Re MP

[2011] QMHC 4

MENTAL HEALTH COURT

CITATION:	Re MP [2011] QMHC 4
PARTIES:	APPEAL AGAINST DECISION OF THE MENTAL HEALTH REVIEW TRIBUNAL
PROCEEDING NO:	0278/10
DELIVERED ON:	3 May 2011
DELIVERED AT:	Brisbane
HEARING DATE:	28 April 2011
JUDGE:	Ann Lyons J
ASSISTING PSYCHIATRISTS:	Dr J M Lawrence Dr A S Davison
FINDINGS AND ORDERS:	The appeal is dismissed 2.   The decision of the Mental Health Review Tribunal dated 23 November 2010 is confirmed.
COUNSEL:	J Briggs for the appellant J Tate for the Director of Mental Health L Syme for the Attorney General
SOLICITORS:	Legal Aid Queensland for the appellant Crown Law for the Director of Mental Health Crown Law for the Attorney General

ANN LYONS J:

1. The appellant “MP” was placed on a forensic order on 25 November 2002.

1. That forensic order has been regularly reviewed by the Mental Health Review Tribunal and the forensic order was most recently confirmed in a decision by the Mental Health Review Tribunal on 23 November 2010.

1. MP has appealed that decision in a notice of appeal which was filed on 15 December 2010. MP’s ground of appeal was that he was “framed by police for stalking which led to a forensic order by doctors I am the victim of an evil conspiracy.”

1. Professor Donald Grant has prepared a comprehensive report dated 19 May 2010. Professor Grant reported that his clinical assessment was that the appellant suffers from chronic paranoid schizophrenia and that he has suffered from this illness since his mid 20s. He considers that his illness has been resistant to treatment and has responded only partially to a range of antipsychotic medications over the years. Dr Grant considers that the medication has served largely to dampen MP’s tendency towards irritability and anger and also to encapsulate his delusional beliefs to some extent so that they have less effect upon his behaviour.

1. Dr Grant also considers that his auditory hallucinations have been controlled but he continues to experience the belief that he receives information and influence from outside in the spirit world. Dr Grant considers that his illness continues to be active but is partially controlled by medication. He considers that MP’s insight into his illness is poor and that he lacks an understanding in regard to the effects of his behaviour in the past on other people. He also considers that he tends to minimise the offences which led him to be on the forensic order as well as minimising other issues which have led to long periods of detention under the Mental Health Act.2000 (Qld) (the Act)

1. Dr Grant noted that MP is compliant with medication and remains on treatment.  He considers that he is a relatively low risk to others and that currently there is no evident risk to himself.  Dr Grant however noted that in the past when MP has been unwell or noncompliant with medication his grandiose and paranoid beliefs have led him to act in antisocial ways with threats and stalking behaviour.

1. Despite the fact his beliefs have become more controlled, Dr Grant considered that they nevertheless lead him to feel suspicious and persecuted and this results in him being rather litigious. Dr Grant stated that the appellant’s lack of insight leads to a constant battle to get him to accept treatment and that there is therefore hostility between MP and his treating team.

1. Dr Grant considered that MP has the potential to develop more active psychotic beliefs and to act on those beliefs if he does not continue with his current treatment and that that treatment needs to be strictly applied. He considered that whilst the risk of stalking behaviour is low on treatment it would be moderately high if he were not to receive treatment and it is very likely he would once again begin acting on his psychotic beliefs in an antisocial fashion with consequent risk to others.

1. Dr Grant considered that given his lack of insight and limited cooperation the treating team were correct in giving him depot medication and having a low tolerance to non-compliance. Dr Grant considered that having regard to his current mental status and his past psychiatric history as well as his past offending the Court should confirm MP’s forensic order. He considered that he should have limited community treatment subject to reasonable conditions. Dr Grant recommended that the conditions include that he have ongoing psychiatric treatment and that he be required to attend as required and to take prescribed medication and other treatment. He considered he should also refrain from using excess alcohol and illicit drugs. It should also be a requirement that he not contact the victim of his stalking behaviour.

1. Dr Slavica Jelesic-Bojicic has provided an update report to the Court dated 2 February 2011. She also gave oral evidence to the Court.  Dr Jelesic-Bojicic states that the appellant has a long history of a psychiatric illness and that his most recent admission was in 2006 which was precipitated by non-adherence with medication and with absconding from his address. She indicated that since discharge from that 2006 admission he has reluctantly adhered to depot medication.  There have also been frequent occasions when “authority to return” paperwork needed to be filed. Dr Jelesic-Bojicic stated that whilst he has attended medical appointments he tolerates the appointments poorly and is easily irritated by inquiry as to his mental state. Once he has had his depot injection he leaves the clinic as soon as possible and consistently refuses to engage with the treating team.

1. Dr Jelesic-Bojicic considers his illness is characterised by well-entrenched persecutory beliefs that his phone is being tapped as well as a belief that he is working as a volunteer for the Queensland Institute of Medical Research undertaking fieldwork. It would appear that his past involvement with QIMR involved threats to staff members from him.

1. Dr Jelesic-Bojicic stated that he was initially placed on a forensic order in relation to two charges of stalking. She stated that the offences related to the appellant’s propensity to harass certain individuals about whom he had delusions regarding their behaviour. Apparently his behaviour was said to be hostile and threatening. MP’s recollection of those events however is that he was courting a woman with whom he wanted to start a relationship and now realises she was not interested in his advances. The appellant believes that his charges were as a result of a conspiracy between Queensland Police and Mental Health Services and that his behaviour was blown out of proportion. He says he should never have been placed on a forensic order and does not fully believe he suffers from schizophrenia.

1. Dr Jelesic-Bojicic states that since she has become his treating psychiatrist MP has concentrated on trying to convince her that he does not have a mental illness. Whilst he considers he previously had a mental illness he no longer has one and he does not need medication. He wants his depot reduced and stopped as the depot makes him tired and he is prepared to take oral medication instead. The appellant says he does not have time and does not deserve the annoyance and nuisance that Mental Health Services impose on him. He states he is very busy working on projects which include a cure for cancer.

1. Dr Jelesic-Bojicic considered that MP has a fixation on some of the doctors at QIMR. The appellant told Dr Grant that the doctors at QIMR tried to murder him on Boxing Day 1986. He states that he was told that they had taken contract killers out to get him and he does seem to have a focus on the doctors at QIMR. He denies threatening the doctors and a politician but does confirm that he has written a couple of letters.

1. Dr Jelesic-Bojicic says that MP is currently managed on fortnightly depot antipsychotic medication, Flupenthixol at 50mgs which was reduced from 60mgs on 17 January 2011. He also takes Artane 5 mgs daily. He is in contact with his case manager every two weeks.  Whilst she initially saw him every two or three weeks this was extended to every four weeks and now it is every six weeks. He has also regularly been seeing a private psychiatrist, Dr William Wilkie, over the last two or three years.

1. Dr Jelesic-Bojicic last saw MP on 1 March 2011 and had previously been seen on 8 February and 19 January 2011. She stated that MP shows very little insight into his psychiatric disorder and is resistant to receiving any treatment. He also has significant paranoid and grandiose delusions which are always present.  She does not consider that his psychotic symptoms are in remission and he suffers from treatment resistant chronic paranoid schizophrenia.  In her view his illness is characterised by chronic, well systematised, paranoid and grandiose delusions and possible religious and referential ideation. She stated that he denied perceptual abnormalities and demonstrates several negative symptoms as blunted affect and social isolation.

1. Dr Jelesic-Bojicic considers that his medication seems to have lowered his tendency towards irritability and anger and also lowered the intensity of his delusional beliefs to some extent so that they have less effect on his behaviour. She considers that the medication has partially controlled his illness but it continues to be active.

1. Dr Jelesic-Bojicic stated that the appellant has a history of stalking behaviour, threats and buying a gun in the 1980s and that he has recently reported that he is thinking of getting married and has shown an interest in a receptionist at a clinic, who he believes has given indications of interest through her eyes and body language. Dr Jelesic-Bojicic considers this shows how quickly he could deteriorate into stalking behaviour if he is not actively treated.

1. Dr Jelesic-Bojicic considers that the Court should confirm the forensic order with limited community treatment; that a forensic order was required to ensure the possible worsening of his symptoms if medication was ceased. She considers he needs to stay on depot medication and on a forensic order under the Act considering his lack of insight and limited cooperation with treatment.

1. Dr Jelesic-Bojicic also considered that he should have limited community treatment on appropriate conditions which should include that he have ongoing psychiatric treatment; that he be required to attend for treatment and that he be required to take the medication and refrain from using excessive alcohol or drugs. She considered that there should also be an order that he not contact the victim of his stalking behaviour and he should be prohibited from possessing a firearm.  Dr Jelesic-Bojicic stated that he threatens people who do not recognise his contributions.

1. Mr Briggs on behalf of the appellant argued that whilst he might be grandiose and delusional he has not acted on those beliefs and that it was nearly ten years since the stalking charges which precipitated the forensic order.  Mr Briggs submitted that MP is not preoccupied by his beliefs and is an intelligent man who manages his life very effectively. He stated that the appellant feels stigmatised by the forensic order.  He stated that the appellant also believes that the depot medication is too severe and he is willing to trial oral medication.

1. Counsel on behalf of the Attorney General argued that the forensic order needed to stay in place given the appellant’s extensive psychiatric history and his well entrenched delusional beliefs.  Ms Syme argued that as the appellant had poor insight and because there were ongoing concerns by his treating psychiatrist the forensic order should continue as revocation of the order would place others at risk.  Ms Syme highlighted the risk the appellant had posed previously and his continuing and well entrenched delusional beliefs in relation to police. Counsel for the Director of Mental Health also argued that a forensic order was required given the past history and the fact that the delusional system was still well entrenched.

1. The assisting psychiatrists noted that a diagnosis of paranoid schizophrenia has been consistently made in respect of MP by a range of psychiatrists over a lengthy period of time. Dr Lawrence indicated that MP’s delusional beliefs were encapsulated in his grounds of appeal. She advised that he remains insightless and that if the forensic order was not in place he would almost certainly not comply with medication and his condition would deteriorate.

1. Dr Davison noted MP’s clear wish for some pathway forward from the impasse that he feels he is in at the moment. He noted that during her evidence Dr Jelesic-Bojicic indicated that she would, if the appellant were to cooperate with her, undertake a trial of a modern oral medication, like Clozapine, in conjunction with the continuing depot medication.  He stated:

“That may well be worth attempting if [MP] were to cooperate with that.  Even under those circumstances the depot medication, in my view, would need to be withdrawn very carefully and very slowly over a period of time. Clozapine could take many months to produce its full therapeutic effect and a forensic order would need to be in place while one was observing the outcome of those changes, and I would think that a forensic order would need to continue for at least a year or maybe two if the outcomes were positive.”

Conclusion

1. There is no doubt that the appellant has been on a forensic order in relation to events which occurred almost ten years ago.  However those charges were serious charges of stalking and the appellant continues to be insightless into those charges and still minimises that offending. Of particular concern is the fact that his psychotic symptoms are ongoing and his condition is considered to be treatment resistant as his symptoms have only partly responded to the various anti psychotic medications.

1. The assisting psychiatrists both advise that the forensic order should continue given the ongoing symptoms and the seriousness of the risk.

1. In relation to this appeal against the decision of the MHRT it is clear that this Court may pursuant to s 325 of the Act confirm or set aside the decision appealed against.  Section 333(2) also provides that the appeal is by way of rehearing, unaffected by the tribunal’s decision, on the material before the tribunal and any further evidence the Court allows. 

1. Section 204 provides that a forensic order cannot be revoked unless it is clear that the patient does not represent an unacceptable risk to the safety of the patient or others having regard to the patients mental illness.

1. On the material before me I am not satisfied that the appellant does not represent an unacceptable risk to the safety of others given the seriousness of the index offences and the entrenched and continuing delusional system which continues to operate.  The extent of this delusional system is exemplified by his ground of appeal in which the appellant states that he was framed by police and that he is the victim of an evil conspiracy.

1. The appeal is accordingly dismissed and the decision of the MHRT of 23 November 2010 is confirmed.