Confessions of a GP

Camouflage man

Camouflage man is frightening when you first meet him. He has a big bushy beard and wears head-to-toe army camouflage gear, complete with balaclava and army cap. He is homeless and carries all his belongings in a large holdall on his back that he secures to his body with a long chain that is wrapped around him several times and locked with a big padlock. Camouflage man has paranoid delusions that he is being followed and people are trying to attack him and steal from him. These thoughts are partly because of his mental illness and partly because life on the street is tough and he regularly gets beaten up and robbed. You would probably cross the road if you saw camouflage man walking towards you, but now that I know him I realise that he is much more afraid of you than you are of him. His real name is Nigel.

Nigel is mentally ill but because he doesn’t fit nicely into one neat category of mental illness, no one has really taken responsibility for him. Nigel has had schizophrenia since he was a teenager but because he is also an alcoholic and homeless, no one is very sure which team should be looking after him. Nigel won’t take any medication and won’t attend any psychiatric appointments. He often disappears for a few months at a time, but he always resurfaces and as his GP, I am perhaps the only healthcare professional with whom he regularly has contact.

He often tells me about his psychotic and frightening thoughts. They have been going on for years and are worse when he smokes cannabis. He sometimes becomes violent when he drinks and he has spent some time in prison. You might think that someone like Nigel should be in a psychiatric hospital and, 20 years ago, that is where he would have been. However, people with mental illness aren’t locked away indefinitely these days as they are treated in the community instead. Care in the community works well for some people with mental illness, but not for Nigel. He is a ‘revolving-door’ patient. He becomes quite mentally unwell and often then ends up being compulsorily detained by the police and brought into hospital. He is forcibly given a drug- and alcohol-detox along with antipsychotic medication. For a period of time, he remains relatively well, but he can’t be locked up for ever and eventually he is discharged and goes back to his old addictions and stops taking his medication.

My main worry with Nigel is that one day he might get very paranoid and kill somebody. It is very rare for somebody with mental illness to commit murder, but it does sometimes happen and when it does, the debate on how we should manage people like Nigel is reopened. The finger is pointed at GPs, psychiatrists and politicians and then everything blows over and not much changes. Today we can’t lock up Nigel because he isn’t harming himself or anyone else. I am scared that if he smokes enough dope, he might get sufficiently paranoid to harm someone, but my fears aren’t a good enough reason to lock him away. Nigel does have a designated psychiatric nurse, who is very nice but struggles to keep track of him. There are only so many times the nurse can wander the city centre looking for him. If she finds him, she buys him a coffee and tries to persuade him to stop smoking weed and to take his medication. Then she leaves and Nigel goes back to his chaotic paranoid existence. There are community support teams and services available to help people like Nigel, but when he is out of hospital he doesn’t really have much interest in using them.

Nigel will always have a difficult, chaotic life, but it would be nice to think that we had the services available to keep him and everyone else safe. At the moment we don’t. If he did take his medication regularly, he would probably stay fairly well. The problem is, like many people with mental illness, he just won’t take it voluntarily. One option is to consider paying people like Nigel to take their antipsychotic drugs. It is a controversial idea but every time Nigel is admitted to hospital it costs the NHS thousands of pounds. If Nigel were paid £20 per month to come and get his injection of antipsychotic medication, it would probably be enough incentive for him to take it and he would almost certainly remain well. This would save thousands of pounds in hospital admissions and also reduce the harm caused to Nigel and those around him every time he becomes unwell. Many are against this idea, feeling that it degrades people with mental health problems. There are many stable, well-supported people with schizophrenia and other types of mental illness who take their medication readily without the need for financial incentives. Unfortunately, there are also an awful lot of Nigels.