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ramblings of an unknown psychiatrist

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adolescent manic

Posted by Dheeraj Kattula on April 25, 2009

I reviewed SB today, by proxy. His brother had come. SB apparently was so…drowsy that he could not be brought in the public transport. Auto-rickshaw would be too costly an affair for a Santhal tribal, especially for a review. I was glad SB was doing well.I had been anxious regarding him.Why?

SB is a 16 year old boy,who had been episodically mentally ill for the past 5 years. He discontinued his schooling 3 years ago during one such episode. He was being treated with low dose anti-psychotics for quite sometime.A clear diagnosis was never made due to lack of a informant, as many times he turned up alone.He went off medicines few weeks ago and hell broke loose in his village.

He was speaking excessively and disturbing others at work.He was singing romantic songs at girls in his village.He started running around threatening to hit others.He demanded ‘good’ food and did not feel like sleeping.His belligerence and over activity propelled his brother to the hospital seeking help.We diagnoses him to have Bipolar affective disorder, current episode mania with psychotic features.

He was admitted and given parenteral anti-psychotics initially.He was started on mood stabilizer,anti-psychotics and benzodiazepines to calm him down and control his psychopathology.Our nurses took good care of him.Considering the fact that they were never trained in Psychiatry, they did an excellent job in de-escalating any tension that arose in the ward.Thus preventing use of injections or restraints.His caregiver ran away leaving his frail old mother to care for SB.Again our nurses helped a lot providing him all that was necessary.

His eldest brother, who had come for review today demanded a discharge within two days of the absconding of his attending younger brother. The hospital staff had by then developed an attachment to SB and desired to see him improve.An early discharge meant possibility of drop out,relapse and who knows what next.His brother was clear about keeping SB chained at home! I lost my cool as I sometimes do,in the paternalistic interest of my patients.I shouted at this man who came today,asking him if he really loved his brother SB.

Just before they went I called SB’s brother.I told him that I was increasing the dose of medicines such that SB would be knocked out with sedation.I added that this was to avoid chaining SB.I called for a review within 10 days.He readily agreed.Today was the day of follow up.He did come…smiling.

SB’s unplanned discharge made me think deeply one issues. Why do people want to get their relative discharged knowing that there are major risks involved? I wrote about SB to one of my teachers.

She replied,” My heart aches for the pain you feel in the face of the reality of our world. In our attempts to minister to the needy we are not told often enough that when we start the engine we must also know how to use the brakes. Our hearts have to know how to open and when to hand over to God.

Our plans have to be made with our eyes on the highest and noblest targets but with our feet firmly planted on the ground of limitations. We need to be able to balance our urge,/need to help others with the wisdom of looking after ourselves. We have to take charge of situations with the knowledge that we are merely playing at the edge of an ocean of need which rests in the palm of His hand. 

I am slowly learning how to accept that more often than not  I am unable to do more than “be with” people in their pain and suffering. The family of the manic boy had obviously reached the limits of their resources. However inadequate the support they have to offer please remember that they have already given more(in proportion) from their penury than we will ever give from our plenty. We will never know the incredible burden of caring for a person with mental illness till we or our loved ones go thro the experience.”

I could just begin to understand her point. Thankfully I could spend sometime with SB’s brother before they left.He did understand that I was meaning good for SB.The reason he came in smiling today is that as I had finally told, SB was indeed knocked out with sedation and did not require chains that he had planned 🙂


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