"Certainty? In this world nothing is certain but death and taxes."
- Benjamin Franklin
Well, he has a point.
This week's been frantic. A lot of folk have been unwell and (as is my wont) a nurse and I've been doing a large number of joint visits. One referral from A&E resulted in a section 136 assessment. What's that? It's when police arrest someone in a public place and convey them to a place of safety (erm, that'll be my hospital, then) for an assessment of mental disorder. In theory a section 136 is applied because the person presents as mentally disordered and is in immediate need of control and restraint. In practice it can be used 'cause someone is acting, "a bit odd," but the police would find it hard (and bureacratic) to arrest the man then go through their custody officer to get him into the cells. Oodles of paper work. Best just cart him off to health, then he's their problem. But on this occasion an assessment was indeed appropriate.
Thus, I was asked to see a retired gentleman who was detained because he wanted to kill himself and had flounced out of his partner's home and driven off (but was curiously found very swiftly after a number of mobile 'phone calls he made) yet notionally he wanted to be left alone and sought to kill himself. He'd injected himself with insulin. He could tell me, to the unit, how much. He had all his papers with him so he could relocate and settle in my patch. He'd brought suitcases and personal effects. But, erm, "I'm suicidal, I'm going to kill myself and going to end it all."
The approved social worker did some sleuthing. He's been assessed in 5 neighbouring hospitals with the same presentation. Euphemism : he's problems of anger management. Truth : he batters his partner and blames it on anger that doctors haven't cured. He feels no responsibility for this, he can be violent since, "It's not my fault." It's other people, "They wind me up, play head games, do my fucking head in, doc." So they deserve it? "Well no, but they're kind've askin' for it, really, aren't they? Kinda got it comin' with what they say." Who is responsible then? "Not me, it's them folk in [town blah 30 miles away] who never helped me. They know I fly off the handle dead easy, like, but don't treat me or anything. Nobody cares." Ah, my colleagues in a neighbouring county fail to control your anger, so you batter your partner, you're not responsible and they are, now I see.
Are there any delusions? No.
Are there any hallucinations? No.
Any cognitive impairement or confusion? No.
Any changes in physical health, medication, wellbeing? No.
Any obsessions, compulsions, odd thoughts? No.
Alcohol misuse, drug problems? No.
Erm, anything to affect your judgement at all? "Yes doc, it's her, she's done this to me."
Done what? "Said she can't live wi' me, asked me to go, so I have. But now I want to kill myself."
He's assessed. Usually a section 136 assessment takes an hour or so. The approved social worker (ASW) wants more details so it goes on a while. He's observed by nursing staff.
Before this event he's had no tiredness, no loss of pleasure, no initial insomnia, no broken sleep, no early morning wakening, no loss of libido, no diurnal variation, no low mood, no hopelessness, no worthlessness, no guilt, no tearfulness. So, no evidence of somatic features of depression a few hours ago, but suicidal now. Crikey.
He's chatty, enjoys watching the telly, talks with patients about his favourite football team and a match he's looking forward to (and how he might drive up to watch it live). He speaks of new things he's ordered and has to collect next month. He talks of accomodation he wants and support he'd need, "I can't cook, like, so I need looking after."
He's expressive, reactive, no psychomotor retardation, no restlessness, no tearfulness, no distress. He speaks fluently, normal rate, rhythm, volume. Spontaneous with neither poverty of speech nor poverty of content. No dysprosody. Mood subjectively "I'm going to kill myself" but objectively is euthymic. Thoughts are of normal form and content. No perceptual anomalies. No cognitive impairement.
The ASW gets a colleague to see him. Then 'phones another. We talk with 3 nurses who've been with him most of the day, now. Reassauringly, everyone feels the same.
Nobody sees any symptoms of mental illness. Nobody feels he's evidence of mental disorder. Nobody feels he's detainable under the Mental Health Act 1983. Everyone sees him as a capacitated adult, able to make his own choices.
He says, "If you let me go, I'm going to kill myself. Don't you have to detain me, don't you have to stop me killing myself?"
I explain that's not the case, I really hope he won't kill himself, but that's his choice.
We arrange a range of accomodation options for him, for today, in a range of locations. We arrange mental health followup from a CPN and Consultant in his own town but he says he won't go to it. "Your choice, we've offered social support, we've offered mental health follow up, if you want to choose to do something else, we can't stop you."
We send him on his way.
I really, really am not sure he'll live. He's impulsive and reckless. The Mental Capacity Act 2005 states that adults with capacity must be allowed to make unwise choices. He's likely to take overdoses and, intentionally or accidentally, at high risk of killing himself through this.
As Mr Vonnegut would say, "So it goes."