RB was the least succesful of a family who did very well academically. The elder brother and sister had gone to OxBridge. RB did not enjoy the social mix at his comprehensive secondary school, feeling something of an outsider to the general. He became interested and familiar with sport and the arts side of school life; music and drama.
He qualified well enough to leave for a course at a provincial university. At the same time his parents moved from cambridge, where he had spent his last ten of years of education, to leicestershire.
During his first year at university he was admitted to the local mental hospital, diagnosed as depression, staying there for seven weeks, and receiving the full dosage of medication for the endogenous type of depression. That kind of depression is expected to begin without precipitation by circumstances and to take its course unresponsive to ordinary events. The illness is expressed as more or less clearcut phases, with intervals where there is no illness.
It does respond, completely when there is response, to the group of medications called- as a category - the tricyclic anti-depressants, when these are given in the full dosage, established from accumulated experience; and the mood returns to normal and to reactive appropriate variation so long as the dosage continues; or when the natural course of the illness leads to its spontaneous recovery, a recovery which is always the eventual subsequence.
This category of medication is not mood alleviating or enhancing in the ordinary way. It has no effect on ordinary disappointment, doleful people, and misery.
RB received the full dosage of a potent member of the class of medication ( Anafranil:Chlomipramine ), and he recovered over the time course that would be expected when there is an response to this medication.
After seven weeks in that hospital he was discharged to his parents home, now in Leicestershire.
The Report is vague about what happened to his medication. It was gradually reduced and finally omitted but over what timescale is not clear. This is unhelpful in weighing up the background to the ebb and flow of mood change when it is not made absolutely clear what the concurrent level of medication is, or whether it is being taken at all.
The social movements of RB are laid out with some clarity, but the subsequent shifts in mood are difficult to assess in duration, or intensity. The Report is not clear either about whether there were clear indications of a length of time without problems with mood- completely well periods, in between breakdown times. The presence of these clearcut well periods - free from any symptoms, particularly sleep distrubance - is one of the best indications that a depression was - 'autonomous , endogenous , constitutional ' i.e. an illness , rather than a greater than ordinary reaction to life's troubles .
It also means that any future persistent mood should be first thought of as being a return of this condition.
RB seems quite early to have been shifted out of a classification of someone liable to endogenous periods of stuck mood - the illness category - given him during his first hospital observation.
He is now in a different category of mental disorder - of someone who feels things hardly and sometimes lets them overwhelm - a personality variation of an enduring kind which has as its outward show, more extreme reactions to life's disappointments , than occur in the general range of reponses to those things, by people in the same sort of age range and circumstance.
This latter conclusion became that adopted for his care by family and advisors.
He was persuaded into psychotherapy. Nothing of the substance matter of the therapy discussion is disclosed.(*)
Two years after the first admission he is described as making progress, working from home for a continuous spell of eighteen months . He has declined a further offer of psychotherapy.The year after that is more difficult , he is unable to complete a business studies course, and some erratic behaviour not fully described, finally led to his leaving home. There followed a period of poor sleep, concentration, and loss of appetite and concentration of interest - generally considered to be commencing a time of endogenous mood.
It culminated in his taking an overdose of paracetamol, sufficient to be dangerous for his health, and to lead to his subsequent admission to a psychiatric Unit. He is described as being in low mood, of low self esteem, and with guilt. He had made cuts to his throat and his wrists. He has unreal feelings. He talked with a student nurse and disclosed inner fantasy thoughts around harming his parents. Neither the medical staff nor the parents were told of this, a more senior nurse advising that such matter was common ( it is not ) and not necessarily significant on that account.
Those symptoms and signs can be attributable to endogenous depression, but here were recorded as belonging to a depressive personality disorder. No anti-depressant medication was prescribed.
He spent some further weeks attending a day centre where he was observed to have remained depressed, and took a further overdose of 'pain-killer' tablets.
Soon he was discharged from the day centre and it seems was found a bed-sit accomodation from which he obtained work and gradually led to his good spell of some five years spent with a companion with whom he bought and shared a house.
This ended when his work colleagues noticed his being 'down' and his work was suffering; his relationship with his companion ended; and he had left the house he shared with his companion. During the final months up to the final event he had moved into the lodgings.
It is the landlady he later kills - in circumstances not described.
This period of uncertainty led to a consultation with his family doctor, and he is prescribed a modern drug, popularly prescribed because it is safe in overdose; prescribed here in preference to the original medication found succesful during his first hospital admission. In the family of Prozac type medications.
RB took all the tablets, which led to him being assessed thoroughly at the local casualty department by a junior psychiatrist staff - a training post. As a result, the possibility that this was a "clinical depression" was raised, ( i.e.the same as his first hospital diagnosis ), an out-patient appointment to see the team consultant was made for three weeks thence, and a letter sent to that consultant about the referral, and a copy sent to the family doctor. The contents are not referred to in the Report.
" Clinical" depression here means the type of depression described in the original admission to hospital, that is - endogenous, and one to be treated with appropriate observation, and as in the apparently succesful first hospital admission, with potent tri-cyclic anti-depressants.
It is not clear in this unsatisfactory Inquiry account what the supervising practice for junior psychiatric doctors in training was in this service. Whether the junior doctor spoke or could speak with their training supervisor - the Consultant lead in the mental health service, or the Consultant on duty for that day in casualty, to call upon them for a second viewpoint on the plan adopted. Nothing is revealed as to the advice in the letter to the family doctor; whether prescriptive medication was discussed and considered in advice to the family doctor; nor is it made clear whether any consideration was given to call in support or intervention from other members of the mental health team.
RB, an isolated figure, would have to wait for a future Out-patient appointment, and having to put up with "clinical depression " in the meanwhile.
It is not disclosed in the Inquiry whether a Social worker intervention was considered, or offered. The latter would be important in the absence of any close people, family or companions, to check out on his condition and his care of himself; and to give a point of contact so that further information could be fed in.
The parents, somewhat estranged, were not approached, nor the recent companion, nor his current domicile, to see if things there were alright for him.
The Inquiry surmises, perhaps in an oblique reflection on the care offered, somewhat outside its general stance, that had the appointment with the consultant been kept, the consultant would have been likely to have invoked the mental health team to provide contact and support.
The appointment was not kept because the tragedy occurred.
RB killed his landlady in circumstances not described. The circumstances leading to that behaviour are an important factor in coming to a diagnosis of the condition that might now need treatment.
An Inquiry meets and delivers its report sometime after the tragedy. The outcome of the subsequent mental healthcare of the subject of the Report is usually given some attention in most Inquiries, partly to attempt a final diagnosis.
Not in this one.
Review Burton
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