On Mental Illness: Scenarios of "Noncompliance" and Relapse

By Jack Bragen
Wednesday August 24, 2011 - 10:37:00 AM

When I met with my first outpatient psychiatrist, he would monitor me for early warning signs of a relapse of psychosis. He would ask me if I was eating and sleeping O.K., and if I had “unusual” thoughts. He would also check me for excessive side effects of the Prolixin. 

When I was nineteen I became medication compliant after a phase of trying to refuse medication. I had experienced a second episode of psychosis while at work. I had worked for a janitorial service in Pacheco for a year, polishing supermarket floors; and had done this while essentially crazy for about the last month. I spent a few weeks on the hospital and became stabilized on medication. Then I spent seven months at a halfway house in Hayward, and then moved back to Concord, to live at my mother’s house once again. When back in Concord, I once again saw the first psychiatrist—to whom I had previously lied about taking medication. He behaved in a mild-mannered, soft-spoken and calm manner. This is a good trait in a psychiatrist, as opposed to authoritarian and overly direct, as some of them are. 

During each of the four or five relapses I have had, I lost weight rapidly due to not eating properly, if at all. Not eating is a strong predictor of imminent problems. Not sleeping can lead to a mental health crisis almost immediately. 

At some point of progression in a relapse, there often comes the decision to stop taking medication. The initial dosage of medication may be too low, and this can foster the delusion or the denial that says medication isn’t needed. (In my case, had I been on a higher dose of antipsychotic medications, I might have processed more clearly and might not have made the foolish decision to discontinue medication entirely.) 

Denial is a trait that can lead to discontinuing mental health treatment and not taking care of oneself. It is easy for someone who is subject to delusions to inaccurately believe that he or she doesn’t have an illness. This leads to stopping medication against medical advice, which sometimes causes a complete relapse of acute symptoms. If the initial dose of medication is too low, or if it gets gradually lowered too much over time, you don’t get that “aha” that the medication is needed. 

Delusions must be continually “pruned” from the mind even while medicated; medication alone often doesn’t do enough to correct the thought processes. Medication slows the mind enough so that you can work with it. That’s where “one-on-one counseling” should come in; so that the person with mental illness can be helped by a therapist to process thoughts with greater clarity. The above description applies mostly to those with schizophrenia. And I believe something very similar takes place for those with bipolar. 

When dealing with someone with whom compliance is an issue, injections of medication are sometimes useful. Prolixin and some other antipsychotic medications are available as a time release injection that can be administered once or twice a month. I was put on regular injections twice in my life. The first time this was over my objections. However, now that I’m older I’m grateful for it. If you are dealing with a son or daughter who is psychotic and who has behaved “wildly” and who doesn’t want to go along with treatment, it may work to be a bit “hard line” with this offspring, at least in terms of forcing him or her to take medication. This can be done with injections, (usually administered by a nurse.) (When taking tablets, it is too easy to hide the pill, and lie that the medication is being taken.) After a year of it, the person may have gained more insight concerning the illness. And then, at some point, the person who suffers from the illness should gain the insight that the medication is needed; and then can switch to oral medication. 

It is good if someone can get their episodes of psychosis or bipolar over with early in life. Having it happen when older can be a rougher ride; and it is harder and more time consuming to bounce back. Also, when older, you do not have parents to help and to provide some guidance. Unfortunately, people do not have control over when in life these illnesses will strike. 

My relapses over the past thirty years were because I briefly became medication noncompliant. Enough time had elapsed since the most recent episode that I forgot how hellish a psychotic episode is, and how powerful the force is that pushes me toward a relapse. My last episode of severe psychosis was in 1996, and I hope to never have another one. Yet, I can’t be certain of this.