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Relapsing schizophrenic wants diazepam

Case history

Three GPs discuss a difficult consultation looming up

Trevor Jones is in his mid-40s, lives alone, and was diagnosed as having schizophrenia in his late teens. You inherited him from a retiring partner. He refused to accept any changes to his treatment, insisting his old doctor would only have given him what was best for him. He also refused to let the community mental health team review him.

Eight months ago, Trevor became unwell. He was hospitalised several times after overdosing on prescribed medication, and on each occasion discharged himself against medical advice. You involved the home treatment team, and he remained under close supervision for three months, during which his antipsychotics were changed to olanzapine 20mg daily and his benzodiazepines were withdrawn.

He has seen you four times in the past fortnight asking for diazepam and he has come as an emergency again tonight. Meanwhile, his key worker has phoned to tell you Trevor will not open his door to her.

Dr Tonia Myers

'It is essential to consider one's own personal safety in these situations'

This scenario is not unfamiliar in a patient with schizophrenia who is beginning to relapse. Trevor may have stopped taking his medication and is now refusing to engage with psychiatric services. Although he was not agitated last time, he is becoming increasingly assertive, and relapsing schizophrenics can be very unpredictable, so it is essential to consider one's personal safety in these situations.

I will tell a colleague I am seeing Trevor so he can find an excuse to check that all is well or perhaps sit in with me. This is particularly important as I am planning to refuse his request for diazepam.

I will try to be as non-confrontational as possible. I would ask Trevor if he is still taking his olanzapine and if he has seen his key worker lately. I would also ask if he is feeling depressed and whether his sleep or appetite is disturbed. I would reassure him that I do trust him and remind him that he had worked extremely hard to come off his diazepam and it would be a shame if he ended up back on it. I would suggest increasing his olanzapine as a better way forward, ideally with a review by his psychiatrist.

During the consultation I will be assessing his mental state and in particular trying to identify any delusional thoughts or hallucinations. I will ask specifically about thoughts of self-harm or aggression, which may suggest that compulsory admission is warranted.

If Trevor still insists diazepam is the only solution I would give him a prescription for a few tablets to avoid aggravating him further and try to use this as a bargaining tool.

I will tell him I am planning to chat to his key worker to let them know how he is. He may own up to refusing access at this stage. The key worker may be in contact with Trevor's parents who can confirm if he is showing psychotic symptoms. If Trevor continues to refuse to co-operate with the mental health team, I will discuss his case with the psychiatrist in charge to see whether a joint visit for assessment is necessary.

Dr Nigel Lord

'I would not wish to be acting as a supplier if he is selling his drugs on'

I would not prescribe benzodiazepines. There are alternatives that are safer and more likely to provide a successful long-term outcome. Represcribing benzodiazepines would be a retrograde step, especially with his overdosing history. Persuading him of this will, of course, be difficult! Is he genuinely anxious?

I would not wish to be acting as a supplier if he is selling his benzodiazepines on. If he is anxious, is there a trigger? Housing, employment and financial issues could be a problem and would be best dealt with by social services or Citizens Advice Bureau rather than by diazepam.

I would explain the risks of benzodiazepines and the methods currently used to manage anxiety. I am sceptical he would be capable of engaging in anxiety management or cognitive behaviour therapy, but I would assess this. He may be better trying medication that does not carry the same risk of addiction, such as ?-blockers or SSRIs ­ especially the latter if his symptoms are a manifestation of depression.

His current problems may, however, be a sign of psychotic illness again. I am concerned that his key worker is not getting access to him. Is he ill, with no insight? He may require adjustments in the dosage of his olanzapine or a change to an alternative anti-psychotic.

It may be sensible to reintroduce the home treatment team, who he already knows. He has to engage in treatment and this needs to be explained to him. If they cannot get access to him and treatment attempts fail, we may arrive at a point where he needs to be reassessed by a psychiatrist, possibly under the mental health Act if he is unwilling to engage in treatment and there are grounds for concern regarding his behaviour. If the psychiatrist was happy to reissue benzodiazepines, I would take that advice.

My long-term relationship with Trevor may be damaged by this issue. He may choose to look for another GP to accommodate his wishes the way his old doctor did.

As I am singlehanded, that would involve him moving practices. This would relieve me of the difficulty but would hardly be a satisfactory or safe conclusion ­ although Trevor may be happy if he gets his benzodiazepines.

Dr Prashini Naidoo

'Already I feel myself preparing to do battle with the patient'

What I do is based very much on time constraints, and I suspect Trevor knows this, which is why he has come to emergency surgery. Already, I've made an assumption. My other assumption is that Trevor wants diazepam, not an assessment and treatment of a problem. Already I feel myself preparing to do battle.

To be fair to Trevor, I would need to look closely at his history of overdose and rule out deliberate self-harm intentions and active psychosis, particularly as he hasn't recently seen his key worker. Before I actually get Trevor into the room, I would check my physical environment and find the emergency buzzer or alert the receptionist about my worries. Feeling safe also gives me more confidence in a possible battle of wills.

In the interview, once I rule out self-harm and active psychosis, I can mentally reclassify this consultation as nuisance behaviour for obtaining diazepam, in other words not an emergency.

I would make him come back for a double appointment. Giving him diazepam now would encourage manipulative behaviour. The battle lines are drawn and the fighting stance is assumed. I would be extremely surprised if I escaped unscathed. Insults and threats would be hurled at me, and accusations of not caring will no doubt bruise.

Before I see the next patient, I will mentally picture Roger Neighbour making a cup of tea, but I will no doubt substitute good Anglo-Saxon epithets for Buddhist maxims.

I will remember to tackle my colleagues, including the local co-operative, about my intention to cut off Trevor's diazepam supply and force him to surrender to a patient contract. I'll make a note in my personal development plan to contact the local drugs team to arrange further training in guerrilla tactics for difficult consultations.

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