Humane care for vulnerable people

The article on depot antipsychotic medication by Patel & David (2005) is welcome, as is its accompanying invited commentary (Barnes, 2005). An issue hinted at but understated in both is that of the risk to others posed by some individuals with schizophrenia and related disorders. Although people with schizophrenia whose symptoms are well-controlled are no more a risk to others than is anyone in the general population, those with active psychosis do pose an elevated risk. The number of people with schizophrenia who kill others or who inflict serious violence on others when stabilised on depot, although not zero, is very low. A number of homicides by individuals with schizophrenia have followed discontinuation of depot and replacement by oral medication, with which full adherence has not occurred (Howlett, 1998). Even among in-patients, I have known individuals returned to intensive care units following discontinuation of depot in preference for oral medication, in both general psychiatric and forensic psychiatric units. In a few cases all that is holding back relapse into dangerous behaviour is the treatment for the mental illness, and some tragedies may be prevented by ensuring that the patient takes the treatment.

Patel & David refer to the modern ethos of a partnership with the patient rather than paternalism. In my view a good father develops a partnership with his children but he still takes care to protect them from harm when they are as yet unable to do so themselves. Adult psychiatric patients are not children but they are vulnerable people often with impaired judgement. The contemporary adverse perspective on medical paternalism need not serve to discredit an historical medical tradition involving humane care.