Mental Health

[kelts]

Hi,

I'm looking for some help regarding mental health issues in Thailand. My mother in law is not well mentally. It's been ongoing for the past 10 years or so, gradually getting worse. My wife and I live in Australia now, ( I previously lived and worked in Koh Samui for 5 years), and we visit the family once a year, about 60kms from Udon Thani.

Ma-in-laws mental health has declined dramatically every year to the point where she is ostracized by the rest of the family and village. She was arrested (and taken home) yesterday for vandalizing a religious shrine and we need to fly over and get her help asap. I'm reluctant to head straight there without any plan or options, as we've had similar dramas the last few times we were there. The police can't help, the local hospital can't help. It seems that there is no help unless she admits herself. Convincing a mentally unstable person that they're mentally unstable and need help has been a futile task, and has only led to deeper divisions and resentment. My poor mother in law is leading a miserable existence and unfortunately it's creating great misery for my wife over here, and her brother, uncle and elderly granddad over there. I don't know what to do and any advice would be greatly appreciated.

Many thanks,

Kelts

[Sheryl]

The first step needs to be a careful evaluation by a neurologist to see if there is a physical cause. You do not mention her age, but I assume she is at least 50 and it sounds like she was not like this until around 10 years ago.

 

Primary psychosis usually has its onset at a much earlier age. Onset of symptoms like this after around age 45 usually signals something else going on. Sometimes it is the first sign of a dementia like Alzheimers; sometimes there is a brain tumor etc. You also need to consider whether there is any possibility of drug use. Is that a possibility? Or does she drink? There are types of psychoses associated with vitamin deficiencies in alcoholics.

 

In other words need to figure out the cause first or at least exclude all treatable causes.

 

To save time and since it would not be unduly expensive I suggest you take her to Khion Kaen University hospital (Srinagarind) to see a neurologist at their after hours clinic. If possible consult Dr. Pongsatorn Paholpak.The purpose of the consultation being to find out what is wrong with her, whether there is some other underlying cause, and develop a treatment plan.

 

She will need comprehensive blood work, a neuro exam and depending on the findings in it, possibly a brain scan.

 

Be sure to get copy of all test results and ask the doctor to provide the treatment plan in writing i,e, a written recommendation for further treatment.  The next step is to take the records back to her local hospital and request a letter to referral to either the specialized psych hospital in Khion Kaen or the regional govt hospital in Udon Thani as appropriate (which will depend on what she needs.). 

 

I am assuming that the "local hospital" you refer to is just a community hospital. they will indeed not be able to help but they can (and are supposed to) refer patients they cannot help to higher levels.  Some assertiveness (which can be hard for Thais to muster with health staff) may be needed.

 

 

 

 

 

 

[kelts]

Sheryl, you are an amazing human for taking the time to respond. I cannot thank you enough!

She is 54 years old. I can attest to the last 10 years of mental instability, however, it appears it started 10 years  or more before that.

My wife is 30, and she has always known her mum isn't quite right, and even mum will admit that. So, it could be 20-30 years or more. This may have always been there. There is certainly no drugs or alcohol involved. She does not drink, never has, and in a small village substance abuse would be common knowledge, if that were the case.

We will fly over in the coming days and get her down to Khon Kaen somehow, but that's another issue.

How do we get her there?

I highly doubt that she will meekly agree to a road trip to Khon Kaen. Whilst she acknowledges that she's not quite right, she vehemently refuses to seek treatment and any mention usually results in a screaming tantrum. She believes the entire family conspires against her and every movement, visit to other relatives, gestures, conversations, it's all taken as a conspiracy against her. She clearly loves and misses her kids, and she can be lovely for short periods of time but she's constantly haunted/troubled by her own thoughts. It's like self sabotage, she craves love and attention from her children/family and drives them away with crazy insecurities. I feel soooo sorry for her, this is no way for anyone to live.

Thank you so much for your advice!!! We now have somewhere to start, and I'll keep this updated as we progress.

Much love and respect,

Kelts

[Sheryl]

If it has been going on from a much  earlier age then a primary psychosis is more probable. The hormonal changes of menopause would aggravate it.

 

Get a letter of referral from her local hospital to the psych hospital in Khon Kaen -- or if they prefer, to a psychiatrist at Udon Thani regional hospital as there should be a psychiatrist there. Government hospitals have a set referral pathway for patients i.e. they knwo where they are supposed to refer what type of patients.

 

The hospital should have done this way back. But possibly they do not know the severity of the situation. Families are often hesitant to speak up. They (or you)_ need to be verty assertive and insist in  a referral.

 

Then tell her the doctors at the local hospital want her to go there because that hospital has better medicine and can help more, or something like that,. Beyond this I can;t advise on how to bring her, you and the family will have to figure that out.

[kelts]

Ok. Thanks Sheryl. Would you still recommend starting with Dr. Pongsatorn Paholpak? The village is Chaiwan, about 2 hours from Khon Kaen, so it's not that much further than Udon.  But it sounds as if it may be more equipped for psychiatric issues?

[Sheryl]

If it is convenient then yes, go ahead and try to see him at the KKU Hospital after hours clinic. You will have to pay but cost will be low. Then with his findings and recommendation in hand ask the local hospital for a referral. They might refer to either Udon Thani regional hospital or the specialized pysch hospital in KK, depends on what the policy is.

 

If she has been on any meds bring them with her to show the doctor.

[kelts]

Thanks again Sheryl. I don't want to keep hassling you, and we will try to get there asap. After just talking to my wife, she remembers her mum having to spend 3 months in a mental hospital when she was about 10 years old. So, 20 years ago. And she currently doesn't take any medication or seek treatment. Hopefully, after being arrested she will agree that help is needed! I'll let you know how we go. Thank you so much

[kelts]

Hi Sheryl,
We are in Chaiwan now. We went to the local hospital to try to get a referral to the psych hospital in KK. They flat out refused, and initially wouldn’t refer her anywhere, saying we’re taking money away from the local hospital.
It appears we will now get a referral to Udon hospital, not sure what will happen next. Any advice would be most appreciated. Thank you


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[Sheryl]

Udon should have a proper psychiatrist, so as you were able to get a referral there, try it.

 

BTW when there are issues with a government hospital (refusing to giove letters of referral or other) under the 30 baht scheme can complain to the NHSO  https://www.nhso.go.th/eng/FrontEnd/index.aspx

 

But as you did ultimately get a referral go ahead and see what happens with psychiatrist at Udon. If it is nto satisfactory then call the NHSO hotline and explai nthe problem (long standing mental illness and  local hospital refusing to refer to the nearest government pysch hospital)

[kelts]

Ok. Thanks Sheryl. We’re at Udon Hospital now. I’ll know more shortly. Thanks again


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[kelts]

So, we’re back to square one. After arriving at the hospital, I went to park the car about 2 kms away. By the time I got back my wife was frantically searching for Ma. She had turned around to fill out the paperwork and Ma disappeared. We alerted security, together we went up and down the street, searching the shores of the nearby lake to no avail. After over an hour, we were advised to go to the police and report her missing. By the time we got there the hospital rang, she had been found in the temple. No damage to this one. We returned to the hospital and after a couple of hours wait Ma started kicking off, we were fast tracked to the doctor and he advised changing medication and come back in 2 months. We sat there while Ma told him she hears voices but can’t see them or find them. We explained to him the whole situation, the history, the recent arrest, her refusal to take any medication at all! By this time Ma is yelling, screaming and security are called to escort us to a different area so she can be given a sedative injection to calm her down. We are then sent home. I just endured 45 minutes of her screaming and smashing the seats and windows of the car interior until she nodded off. We are back home now and she seems calmer but is now completely uncooperative and still agitated. All we seem to have done today is turned her against us by ‘kicking the hornets nest’.
The Udon Hospital also wouldn’t give us a referral to KK, only offering a referral to Loei, which a lot further from the village, and highly impractical for relatives to be able to visit her. They told us the hospital at Khon Kaen is a different system and they could not refer us there.? We plan on heading there tomorrow regardless as we don’t have any options. We may need the police to force her to go and possibly actually take her there with us, as she is now not cooperating (the police have said they will do this if needed).
I’m not sure what we’re in for tomorrow, and again any more advice would be greatly appreciated. Thanks so much.


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[NancyL]

I've been involved in situations where foreigners in Chiang Mai develop severe psychiatric problems and come to the attention of the police by acting out in public.  Some times the local police will just put the person in lockup overnight, thinking it's just a drunk episode and attempt a release the next day, not wanting to create too much work for themselves.  Or try to locate family or friends who will take over the care of the person.  However, if they can be convinced that it's a situation where someone is having a genuine psychiatric episode (usually it's someone with a history of mental illness who has stopped taking their medications) they are willing to do a "police commitment" to the local gov't mental hospital, Suan Prung, which is fairly well regarded.  This means that the person can't discharge themselves without police OK and the person's consulate/embassy is notified.  Technically, the person isn't arrested, but it's a big help to family and friends to have the police involved in these situations.  The police become the "bad guys" forcing the hospital stay not them.

 

So, drawing upon my experience in helping unwilling foreigners in need of mental health assistance, I'm wondering if the local police could have some influence at the local hospital to see that the proper referral for in-patient treatment is given?  I'm not a medical professional, just a social worker, but I think Sheryl will agree that Ma should not have been sent home after being given a sedative injection.   Much could have gone wrong medically for Ma.  

[harrry]

Someone I know went to Sripat in Chiangmai.  Got a private consultation with the head Psychiatrist at the Government hospital but at Sripat with no waiting.  Cost was 500 baht but the 200 baht nursing charge.  A  good hour, , medication changed and a review form given to her to take to her home hospital with the government stamp.

 

[kelts]

Thanks Nancy. I agree. In a western country we’d be crying gross negligence. However in Thailand, expats cry T.I.T. This is Thailand. Sadly, I was one of these when I lived in Samui for 5 years. But for the sake of improving the system especially for the Thai people, instances like these must be documented/reported. I’m in rural North Eastern Thailand trying to get help for my mother in law, and for the life of me I cannot see what agenda any medical professional could have that would make them do anything other than try to help.


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[NancyL]

4 minutes ago, harrry said:

Someone I know went to Sripat in Chiangmai.  Got a private consultation with the head Psychiatrist at the Government hospital but at Sripat with no waiting.  Cost was 500 baht but the 200 baht nursing charge.  A  good hour, , medication changed and a review form given to her to take to her home hospital with the government stamp.

 

Sripat Hospital in Chiang Mai is a little distant for the OP, but this idea is good.  Perhaps the head Psychiatrist at the KK government psychiatric hospital has a private clinic or hours at a private hospital, like Sripat.  Then perhaps Ma could be seen by the top guy and a review form issued instructing the home hospital to issue a referral.  

[NancyL]

3 minutes ago, kelts said:

Thanks Nancy. I agree. In a western country we’d be crying gross negligence. However in Thailand, expats cry T.I.T. This is Thailand. Sadly, I was one of these when I lived in Samui for 5 years. But for the sake of improving the system especially for the Thai people, instances like these must be documented/reported. I’m in rural North Eastern Thailand trying to get help for my mother in law, and for the life of me I cannot see what agenda any medical professional could have that would make them do anything other than try to help.


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The medical system, especially in the north and northeast is under tremendous cost pressure.  You yourself said it in post #8 that if they gave a referral it would be taking money away from the local hospital.  They'd be the ones paying for her care in the higher level hospital if they gave a referral.  They're hoping that since there's a foreigner in the family, you'll simply give up and pay for her treatment out of your own pocket.

[harrry]

Remember the doctors they see at the hospital are not generallly specially trained in Mental Health.  True Specialists are very rare here but most hospital.s will have someone with some expertise.  Sadly it is not always possible to see them but in my view Thailand does better than Australia in handling mental illness.

[kelts]

Well, we’re heading to KK tomorrow, as we’re out of options. I’ll look into this, and Sheryl has recommended a Dr in an earlier post that is an after hours clinic. To be honest, I’m not leaving KK until something happens. It can’t go on. My wife and I can’t fly back to Australia hoping it will fix itself. It’s already emotionally tragic, but it’s literally a disaster waiting to happen. I really appreciate the input guys.


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[kelts]

The medical system, especially in the north and northeast is under tremendous cost pressure.  You yourself said it in post #8 that if they gave a referral it would be taking money away from the local hospital.  They'd be the ones paying for her care in the higher level hospital if they gave a referral.  They're hoping that since there's a foreigner in the family, you'll simply give up and pay for her treatment out of your own pocket.

But wouldn’t a referral be sending the problem elsewhere? Therefore freeing up the small community hospital, police etc. and getting the specific treatment and knowledge she needs?



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[NancyL]

5 minutes ago, kelts said:

But wouldn’t a referral be sending the problem elsewhere? Therefore freeing up the small community hospital, police etc. and getting the specific treatment and knowledge she needs?



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It's my understanding that the referring hospital pays the costs at the upper level hospital.  I could be wrong and Sheryl would have a better understanding of how this works.  But, it's fairly common for Thai people who are fed up with delays and problems in getting referrals to "self-refer" and pay for treatment at higher level hospitals, like the one associated with Chiang Mai University rather than waiting and dealing with their local hospital to make the referral, or worse yet decide they're capable of providing the service.  

 

Sometimes it's better to pay out-of-pocket to have bright, young residents under the watchful eye of professors providing the treatment at a university hospital, with skilled, mature caring nurses (who delight in teaching the young pups a thing or two) than receive treatment at a local hospital where the standards of hygiene may be sketchy, the nurses indifferent or overworked and the doctors straight out of medical school without any proper mentors.   

[kelts]

It's my understanding that the referring hospital pays the costs at the upper level hospital.  I could be wrong and Sheryl would have a better understanding of how this works.  But, it's fairly common for Thai people who are fed up with delays and problems in getting referrals to "self-refer" and pay for treatment at higher level hospitals, like the one associated with Chiang Mai University rather than waiting and dealing with their local hospital to make the referral, or worse yet decide they're capable of providing the service.  
 
Sometimes it's better to pay out-of-pocket to have bright, young residents under the watchful eye of professors providing the treatment at a university hospital, with skilled, mature caring nurses (who delight in teaching the young pups a thing or two) than receive treatment at a local hospital where the standards of hygiene may be sketchy, the nurses indifferent or overworked and the doctors straight out of medical school without any proper mentors.   

Aha! I see. This may explain something that the Doctor at Udon said. He wouldn’t give the referral, but said we could go there but there’d be a fee involved of around 10,000B. Couldn’t get anymore out of him, i.e for consultation? or per month? on going fees? etc.
I’d be happy to pay that to get the ball rolling but at the end of the day, I’m not wealthy, we’d eventually run out of funds and Thai nationals are entitled to some form of medical assistance. I know it’s unlikely, but if they explained their reluctance or misgivings, most people would happily contribute to take the pressure off the system to see their loved ones get the care they needed.


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[FluffySun]

Hello, Kelts!

Unfortunately, I cannot give you any advice because I don't live in Thailand, but I just want to wish you lots of patience 

My grandmother has the same problems, so I know how hard it is. 

[NancyL]

9 minutes ago, kelts said:

Aha! I see. This may explain something that the Doctor at Udon said. He wouldn’t give the referral, but said we could go there but there’d be a fee involved of around 10,000B. Couldn’t get anymore out of him, i.e for consultation? or per month? on going fees? etc.
I’d be happy to pay that to get the ball rolling but at the end of the day, I’m not wealthy, we’d eventually run out of funds and Thai nationals are entitled to some form of medical assistance. I know it’s unlikely, but if they explained their reluctance or misgivings, most people would happily contribute to take the pressure off the system to see their loved ones get the care they needed.


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10,000 baht is probably what the hospital would ask for an initial deposit.  This is the standard request of the gov't hospital in Chiang Mai.  The hospital at KK should be very able to supply a chart of their costs.  If it's anything like the gov't hospital in Chiang Mai, it's really very reasonable for Thai people.  Sadly, Suan Prung in Chiang Mai instituted dual pricing several years ago for foreigners for their room rates, but at least the medications are still at gov't rates.  It's very possible that Ma could have very good improvement with just a couple weeks hospital stay.  There are modern antipsychotic meds that can be injected monthly for people who have a history of compliance in taking medications.   But first, she has to be treated inpatient with oral meds and observed to see what med is appropriate and at what dose.  

[kelts]

Hello, Kelts!
Unfortunately, I cannot give you any advice because I don't live in Thailand, but I just want to wish you lots of patience:heart_001: 
My grandmother has the same problems, so I know how hard it is. 

Thank you for your sentiments. Sometimes a beautiful gesture is just as valuable as good advice. Many thanks, and much love to you and your grandmother. May we all learn something here that can help. xox


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[kelts]

10,000 baht is probably what the hospital would ask for an initial deposit.  This is the standard request of the gov't hospital in Chiang Mai.  The hospital at KK should be very able to supply a chart of their costs.  If it's anything like the gov't hospital in Chiang Mai, it's really very reasonable for Thai people.  Sadly, Suan Prung in Chiang Mai instituted dual pricing several years ago for foreigners for their room rates, but at least the medications are still at gov't rates.  It's very possible that Ma could have very good improvement with just a couple weeks hospital stay.  There are modern antipsychotic meds that can be injected monthly for people who have a history of compliance in taking medications.   But first, she has to be treated inpatient with oral meds and observed to see what med is appropriate and at what dose.  

I really appreciate your time and input. For years we’ve been trying to get help, not knowing the best resource is the people. I’ve got to park it up, as it’s been a long emotional day and I imagine it’s not going to get any easier anytime soon. We’ll be up at 6am and heading to KK shortly after, if all goes according to plan. Thank you all so much, I’ll update the progress as the day unfolds. Much love and respect.
Kelts


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[Sheryl]

The referral to Udon was correct process in terms of the network of facilities in the government system, but Udon can and should refer her to the pysch hospital in Khon Kaen since there is no pysch hospital in Udon and she obviously needs hospital admisison. However it would likely take time for them to first conclude that she is not responding to their meds and isn't manageable as an outpatientetc. They aren't going to refer right off the bat since from their viewpoint she is a new patient.

 

Given how resistant she is to care, paying out of pocket for an an inpatient stay (at government psych hospital) for stabilization is probably the best course of action. If they are able to get her stabilized, at discharge have them write out her recommended course of treatment and bring it back to Udon (not your local Community hospital - they will not have the meds and are not the  appropriate level of care for psych issues !). -Since you already got  a to Udon and she has been seen there should not be a big problem to continue treatment there for free, and the pysch dr there will probably listen to what the pysh hospital  recommended, even though he did not particulalry listen to the family. If for some reason there is an issue of payment with Udon, call the NHSO.  A psychotic patient cannot be managed at community hospital level as they have no psychiatrists, she has to be cared for at a higher level where psychiatrists are available.

[Riojasue]

Thinking of you today. Hope you get the help and support you all need. I believe Khon Kaen has excellent mental health support.
Let us know how it all goes

Sue



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[kelts]

Update:
There was a change of plans this morning. Ma is still not cooperating, basically telling us to stop talking cause she’s not going anywhere. We went to the police station and after a couple of hours and just as we were leaving to get her to take her to Khon Kaen, the police decided Loei would be better as “they’ll keep her for longer”. Therefore, another hours drive to Udon Hospital a few hours wait we get the referral to Loei Hospital. The very same referral we declined yesterday. Doh!
We rang the police on the way home and they said, quite rightly, it’s a bit late to be heading from Chaiwan to Loei and back now. If Ma is still adamant she’s not going to the hospital in the morning, we pick up 2 officers to sit next to her in the back seat whilst I drive the 3 hours to Loei. I don’t imagine this will be pleasant trip but we have to do whatever is needed to get her the help she needs. It’s really sad, and I only hope that she can forgive us in the future. Sheryl, would you have any info or insight into the facility at Loei?
Thanks so much.



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[NancyL]

kelts, I've been thinking about you today as I go about my day, much of which was involved in tasks assisting an older expat who is in the mental hospital in Chiang Mai, doing much, much better than he had been three weeks ago.

 

Please don't beat yourself up thinking that you hope she'll "forgive" you for what you're doing in the future.  You're doing the right thing for her, to help control her illness.  It's a rare mentally ill person who thinks it's a good idea for them to be treated when they're in the midst of an out-of-control experience. 

 

One of the goals of psychiatric treatment is for the patient to develop "insight" into their condition and understand why they have to continue to take their medications.  Sadly, this often doesn't happen, but when it does, it's a beautiful thing to have someone you helped who initially was very resistant to treatment return when well and thank you for being willing to intervene when they were out-of-control.   

[kelts]

kelts, I've been thinking about you today as I go about my day, much of which was involved in tasks assisting an older expat who is in the mental hospital in Chiang Mai, doing much, much better than he had been three weeks ago.
 
Please don't beat yourself up thinking that you hope she'll "forgive" you for what you're doing in the future.  You're doing the right thing for her, to help control her illness.  It's a rare mentally ill person who thinks it's a good idea for them to be treated when they're in the midst of an out-of-control experience. 
 
One of the goals of psychiatric treatment is for the patient to develop "insight" into their condition and understand why they have to continue to take their medications.  Sadly, this often doesn't happen, but when it does, it's a beautiful thing to have someone you helped who initially was very resistant to treatment return when well and thank you for being willing to intervene when they were out-of-control.   

Thank you Nancy. Thank you.
I’ve never been the focus of a forum like this, but I can honestly say I appreciate it more than I could of possibly imagined. I feel like we’re not struggling blind, and I have knowledgeable people who care. I didn’t realise how much of a difference that can make. Tomorrow will be interesting, I’ll keep you updated. Thanks again.


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