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Is it acceptable to lock-down a patient who has no intention to self-harm or harm others?

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Posted on Thu, 19 May 2016
Question: Hi, recently a family member has been diagnosed with type 1 bi-polar disorder with delusions of grandeur.

I am aware that isolation is one of the treatments for this, however, I am wondering to what extent is acceptable as isolation is also a form of torture implemented by many governments. Also we happen to be in a country where mental health services are mostly not covered by insurance and the country has one of the highest suicide rates in the world, and going to a psychologist/psychiatrist is seen as taboo.



Anyways, my question is, is it acceptable to isolate and lock-down a patient who has no intention to self-harm or harm others? She does not speak the language and none of the staff speak English. One doctor barely speaks English but struggles very much to do so, and it is very difficult to understand what he is saying at times.

Even if she gets interaction from nurses, she cannot communicate with them. She is allowed to have a journal, (No technology of any sort, TV, entertainment etc. - which I completely understand. She is having delusions of being a pop singing celebrity as well as being omnipotent), and in the journal, she's writing non-stop about what she is going to accomplish and lists of demands from people. The parents and close relatives are allowed to see her for no more than 5-10 minutes every other day. I understand giving her an audience can rile her up, but, I would like to know how XXXXXXX doctors would handle this. I know people with bi-polar disorder who, along with proper medication and care, are out functioning in society in the states. The doctor has her on lock-down until, at the very least, March 22nd (she has been there since March 3rd), but may keep her longer.

We were told that this is this country and this country has their way of dealing with these things, so it has to be done their way. But the fact that she is under isolation and total lock down on top of no one speaking English, with little interaction with nurses, and the fact that they have one of the highest suicide rates in the world, really worries me. I'm no doctor, but it does sound slightly 19th century-ish to me. Would love to hear some professional insight.
doctor
Answered by Dr. Chintan Solanki (3 hours later)
Brief Answer:
restraining the patient and isolation are almost outdated approach

Detailed Answer:
Hello,

Thanks for writing to us.

In any of the psychiatric disorder including bipolar disorder there is no indication of isolation of the patient until patient is severe suicidal or doing harm to others. Lots of oral, mouth dissolving medicines as well injections are available to calm the patient. Yes sometime patient is given injection forcefully according to local laws to prevent the harm to self or others.

In XXXXXXX no treatment is given until asked by patient or in some cases by relatives. And sometime according to laws patient is given treatment forcefully to save life or prevent harm to others/patient himself/herself.

I am from XXXXXXX and here same protocol applies.

If patient is not harming others or herself there is no need of isolation for delusion of grandeur. Rather allowing relatives to stay with her make them able to understand the patient well and social caring and support improves patient fast.

If feasible let me know in which country patient is right now.

Also provide details about her symptoms for which she has been isolated.

Hope I have answered your query, I will be happy to help further.
Regards,
Dr.Chintan Solanki.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Chintan Solanki (55 minutes later)
The country is Japan. 2 different doctors and my mother, who majored in neurology and now works in the medical field in the United States, have suggested that isolation is not a necessary or even recommended treatment for her right now. As I said, we were told "This is Japan, and we have our own set ways of treating patients."

It was quite off-putting being told that. And after getting feed back from 2 different doctors, I asked her some questions today.
I asked if she was undergoing any counseling or therapy while in hospital, and she said basically she isn't receiving any sort of counseling or therapy and she is just existing there. I asked if the doctor explained to her what her disorder is, and no one has explained to her. I briefly explained what it was and quickly explained symptoms (only allowed to see her for 10 minutes) and she was completely coherent and wanted to find out more about her diagnosis. She wants to receive treatment and make weekly visitations to a psychiatrist. I suggested family sessions as a lot of this also stems from her childhood and parents, and she said she has been wanting to do so for a long time.
She has so much to talk about but absolutely no outlet right now, and the doctor can't properly talk to her even if he wanted to. After letting her talk about her frustrations and stress, she seemed 100 times better - I saw a sense of relief, and yearning to speak more. The more she talked, the more calm she became. She isn't combative, and is willing to hear input and suggestions, for example, staying off of social media while she heals. She completely agreed and understands it is part of why she may have had a manic fit.
But I wasn't allowed to stay due to the doctor's orders.

Now, she is restless and wants to get out. I asked if it stresses her to have little to no communication and she said it frustrates her very much.

She has been isolated because she was making phone calls to everyone saying she was going to become famous. She is actually an entertainer and sings for famous musicians here, and she has met a successful producer recently and spoke about producing an album. So that was probably the trigger.

I do feel her underlying type 1 bi-polar disorder exacerbated the problem at hand.
But at no point was she threatening or considering harming herself or others. In fact, she was more concerned of getting hurt by someone else due to becoming famous.
She was talking about re-writing the bible and running for president in 2050, and saving the world, which raised flags for suspicion of grandiose delusions.

She was rambling constantly, and very hyper. The doctor sedated her and she went to sleep. Her parents do not understand mental illness, and they do not completely understand it is a chemical imbalance of the brain. So her mother felt she could discipline her into stopping, but it only exacerbated the problem. So the decision was made to sedate her.

The parents did not want to commit her, but the doctor pushed them into agreeing.
We pleaded with the doctor to allow at least one parent to stay with her through the night, in case she woke up by herself confused that she is in a hospital bed (they also restrained her before telling her parents, due to the IV. they told her parents after she was restrained that she was restrained), but they did not allow them to stay due to visitation hours.
The doctor did not ask thorough questions to the parents, so I was a little concerned about that. He had no idea they were separated until the 3rd day of her stay, and found out only because he asked me details about her.

So I am quite worried about her treatment at the moment.

What is your insight on this method of treatment and the way this has been handled?
doctor
Answered by Dr. Chintan Solanki (1 hour later)
Brief Answer:
parents should be allowed to meet her

Detailed Answer:
Hi,

Thanks for information.

From history it is almost clear that she has manic episode as she was needed hospitalization. Initial sedation is also fine in most of the patients with mania as decrease need for sleep is one of the symptoms and with sleep there may be some improvement. Mood stabilizer medicines like lithium (in cheerful mania like she has) or valproate sodium (in irritable mania) should be started. However this drug can take time up to 1 week for proper effect. In between anti psychotic medicines help to control talkativeness, delusion, sleep problem as well as restlessness. If patient is not taking oral medicines, injections should be given as per local guidelines. As soon as patient improves and ready to take the medicines, shift to oral medicines.
In acute phase counseling with patient is not feasible or helpful. However as soon as patient becomes calm and cooperative, he/she should be explained about the disorder and treatment. Meanwhile detail history from patients’ parents/relatives/friends should be taken to know the precipitating event, psychopathology and course of illness. And doctor should also explain in detail about her illness to concerns parents/persons considering long term outcome.

In your relative's case she may be given appropriate medicines (without details of medicines it is difficult to comment) but she must not be isolated or restrained. Her parents or close relative/friend should be allowed to stay with her. I do not agree with this method. Otherwise they may be right on their approach if they are not harming her. And I hope no doctor in the world at least harm the patient by treating in unethical way.

I recommend talking with her treating doctor for your concern. They should respond.

If still any query there, I will be happy to answer if not, you can close the discussion and if feasible give your feedback and rating so I can improve my service.

In future if you wish you can contact me directly on this site with following link:
http://bit.ly/drchintansolanki

by clicking on 'Ask me a question' on same page with three follow up questions.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Chintan Solanki (1 hour later)
Thank you for replying. I do agree she needed the sedatives and she needs the anti-psychotics. But I did not agree with her isolation and not being able to meet her close relatives for any more than 5-10 minutes every other day, as she has shown no indication of self-harm or potential to cause harm to others, nor has she ever in her life-time.

At the moment, she is completely calm and coherent - no rambling, and very level headed. I am sure the anti-psychotics played a great role in that, but the doctor wouldn't be able to understand her even if she explained in detail due to the language barrier. He couldn't understand the parents either.
Also, it's important to note that she has been co-operative this entire time. She has never been combative. She agreed to go the hospital on her own accord. Of course, she was in a manic state at the time, but she has been co-operative this whole time. Even more so now. She agreed to be sedated. I don''t understand why she has to be locked down and isolated at this point. The doctor claims the if she walks out of her room, that view of the city from the window of the waiting room can set her off but.... there is a window in her room with a view of the city..... almost the exact same view....

Is there any type of proof of isolation and locking down a patient, being an outdated method that I could show them? Is there a book of regulations or anything like that? The doctor refuses to budge on this order. And plans to keep her for almost 3 weeks.

Also, they would not tell us what medications she is under. Does this sound right? Is there anything I could bring up to demand they show her parents what medications she drugs she is under?

Thank you very much.
doctor
Answered by Dr. Chintan Solanki (13 hours later)
Brief Answer:
it right of patient/parents to know the details of treatment

Detailed Answer:
Hi,

Sorry for delayed response.

I am sorry that I am totally unaware about laws of Japan. You can search on local internet.

According my opinion you can do the following.

- Take help of local friend or relative who knows the japanes/local language and can discuss with doctor.

- It is a basic human right of patient ( if patient is not in a status to understand then right of parents) that he/she must be aware about treatment in details. You (signed by her parents or patient herself) can ask/apply the same thing in writing.

- Ask you mother if she knows any doctor from Japan there in USA and can throw light on this issue.

- And ultimately if her parents are agree, you can take help of law, US embassy or human right commission.

Do everything/talk in polite manner without showing any agitation. Keep requesting and you should get results.

All the best and take care.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Chintan Solanki

Psychiatrist

Practicing since :2007

Answered : 2406 Questions

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Is it acceptable to lock-down a patient who has no intention to self-harm or harm others?

Brief Answer: restraining the patient and isolation are almost outdated approach Detailed Answer: Hello, Thanks for writing to us. In any of the psychiatric disorder including bipolar disorder there is no indication of isolation of the patient until patient is severe suicidal or doing harm to others. Lots of oral, mouth dissolving medicines as well injections are available to calm the patient. Yes sometime patient is given injection forcefully according to local laws to prevent the harm to self or others. In XXXXXXX no treatment is given until asked by patient or in some cases by relatives. And sometime according to laws patient is given treatment forcefully to save life or prevent harm to others/patient himself/herself. I am from XXXXXXX and here same protocol applies. If patient is not harming others or herself there is no need of isolation for delusion of grandeur. Rather allowing relatives to stay with her make them able to understand the patient well and social caring and support improves patient fast. If feasible let me know in which country patient is right now. Also provide details about her symptoms for which she has been isolated. Hope I have answered your query, I will be happy to help further. Regards, Dr.Chintan Solanki.