Mental health issues: Enter the psychiatrist
I will devote this month’s column to readers’ queries and answer some of the main issues raised in these letters. I have had some difficulty in answering such letters individually for several reasons. Some of these are: The patients concerned do not want help and refuse to accept there is anything wrong with them, the person writing is not the patient, nor even the parents, but another relative or a friend, the writer wants a personal appointment or to telephone them for further information, I am sent prescriptions of medicines given by other psychiatrists with a query as to whether I agree with the treatment. Ethical and practical reasons make it difficult for me to oblige.
In psychiatry especially, it is not possible to make a definite diagnosis from a description given by a third party. If the history is clear I may strongly suspect a particular diagnosis but that is not sufficient. The main tool of diagnosis in psychiatry is the mental state examination where we question a person in detail in a systematic manner about their thinking processes, moods and behaviours. Most of our diagnoses are made after the mental state examination combined with a good background history. There are no diagnostic blood tests in psychiatry. Minus at least one face to face consultation I am unable to speculate on a diagnosis or to offer treatment.
Without going into the specifics of an individual query I will give some general advice on how to deal with a person who you think may be in need of psychiatric help.
Who is a qualified psychiatrist?
In Sri Lanka, a specialist psychiatrist, in addition to his basic medical degree of MBBS, has an MD in psychiatry awarded by the Postgraduate Institute of Medicine (PGIM) affiliated to the University of Colombo. He or she should be Board Certified as a Specialist in Psychiatry, again by the PGIM. This certification is given after a doctor has completed a further two years of training after the MD, locally and abroad. A fully-fledged specialist would have spent a minimum of 13 years qualifying in medicine, and then in the speciality, before he or she could even start life as a specialist. This is the longest period of training of a professional that I know of. These are the minimum qualifications and in their absence one is not qualified to practise as a consultant psychiatrist in Sri Lanka. So ensure you are seeing a properly qualified specialist.
How do you go about seeing a psychiatrist?
You have two options. You can see a psychiatrist in the state sector or in the private sector. If you wish to see a psychiatrist in the state sector, nearly all districts in Sri Lanka have the services of a consultant psychiatrist. You can request for an outpatient appointment from any of these hospitals. The specifics of how to go about this would differ according to the hospital.
If you wish an outpatient appointment from the University Psychiatry Unit, Colombo you can obtain an appointment from the reception desk in ward 59 of the NHSL on any weekday between 8.30 a.m. and 4 p.m., and on Saturdays from 8.30 to 12.30 p.m. The clinics are on Monday, Tuesday and Saturday mornings. A letter of referral from a doctor (not necessarily a psychiatrist) is preferred but not essential. The usual waiting time is less than two weeks.
For any other inquiry you can call 0112691111 extension 2279.
If you wish to see a psychiatrist (or any other specialist) in the private sector the easiest is to go online and look for your preferred specialist. There are two websites, www.echanelling.com and www.doc.lk. The latter is specifically for specialists in the Asiri group of hospitals. Asiri now offers telephone bookings and you can pay when you attend the appointment.
Can you see the doctor without the patient?
If you wish to discuss about a close relative we do accommodate such requests but there are certain restrictions. If the person is already a patient of mine I will not discuss about him or her in their absence unless I have been granted permission by the patient. Sometimes relatives find it difficult to understand why I cannot do so as it is in the best interest of the patient. But breaking medical confidentiality is a serious offence and would undermine my relationship with the patient if they were to know. If I have never seen the patient before and the relatives are concerned about a person’s mental health I would be happy to discuss the issue and give the best advice possible.
If you think a relative is mentally ill but he or she refuses to consult a psychiatrist what can you do?
As I stated before, a mental state examination is essential for a proper diagnosis. And this can’t be done without talking to the patient. A person may initially refuse but if several trusted family members keep persisting, the patient may consent to at least see the psychiatrist for a chat, not necessarily for treatment. This should be possible where the person is reluctant to see the psychiatrist due to fear of stigma. Sometimes the disease makes the patient suspicious and prevents them from trusting the family or doctors. Some patients may be unaware that they have an illness and see no necessity to see a psychiatrist. If persuasion fails, and the patient’s condition is deteriorating, with risk of harm to self and others, there is no option but to seek help in the provisions of the mental health act. The mental health act provides for concerned next of kin or the police to convey a person suspected to have a mental illness to an institution for assessment.
Unfortunately the current mental health act is ancient and designates the National Institute of Mental Health (previously known as the Angoda Mental Hospital) as the only institution empowered to hold persons. The practical way to enforce the act is for the relative to obtain a letter from a consultant psychiatrist to the OIC of the nearest police station instructing the officer to help in conveying the person to hospital. Often the huge stigma arising out of such an operation makes it difficult for relatives to take this drastic step. But failure to do so can also cause serious harm to the patient and others.