemed to control the symptoms. Sam has not been able to find a job since university and has few friends. There is no known illicit drug use and he has no other past medical history.
Sam has a history demonstrating schizophrenia that has not responded to first line treatments (treatment-resistant schizophrenia). Clozapine is indicated for treatment resistant schizophrenia, specifically when the illness has been unresponsive to at least 2 antipsychotic medications (at least one of which is an atypical antipsychotic).
Baseline bloods – FBC (particular attention to white cell count & neutrophil count)
Cardiovascular risk status / BMI / fasting lipids – ↑ cardiovascular disease / myocarditis
Fasting blood glucose or HbA1c – Clozapine is associated with an increased risk of diabetes
Baseline vital signs – Clozapine can cause postural hypotension
ECG – to act as a baseline – ↑ risk of cardiovascular disease with Clozapine
Often initiated during an inpatient stay – started on a low dose and titrated upwards.
Plasma clozapine should be measured after the initial target dose is reached (approx 2 weeks).
A normal maintenance dose is 300-600 mg daily.
Blood pressure should be monitored regularly, as postural hypotension can occur.
For the first month patients on clozapine should have the following monitored:
- Vital signs – temperature (?fever) / blood pressure / pulse
- Troponin levels
This is because a rare side-effect of clozapine therapy is myocarditis, which can lead to myopathy.
During the first 6 months of treatment WCC should be measured weekly, then fortnightly.
1 in 1000 people on treatment develop agranulocytosis, and this usually in the first 6 months of treatment.
Clozapine should be temporarily stopped or discontinued if granulocytopenia develops.
Weight gain / Impaired glucose tolerance
Weight should be monitored regularly as weight gain is likely.
Alongside this, insulin-resistance may develop, so HbA1c should be measured 6 monthly.