Self-assessment Cases

Chapter 37 Care for people with mental illness

Jean is a 57-year-old single lady who is currently living in supported accommodation with a group of other people who also have a long-term mental illness. Jean was first diagnosed with schizophrenia when she was 24 years old. In the years preceding this diagnosis, Jean had undertaken her primary degree in teacher training and was hoping to complete her master’s degree but became unwell during this period. Jean experiences a range of symptoms associated with her illness including hearing up to three different voices talking to her and feeling that people are watching her for some sinister purposes, but she is not really sure what those purposes are. Although these symptoms are not always present, when they are, Jean describes the voices she hears as very real, very loud, powerful and relentless. These voices say very negative things to Jean like she is a dirty, no good useless whore who should be ‘put down’. These voices also accuse her of being a thief, stealing from others and that nobody wants her to live. During these periods, Jean feels like she is unravelling and is powerless to change her situation. She finds it difficult to focus on anything else or to spend time with other people. The voices are present day and night, so her sleep is affected, she is unable to concentrate on anything or anybody else and she may not even eat during these periods.

Jean has experienced a number of physical health problems over the past decade including type II diabetes and hypertension. Over the past year, Jean has had a persistent cough. She has been referred for X-ray on three separate occasions during this period but only attended the last referral. Following the results of the X-ray, her general practitioner contacted her to say there was a shadow in both lungs and further investigations were required. These subsequent investigations identified that Jean has stage IIIb small-cell lung cancer.

• 1. Where is the cancer pathology likely to be located in this woman?

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  Correct answer:
  Given the nature of the cancer and its staging, cancer pathology is likely to be located in both lungs and lymph nodes on both sides of the chest. The cancer is also likely to have spread outside of the chest to surrounding areas including the collarbone, long bone of the arms and/or shoulder and to other areas of the body including the brain.

• 2. What is the relevance of her previous psychiatric and medical history?

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  Correct answer:
  People with mental illness have higher rates of co-morbidity including cardiovascular disease, respiratory disorders, diabetes, obesity, malignant neoplasm, osteoporosis and higher incidence of hepatitis C. Mental illness also acts as a barrier to accessing and obtaining effective medical care associated with the reduced likelihood of participating in screening for cancer or having immunizations and where diagnostic overshadowing may result in the misattribution of physical symptoms to mental illness. An absence of or limited insight into mental and physical health condition may also contribute to poor engagement with investigations and/or adherence with prescribed treatment plans.

• 3. What are the likely challenges in caring for this woman?

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  Correct answer:
  Carers need to recognise that people with severe and persistent mental illness may present to palliative care services in an atypical fashion. They are likely to have difficulty presenting a detailed history of their illnesses, with the possibility that symptoms of their mental illness may obscure symptoms of cancer. Stigma associated with mental illness may also impact care delivery. Care providers may not fully believe the person about their physical illness symptoms such as pain and may attribute all distressed behaviour exclusively to their diagnosis of mental illness. This misattribution of physical symptoms to mental illness can result in poor-quality care and poor cancer symptom management. Illness symptoms such as hallucinations, delusions, emotional flatness, poverty of speech and issues with illness insight will seriously impact communication and will challenge care providers to find patterns of communication and therapeutic engagement that enables care to be provided in a constructive, compassionate and collaborative way.