Covert Treatment of Violent Patients

Mr. T is a 28-year-old Singaporean with a longstanding history of schizophrenia characterised by prominent paranoid delusions and command auditory hallucinations. He struggled academically in school and had difficulties making friends, but reported no significant behavioural problems. Like all young Singaporean males, Mr. T enlisted into the compulsory National Service at the age of 18. A month into his basic military training, he started believing that his platoon commander was part of a conspiracy to kill him. Mr. T was referred to the state mental hospital by the medical officer. In the hospital, he revealed to the attending psychiatrist that he was part of a secret intelligence organisation and that he could hear the enemies conspiring to take control of his mind and kill him.

Antipsychotic medication was started with subsequent resolution of the psychotic symptoms. He was discharged from the army and was eventually able to secure employment with a family friend at the local fish market. There, he met his wife-to-be. He told her that he had previously been admitted to the state mental hospital but she felt that she could help him. They married and moved into a one-bedroom flat.

18 months later, he was brought back to the hospital by police after threatening his wife with a knife, believing that she was part of a conspiracy that was monitoring him. It was revealed that he had stopped seeing his psychiatrist and had discontinued his medication for more than three months as he did not think that there was anything wrong with him. Antipsychotic medication was started and psycho-education was also given to him and his wife. The delusion resolved and he was discharged.

Over the four years, Mr. T was re-admitted to the hospital on another four occasions following an exacerbation of his illness after he stopped his medication on his own accord. Each time, he was brought in by the police following reports of domestic violence where he would threaten his wife with a knife and accuse her of being an enemy agent trying to control his mind. After being released, his symptoms would resolve but he continues to lack any awareness that he has an illness and, after awhile, refuses to take his medication and see his psychiatrist. He has also vehemently refused any depot antipsychotics. He has recently been discharged from the hospital and has again refused to take his medication. Mrs. T is terrified that he will become unwell again and has come to see the psychiatrist at the clinic. She wants to collect Mr. T’s medication and tells the psychiatrist that she intends to give them to him covertly in his food.