INTRODUCTION
Schizophrenia is a multifaceted chronic disabling illness which poses a significant cost at the distress of the patient and to the burden of the caregiver. The traditional hospital-only psychiatric services have been shown to be inadequate in providing comprehensive care for people with mental illness (Coldwell & Bender 2007). This case highlights the burden faced by a family with three members suffering from schizophrenia and the role of ACT in improving their clinical condition and relieving their suffering.
CASE REPORT
MADAM A
Madam A was a 48-year-old lady, widowed since 20 years ago and had two children out of consanguineous marriage. She was diagnosed with schizophrenia at the age of 28 years where she presented with second and third person auditory hallucinations and delusions of persecution and reference. Soon after the diagnosis, she developed marked depressive symptoms with active suicidal ideation secondary to the frightening psychotic experiences.
Since the first episode, she had never attained full remission. She had frequent relapses requiring hospitalizations partly due to her poor insight leading to non-adherence to medications and at times triggered by stressors present in the family. She was treated with a series of antipsychotics including haloperidol, chlorpromazine and, risperidone with suboptimal response. Her mother, Madam D, claimed to supervise her medications. However, it could not be ascertained as she was frequently distressed having to care for Madam A and two other sick family members. Madam A was once tried with clozapine with total dose of 700 mg daily which yielded better clinical response. However, due to her erratic intake of this oral medication, in addition to the risks of severe side effects the medication may pose, it was switched to intramuscular depot flupentixol and tablet olanzapine which resulted in similar satisfactory response. Unfortunately, olanzapine was later substituted with the cheaper haloperidol due to financial reason after her Parkinson-stricken father passed away with the termination of financial benefit which he used to receive from the Welfare Department.
Electro-convulsive treatment (ECT) was once commenced during one hospitalization and was continued on maintenance basis. However, she defaulted mainly due to the difficulty that the mother had to bring her to the hospital.
She was referred to the Community Mental Health Team (CMHT) of Universiti Kebangsaan Malaysia Medical Center (UKMMC) since last seven years. Through regular home visits of weekly to monthly by the team, her medications were monitored more closely and the family was helped to overcome the financial problem by engaging the relevant agencies. These services helped to gradually reduce her hospital admissions from four times a year to an average of once a year.
MISS B
Miss B, the younger sister of Madam A; a 44-year-old single lady, first presented to UKMMC at the age of 22 years and was diagnosed with mental retardation with schizophrenia. She had history of multiple psychiatric admissions with typical presentation of florid auditory hallucinations and disorganized behaviour, causing significant distress to the family. She also received similar services from the CHMT which helped to stabilise her condition. Her last admission was four years ago. Her symptoms were controlled by sulpiride 200 mg bid and IM fluphenazine 25 mg, monthly.
MISS C
Miss C, the eldest daughter of Madam A, currently 24-years-old, was diagnosed with mental retardation since younger days. She was first hospitalized when she was 19 years due to psychosis and disorganized behavior which disrupted the family’s function, as she needed extra care. She subsequently required frequent admissions two to three times a year when she relapsed with similar presentations. She was diagnosed with mental retardation and schizophrenia. Her symptoms were well controlled when she was on olanzapine. However, due to financial constraint; olanzapine was substituted with sulpiride at one stage, which had destabilized her illness with impending relapse. The CMHT managed to secure financial aid to sustain her previous medication. Currently she is doing well on olanzapine 15 mg nocte. With regular supervision of her medication by the CMHT, she had maintained to be symptom free and had not required hospitalization for a long time. She also regularly participated in group psychosocial rehabilitation activities scheduled by the team which provided the family some respite from caring for her.
MADAM D
She was a 68-year-old lady and a widow, who out of consanguineous marriage was blessed with two daughters; Madam A and Miss B. She was the only mentally healthy care-taker in the family; who had to care for her mentally ill daughters, grand-daughter and husband who suffered from Parkinson disease for many years before his death. She developed major depressive disorder seven years ago with family wellbeing and financial issues being her constant worries. She also suffered from long-standing diabetes mellitus, hypertension and had a right lacunar infarct four years back. She had a few admissions to the Medical Ward, due to the complications of her medical illness but had never been admitted to the Psychiatric Ward.
Treatment with escitalopram 15mg nocte helped to control her symptoms. However, she would still have bouts of low mood when faced with difficulties in caring for her mentally ill family members. In view of her family’s condition, she felt stigmatized and isolated from the community. She took care of the household and managed her mentally ill family members. The CHMT had worked with her in creating medication charts to improve medication adherence. The team was also vigilant in monitoring her mood and giving her emotional and practical support. This involved mobilizing support from relatives and relevant agencies.
DISCUSSION
This report demonstrated the complexity of managing a family with its households suffering from mental illness and what ACT could provide in restoring remission and improving their quality of life. ACT which is the earliest available component of community-oriented services in Malaysia, functions to integrate and organize psychiatric care for patients with severe mental illness to cater for their different needs at different stage of life (Ruzanna & Marhani 2008). As demonstrated in this case, ACT has been proven in one study to reduce hospitalization, retain contact with service, improve patient satisfaction, and reduction of illness severity (Lambert et al. 2010). In accordance with the latter finding, a local study showed a high prevalence of symptomatic remission among schizophrenia patients who received ACT (n: 118, remission rate 78%) (Dahlan et al. 2013). In keeping view with all these facts, ACT should be provided to patients who are at high risk of repeated hospitalization and homelessness (Dixon et al. 2010).
In the present case, ACT helped one entire family in their journey of living with mental illness. ACT could be an essential psychiatric service component that should be established at all localities.