SAI Re

[2011] QMHC 21

MENTAL HEALTH COURT

CITATION:	Re SAI [2011] QMHC 21
PARTIES:	APPEAL AGAINST DECISION OF THE MENTAL HEALTH REVIEW TRIBUNAL
PROCEEDING NO:	0228/11
DELIVERED ON:	2 November 2011
DELIVERED AT:	Brisbane
HEARING DATE:	31 October 2011
JUDGE:	Ann Lyons J
ASSISTING PSYCHIATRISTS:	Dr J M Lawrence Dr E N McVie
FINDINGS AND ORDERS:	The appeal is dismissed The decision of the Mental Health Review Tribunal dated 5 August 2011 is confirmed
COUNSEL:	J Briggs for the appellant J Tate for the Director of Mental Health
SOLICITORS:	Legal Aid Queensland Crown Law for the Director of Mental Health

ANN LYONS J:

This appeal

1. On 5 August 2011 the Mental Health Review Tribunal confirmed an involuntary treatment order (ITO) with respect to SAI. On 29 August 2011 SAI lodged an appeal against that decision. In his reasons for the appeal SAI states:

“From 2009 they [MHRT] keep me on ITO by force and made me experience all kinds of psychiatric drugs, which have damaged my heart, blood and brain, against my will.”

Dr Timmins’ evidence

1. Dr Timmins is SAI’s treating psychiatrist and has prepared a report dated 13 September 2011. Dr Timmins also gave evidence to the Court. Dr Timmins had prepared an earlier report which the Tribunal relied on in coming to its decision. She indicates that SAI is currently being managed in the Wolston Correctional Centre by the Prison Mental Health Service.

1. SAI is currently serving a sentence of 12 years imprisonment in relation to sex offences against a minor.

1. Dr Timmins states that SAI is a 53 year old Romanian man with a well established diagnosis of chronic paranoid schizophrenia which was initially diagnosed approximately 27 years ago in 1984. Dr Timmins indicates that SAI’s illness has been complicated by poor compliance with psychiatric treatment as well as itinerancy and poor insight into the need for treatment. SAI has had multiple psychiatric hospitalisations over the last 20 years including admissions interstate and to the Park High Secure Inpatient Unit.

1. Dr Timmins also gave evidence that SAI has had suicide attempts by overdose secondary to command hallucinations in 1996 and 2002. SAI also has a history of heavy alcohol use since the early 1990s which are also associated with possible alcohol hallucinosis. Dr Timmins states that SAI’s illness is characterised by formal thought disorder and delusional beliefs of a religious and persecutory nature regarding demons attacking him through his food and body. He also has ideas of reference from television. Dr Timmins indicated that he also experiences auditory hallucinations which can be command in nature as well as visual hallucinations.  SAI also has co-morbid depressive symptoms.

1. It would seem that SAI was initially incarcerated on remand on 6 September 2008 in relation to charges of sexual assault of a minor and received treatment in custody from the Prison Mental Health Service. He was then transferred to The Park High Secure Inpatient Unit on 12 June 2009. He was noted on admission to be experiencing psychotic symptoms and was refusing treatment. He had not eaten for 10 days and his mental state was worsening. He was placed on an involuntary treatment order at that time. During his admission to The Park, he was recommenced on antipsychotic medications and his mental state improved as did his self cares and motivation.

1. Dr Timmins in her report outlined SAI’s mental health issues throughout 2010 and 2011. It is clear that SAI remained unstable throughout that period as well as refusing and arguing about his medication. SAI insists that his medication at various times was too high and he has complained of side effects. He has written several letters complaining about his treatment to the Prison Mental Health Service.

1. In February 2010 he was found guilty in relation to his charges however a retrial was ordered on appeal. In March 2011 he was released into the community on bail whilst awaiting a retrial.

1. Whilst in the community SAI was seen by psychiatrist Dr Sawhney on 24 March 2011, who noted that he was irritable and preoccupied with the injustices of the legal system. He also referred to adverse side effects of medications such as “damage to my blood and liver”. Dr Sawhney indicated that SAI was voicing psychotic phenomena such as auditory hallucinations of demons which were responsible for and able to predict natural disasters. SAI was commenced on a monthly depot injection of Paliperidone in April 2011 but continued to be irritable and difficult to engage in treatment.  SAI refused depot medication in early May 2011 voicing poor sleep as a side effect.

1. SAI was seen by a general practitioner, Dr Holsbro on 9 May 2011 and a decision was then made to enact an authority to return on 10 May 2011. SAI was transported to the Princess Alexandra Hospital for his depot injection. He was noted to be hostile and threatening. He continued to describe psychotic symptoms that were vague and non specific.

1. SAI’s retrial was held and he was subsequently found guilty by a jury. He was sentenced to 12 years’ imprisonment and was transferred into custody on 19 May 2011. SAI was subsequently seen by the Prison Mental Health Service and has been seen regularly by Dr Timmins as his treating psychiatrist. He remains under the involuntary treatment order and continues to receive the depot Paliperidone.

1. Dr Timmins indicates that SAI has continued to voice his unhappiness with the medication and has threatened suicide if the involuntary treatment order is not revoked or the medication not changed. Dr Timmins noted he remained insightless into the nature of his illness or the need for treatment citing that doctors interfere with his life and that the medications are “a pathway for the demons”. Dr Timmins states that SAI remains difficult to engage and has continued to report ongoing psychotic symptoms.

1. Due to consistent reports of auditory and visual hallucinations as well as persecutory and religious beliefs and neuro vegetative disturbance on each review during May to August 2011 the depot Paliperidone dosage was increased. SAI was then transferred on 29 August 2011 from the Brisbane Correctional Centre to the Wolston Correctional Centre. He has reluctantly been receiving his depot medication and is very angry at the increase in the dosage. He is still noted to be threatening and aggressive.

1. Dr Timmins stated that it was her view that SAI had been treated for a long time sub-optimally and that he had a clear history of sub-therapeutic treatment. She considered that it was important that he continued receiving treatment under the ITO. Dr Timmins stated that despite SAI indicating that the medication had a marked effect on his functioning she did not consider that he was physically compromised and that he was very involved in organising his appeal which he is able to do quite effectively.

SAI’s evidence

1. SAI gave evidence at the hearing and indicated that he had a blood infection in 1986 and as a result of that blood infection he experienced hallucinations and was admitted to the Mater Hospital.  He stated that he was treated for the blood infection and for schizophrenia. In his view the medication he was placed on for the schizophrenia has in fact caused his hallucinations. For this reason he submitted that he has for the last 25 years been wrongly treated.

1. SAI indicated that he has very severe side affects from the medication including poor sleep, paranoia and lack of appetite. In particular he hears snakes and barking and he is very fearful. He is very concerned about his level of medication and wants the ITO to be revoked. In particular he wants to be taken off all medication for a month so that the level of damage to his body can be assessed. He is very concerned about the medication because his life is a misery and he cannot concentrate. This means he cannot do courses in prison or participate in meaningful work.

The advice of the assisting psychiatrists

1. Dr McVie advised that SAI has severe treatment resistant schizophrenia and has been tried on a number of medications in the past without any real success. Dr McVie stated that all of his symptoms are consistent with his psychiatric illness and not the side affects of his medication.

1. Dr McVie considered that SAI’s current level of illness was quite disabling and that he had no insight into his illness. She considered that it was important that he remain on an ITO and was satisfied that he fulfilled all of the treatment criteria.  

1. Dr Lawrence agreed with Dr McVie and endorsed SAI’s lack of insight. She considered that an ITO was clearly required given his history. In particular Dr Lawrence gave the following advice.

“I believe all of the evidence from all sources confirms that he does not have insight into the nature and extent of his illness and, therefore, is not able to give proper consent to treatment...  the illness itself is quite disabling.  I think I would agree that his side effects that he describes as being due to the present medication are the results of his illness. 

The hallucinations, the delusions, the paranoia, the difficulty in concentration, the difficulties that he describes, hallucinations - both live and the auditory and visual ones - and his difficulty in doing anything, as he says, are very typical symptoms of a schizophrenic illness in itself.

He has no insight.  I think it is important that he remains on an involuntary treatment order, so that he can get the adequate treatment for his illness, lest - without it, if one complied with his request to cease all medication, then I believe that he would deteriorate seriously and could potentially harm himself or others.  I recommend continuing of the ITO.”

Should the ITO be revoked?

1. It is clear that on the evidence before the Tribunal and on the evidence currently before that Court that SAI has a mental illness, namely chronic paranoid schizophrenia. Because of the nature of that illness SAI is unable to consent to treatment himself.

1. It is also clear however that the illness requires immediate treatment and that even when taking medications SAI remains unwell. SAI is currently receiving treatment at the Prison Mental Health Service.

1. I am satisfied that the evidence indicates there is a clear risk to SAI of a serious deterioration to his physical and mental health without appropriate treatment being given.

1. I consider that there is no less restrictive way of ensuring he receives appropriate treatment and it is clear that SAI does not wish to receive the medication voluntarily and he does not wish to be treated under an involuntary treatment order. He clearly disagrees with his diagnosis and his treatment regime.

1. It is clear however that when SAI receives treatment there is a significant therapeutic response.

1. I am satisfied that on the information before the Tribunal and the information currently before the Court that all the criteria for an involuntary treatment order have been met.

1. I confirm the decision of the MHRT on 5 August 2011.

1. The appeal is dismissed.