Stigma of psychiatric in-patient care

Sir: In their descriptive study of attitudes to illness in 30 first-admission psychiatric and medical inpatients, McCarthy et al (Psychiatric Bulletin, 1995, 19, 349-351) found, not surprisingly, that psychiatric patients were more likely to regard admission as unnecessary and to hide their diagnosis from relatives, friends and workmates. A simple audit of flowers and Get Well cards received on the two wards would probably point in the same direction. Certainly, medical and nur sing staff do not complain of hay-fever symptoms on psychiatric wards! What is surprising about the results is that 10% of the medical patients questioned did not agree that their admission had been necessary. Does this suggest that a lack of insight into illness is not an exclusive preserve of psychiatry or should these medical patients have had a mental state examination?

A simple audit of flowers and Get Well cards received on the two wards would probably point in the same direction. Certainly, medical and nur sing staff do not complain of hay-fever symptoms on psychiatric wards! What is surprising about the results is that 10% of the medical patients questioned did not agree that their admission had been necessary. Does this suggest that a lack of insight into illness is not an exclusive preserve of psychiatry or should these medical patients have had a mental state examination?

The Maudsley Hospital, Denmark Hul. London SES 8AZ
To be or not to be discharged: an ethical dilemma Sir: I sympathise with my colleagues (Psychiatric Bulletin,19,(199)(200)(201)(202) describing their plight in such a lucid and heart-felt way. We have all experienced, in clinical work at one time or another, such patients who 'refuse to get better' and sabotage any attempts made by professionals to help them. Staff find this type of patient difficult to cope with, especially if they have been violent and disruptive, and it is demoralising to contem plate that one's efforts are met with almost unmitigated failure. The case in point is a particularly damaged individual with a debilitating mental illness, poor impulse control, drug and alcohol problems, possible learning disabilities and there is substantial evidence of lack of adequate parenting and personality development.
Although the risks of the patient becoming uncontainable and engaging in dangerous beha viour if (and when) discharged can not be under estimated, it seems that there may still be things that can be done to alleviate some of the pressures imposed by looking after such an 'unrewarding' patient. I wonder whether his needs have been thoroughly assessed, including his intelligence (how limited is limited?). We are told about a behavioural programme that was instigated but perhaps staff support and a more dynamic understanding of the issues involved (expecta tions, hospital as container, aggressive impulses and emotional vulnerability) might make more sense of the problem that Kotak et al are confronted with.
In my opinion 'discharge refuser' is another unfortunate term for people who present with extremely complicated problems and special needs and which (term) obscures the underlying nature of the presenting symptoms and does not allow a deeper understanding of these patients.

A. HASSIOTIS Learning Disabilities Service. St Charles Hospital Exmoor Street, London W10 6DZ
Sir: We agree with Dr Hassiotis that to cope effectively with the constant frustrations and challenges posed by our patient good staff support is essential and that psychodynamic understanding is helpful in elucidating the complex issues involved.
Our patient had psychometry which revealed that his cognitive functioning is in the borderline learning disability range. However, having re ferred him to Learning Disability Services many months ago, it is still uncertain whether they have anything to offer to this man in terms of his long-term management.
Having said this we feel that Dr Hassiotis has misunderstood our main point: as outlined in the paper there are many different reasons why patients refuse discharge. Clearly, there is a danger that to label someone a 'discharge refuser' and to take this as justification for discharging them abruptly may be 'acting out' on the part of staff, who feel unable to tolerate their feelings of helplessness, anger and irritation with a very difficult clinical problem. However, there are also patients whose psychopathology gets hugely intensified in an institutional setting and these are usually individuals with anxietyprovoking 'complicated problems and special needs' like our patient. Our main point is that the current political climate of multiple enqui ries into the 'failures' of community care makes